Educational Pediatric Case History: Outline, Example, and Generator

Pediatric Educational Case History Outline

Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.

1. 1
   General patient data

   Child's age (years/months), gender, childcare/school attendance, admission date, department, referring provider, and referral diagnosis. Parental information: age and occupation only. No full names or addresses.

2. 2
   Complaints

   Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.

3. 3
   History of the present illness (Anamnesis morbi)

   Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.

4. 4
   Child's Life History (Anamnesis vitae)
5. Antenatal and intranatal period

   Obstetric history (gravida/para), course of pregnancy (gestational toxicosis, threatened miscarriage, maternal illnesses and medications), gestational age at birth and delivery course, Apgar score, birth weight, and length.

6. Neonatal period

   Time of first breastfeeding, umbilical cord separation, neonatal jaundice, physiological weight loss, hospital discharge date, BCG and hepatitis B vaccination in the maternity hospital.

7. Feeding history

   Type and duration of feeding, formula types, introduction of complementary foods, current diet.

8. Physical and neurodevelopment

   Weight and height gain, timing of dentition, age-appropriate motor and speech milestones, academic performance.

9. Preventive vaccinations

   Adherence to the National Immunization Schedule, missed vaccinations, medical exemptions, and post-vaccination reactions.

10. Past medical history, surgeries, injuries

    Past illnesses (ARVI: frequency, childhood infections), surgeries, injuries, and blood transfusions.

11. Allergic history

    Drug, food, and household allergen intolerance; type of reaction.

12. Epidemiological history

    Contact with infectious patients, travel outside the region/country over the past 6 months, parenteral interventions, bites, dietary history, contact with animals.

13. Social and living conditions and heredity

    Family composition, housing conditions, care; diseases of parents and relatives; parents' bad habits.

14. 5
    Objective examination (Status praesens objectivus)
15. General physical examination

    General condition, well-being, level of consciousness, posture; skin, mucous membranes, subcutaneous fat, lymph nodes, muscles, skeletal system, anterior fontanelle (in children under 2 years of age).

16. Respiratory system

    Chest inspection, respiratory rate, palpation (resistance, vocal fremitus), comparative and topographical percussion, auscultation (breath sounds, rales, crepitation, pleural friction rub), bronchophony, SpO2.

17. Cardiovascular system

    Inspection of the heart and neck vessels, apex beat, boundaries of relative cardiac dullness, auscultation (heart sounds, murmurs), pulse (rate, rhythm, volume, tension), blood pressure on both arms, peripheral arterial pulsation.

18. Digestive system

    Oral cavity, tongue, abdomen (inspection, superficial and deep palpation according to Obraztsov-Strazhesko, percussion, auscultation), liver dimensions according to Kurlov, gallbladder (symptoms), spleen, stool.

19. Urinary system

    Lumbar region inspection, kidney palpation, tapping sign (Pasternatsky's sign), urination, diuresis.

20. Endocrine system

    Thyroid gland (palpation, eye signs), subcutaneous fat distribution, secondary sexual characteristics.

21. Nervous system and sense organs

    Consciousness, orientation, sleep, memory, meningeal signs, focal symptoms, reflexes, vision, hearing.

22. 6
    Preliminary diagnosis and its rationale

    Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.

23. 7
    Examination plan

    Laboratory and instrumental studies and consultations with the purpose of each: according to clinical guidelines of the Russian Ministry of Health (mandatory and as indicated).

24. 8
    Results of laboratory and instrumental studies

    All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".

25. 9
    Differential diagnosis

    At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).

26. 10
    Clinical diagnosis and its rationale

    Formulation according to the classification from clinical guidelines and ICD-10 (code): underlying disease, complications of the underlying disease, comorbid conditions; rationale for each component.

27. 11
    Etiology and pathogenesis

    Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).

28. 12
    Treatment and its rationale

    Regimen, diet, non-pharmacological treatment, drug therapy: drug (INN), dose, route, frequency, duration, and rationale with reference to clinical guidelines; At the end: prescriptions in Latin (Rp.: … D. S. …) for 2–3 main drugs. Doses: per kg of the child's body weight.

29. 13
    Observation notes

    prescriptions).

30. 14
    Stage (discharge) epicrisis

    Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.

31. 15
    Prognosis and recommendations

    Prognosis for life, for recovery, for working capacity (with justification); discharge recommendations and follow-up care according to clinical guidelines.

32. 16
    References

    formatted according to GOST R 7.0.100-2018.

Pediatric medical history format: how it differs from the adult version

The framework is familiar: demographic data, complaints, history of present illness, history of life, objective examination, preliminary diagnosis, diagnostic plan, clinical diagnosis, treatment, daily progress notes, and epicrisis. However, in pediatrics, the instructor evaluates not just the disease, but the child as a whole: how they grew and developed, past illnesses, vaccination status, and whether their metrics correspond to their age.

