Table of Contents
Definitions
- Neonate = <28 days
- Infant = 1-12 months
- Child = 1-12 years
- Adolescent = >12 years
Presenting complaint
- Determine symptoms which brought patient in
History of presenting complaint
- Explore each symptom (including further symptoms you elicit in system reviews)
- Timeframe
- Duration
- Onset (sudden or gradual)
- Progression
- Timing (intermittent or continuous)
- Symptom-specific questions, e.g. SOCRATES for pain (see exploring symptoms)
- Timeframe
- Paediatric systems review (similar to adults but slightly different)
- General: fever, behaviour, activity/apathy/alertness, rashes, growth and weight
- Cardiorespiratory: cough, noisy breathing (stridor, croup, wheeze), dyspnoea, cyanosis
- Gastrointestinal: vomiting, abdominal pain, diarrhoea/constipation
- Genitourinary: wetting nappies/toilet trained, dysuria, frequency
- Neuromuscular: seizures/fits, headaches, abnormal movements
- ENT: sore throat, snoring, noisy breathing, earache
Birth
- Pregnancy: scan results (dating and anomaly; if had extra scans – why?), any problems (e.g. maternal illness/alcohol/drug use)
- Birth history
- Location, mode of delivery, gestation (term = 38-42 weeks) and birth weight (normal = 2.5-4.5kg)
- Birth complications, e.g. resuscitation required, birth injury, maternal/fetal compromise, risk factors for sepsis (group B Streptococcus, maternal fever, prolonged rupture of membranes), any meconium?
- Neonatal problems, e.g. jaundice, fits, fevers, bleeding, feeding problems, admissions to neonatal unit/neonatal ICU
Feeding
- Diet and appetite – ascertain what the child normally feeds and compare against current feeding
- Breast/bottle milk (usually <12 months): type (breast, standard formula, modified formula e.g. hydrolysed, high energy etc.), volume and frequency, feeding difficulties (e.g. latching difficulties, reflux symptoms, SOB)
- Weaning (usually from 6 months): starts with pureed jars, then mashed up food, then solids gradually added
- Solid meals and cow’s milk (usually >12 months)
- Toileting
- Toilet training (between 2-4 years; dry by day at 2 years; dry by night at 3-4 years)
- Frequency: wet nappies? (usually ~5 soaking wet nappies per day and 3 yellow stools)
Growth
- Weights: ask to see The Red Book (personal child health record) – used from birth to 5 years
- Puberty if older child/adolescent (on average, starts at 11 years for girls, 12 years for boys)
Development
- Any concerns
- School progress and attendance
- Developmental screen if <5 years
- Smiling by 6 weeks
- Turns to sounds by 6 months
- Sitting by 9 months
- First words by 18 months
- Walking by 18 months
- Short sentences by 3 years
Normal developmental milestones

Some developmental red flags
- Loss of skills
- Not fixing/following objects
- Hearing loss
- Low muscle tone/floppy
- Can’t hold objects by 5 months
- Can’t sit unsupported by 12 months
- Can’t walk by 18-24 months
- Persistent toe walking
- No speech by 18 months
Past medical history
- Medical problems
- Previous illness, accidents, surgery
- Previous hospital/emergency department visits
Drug history
- Immunisations: up to date? – see schedule below
- Current medication (including creams etc.): include dose, route, compliance
- Relevant recent medication, e.g. course of corticosteroids for asthma
- Allergies: drugs, foods, others
Family history
- Anything relevant to HPC
- Anyone else ill?
- ‘Anything in the family that affects newborn babies or children?’
Social history
- Family unit: parents, siblings, who lives at home – draw family tree of who’s at home
- Does anyone smoke in the family (inside or outside)?
- Housing situation
- Social services involvement (child, parents or siblings) or any other safeguarding concerns
- Playgroup (2-5 years), nursery school (3-4 years) or school (5-16 years) – performing well?
- Other, e.g. hobbies, travel, pets
Ideas, concerns and expectations
- How has the illness affected the family?
- Have the symptoms kept the child from attending nursery/school?
- What are the parents’/child’s concerns, beliefs, hopes etc.?
Immunisation schedule
- 2 months: 6 in 1, rotavirus, meningitis B
- 3 months: 6 in 1, rotavirus, pneumococcal
- 4 months: 6 in 1, meningitis B
- 1 year: MMR, pneumococcal, meningitis B, Haemophilus influenzae type B/meningitis C
- Preschool (3 years 4 months): MMR, 4 in 1 (diphtheria, polio, tetanus, pertussis)
- Girls 12-13 years: HPV (two injections 6-12 months apart)
- Teens: 3 in 1 (diphtheria, tetanus, polio), meningitis ACWY
- 6 in 1: diphtheria, tetanus, polio, pertussis, Haemophilus influenzae type B, hepatitis B MMR = measles, mumps, rubella NB: influenza annual nasal vaccine is also offered to 2-7 year olds