Chapter: Paediatrics: Clinical assessment

Paediatrics: Past health history

On reviewing the child’s past health history there are five areas that should be covered by your questioning.

Past health history

On reviewing the child’s past health history there are five areas that should be covered by your questioning. It is important to consider and record at least those that relate to the current health problem.

Prenatal history

·How many pregnancies has mother had; what were the outcomes

·What was the length of the pregnancy with this child?

·Were there any complications during the pregnancy, such as abnormal bleeding, illness, or infection?

·Did the mother take any medication during pregnancy?

Birth history

· What was this child’s gestation at birth and what was the weight?

· How long was labour?

· Was there maternal fever or premature rupture of membranes?

· Was any intervention required at delivery?

Neonatal period

·Did the child have any neonatal problems, e.g. jaundice, cyanosis, or respiratory distress?

·Was vitamin K given?

·Was the baby treated on the special care baby unit?

·When did the baby and mother go home?

Child development

· When did the baby achieve key developmental milestones, e.g. smiling, rolling over, sitting unaided, standing, speaking, and toileting skills?

· How well has the child grown in weight and length/height?

· Have there been any concerns about development, vision, hearing?

Immunization

What immunizations has the child had? Start from birth and review the date when each was given, as well as what was given. If any immuniza-tions have been missed or omitted, identify any reasons, e.g. was the child unwell?

Past medical history

In this part of the history you will need to find out about past visits to the doctor and any admissions to hospital that the child has had.

· Childhood illness and infections: What infections and illnesses has the child had? Does the child have asthma, diabetes, epilepsy?

· Is the child on any medication? Why? Are there any allergies? Which?

· Surgical procedures and investigations: What, if anything, has been done in the past?

· Is the child seeing another clinician? What for?

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Paediatrics: Clinical assessment : Paediatrics: Past health history |