PAEDIATRIC HISTORY

1. Introduction/Demographics
- Name
- Age
- Date of Birth
- Gender
- Name and relationship of informant
- General Location

2. Presenting Complaint
- RECORD OLDEST SYMPTOM FIRST
- Symptom x Onset (Recorded in THEIR OWN
WORDS)

3. History of Presenting Complaint

- Premorbid Conditions (Known)
- Symptom: Site
Onset
Characteristics
Radiation
Associated Findings
Timing
Exacerbating/Relieving Factors
- How has the current complaint affect their
appetite, activity, stool and urine output.
4. Review of Systems
CVS
- Known heart murmurs
- Exertion; Any sweating while feeding?
(infants)
-

Shortness of breath (On exertion or at

rest?)
Exercise tolerance
Edema (Sacral in babies, pedal in children)
Palpitations/Racing heart (children >6yrs)
Cyanosis (Peripheral or central)
Tiredness, lethargy
Paleness

GIT

Cough
[Sputum (usually coryza)] *remember that
children dont usually bring up their

How often do they pass stool?

Consistency, blood or mucus?
Diarrhea or constipation?
Vomiting
Feeding and appetite
Weight loss
Dentition
Jaundice

CNS
-

Seizures
Headaches (Early morning? Associated with
vomiting? Causing visual problems?)
Weakness
Loss of consciousness/Fainting
Problems sleeping
Abnormal movements
Gait
Clumsiness
Problems with vision or hearing

GU
-

RS
-

sputum, they swallow it. Hence, this is only

for older children.
Audible wheezing
SOB
Stridor
Apnoea
Snoring

Frequency of urination
Pain while urinating?
Toilet trained?
Nocturia
Drinking a lot of water?
Does the urine have a smell? Blood?
Boys: Does the stream come from the tip of
the penis?
Girls: Any vaginal discharge (This is usually
due to maternal hormones & goes away
after some time)

Skin
-

Rashes

Hyper/Hypopigmented patches or
birthmarks
Strawberry naevi
Eyes: Cross eyed, squints, convergence or
divergence

MSS
- Swelling, tenderness, warmth of joint
- Deformities e.g. Knock knee, Cay feet, Intoeing
- Limp
5. Past Medical History
- Chronic Illness Screen
o Sickle Cell Disease
o Asthma
o Seizures
o Congenital Heart Disease
o Thalassemia
Who diagnosed it, what brought about
the diagnosis & when.
-

Surgeries
Hospitalizations:
When? (At what age)
Where? (Hospital and Ward)
Why? (Presenting Complaint & Final
Diagnosis)
How long?
What happened in hospital?
o Complications
o Follow up
o Treatment

6. Drug History
- Currently on any medication?
- Name of medication. Dose. Why?
Frequency? Duration? Adverse drug
reactions? Last Dose? Compliance.
- Allergies (Drugs (esp penicillin) and Food
**Eggs and Peanuts of particular
importance)
- Herbal remedies?

7. Birth History
Maternal Antenatal Care
o Planned or unplanned pregnancy?
o Obstetric Care - Ultrasounds? How
many?
o Gestational Age
o Supplements (Iron and Folate) & at
what stage in the pregnancy did
they begin supplements?
o Medications during pregnancy?
What and why?
o Bloods (ABO and Rhesus, HIV,
VDRL)
o Conditions during pregnancyTORCHES, Group B Strep,
Diabetes Mellitus (Sugar),
Hypertension (Pressure), Preeclampsia, maternal pyrexia,
hospitalizations.
o Smoked or drank alcohol?
Intrapartum
1. Mode of Delivery
o Vaginal Spontaneous or Induced
(If induced, indication)
o C Section Elective or emergency
(if emergency, indication)
2. Complications during delivery
o PROM (How long after your water
bag burst did you give birth? Were
you treated with antibiotics?)
o Breeched
o Cord around the neck
o Assisted delivery (forceps or
vacuum)
o Prolonged Delivery
Postnatal
o Where was the baby born?
o APGAR score
o Birth Weight
o Infections, jaundice, breathed at
birth?
o Admissions to NICU (& reason)
o Were you and the baby discharged
at the same time?
o Congenital anomalies identified at
birth

8. Developmental History
Refer to Denver chart, textbook or table at the
end for Fine Motor, Gross Motor,
Language/Speech and Social/Behavioral
assessment. All 4 areas must be covered when
clerking EVERY patient. Ask these additionally
for older children:
- What school?
- What class? How many children in the
class?
- Grades in class & place.
- Compared to other siblings, how are they
performing?

