Paediatric History

This is a history taking template for a young child where you will be taking the history from the parent. 

Now that you are familiar with taking basic histories, there are some situations where we have to amend our general structure. Keep in mind, whether it be children, mental health patients or other specific conditions, we are still very much interested in finding out the presenting complaint, ICE and the past medical, family, drug and social history. The only difference in these histories is that we must also ask some additional questions to screen for problems specific to this group of patients.

One of the most difficult aspect of the paediatric history is working out who to ask the question to. Clearly if the patient is a 6 month old baby, you will be directing the questions towards the parent. However, if the child is a bit older, you want to encourage them to speak up and hear the problem in their own words, to ensure the parent is not just putting words in their mouth.‌

The example history below is a generic paediatric history for a young child, who has a respiratory infection. Here we are going to assume that the child is either absent or unable to give answers, and so we are directing these questions to the accompanying adult. The three areas to concentrate are:‌

• Systems review – It is difficult to distinguish the paediatric systems review into specific and general, as many of the questions will overlap. When a child presents with fever, cough etc, one of the most important diagnoses to rule out will be meningococcal meningitis and sepsis. Therefore you must ask about fevers, photosensitivity and a non-blanching rash, urine output, bowels, as these will all be connected.
• Past medical history – After asking the 4 questions from our usual history, it is imperative to find out about the pregnancy, birth and vaccinations. This may reveal an underlying diagnosis immediately, but will also give you a general sense of the overall health of the baby. To make this easy, there are 6 types of questions that we must ask, shown below.
• Social history – It would be extremely rare to find a baby who smokes/drinks/works etc. Therefore the social history is truncated in a paediatric history to cover two main aspects – how they are at school and whether they get any help from social services.

Introduction

• Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)?
• I just wanted to ask you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there.
• Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?
• So, what has brought you in to see the doctor today?

(P) Presenting Complaint

• Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
• (Ask second screening question) – Ok, anything else?
• (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
• (Last screening question) – Are you sure that there is nothing else?
• (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom using OATES or SOCRATES for pain

(I) Ideas, Concerns, Expectations

• Ok, do you have any idea of what it could be?
• Are you particularly concerned about anything?
• What were you hoping to get out of the visit today?

(S) Systems Review

• (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.

Specific Systems Review (Ask specific questions regarding that system)

General Systems Review: (Ask general questions to rule out red flags):

Fever: Have they got a fever? What is the temperature?
Cough: Have they got a cough? Any wheezing? 
Appetite: Are they eating and drinking fine?
Bowels: Has he/she gone to the toilet? Is it normal?
Waterworks: How many wet nappies has he/she produced in the last 24 hours?
Temperament: Are they much more cranky than usual?
Photosensitivity: Is bright light an issue for him/her?
Rash: Have they developed a rash anywhere on their body?

(P) Past Medical History

• And now, about their health in general, have they ever seen your doctor about something like this before?
• Do they have any other medical conditions, such as diabetes, blood pressure or asthma?
• Have they ever had any surgeries?
• Have they ever been admitted into hospital before?

Paediatric specific past medical history:

• Prenatal history:
  Were there any problems during the antenatal scans or screening tests?
  Were any medications taken during the pregnancy?

• Birth history:
  Were there any problems with the birth?
  Was his/her birth weight normal?

• Neonatal period:
  Were there any other problems after his/her birth?

• Child development:
  Did he/she start speaking/crawling at the right age?

• Normal growth:
  Is he/she following the normal height and weight growth centiles?

• Immunisations:
  Has he/she had all of his vaccinations?

 (F) Family History

• Is there any incidence of [Patient’s condition type] in your family?
• Are there any other conditions which run in your family?

(D) Drug History

• Are they currently taking any prescribed medication?
• Do they take anything else, over the counter?
• Do they have any allergies?

(S) Social History

• (School) Are they happy at school?
• (Home) Who is at home with you? Do you have any other children?
• (Social Services) Do you have any help from health workers or social services?