History Station

Framework

Demographics (Name, Age, Gender, Nationality, Martial, Residency)
Chief of complaint (Cause of hospitalization + days)
HOPI (OPERATES NON PAIN | SOCRATES PAIN)
B-Symptoms
Systemic Review - Inquiry

Journey 6. Neonatal, Nutritional, Immunization, Developmental History 7. Family & Social History 8. Past history (medical, surgical, medication, transfusion, drug, allergies, family, social)

Diagnosis / Management 9. summary 10. differential + justify differential 11. investigations - appropriate 12. treatment - suggestive

Introduction

Framework (12 Steps)

Step	Component	Details
1	Demographics	Name, Age, Gender, Nationality, Marital, Residency
2	Chief Complaint	Parent/child words + duration
3	HOPI	OPERATES (non-pain) / SOCRATES (pain)
4	B-Symptoms	Fever, night sweats, weight loss
5	Systemic Review	Full body systems inquiry
6	Journey	Neonatal, Nutritional, Developmental, Immunization
7	Family & Social History
8	Past History Z	Medical, surgical, medication, transfusion, allergies
9	Summary
10	Differential + Justification
11	Investigations	Appropriate tests
12	Treatment	Suggestive management

1. Personal Data / Demographics

Age, Sex, Residency/Address, Nationality
Source of history/informant + reliability: (mother, father, brother)

2. Chief Complaint

In parent/child words - open question

Format: Duration + Symptom
Example: “5D Abdominal pain, fever”

3. HOPI (History of Presenting Illness)

Mnemonics

Mnemonic	Elements
SOCRATES (Pain)	Site, Onset, Character, Radiation, Associations, Time course, Exacerbating, Severity
OPERATES (Non-pain)	Onset, Provoking/Palliating, Region, Exercise tolerance, Associated symptoms, Timing, Exacerbating/Relieving, Severity

Key Questions

Onset - Course - Duration - Site - Frequency - Severity
Relieving factors - Exacerbating factors
Diurnal or seasonal variation
Relation to food - Relation to exercise
School missing related to the complaint
Any associated symptoms

Contextual Questions

Is this disease endemic?
Is there anyone in family with chronic cough?
Occupation of family?

4. B-Symptoms

Fever
Night sweats
Weight loss

5. Systemic Review

Category	Symptoms
General	Feeding and appetite (very important), Irritability, Weight loss
Cardiovascular	Breathlessness, Sweaty on feeding, Cyanosis
Respiratory	Breathlessness, Runny nose, Cough, Noisy breathing (wheeze/stridor), Sore throat/earache, Hemoptysis
Gastrointestinal	Vomiting, Abdominal pain, Constipation/diarrhea (frequency/stool appearance), Jaundice
Genitourinary	Frequency, Dysuria, Nocturia/enuresis, Hematuria, Incontinence, Age of menarche
Neurological	Irritability, Drowsiness, Fits/abnormal movements, Headaches, Numbness, Weakness
Hematological & Oncological	Pallor, Jaundice, Bone pain, Bruises, Epistaxis
Infections	Skin rash, Contact with infectious patients, Recent travel
Musculoskeletal & Skin	Joint swelling, Joint pain, Skin rash
B-symptoms	Fever, night sweats, weight loss

6. Journey

A. Medical History (Past History) Z

B. Natal History

Antenatal

Antenatal care: booked/un-booked? Where? Frequency of visits?

Parameter	Details to Ask
Exposures	Drugs, toxins, infections; maternal diabetes; acute maternal illness; trauma; radiation; fetal movements
Medications	Timing, dose, duration
Maternal conditions	Thyroid disorder, seizure disorder
Fluid status	Polyhydramnios/Oligohydramnios
Maternal health	Severe proteinuria, high blood pressure
Third trimester	Bleeding
Pregnancy	Multiple gestation, chorioamnionitis
Parity	Primi or no abortion
Blood work	Maternal blood group/RH status
Infections	Maternal illnesses (TORCH, HTN, DM)
Screening	Antenatal screening (HAVsAg, blood group)

