1. Introductory information
2. Presenting complaint
3. History of presenting complaint
4. Past medicalsurgical history: birthnutritionalimmunizationillnessesdevelopmentaleducation
5. Family history
6. Socialpersonal history
7. Drug history
8. Systems review
9. History tips

Introductory information

• Introduceestablish rapport.
• Nameagegender.
• Person giving the history (parentetc).
• Origin.

Presenting complaint

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

History of presenting complaint

• SOCRATES:
• Time course: seasonal or diurnal fluctuation.
• Exacerbating factors: foods.

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

Past medicalsurgical history

Birth history

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

• Where born: cityhospital.
• Birth weightmode of deliverydifficulties in delivery.
• Resuscitationintensive care requirement at birth.
• Cyanosispallorjaundiceconvulsionsbirthmarksmalformationsfeeding orrespiratory 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 startedstopped.
  • If formula: typeamountpre-mixed vs concentrate [and dilution used].
• Vitamin supplements.
• Age when beikost started.
• Appetite and growth.
• Current diet.

Immunization history

• See Immunization Schedule Reference.
• Get dates of each.

Illnesses and operations

• Past illnessesoperations.
• Childhood illnessobs/gyn.
  • Tests and treatment prescribed for these.
  • Problems with the anesthetic in surgery.

Developmental history

• Gross motor.
• Fine motor.
• Visionspeechhearing.
• Social.
• See Developmental MilestonesReference.

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: healthcause of deathage of onsetage ofdeath.
• Parents/siblings: agehealthwhere living.
• Height and weight of parents.
• Hereditary dz suspected: do a family tree.

Socialpersonal history

• Ageoccupation of parents.
• Race and migration of parents [if relevant].
• Any others at daycare/ school with same complaint.
• Travel: wherehow lived when thereimmunization/ prophylactic status when went.
• Does the child live at homeand 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: dosewhen startedwhat for.
• OTCs.
• Alternative medications.
• Allergiesand reaction of each:
  • Eczemaasthmahay feverhives.
  • Drugsfoodsdyes.

Systems review

• See Systems Review.

History tips

• Use "the father" or "the mother" instead of "your husband"or "your wife"as current spouse may not be the genetic parentalso avoidsissue of a divorce/separation.
• Parents may use slang. Ask "do you mean..." for clarification as needed.
• Ask if the temperature was actually measuredand if sowhat it was.

Pediatrics Exam »

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