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.
- 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?
- 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?
- 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?
- 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?
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 immunizations have been missed or omitted, identify any reasons, e.g. was the child unwell?
Past medical history
In this part of 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 thechild 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 donein the past?
- Is the child seeing another clinician? What for?