Perinatal

Period: 22 completed weeks gestation → 7 completed days after birth

Parameter	Details
Place of delivery
Presentation	Crying immediately? Breech/face presentation?
Mode	NSVD, assisted vaginal, C/S (reason?)
Cord	Delayed cord clamping (possible polycythemia)
Gestational age
Birth measurements	Weight, Length, Head circumference
Resuscitation
Apgar Score	Or condition at birth (mother’s words)
Maternal sepsis risk	PROM, maternal UTI, maternal fever
Blood groups	Baby & mother’s
Complications	Oxygenation, intubation, NICU admission

Neonatal

When did baby pass urine/meconium?
Respiratory distress, anemia, jaundice, cyanosis, convulsions, infection, congenital anomalies

If admitted:

Length of hospital stay
Complications (intubation time, ICH on U/S, feeding difficulties, apnea, bradycardia)

Postnatal

Admission to neonatal unit? Duration? Drugs given? (If yes → take full history)
Screening tests (hypothyroidism) - transcutaneous?

C. Nutritional History

Question	Details
Feeding type	Breast-fed or Bottle-fed? Duration?
If Bottle-fed:
Formula type	Which formula received?
Preparation	How prepared?
Volume	Volume per feed?
Duration	How long took to feed?
Frequency	Frequency of feeds
Total intake	Daily total
Weaning	Time of weaning
Solids	Timing of introduction of solids and cereals

Note: Breast-fed babies may pass up to 6 motions daily.

D. Developmental History

Domain	Assessment
Gross Motor
Fine Motor
Visual
Speech and Hearing
Social and Play
Schooling	Level and Performance

Compare with siblings if available
Reference developmental milestones (described elsewhere)

E. Immunization History

Check immunization card
Recommended vaccinations in Saudi Arabia (described elsewhere)
Any missed vaccines? Reasons?
Any vaccine side effects?

Category	Details
Parents	Ages
Consanguinity
Siblings	Number, age range (any from previous/another marriage)
Similar conditions	Family history
Origin	Region parents came from (e.g., sickle cell in SW/Eastern KSA)
Neonatal deaths	Consider metabolic disease
Previous abortions
Housing
Type	Rented/owned, house/flat
Bedrooms	Number
Facilities	Washing and toilet
Climate control	Air conditioning and heaters
Parents’ details
Occupation
Income	Family income
Education
Smoking	Especially important in bronchial asthma
Exposures
Animals	Contact
Travel	Recent (e.g., malaria in SW KSA)

8. Closing the Consultation

Golden Rule

“Is there anything else you would like to tell me, or any other questions you expect me to ask about your child?”

Formal Closing

Summarize key points to child and parents/carers
Ask if anything has been missed
Thank the child and parents/carers for their time

Summary Structure

Section	Format
Summary	”Fever was 40 degrees intermittent for X days + OPERATES associated with…”
Differential	List with justification
Diagnosis
Investigations	Appropriate tests
Treatment	Suggestive management

Approach to infant wheezing Skin Rash Child with abdominal pain BRUE Limping Approach to infant with sepsis & febrile Approach to shock Henoch-Schönlein Purpura (HSP) Acute Lymphoblastic Leukemia (ALL) Approach to lymphadenopathy

Chief Complaint

Condition	Expected Chief Complaint (Parent/Child Words)	Duration Pattern
Infant Wheezing	”Barking cough,” “noisy breathing/stridor,” “wheeze,” “difficulty breathing,” “chest retractions”	Sudden onset (foreign body) vs. gradual (URI)
Skin Rash	”Red spots,” “itching,” “blisters,” “bruising without injury,” “skin peeling,” “purple spots,” “sandpaper skin”	Acute (hours-days) for allergic; subacute for infections; fever before rash (viral) vs. rash before fever (toxin)
Abdominal Pain	”Tummy ache,” “crying with knees to chest” (intussusception), “constipation,” “vomiting,” “unable to walk straight”	Acute (<1 week) vs. chronic (>2 months)
BRUE	”Stopped breathing,” “turned blue/pale,” “went limp,” “unresponsive for a minute,” “gasping episode”	Brief (<1 min), resolved
Limping	”Not walking right,” “favoring one leg,” “refusing to walk,” “leg pain,” “hip pain”	Acute (trauma/infection) vs. insidious (Perthes, tumor)
Febrile Child/Sepsis	”Fever,” “hot body,” “not feeding,” “lethargic/irritable,” “not playing,” “sleepy,” “cold hands”	Continuous vs. intermittent (malaria)
Shock	”Very sleepy,” “cold hands,” “not responding,” “pale/blue,” “not waking up”	Acute onset
HSP	”Rash on legs/buttocks,” “stomach pain,” “swollen knees,” “blood in urine,” “purple spots”	Prodromal URI → rash → GI/joint symptoms
ALL	”Pale,” “tired,” “easy bruising,” “fever that won’t go away,” “bone pain waking at night,” “lumps in neck”	Weeks to months (insidious)
Lymphadenopathy	”Lump in neck/armpit,” “swollen glands,” “neck stiffness,” “big lump in groin”	>2-4 weeks (concerning for malignancy)
ASTHMA / ALL (pallor+rash) Z

