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

RS
-

swallow it. Hence, this is only for

older children.
Audible wheezing
SOB
Stridor
Apnoea
Snoring

GIT
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
-

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

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, In-toeing
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

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
pregnancy- TORCHES, 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
o

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?
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

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
-

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

(non-productive), 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

SEIZURES
-

FEVER
-

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
Did it work? For how long? When was
the last dose (panadol)?

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

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

MENINGITIS
-

Presents as: photophobia, neck

stiffness, headaches, visual
disturbance, bulging fontanelle,
irritability, lethargy

NEPHROTIC/NEPHRITIC SYNDROME
-

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: poststreptococcal glomerulonephritis)