Pediatric History

Pediatric Medical History and Examination

Identifying Data

Chief Complaint "what is the reason you have brought X here?"

History of Present Illness OPPQRS...but also ask specifically:

"when was the child last well? any similar problems in siblings, relatives, daycare?

any family concerns? management of the problem?

Past Medical History - HITS

"what illnesses has the child had in the past?"

Family History

- looking for any genetic, inherited diseases

- parents, consanguinity, siblings (there ages, health, illnesses)

Allergies and Medications - important to ask about family history of allergies, foods, pets, and environmental allergies

Social History

- parents occupation and employment history (absences)

- home environment

- child's interests and activities

Adolescent History

HEADSS

H - home environment - family issues, problems, siblings, relationships, arguments

E - education - school attendance, courses, abilites, suspensions

A - activities - "what do you do after school?"

D - drugs

S - sexuality

S - suicide

REVIEW of SYSTEMS

IMMUNIZATIONS

(always ask about!!!)

Growth

Developmental Milestones, such as Gross and Fine Motor, Social and Language

Can you keep up with your peers                               

Siblings Health     

Irritability

Temperment  

Otalgia, Otorrhea

Enuresis

Rashes 

Seizures