Step 1: Demographics & Source

Standard: Name, Age, Gender, Nationality, Marital (parents), Residency.

Condition-Specific Additions:

BRUE: Gestational age at birth (prematurity <32 weeks, IUGR are key risk factors), exact age in days (risk higher <60 days).
Limping: Birth history (breech → DDH; asphyxia → CP), developmental milestones.
Febrile Child: Exact age in days (if <90 days, criteria change completely; <28 days = full sepsis workup).
ALL: Age peak 2-5 years; ask about identical twin (shared risk), Down syndrome, other genetic syndromes.
Shock: Ask about recent trauma, bleeding, vomiting/diarrhea duration, allergen exposure.

Step 2: Chief Complaint

Standard: In parent’s/child’s own words + duration.

Critical Variations:

BRUE: Do NOT accept “choking” as BRUE (exclusion criterion - suggests GERD/aspiration). Clarify: “Did the baby gag/cough first, or stop breathing spontaneously?”
Shock: Chief complaint may be vague (“sleepy,” “not himself”) – maintain high index of suspicion.
HSP: Often multiple complaints: “Rash AND tummy pain AND swollen joints” – use OPERATES for each.
Lymphadenopathy: Exact duration (>2 weeks concerning; >4-6 weeks requires biopsy consideration).
Abdominal Pain: Ask about testicular pain (referred from torsion), sore throat (mesenteric adenitis).

Step 3: HOPI (History of Presenting Illness)

Use SOCRATES for pain (Abdomen, Limping, HSP joints). Use OPERATES for non-pain (Respiratory, Rash, BRUE events).

A. Infant Wheezing

OPERATES:
- O - Onset: Sudden (foreign body aspiration) vs. gradual (bronchiolitis)?
- P - Provoking: Relation to feeding (reflux vs. aspiration)? Worse with crying/excitement (laryngomalacia)?
- A - Associated: URI prodrome (croup), drooling (epiglottitis – emergency), fever, hoarseness.
- T - Timing: Episodes at night (croup), constant (fixed obstruction).
- S - Severity: Can feed? Stridor at rest? Cyanosis? Can speak/cry (if no sound = complete obstruction).

High-yield patterns:

Laryngomalacia: 4–8 weeks infant, high-pitched inspiratory noise worse with crying/excitement, no distress/hoarseness.
Vascular ring/tracheal compression: biphasic stridor + feeding difficulty/poor feeding ± recurrent symptoms.

Red Flags: Drooling + sitting tripod + toxic appearance = Epiglottitis (emergency). Sudden onset while eating/laughing then cannot vocalize = Foreign body aspiration.

B. Skin Rash

OPERATES:
- O - Onset: Hours (allergic) vs. days (infectious)?
- P - Provoking: New soaps (contact dermatitis), hiking (ivy), pets (scabies), medications (SJS/TEN – ask specifically about anticonvulsants, antibiotics, MMR/varicella vaccines)?
- R - Region: Diaper area with satellite lesions (Candida), web spaces (scabies), buttocks/legs (HSP), trunk spreading outward (measles), palms/soles (HFMD, Kawasaki, SJS/TEN), sandpaper texture (scarlet fever).
- A - Associated: Fever before or after rash (viral exanthems), itching (scabies, contact dermatitis > HSP), pain (SJS), arthralgia (HSP, serum sickness), conjunctivitis (Kawasaki, measles), lymphadenopathy (Kawasaki).
- E - Exacerbating: Sunlight (lupus), scratching.

