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Pediatric History: What is the childs gender? What is her/his name? Where and when was she/he born? How old is she/he? What is her/his father's name? What is her/his mother's name? Are they living? Where are they now? What is todays date? What is the source of this history? What are the sources to verify this history? What is the reason for consultation? |
| Pediatric History |
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Pediatric History Prenatal and birth history Developmental history Social history Immunization history Parent history Chief Complaint History of Present Illiness Past Medical History Pregnancy and Birth History Development History Feeding History Review of Systems Family History Social Position of child: parent's lap vs. exam table Weight, height Vital signs Head Eyes Ears Nose Mouth and Throat Neck Lungs/Throax Cardiovascular Abdomen Musculoskeletal Neurologic GU How long has she been sick? What symptoms does she have? What treatments have you already tried? Do they make her better or worse? These are just some of the typical questions a pediatrician will ask when you go in for a visit when your child is sick. If it seems like your pediatrician is playing "20 questions" or is on a fact-finding mission, that is because she is. The answers to these questions, and others, will help your pediatrician figure out what is wrong with your child and what the appropriate treatments will be. Of course the physical exam is important, too, but you would be surprised at how much your pediatrician relies on this history of your child's illness to make a diagnosis. In addition to answering your pediatrician's questions, you should ask your own so that you have a good idea of what is wrong with your child, how you are supposed to treat her and when she should get better. Knowing the answers to the following questions can also help to relieve your anxiety, prevent misunderstandings and avoid missing complications or signs that your child is getting much sicker. What's Wrong? Getting an accurate diagnosis is one of the big reasons that you go to the doctor. Unfortunately, parents often don't have a good understanding of what their child was diagnosed with. What does it mean to have "just a virus," bronchitis, a sinus infection or a "stomach bug"? When your pediatrician says that your child has bronchitis, what he is really saying is "your child has an infection with a virus that is causing her to have a productive cough and she should get better without antibiotics in a few weeks." If you don't understand that, you will likely be surprised when she isn't quickly getting better or why she wasn't prescribed antibiotics. So don't be afraid to ask questions about your child's diagnosis, especially if you aren't sure what the diagnosis means. What Else Could It Be? What Are the Prescribed Treatments? Before leaving your pediatrician's office, you should have a good understanding of how you are supposed to treat your child. This includes knowing the directions for any prescriptions so that you can double check what the pharmacy dispenses to you and hopefully catch any mistakes that might be made. If you aren't given a prescription, you should still ask about symptomatic treatments that may help your child feel better. This might include using an over-the-counter cold medicine, a cool mist humidifier and getting your child to drink lots of fluids when he has an upper respirator tract infection. Are There Any Alternative Treatments? For many childhood conditions, the big "alternative" is going to be simply watching and waiting to see if your child gets better on her own. So if your child has a green runny nose for two weeks and is prescribed an antibiotic for a sinus infection, one alternative would be to wait a few more days to see if she starts getting better on her own. Of course if your child has a more serious illness or more severe symptoms, your pediatrician may say that waiting isn't a good idea and that you should start the prescribed treatments right away. Asking about alternative treatments can also be helpful if you aren't happy or comfortable with what your pediatrician has prescribed for your child. There is almost always more than one way to treat a child, so don't feel bad asking about alternatives. When Should You Expect Her to Be Better? This is probably the most important question to ask, both so that you don't miss signs that your child is getting worse and so that you don't rush back to the pediatrician too soon. For example, if your child is diagnosed with a cold or the flu, you shouldn't be surprised that she isn't getting better or is getting worse during the next few days. On the other hand, after getting diagnosed with an ear infection or strep throat, you should expect quick improvement during the next few days and may need to call your pediatrician if she isn't. As important parts of this question, you should also ask about what you should do if she isn't getting better at the expected time and what signs to look for that may mean that she is really getting worse. What Could Have Prevented This? In many cases, there is nothing that could have prevented your child from getting sick, especially if they caught a "bug" at school or daycare. But sometimes there are things you can do to keep your kids well, so don't be hesitant to ask. For example, for kids who get a lot of ear infections, it can help if you don't give your child bottles while he is lying down, don't let him fall asleep with a pacifier and for family members to stop smoking. Do You Need to Come Back for a Recheck? Parents, especially if they have to miss work or pull their kids out of school, often underestimate the importance of rechecks. After all, why should you go to the doctor if your child isn't sick anymore? A recheck appointment is very important, though, both to make sure that your child really is doing well and to prevent further problems. Rechecks are especially important if your child has a chronic condition, like asthma, allergies, constipation or any other condition for which your child takes medicine on a daily basis. Getting Your Answers Getting answers to all of these questions is important for parents, but your pediatrician will likely be happy, too, if you have a better understanding of all of these things. If you don't have these answers, you will probably call and ask for them later, be unhappy with your visit or end up back in the office or in the ER unnecessarily. So don't be afraid to ask questions when your see your pediatrician. Remember that you both have the same goal â to help your child get better and to keep him safe and healthy. OUTLINE FOR PEDIATRIC HISTORY AND PHYSICAL EXAMINATION HISTORY I. Presenting Complaint (Informant/Reliability of informant) Patient's or parent's own brief account of the complaint and its duration. Use the words of the informant whenever possible. II. Patient Profile A good patient profile will eliminate the need for a social