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While a clinician is asking questions, he or she is also watching how your child is interacting with you and the environment. Even without touching or listening to your child, a clinician is doing a “physical examination” at the same time. It is this general assessment of your child plus the “severity” of the Present Illness history that help a clinician to either put your child in the hospital or observe at home.

The Clinical History, usually the Present Illness, provide about 85% of the Clinical Diagnosis. For this reason, I think most parents can help in the diagnostic process.

If you know how to give a good Clinical History, a clinician will have an easier time of figuring out the problem of your child.

So let me tell you how to give a good Present Illness history. Suppose your child has a fever, you can tell your story like this: “Johnny has been having fever for 3 days. The fever is between 101 to 103 Fahrenheit taken under the arm. There is no vomiting, diarrhea, cough, runny nose, rashes, or red eyes. I have given Tylenol about 4 times a day. He is drinking OK and his urination is normal. When the fever is down, he is playing with his sister.”

If you have a computer, it would help to type and print the Chief Complaint and Present Illness so you won’t forget the details. Your clinician will appreciate this.

Suppose Johnny, 4 years old, is vomiting. This is a good Present Illness script format: “Johnny has been vomiting for two day. He has been vomiting three times a day. The vomitus is whitish yellow and no blood. There is no fever, diarrhea, rashes, headache, cough, or runny nose. He complained of belly pain yesterday, but today he seems fine. He is drinking fine and his urination is normal. He is playing with his sister today. He has not eaten any new food and he is not on any medications.”

When giving a History of Present Illness, always include the duration of the symptom (number of days or weeks), number of times the symptom is occurring (e.g. diarrhea is 4 times a day; vomiting is two times a day), any associated symptoms (fever, cough, runny nose, headache, rashes, back pain, etc.)

It is a good idea to offer your opinion as to why you think the child is having the Chief Complaint or why the child has the symptom.

Continued Tomorrow, 3 August

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Leo Leonidas, MD, FAAP

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