Specific Patterns to Identify:

Kawasaki: Fever ≥5 days + bilateral non-purulent conjunctivitis + cracked lips/strawberry tongue + extremity edema/erythema + polymorphous rash + cervical lymphadenopathy (≥1.5cm).
SJS/TEN: Recent drug exposure (anticonvulsants, sulfonamides), painful skin, positive Nikolsky sign, mucosal involvement ≥2 sites.
HSP: Palpable purpura on buttocks/lower legs, arthritis, abdominal pain, hematuria.
Meningococcemia: Non-blanching petechial/purpuric rash, ill-appearing, rapidly progressive.
Scabies: intense night itching, web spaces/wrists/waistline, household contacts itching.
Measles clues: fever + cough/coryza/conjunctivitis; consider Koplik spots; rash classically starts on face then spreads.
HFMD: painful oral ulcers + rash on palms/soles ± buttocks; ask about daycare contacts; fever can be high.

C. Abdominal Pain

SOCRATES: Full pain analysis PLUS:
- Character: Colicky (intussusception/colic), constant (peritonitis), burning epigastric (PUD).
- Radiation: To back (pancreatitis), to groin (testicular torsion, nephrolithiasis), to shoulder (phrenic nerve irritation).
- Associations: Relation to meals (worse after eating – PUD/gallbladder), bowel movements (relieved by defecation – functional pain/IBS), preceding URTI (mesenteric adenitis).
- Aggravating: Movement (peritonitis), coughing (parietal pain).
- Special:
  - Ask about testicular pain (torsion can present as abdominal pain).
  - Ask about sore throat (mesenteric adenitis).
  - Infantile colic pattern: first months, episodic crying, knee-to-chest, gas/flatus, may follow formula change.
  - FMF pattern: recurrent self-limited abdominal pain + fever (Mediterranean origin/FH/consanguinity).

Physical Clues to Ask About:

McBurney sign: Pain at 2/3 between umbilicus and right ASIS (appendicitis).
Rovsing sign: Pain in RLQ on left-sided palpation (appendicitis).
Psoas sign: Pain with right hip hyperextension (retrocecal appendix).
Obturator sign: Pain with internal rotation of flexed right thigh (pelvic appendix).
Murphy’s sign: Pain on inspiration when pressing beneath right costal margin (cholecystitis).
Cullen’s sign: Bluish umbilicus (hemorrhage).
Grey Turner’s sign: Flank discoloration (hemorrhage).

D. BRUE (Brief Resolved Unexplained Event)

Event Details (Crucial):
- Duration: typically <30–60 seconds (brief). Events >1 minute are higher-risk and may not meet low-risk BRUE criteria.
- Appearance: Color change (pale/blue/red?), breathing pattern (gasping/apnea?), tone (limp/stiff?).
- Intervention: Did caregiver need CPR? (High risk if yes). Was stimulation needed?
- Recovery: How quickly back to normal? Complete return to baseline?
- Context: Asleep? Feeding? Crying? (Choking/gagging excludes BRUE diagnosis - indicates GERD/aspiration).

Risk Stratification:

Higher Risk: Age <60 days, born <32 weeks gestation, >1 event, event >1 minute, CPR by trained provider needed, concern for abuse.

E. Limping

OPERATES/Pain hybrid:
- Onset: Sudden (trauma/septic arthritis) vs. insidious (Perthes, tumor, DDH).
- Pain: Night pain waking child (malignancy/ALL), morning stiffness (JIA), pain with weight bearing (fracture/septic arthritis).
- Associated: Recent URI (transient synovitis), fever (septic arthritis), rash (HSP), HSM (leukemia), recent weight loss (malignancy).
- Referred pain: Hip pathology often presents as knee pain – always examine hips when knee pain present!

Red Flags:

Age <3 years (septic arthritis/osteomyelitis/NAI risk)
Unable to bear weight
Fever + limping = Septic arthritis until proven otherwise
Night pain/night sweats (malignancy)
Lymphadenopathy/HSM (ALL, lymphoma, brucellosis)
Hepatosplenomegaly with fever (brucellosis, leukemia – often misdiagnosed as each other)

Specific Exposures to Ask:

Raw milk or unpasteurized dairy ingestion (brucellosis)
Contact with goats, cattle, or livestock (brucellosis)
Recent URTI 1-2 weeks prior (transient synovitis)

Kocher Criteria for Septic Arthritis:

Unable to bear weight
Fever >38.5°C
ESR >40 mm/hr
CRP >20 mg/L
WBC >12,000

Note: Septic arthritis can still occur with normal inflammatory markers. Synovial fluid analysis (turbid/purulent vs. clear/straw-colored) remains the gold standard for differentiation from transient synovitis.

