Pediatrics: History
  1. Introductory information
  2. Presenting complaint
  3. History of presenting complaint
  4. Past medical, surgical history: birth, nutritional, immunization, illnesses, developmental, education
  5. Family history
  6. Social, personal history
  7. Drug history
  8. Systems review
  9. History tips
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:
  • 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
Illnesses and operations
  • Past illnesses, operations.
  • Childhood illness, obs/gyn.
    • Tests and treatment prescribed for these.
    • Problems with the anesthetic in surgery.
Developmental history
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
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.

Pediatrics Exam