Pediatric Medical History

Main Complaint

A brief statement by the caregiver or parent describing the reason for seeking medical attention. Try to document this in their own words.

• Let them talk initially without interruption; then clarify details.
• Elicit all relevant symptoms (respiratory, GI, neuro, urinary, systemic).
• Be aware that caregivers are not clinicians – you may need to “translate” their observations into medical terms.
• Always ask about the context of the illness or injury (where, when, who was present).
• For injuries, clarify:
  • Exact mechanism (fall from what height? onto what surface? vehicle speed?).
  • Witnesses and any delay in presentation.

History of Present Illness

Structured description of the current problem. Think in terms of onset, course, and impact.

• Onset
  • When did the problem start? Sudden or gradual?
  • First episode or recurrent? If recurrent, is this episode similar or different?
• Duration
  • How long have the symptoms been present?
  • If > 24 hours, what has changed to prompt seeking help now?
• Severity
  • Use age-appropriate scales (e.g. Wong-Baker, FLACC) for pain where possible.
  • Ask how the symptoms affect feeding, play, sleep, school, and activity.
• Character and Associated Symptoms
  • Explore site, radiation, character of pain, presence of fever, vomiting, cough, diarrhoea, rash, seizures, etc.
• Aggravating / Relieving Factors
  • What makes it better or worse (position, medications, feeds, exertion)?
• Treatments Already Given
  • Any medication given at home or at a clinic (dose, timing, response)?

Past Medical & Co-Morbid History

Summarise previous illnesses, chronic conditions, surgeries and hospitalisations. This strongly influences triage and risk in the ED.

• Prematurity, NICU stay, congenital anomalies.
• Chronic conditions (asthma, epilepsy, cardiac disease, HIV, TB, renal, endocrine, neuromuscular).
• Previous ICU admissions, intubation or major infections.
• Previous surgeries (especially cardiac, neuro, abdominal, orthopaedic).

For a structured approach to common paediatric co-morbidities, see the Co-Morbid Conditions Guide.

Medications

Document all current and recent medications, including non-prescription items.

• Prescribed drugs (names, doses, frequency, route).
• Inhalers, nebulisers, supplements, traditional/herbal medicines.
• Recently stopped medications and reasons (side effects, cost, non-compliance).

Hint: If caregivers bring medications or a prescription, thank them – it builds rapport and helps avoid errors.

Allergies

Always ask specifically about allergies.

• Medications (especially antibiotics, contrast, anaesthetics).
• Foods (e.g. peanuts, eggs, cow’s milk, shellfish).
• Other: latex, insect stings, environmental triggers.
• Clarify the reaction (rash, anaphylaxis, vomiting, “just nausea”, etc.).

Family History

Identify inherited or familial illness that may affect the child’s risk.

• Chronic conditions: asthma, epilepsy, diabetes, hypertension, TB, HIV, heart disease.
• Genetic or metabolic conditions, sudden unexplained deaths, early-onset cardiac disease.
• Bleeding disorders, clotting disorders, autoimmune disease.

Social History

Understand the child’s environment and supports.

• Who lives at home with the child? Primary caregiver?
• Exposure to tobacco smoke, alcohol or substance use in the home.
• School/crèche attendance, recent absences, bullying or stressors.
• Housing, overcrowding, access to transport and health care.

Events Preceding Illness or Injury

Crucial for trauma and cases where non-accidental injury is a concern.

• Exact sequence of events, including who was present and any delays in seeking care.
• Consistency of the story between different caregivers.
• Red flags for abuse: changing stories, mechanism inconsistent with injury, recurrent injuries.

Child’s Last Meal

Particularly important if sedation, anaesthesia or urgent procedures may be required.

• Time and type of last oral intake (solids vs liquids).
• Any vomiting or aspiration risk since last meal.

It is impossible to cover all the intricacies of paediatric history taking on a single page, and you should use this as a basic structure. Build on it with your clinical texts, protocols, and advice from seniors.