F. Febrile Child/Sepsis

Fever Pattern (Critical):
- Continuous (pneumonia/typhoid), Remittent (viral), Intermittent (malaria/abscess).
- Response to antipyretics (comfort vs. no response – concerning).
Associated: Cough (pneumonia), vomiting (GE/UTI), diarrhea, rash (meningococcemia – non-blanching), stiff neck (meningitis), altered mental status.
Behavior: Lethargy, inconsolable crying, poor feeding, decreased wet diapers (dehydration).

NICE Traffic Light System (Critical for Risk Stratification):

Feature	Low Risk (Green)	Intermediate Risk (Amber)	High Risk (Red)
Color	Normal	Pallor	Pale, mottled, ashen, blue
Activity	Responds normally, content, wakes quickly	Not responding normally, decreased activity, no smile	No response to social cues, unrousable, weak/high-pitched cry
Breathing	Normal	Tachypnea, crackles, SpO2 ≤95%	Grunting, RR >60, severe chest recession
Circulation	Normal CRT, moist mucosa	CRT ≥3 sec, dry mucosa	Reduced skin turgor
Other	None	Fever >5 days, temp ≥39°C (3-6mo), rigors	Temp ≥38°C (<3mo), non-blanching rash, bulging fontanelle, neck stiffness

G. Shock

Precipitating Events: Trauma (hemorrhage), vomiting/diarrhea (hypovolemic), allergen exposure (anaphylaxis), fever (septic), congenital heart disease.
Progression: Thirst → irritability → lethargy → coma (ask about mental status changes).
Breathing clue: Quiet tachypnea/rapid breathing can be an early sign of shock/metabolic acidosis even before overt respiratory distress.
Skin: Warm/flushed (early distributive) vs. cold/mottled (late hypovolemic/cardiogenic).

Primary Assessment (ABCDE):

Airway: Patency, stridor, drooling, positioning.
Breathing: Rate, effort (retractions, nasal flaring, grunting), SpO2.
Circulation: Heart rate, peripheral pulses (weak vs. bounding), capillary refill (>2 sec concerning), blood pressure (hypotension is late sign), skin color.
Disability: AVPU scale, glucose, pupils.
Exposure: Temperature, trauma signs, rashes.

Types of Shock:

Hypovolemic: Cool extremities, delayed CRT, dry mucosa, weak pulses.
Distributive (Septic/Anaphylactic): Warm extremities early, bounding pulses, wide pulse pressure, flushed skin.
Cardiogenic: Tachypnea with increased effort, crackles, hepatomegaly, JVD, gallop rhythm.
Obstructive: Tension pneumothorax (tracheal deviation, absent breath sounds), cardiac tamponade (muffled heart sounds, JVD), pulmonary embolism.

H. HSP (Henoch-Schönlein Purpura/IgA Vasculitis)

Classic Sequence: URI prodrome (1-2 weeks ago) → Rash (palpable purpura on buttocks/legs) → Joint pain (knees/ankles) → Abdominal pain (colicky).
Ask specifically:
- “Have you noticed blood in the urine?” (Renal involvement - microscopic hematuria most common).
- “Any swelling in the scrotum?” (Epididymitis/orchitis, torsion risk).
- Joint pain: Migratory, non-deforming, periarticular swelling.

Diagnostic Criteria (Classification):

Palpable purpura (no thrombocytopenia) PLUS one of:
- Abdominal pain (acute, diffuse, colicky)
- Biopsy showing IgA deposition
- Arthritis/arthralgia
- Renal involvement (proteinuria >0.5g/day or hematuria)

I. ALL (Acute Lymphoblastic Leukemia)

Bone Pain: Night pain that awakens the child is a major red flag for leukemia/malignancy (vs. growing pains which typically don’t wake the child).
Bleeding: Petechiae, epistaxis, gum bleeding. Important: Ask if platelet count is normal (distinguishes from ITP – in ALL, WBC abnormal, Hb low, blasts present).
B-symptoms: Night sweats (drenching), weight loss, anorexia, fever.
CNS symptoms: Headache, vomiting with headache (morning), behavioral changes.