Child's history of life

The most extensive section, which is checked the most rigorously. For an infant or young child, the following order is convenient:

• Antenatal period: pregnancy and delivery number, how the pregnancy proceeded (toxicosis, threat of termination, infections, anemia), mother's age and health.
• Delivery and neonatal period: gestational age, mode of delivery, birth weight and length, Apgar score, when placed to the breast, day of discharge, and discharge weight.
• Feeding: breastfeeding, mixed, or formula feeding; age at introduction of complementary foods and what was introduced.
• Neuropsychological development: when the child began holding the head up, sitting, walking, saying first words; for a school-aged child, academic performance, daily routine, and workload are assessed instead.
• Vaccinations: checked against the National Schedule of Preventive Vaccinations (Order of the Russian Ministry of Health No. 1122n dated 06.12.2021); deviations from the schedule and medical exemptions are recorded with reasons.
• Past illnesses, allergic history, family history, social and living conditions.

Physical development and age-related norms

Height and body weight are assessed using centile charts or curves (WHO standards are used most frequently): for each parameter, the centile corridor is indicated, and a conclusion is drawn regarding the level and harmoniousness of development. Development is considered harmonious if the corridor numbers differ by no more than one. Respiratory rate, pulse, and blood pressure are compared against age-related norms rather than adult ones: 28 breaths per minute in a 4-year-old child is within the normal range, whereas in an adolescent it would already be tachypnea.

Objective status and treatment

For an infant, the physical examination additionally includes the anterior fontanelle (size, tension, level relative to the cranial bones) and assessment of age-appropriate primitive reflexes. Treatment in a pediatric case history always involves calculation: dose per kilogram of body weight, single and daily dose, frequency, route of administration, and verification against the maximum dose. Drugs with age restrictions must not be present in the prescription sheet; for example, acetylsalicylic acid is not prescribed to children as an antipyretic. The severity of the condition and respiratory failure are conveniently supported by scales from the clinical scales section.

Example of a pediatric medical history: pneumonia in a 4-year-old child

Below are fragments of a model case history. The patient is fictional, and the data are for educational purposes.

Physical development

Patient N., a boy aged 4 years and 2 months. Height 104 cm (4th centile corridor), body weight 17 kg (4th corridor). Physical development is average and harmonious.

Justification of the preliminary diagnosis

The preliminary diagnosis of "community-acquired pneumonia" is established based on:

• complaints of temperature elevation up to 38.9 °C for 3 days, moist cough, lethargy, decreased appetite;
• history: fell ill acutely at home, has not been treated in a hospital in preceding months, received no antibiotics;
• objective findings: respiratory rate 44 breaths per minute (above the tachypnea threshold of 40 per minute for children aged 1-5 years), SpO2 96% on room air, dullness to percussion on the right below the scapular angle, diminished breath sounds and fine moist rales in the same area;
• syndromes: intoxication syndrome and the syndrome of local pulmonary tissue consolidation in the lower parts of the right lung.

The diagnosis is definitively confirmed by radiography: without an infiltrate on the image, pneumonia remains a preliminary diagnosis.

Examination plan

1. Complete blood count with differential leukocyte count.
2. C-reactive protein.
3. Chest radiography in anteroposterior projection.
4. Dynamic pulse oximetry.
5. Urinalysis.

Clinical Diagnosis

Main disease: Right-sided lower lobe community-acquired pneumonia, non-severe (J18.9). No respiratory failure.

Code J18.9 is assigned when the causative agent is not identified; if confirmed, the code is specified (e.g., J13 for pneumococcal pneumonia).

How to show dose calculation

Antipyretic for temperature above 39 °C or pronounced discomfort: paracetamol 15 mg/kg per dose. For a body weight of 17 kg: 15 × 17 = 255 mg per dose, interval at least 4-6 hours, maximum 60 mg/kg per day (1020 mg). Starting antibiotic for non-severe pneumonia in a child without risk factors: oral amoxicillin; take the dose in mg/kg/day, number of doses, and course duration from the current version of the clinical guidelines for "Pneumonia (community-acquired)" in children and present the calculation step by step. Doses and formulations can be verified in the clinical guidelines section.

Common mistakes in pediatric medical histories

• The history of life is written like an adult's: no information about pregnancy, delivery, Apgar score, feeding, and development.
• Vaccinations are recorded with the words "age-appropriate" without checking against the schedule and without reasons for exemptions.
• Physical development is not assessed using centiles, or height and weight are stated without a conclusion regarding harmoniousness.
• Respiratory rate, pulse, and blood pressure are compared against adult norms.
• Doses are indicated "in tablets" or as adult doses, without calculation per kilogram, without single and daily doses, and without verification against the maximums.
• Prescriptions include drugs with age restrictions, such as acetylsalicylic acid as an antipyretic.
• The clinical diagnosis lacks localization, severity, and complications; pneumonia is diagnosed without radiological confirmation.
• Daily progress notes are identical day after day: no dynamics of temperature, respiratory rate, SpO2, and appetite.
• The demographic section contains the child's real full name, date of birth, and address. This constitutes medical confidentiality (Article 13 of Federal Law No. 323-FZ) and personal data (Federal Law No. 152-FZ): write the initials and age instead.

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