12. Social History

- Living conditions
- Are mom & dad together?
- For asthma: Carpets, drapes, pet dander,
stuffed animals, SMOKING in the
household.
- For dengue: Bushy area, stagnant water
ADDITIONAL QUESTIONS FOR ASTHMA:
Atopic History: Asthma, migraines, allergic
conjunctivitis, allergic rhinitis and eczema (History of
this in the patient AND in family members)
OTHER QUESTIONS IN BIRTH HISTORY FOR A NEONATE

9. Immunization History
- Have they had all their immunizations on
time? Ask to see card.
- When was their last immunization?
- *For Sickle Cell patients and those <3yrs
old, ask about pneumococcal vaccine.
10. Nutritional History
- Breast fed or bottle fed (if bottle fed, what
formula?). How long they were breast
fed/bottle fed & how often did they feed
(for bottle fed, ask about how many oz &
how the formula is mixed).
- When were they weaned?
- Do they eat foods from all food groups?
- 24 hr recall Breakfast, Lunch, Dinner & 2
snacks in the last day.
11. Family History
- Mom & dads ages & jobs
- History of HIDEABC in family
- Other siblings ages
- All children by the same father?
- History of chronic illness screen in other
siblings

Planned or unplanned?
Expected due date?
Was antenatal care in the hospital or a
health center? (If hospital, why?)
Supplements (Iron & folate)
Drugs
TORCHES and Group B Strep
How far along were you when the baby was
born?
Complications during pregnancy.
Any alcohol use during the pregnancy?
Any cigarette use during the pregnancy?
Babys weight at birth?
Mode of delivery
Baby passed stool inside of you?
Was the baby jaundiced? Did they have to
put the baby under light? Was the baby
given blood for the jaundice?
Did the baby breathe/cry at birth?
Moms education level (used in deducing
how to explain things to the mother during
counseling)
Ask: What job does she have? How far did
she go in school?
How many children does she have? (Hence,
which baby is this?)

SPECIFIC QUESTIONS FOR COMMON PRESENTING

COMPLAINTS
COUGH
-

Characteristics: Wet (productive), Dry (nonproductive), barking, whooping

Timing: throughout the day & night/at night
alone
Triggers: cold, dust, illness, animal dander,
pollen, smoke, exercise, temperature changes
Associated factors: runny nose, sneezing,
wheezing
History of Atopy
DDx: Nocturnal cough ( Asthma),
Bronchiolitis, Sinusitis, LRTI

FEVER
-

SEIZURES

Onset
Did you measure it with a thermometer?
Where? Type of thermometer?
Characteristics: intermittent or constant?
Particular pattern?
Associated factors: chills, rigors, excessive
sweating, seizures
Alleviating factors:
1. Tepid sponging
2. Fan Therapy
3. Panadol

MENINGITIS
-

DIARRHEA AND VOMITING

Vomiting: evolution, contents, colour (green bile, blood - hematemesis), frequency, vomiting
on an empty stomach, volume. Is the vomiting
after a bout of coughing (post-tussive vomiting)
Diarrhea: evolution, frequency, consistency,
blood or mucus, odor, abdominal pain, urgency,
outbreaks at school, travel history, sick contact
HYDRATION STATUS: volumes and frequency of
input and output, lethargy, irritability, sunken
eyes, skin turgor

Presents as: photophobia, neck stiffness,

headaches, visual disturbance, bulging
fontanelle, irritability, lethargy

NEPHROTIC/NEPHRITIC SYNDROME

Did it work? For how long? When was the last

dose (panadol)?

Characteristics: Type: Was he/she shaking all

over (generalized)? or Did is start in one place
then become generalized (Jacksonian March)?
or Did it start in one place and stay at that place
(Focal)? Duration? What was the child doing at
the time it happened? Describe the fit: twitch
in one muscle, violent shaking, sudden stiffness
Associations: Fever (DDx - febrile seizure),
frothing, eye rolling, tongue biting,
incontinence, unresponsiveness, stiffness;
neonates: lip smacking, cycling movements
Prodrome: Aura (smell, flashing lights)
Post-ictal drowsiness (<30 mins), weakness,
Todds paresis (DDx - space occupying lesion)
Paternal history of febrile seizures
Family history of epilepsy

Nephrotic: Presents with peri-orbital, pedal,

scrotal oedema.
Where were the eyes swollen? One eye or both
eyes? Was there a discharge? Associated
erythema? Is vision affected? Itchiness? Is it
better/worse during the day? Is anywhere else
swollen (feet and scrotum)?
Is their urine frothy (points to proteinuria)
Rash on the legs? Sore throat? Associated viral
illness? (DDx: post-streptococcal
glomerulonephritis)