history. It should include information relative to the child's living conditions, what the family unit is like, where the patient fits into this unit, background and education of parents, father's work or lack of such, how child spends an average day (plays in house, plays outside with many friends, etc.). In the school age child, information should be checked relative to his functioning in school, and the presence of specific learning or behavior problems. The family's socio-economic situation should be asked about as well as medical insurance. This paragraph is most useful for paramedical personnel as it gives them a summary of the "whole" child. III. Present Illness Begin with statement that includes age, sex, color and duration of illness, ex.: This is the first UMC admission for this 8 year old white male who has complained of headache for 12 hours TPA. When was the patient last entirely well? How and when did the disturbance start? Health immediately before the illness. Progress of disease; order and date of onset of new symptoms. Specific symptoms and physical signs that may have developed. Pertinent negative data obtained by direct questioning. Aggravating and alleviating factors. Significant medical attention and medications given and over what period. In acute infections, statement of type and degree of exposure and interval since exposure. For the well child, determine factors of significance and general condition since last visit. IV. Past Medical History A. Antenatal: Health of mother during pregnancy. Medical supervision, drugs, diet, infections such as rubella, etc., other illnesses, vomiting, toxemia, other complications; Rh typing and serology, pelvimetry, medications, x-ray procedure, maternal bleeding, mother's previous pregnancy history. B. Natal: Duration of pregnancy, birth weight, kind and duration of labor, type of delivery, presentation, sedation and anesthesia (if known), state of infant at birth, resuscitation required, onset of respiration, first cry. C. Neonatal: APGAR score; color, cyanosis, pallor, jaundice, cry, twitchings, excessive mucus, paralysis, convulsions, fever, hemorrhage, congenital abnormalities, birth injury. Difficulty in sucking, rashes, excessive weight loss, feeding difficulties. You might discover a problem area by asking if baby went home from hospital with his mother. D. Growth and Development: 1. Mother and Mental Development a. First raised head, rolled over, sat alone, pulled up, walked with help, walked alone, talked (meaningful words; sentences), DDST when appropriate. b. Urinary continence during night; during day. c. Control of feces. d. Comparison of development with that of siblings and parents. e. School grade, quality of work. E. Nutrition 1. Breast or Formula: Type, duration, major formula changes, time of weaning, difficulties. Be specific about how much milk or formula the baby receives. 2. Vitamin Supplements: Type, when started, amount, duration. 3. "Solid" Foods: When introduced, how taken, types. 4. Appetite: Food likes and dislikes, idiosyncrasies or allergies, reaction of child to eating. An idea of child's usual daily intake is important. F. Past Illnesses - A comment should first be made relative to the child's previous general health, then the specific areas listed below should be explored. 1. Infections: Age, types, number, severity. 2. Contagious Diseases: Age, complications following measles, rubella, chickenpox, mumps, pertussis, diphtheria, scarlet fever. 3. Past Hospitalizations: including operations, age. 4. Allergies, with specific attention to drug allergies - detail type of reaction. 5. Medications patient is currently taking. G. Immunizations and Tests - Be familiar with departmental recommendations for immunizations. List date and type of immunization as well as any complications or reactions. H. Accidents and Injuries (include ingestions): Nature, severity, sequelae. I. Behavioral History 1. Does child manifest any unusual behavior such as thumb sucking, excessive masturbation, severe and frequent temper tantrums, negativism, etc.? 2. Sleep disturbances. 3. Phobias. 4. Pica (ingestions of substances other than food). 5. Abnormal bowel habits, ex. - stool holding. 6. Bed wetting (applicable only to child out of diapers). V. Family History - use family tree whenever possible A. Father and mother (age and condition of health). What sort of people do the parents characterize themselves as being? B. Marital relationships. Little information should be sought at first interview; most information will be obtained indirectly. C. Siblings. Age, condition of health, significant previous illnesses and problems. D. Stillbirths, miscarriages, abortions; age at death and cause of death of immediate members of family. E. Tuberculosis, allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular diseases, kidney disease, rheumatic fever, neoplastic diseases, congenital abnormalities, cancer, convulsive disorders, others. F. Health of contacts. VI. Social History VII. Environmental History VIII. System Review A system review will serve several purposes. It will often bring out symptoms or signs missed in collection of data about the present illness. It might direct the interviewer into questioning about other systems that have some indirect bearing on the present illness (ex. - eczema in a child with asthma). Finally, it serves as a screening device for uncovering symptoms, past or present, which were omitted in the earlier part of the interview. There is no need to repeat previously recorded information in writing a Review of Systems. A. Skin: Ask about rashes, hives, problems with hair, skin texture or color, etc. B. Eyes: Have the child's eyes ever been crossed? Any foreign body or infection, glasses for any reason. C. Ears, Nose and Throat: Frequent colds, sore throat, sneezing, stuffy nose, discharge, post-nasal drip, mouth breathing, snoring, otitis, hearing, adenitis. D. Teeth: Age of eruption of deciduous and permanent; number at one year; comparison with siblings. E. Cardiorespiratory: Frequency and nature of disturbances. Dyspnea, chest pain, cough, sputum, wheeze, expectoration, cyanosis, edema, syncope, tachycardia. F. Gastrointestinal: Vomiting, diarrhea, constipation, type of stools, abdominal pain or discomfort, jaundice. G. Genitourinary: Enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of stream, vaginal discharge, menstrual history, bladder control, abnormalities of penis or testes. H. Neuromuscular: Headache, nervousness, dizziness, tingling, convulsions, habit spasms, ataxia, muscle or joint pains, postural deformities, exercise tolerance, gait. I. Endocrine: Disturbances of growth, excessive fluid intake, polyphagia, goiter, thyroid disease. J. Special senses. K. General: Unusual weight gain or loss, fatigue, temperature sensitivity, mentality. Pattern of growth (record previous heights and weights on appropriate graphs). Time and pattern of pubescence. http://www.peds.arizona.edu/medstudents/PedsHistoryandPhysicalExam.asp |