Key Lab Clues:

CBC: Pancytopenia (Hb low, WBC high/low with blasts, platelets low).
Peripheral smear: Blasts (supportive); other smear artifacts/findings (e.g., “smudge cells”) are not diagnostic on their own.
Bone marrow: ≥20% lymphoblasts.

J. Lymphadenopathy

Node Characteristics:
- Location: Supraclavicular is always abnormal/high risk.
- Size cutoffs: Cervical/axillary >1 cm, inguinal >1.5 cm, epitrochlear >0.5 cm; >2 cm anywhere is concerning.
- Texture: Tender = often infection; hard/rubbery/fixed = malignancy; matted = TB.
Exposures: Cats (scratch disease – tender node after kitten scratch), unpasteurized milk (brucellosis), TB contacts, recent throat/ear/scalp infections (drainage pattern).

Red Flags for Malignancy:

Supraclavicular location (always abnormal)
Size >2cm, increasing over 2 weeks
Hard, rubbery, matted, non-tender
Associated with weight loss, night sweats, bone pain
Hepatosplenomegaly
No decrease in size after 4-8 weeks

Step 4: B-Symptoms (Fever, Night Sweats, Weight Loss)

Always ask for ALL, Lymphadenopathy, HSP, and any concerning systemic illness:

Fever: Duration >5 days (Kawasaki criteria, lymphoma).
Night sweats: Drenching? Need to change clothes/bedding?
Weight loss: Quantify in kg or clothes size change.

Specifics:

ALL: Present in 20-30%; indicates high tumor burden.
HSP: Fever usually mild; high fever suggests secondary infection.
Febrile Child: Use NICE Traffic Light criteria here to risk stratify.

Step 5: Systemic Review (Targeted by Condition)

System	Key Questions by Condition
General	Activity level (limping/ALL), growth failure (celiac/cystic fibrosis/ALL), irritability (meningitis/sepsis).
CV	Breathlessness, sweaty on feeding (heart failure in shock/cardiogenic), cyanosis.
Resp	Cough, wheeze, stridor (infant wheezing), retractions, nasal flaring, grunting (shock/sepsis), crackles (pneumonia).
GI	Vomiting (bilious? = obstruction), diarrhea (GE), constipation (most common cause of abdominal pain), blood in stool (HSP/intussusception), jaundice.
GU	Hematuria (HSP/UTI), dysuria (UTI), testicular pain (torsion/HSP), scrotal swelling (HSP), menarche age (ectopic pregnancy/hematocolpos in adolescent abdominal pain).
Neuro	Headaches (ALL/CNS tumors), altered consciousness (shock/sepsis), seizures, stiff neck (meningitis), weakness (Guillain-Barré).
MSK	Joint pain/swelling (HSP/septic arthritis/JIA), bone pain (ALL), refusal to bear weight (septic arthritis), waddling gait (DDH).
Skin	Rash characteristics (see Skin Rash section), bruising (ALL/ITP/HSP), petechiae (meningococcemia/ALL).
Heme/Onc	Pallor (ALL), HSM (ALL/lymphoma), lymphadenopathy (ALL).

Step 6: Journey (Neonatal → Present)

Neonatal History (Critical for BRUE, Sepsis, Limping):

Antenatal: Maternal infections (TORCH), GBS status, maternal fever/PROM (sepsis risk).
Perinatal: Gestational age (prematurity = BRUE/shock risk), mode of delivery (breech → DDH), Apgar scores, resuscitation needed, NICU admission (BRUE risk).
Postnatal:
- BRUE: When did baby pass urine/meconium? Any congenital anomalies?
- Limping: Hip click/dislocation detected (DDH screening), birth trauma, asphyxia.
- Sepsis: Umbilical cord care (tetanus risk), early onset sepsis signs.

Nutritional:

BRUE/GERD: Feeding type, volume, duration, vomiting/spitting up, overfeeding?
Abdominal Pain: Too much milk (constipation), weaning foods, formula changes (colic).
ALL: Anorexia, difficulty feeding.

Developmental:

Limping: Delayed walking (DDH/CP), loss of milestones (ALL affecting CNS).
ALL: Regression of milestones (CNS involvement).

