Pediatrics Examination ( Part 1 )

History - Pediatrics

Introductory information

• Introduce, establish rapport.
• Name, age, gender.
• Person giving the history (parent, etc).
• Origin.

Presenting complaint

• Description of the presenting complaint, in chronological order.
• Including whether came in through casualty or admitted by GP.

History of presenting complaint

• SOCRATES ( find this thread in STEP - 3 )
• Time course: seasonal or diurnal fluctuation.
• Exacerbating factors: foods.

• Referral by GP vs. came in through casualty.
• Relevant negatives.
• If using slang, ask for clarification.

Past medical, surgical history
Birth history

• Length of gestation.
• Age and parity of mother at delivery.
• Any maternal insults [alcohol, smoking] or illnesses during gestation.

• Where born: city, hospital.
• Birth weight, mode of delivery, difficulties in delivery.
• Resuscitation, intensive care requirement at birth.
• Cyanosis, pallor, jaundice, convulsions, birthmarks, malformations, feeding or respiratory difficulties.
• Apgar score at birth if known.

• How baby was fed in first few days.
• Whether child went home with mother.

Nutritional history

• Breast-fed vs. bottle-fed
  • When breast started, stopped.
  • If formula: type, amount, pre-mixed vs concentrate [and dilution used].
• Vitamin supplements.
• Age when beikost started.
• Appetite and growth.
• Current diet.

Immunization history

• See Immunization Schedule ( find this thread in STEP - 3 )
• Get dates of each.

Illnesses and operations

• Past illnesses, operations.
• Childhood illness, obs/gyn.
  • Tests and treatment prescribed for these.
  • Problems with the anesthetic in surgery.

Developmental history

• Gross motor.
• Fine motor.
• Vision, speech, hearing.
• Social.
• See Developmental Milestone ( find this thread in STEP - 3 )

Education history

• Start of school attendance.
• Where attend school.
• Special needs requirements.
• Impact of symptoms: absent school days.

Family history

• The current complaint in parents/ siblings: health, cause of death, age of onset, age of death.
• Parents/siblings: age, health, where living.
• Height and weight of parents.
• Hereditary dz suspected: do a family tree.

Social, personal history

• Age, occupation of parents.
• Race and migration of parents [if relevant].
• Any others at daycare/ school with same complaint.
• Travel: where, how lived when there, immunization/ prophylactic status when went.
• Does the child live at home, and with whom [include siblings].
• Smokers in the home.
• Pets in the home.
• "Is there some things that worry you about the symptoms you child is having?"

Drug history

• Prescriptions currently on: dose, when started, what for.
• OTCs.
• Alternative medications.
• Allergies, and reaction of each:
  • Eczema, asthma, hay fever, hives.
  • Drugs, foods, dyes.

Systems review

• See Systems Review below.

History tips

• Use "the father" or "the mother" instead of "your husband" or "your wife", as current spouse may not be the genetic parent, also avoids issue of a divorce/separation.
• Parents may use slang. Ask "do you mean..." for clarification as needed.
• Ask if the temperature was actually measured, and if so, what it was.