Paediatric history
Presenting Complaint: 3 year old girl with a sore throat
History of Presenting Complaint: Been present for 3 days, not getting any better, child has also been unwell. No earache, no nausea.
Past Medical History: One case of tonsillitis last year, no other relevant history.
Perinatal History: No problems during pregnancy, birth was normal vaginal delivery and a short episode of neonatal jaundice.
Developmental History: No developmental delays. Child is playing with other children happily, and talks in short sentences.
Family History: Mother has tonsillectomy as a child.
Social History: Lives with mother. No brothers and sisters.
Drug History: No medication.
Immunisations: Up to date.
On Examination: Throat was reddened, with a white exudate on the tonsils. Both ear canals were clear. She has a temperature of 37.0°C. No other signs.
The paediatric history is a normal history, with some nice additions. Follow it below, or see an example on the right:
Presenting Complaint
As in a normal history, what's wrong with them. See here.
History of Presenting Complaint
How long they've had it, what makes it worse, better, etc. See here.
Past Medical History
Check to see if they've had it before, or anything similar (ie. with sore throat, ask about ear ache; diarrhoea, ask about constipation). See here.
Perinatal History
This is the very start of their life. Obviously, more important in a 2 week old than a 10 year old, but always important to ask in exams! This is split into three main sections: prenatal, perinatal and neonatal:
Pre natal This is everything before birth, so from the time of conception, all through the pregnancy. Especially focus on things like maternal infections and if mum smoked, etc. Perinatal How was the birth? Was the patient born early/late. Was it a normal delivery, and were there any complications? Neonatal How was the patient as a baby, especially the first month or so. Was the patient discharged quickly from the hospital, or was there any jaundice, or later hospitalisations?
Family History
As in a normal family history, but do check to see if there was a similar episode presentation in childhood in siblings or parents. See here.
Developmental History
This is important to ascertain if there is any developmental delay. Simply take the child's age, and check they are currently achieving relevant developmental targets. Usually you can get away with saying are they walking, talking, playing appropriately, and the parent will know if there's a problem and tell you.
After about 4 years old, pretty much just check they are getting on at school, reacting well with other kids.
Social History
If they are having any problems socially, it is very important to check all this stuff. It's also good to ask things like "Does Dad smoke?" if you are getting asthma problems, etc. For advice on a normal social history, see here.
Drug History
In the drug history, make sure you ask them what inhalers are used, as often these aren't thought of as medications. For more on this, see here.
Immunisations
You should visit the immunisations page. It is important to ask about these for two reasons:
- 1. To check if a missed immunisation fits their illness.
- 2. To nag them to get the immunisations.
On Examination
Learn how to do a paediatric examination or a neonatal examination. Have fun!