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Comprehensive Pediatric History Taking for Effective Child Healthcare

This document outlines the essential components involved in gathering a complete pediatric history, crucial for effective child healthcare assessments. Key elements include identifying details about the child and parents, chief complaints, birth history, past medical history, current medications, allergies, feeding practices, developmental milestones, family and social history, and anticipatory guidance. Additionally, a focused review of systems (ROS) is emphasized to identify any significant health issues, ensuring a holistic approach to pediatric care.

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Comprehensive Pediatric History Taking for Effective Child Healthcare

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  1. Pediatric History Brenda Beckett, PA-C

  2. History • Identifying Data • name/parent’s name • date of birth/age • sex/race • Source (parent and/or child) • Reliability • Chief Complaint • main reason for child’s visit • Who has the concern ? • History of Chief Complaint

  3. Birth History • Prenatal • Maternal health, meds, drugs or alcohol use • Natal • Duration of pregnancy, labor and delivery, birth weight • Neonatal • Condition of baby at birth, Apgars 1 & 5 minutes, jaundice, and other issues

  4. Past Medical History • General health • Illnesses/injuries • Hospitalizations • Surgeries • Current medications

  5. PMH, continued • Allergies • Meds and reactions • Eczema, urticaria, perennial allergic rhinitis, asthma, food intolerance, insect hypersensitivity • Immunizations • Type, dates, reactions • Screening Tests • Newborn screening, H/H, lead level, vision, hearing, cholesterol

  6. Feeding History • Breast feedings • frequency and duration, any difficulties • Formula feedings • type, amount, frequency • Solid foods • when and what • Vitamins, iron, fluoride, vitamin D • Older children: present diet, milk intake, vitamins, fluoride

  7. Development • Gross motor - roll over • Fine motor – grasps object • Personal/Social – smile • Language – babble • Cognitive – school grades

  8. Habits and Personality • Relationship with parents/siblings/peers • Discipline problems • Crying • Day and night sleep patterns • Toilet training/continence • Stools and urine • Exercise, “screen” time, interests

  9. Family History • Family History • Include child’s parents, grandparents, siblings • Social History • Current living arrangement • Who lives with child? • Parents divorced • Who cares for child? • daycare • Parents’ occupation/employment

  10. Anticipatory Guidance • Anticipate next step in growth / development • Discuss common issues, concerns, areas for problems

  11. Review of Systems A focused ROS is essential for any identified problem ! High incidence disease/disorder: Vision/hearing Skin Respiratory Gastrointestinal Genitourinary

  12. HPI • History of present illness • Time of onset, initial symptoms, subsequent systems • Feeding difficulties • Refusal of liquids/solids • Sleeping difficulties • Playful/alert or acting sick • Temperature taken at home • Medications/dosage • **What concerns parent the most?

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