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History taking in Pediatrics

Basic elements of a paediatric history:
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Demographic information
Presenting complaint(s)
History of the presenting complaints
Systematic enquiry
Past medical history
Perinatal history:
a. Mothers pregnancy history
b. Birth details
Early neonatal history
Feeding and diet history
Immunization history
a. Inspect the RTHC
Growth and development
Drug history
Family and social history

Remember to introduce yourselves, state your

position and be polite at all times.
Demographic information relates to the childs age,
gender, where theyre from and which health
institution they were referred from.
Its important also to find out who the person with the
child is, i.e. is it the childs mother, aunt, granny,
father or uncle. This will influence the quality of the
information you receive and might also give you an
insight already into the childs social circumstances.

The presenting complaint(s)

Let the parent tell you this in their own words. If its
an older child, its also useful to ask them directly. Not what the doctor who sent them or the
sisters at the clinic said is wrong with the child.
It might be useful to ask What made you take the child to the doctor, clinic, hospital? what
worried you a lot?
List the complaints as they are related to you.
History of the presenting complaint(s)
Go into specific detail about each of the complaints presented to you
Onset of the complaint/ circumstances in which it happened
Duration/progression
Specific nature e.g. Pain (type sharp vs dull etc, vomiting, full description projectile or not, colour
of vomit, when it happens etc.
Factors that ameliorate or aggravate the complaints
Other related symptoms
Systematic enquiry
Ask about symptoms relating to involvement of each system, other than the one primarily involved.
A set of standard questions
Past medical history
Details of past hospitalizations
Previous illnesses necessitating clinic/general practitioner visits.
Parents may not recall exact details; ask if they were given a discharge summary.
Perinatal history
Did mum attend antenatal clinic? Health during pregnancy did the nurses/ doctors say they were
worried about anything? Did she have to be treated for something?
In this day and age, important to ask about testing for HIV (as sensitively as possible)
Birth: where, how, why? What happened to baby immediately after birth?
First seven days of life
Feeding and diet
Early, breast, formula why?
Introduction of solids
Current diet, childs appetite
Immunizations:
Check the RTHC
Any problems? E.g. rash, swelling, protracted crying?
Growth and development
Check the RTHC

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In comparison with other children, achievement of milestones
Drug history
Prescribed medication, allergies?
Over the counter (OTC) meds, herbal remedies (be sensitive and non-judgmental
Family and social history
Pedigree chart
Ask about children that demised if applicable
Family history of specific illnesses e.g. TB, heart disease, diabetes
Environmental circumstances the child lives in: access to clean water, sanitation, housing
structure
Nearest local healthcare centre
Home circumstances (parents employed? Living together? is child in receipt of child support
grant?