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The Chief Complaint and the History of Present Illness are the two most important steps in the diagnostic process.

The other parts of a complete Clinical History are:

Past History, Family History, Social History, Immunization, Environmental, Developmental, and Allergy History.

The Past History is important in chronic conditions and other illeness like seizure disorder, fainting spells, failure to thrive, constipation, recurrent belly pain, ear infections, sleep problem, etc.

The family history is helpful sometimes in illnesses like asthma, migraine, failure to thrive, ADHD, cystic fibrosis, short stature, familial cancers, etc.

The Social History is important in behavioral problems, ADHD, depression, child abuse, school failure, etc.

Environmental History is helpful in asthma, allergy, lead poisoning, diarrhea, etc.

Developmental history contributes in children who are delayed in motor and language development.

The allergy history is very important in the decision making on what antibiotics or other medications to give.

Your clinician will ask you questions that is pertinent to the Chief Complaint and History of Present illness that will narrow down his or her list of differential diagnosis.

Tomorrow 4 August, Example of a Clinical History

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Leo Leonidas, MD, FAAP

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