Pediatric History

Adapted from Davies Pediatric Chiropractic, Ch. 2 & Mosbys Guide to Physical Examination, 6th Ed., Ch. 1

Fundamentals of Diagnosis
Skillful history-taking Careful physical exam Keen powers of observation Wise selection of other exams
x-ray, labs, etc.

Good clinical judgment

LOOK LISTEN FEEL

More errors are made because of inadequate history-taking and superficial exam than any other cause.

Tips Definite No-Nos

Never be critical of another practitioners diagnosis or treatment suggestions Never allow a child who has been brought to you for care to leave without it
do what you have to do, despite protests from the child

Never allow a child to be rewarded for being sick

Discussing Difficult Subjects

sexuality abuse serious disease psychological etiology suicide divorce drug addiction peer issues

I need to ask you some personal questions, is that OK?

I know some things are difficult to talk about and I really wish I didnt have to ask but I need to know about, is that OK?
Take all the time you need, I know this is difficult for you.

Be Aware
I want to talk to you about something, but I want to be sure that you will not tell anyone.

Recording the Pediatric History

Reliability of the Historian Historian is any person providing historical data
describe by name and/or relationship to the patient also record reliability

History
The history for an infant or child will be modified according to age The following is just an outline

Chief Complaint
May be taken from a parent or guardian
Note the name, relationship & reliability of the person providing the history The child should be included as much as possible Appropriate for his/her age

Present Problem
Note the degree and character of the reaction to the problem
Both parent and child

Different aspects of the history assume or lose importance depending on the age of the patient or the nature of the problem. Reserve detailed questioning for those aspect s most pertinent to the child.

Past Medical History

General Health and Strength

Past Medical History

Mothers Health During Pregnancy
General health, extent of prenatal care Specific diseases or conditions
Infectious diseases (gestational month) Weight gain Edema, hypertension, proteinuria Bleeding (approximate time) Pre-eclampsia

Past Medical History

Mothers Health (contd)
Medications hormones, vitamins, special or unusual diet, general nutrition status Quality of fetal movement; time of onset Emotional and behavioral status Radiation exposure Use of alcohol or elicit drugs
Attitudes toward pregnancy and children

Past Medical History

Birth
Duration of pregnancy Place of delivery Labor
spontaneous or induced duration analgesia or anesthesia complications

Past Medical History

Birth (contd)
Delivery
presentation forceps, vacuum extraction vaginal or cesarean section complications

Condition of infant, onset of cry, APGAR scores (if available) Birth weight of infant

Past Medical History

Neonatal Period
Congenital anomolies Babys condition in hospital, oxygen requirements, color, vigor, cry, feeding Duration of babys stay in hospital; infant discharged with mother? Bilirubin phototherapy Prescriptions (antibiotics)

Past Medical History

Neonatal Period First Month of Life
Jaundice, color Vigor of crying Bleeding Convulsions Other evidence of illness

Past Medical History

Neonatal Period Early bonding
Opportunities at birth and during the first days of life for the parents to hold, talk to, and caress the infant Opportunities for BOTH parents to relate to and develop a bond with the baby

Past Medical History

Feeding
Breast or bottle (type of formula)
Reason for changes, if any Frequency of feedings Amounts offered and consumed Weight gain

Past Medical History

Feeding (contd)

Present diet and appetite

Age of introduction of solids Age child achieved 3 feedings per day Present feeding patterns Elaborate on any feeding problems Age weaned from breast or bottle Type of milk and daily intake Food preference Ability to feed self

Past Medical History

Development
Commonly used developmental milestones
NOTE: Parents my have baby books which can stimulate recall Photographs may be helpful

Past Medical History

Development (contd)
Age when able to
Hold head erect when in sitting position Roll from front to back; back to front Sit alone; unsupported Stand with support; without Use words Talk in sentences Dress self

Past Medical History

Development (contd)
Age when toilet trained
Approaches to and attitudes toward toilet training

Dentition
Age of first teeth Loss of deciduous teeth Eruption of first permanent teeth

Past Medical History

Development (contd)
Growth
changes in rates of growth or weight gain

Sexual
Present status, any concerns
Female: breast development, sexual hair, acne, menstruation (description of menses) Male: sexual hair, voice changes, acne, nocturnal emissions

School
Grade, performance, problems

Past Medical History

Illnesses
Vaccinations Communicable diseases Injuries Hospitalizations

Family History
Maternal gestational history
List all pregnancies
Health status of living children Deceased children: date, age, and cause of death Miscarriage: dates and duration of pregnancies

Age of parents at the birth of this child

*Review at least 2 generations on each side of the family.

Personal and Social History

Personal status
Nail biting, thumb sucking, breath holding, temper tantrums, pica, tics, rituals, etc. Bed wetting, constipation, or fecal soiling of pants School adjustment

A day in the life of the patient is often helpful in providing insights.

Personal and Social History

Home Conditions
Fathers and mothers occupations Principal caretaker(s) of the child
Daycare?

Parents divorced or separated Food prepared by whom Sleep habits; sleeping arrangements

 In addition to the usual concerns, inquire about any past medical or psychological testing of the child
First visit to the dentist? optometrist? Hearing checks? Speech therapist? Etc.

Review of Systems
Skin
Ears
Eczema; seborrhea (cradle cap) Otitis media (frequency and laterality) Snoring, mouth breathing Allergies Dental care

Nose

Teeth

Adolescents
Use open-ended questions Dont force the adolescent to talk Sometimes, allowing an opportunity to write a concern may help.

Adolescents Common Issues

H E A D S Home Education Activities, affect, ambition, anger Drugs Sex

Adolescents Common Issues

P A C E S Parents, peers Accidents, alcohol & drugs Cigarettes Emotional issues School, sexuality