Immunization:

ALL/Shock/Sepsis: Up-to-date? (Pneumococcal, Hib, Meningococcal).
BRUE: Pertussis status (can present as apnea).
Skin Rash: MMR, Varicella (breakthrough vs wild-type).

Critical Exposures & Genetics:

ALL: Down syndrome, NF1, Bloom syndrome, ataxia-telangiectasia, identical twins.
HSP: Family history of atopy/allergic rhinitis (higher risk of renal involvement).
Lymphadenopathy: TB exposure, Mediterranean fever (recurrent abdominal pain), cat ownership (toxoplasma/scratch).
BRUE: Siblings with similar events (metabolic disorders?), secondhand smoke exposure.
Shock/Sepsis: Recent travel (malaria), sick contacts (meningitis), animal exposures (brucellosis).
Limping/Abdominal Pain: Consanguinity (sickle cell, metabolic bone diseases).
Social: Parental occupation (exposures), housing (overcrowding → infections).

Step 8: Past History (Medical, Surgical, Medication, Allergies)

Red Flags:

Medications: Recent antibiotics (febrile child already on antibiotics = higher risk), anticonvulsants (SJS/TEN), phenytoin (lymphadenopathy).
Surgical: History of intussusception (recurrence risk), previous lymph node biopsy.
Medical:
- Shock: CHD, arrhythmias, previous anaphylaxis.
- Limping: Hemophilia (bleeding into joint), sickle cell (avascular necrosis), JIA.
- ALL: Previous malignancy (secondary), immunodeficiency.
- BRUE: Prior similar events, GERD diagnosis.

Steps 9-12: Summary, Differential, Investigations, Treatment

For each case, your closing summary should highlight:

Differential Diagnosis Priorities:

Infant Wheezing:

Croup (viral, barking cough, stridor)
Epiglottitis (bacterial, toxic, drooling, tripod sitting) - EMERGENCY
Foreign body aspiration (sudden onset, unilateral wheeze) - EMERGENCY
Bronchiolitis (viral, gradual onset, wheezing)
Asthma (older, recurrent, responsive to bronchodilators)

Skin Rash:

Meningococcemia (non-blanching, ill-appearing) - EMERGENCY
SJS/TEN (painful, mucosal involvement, recent drug) - EMERGENCY
Kawasaki Disease (fever ≥5 days, specific criteria) - URGENT
HSP (palpable purpura, arthritis, abdominal pain)
Benign viral exanthem (fever resolves, rash appears, well-appearing)

Abdominal Pain:

Appendicitis (migratory RLQ pain, anorexia, McBurney/Rovsing signs)
Intussusception (<2 years, currant jelly stool, colicky pain, knee-to-chest)
Testicular torsion (acute scrotal pain, nausea/vomiting) - SURGICAL EMERGENCY
Mesenteric adenitis (mimics appendicitis, recent URI)
Constipation (most common, dietary history)
Peptic ulcer disease (epigastric burning, relation to meals)

BRUE:

GERD (exclusion criterion - choking/gagging with feeds)
Seizure (tonic posturing vs. limpness)
Cardiac arrhythmia (long QT, family history of sudden death)
Non-accidental injury (if trauma signs, inconsistent history)
Metabolic disorder (recurrence, family history)

Limping:

Age-Based Approach with Clinical Scenarios:

Condition	Typical Age	Key Features	Differentiation
Septic arthritis	<3 years	Fever, toxic, unable to bear weight, elevated ESR/CRP, WBC >12k	Urgent aspiration: purulent fluid confirms diagnosis
Transient synovitis	3-10 years	Recent URTI (7-14 days prior), afebrile/low-grade fever, well-appearing, normal/slightly elevated inflammatory markers	Ultrasound shows effusion; synovial fluid = clear/straw-colored
Perthes disease	4-8 years	Insidious onset, males > females, gradual limp, limited hip abduction/rotation	X-ray shows flattening/fragmentation of femoral head
SCFE	10-16 years	Obese adolescent, hip/thigh/knee pain (referred), external rotation deformity, shortened limb	X-ray frog-leg: posteroinferior displacement of epiphysis; make non-weight-bearing immediately
Leukemia	Any	Night pain waking child, HSM, pallor, easy bruising, lymphadenopathy	CBC: pancytopenia with blasts; peripheral smear shows smudge cells
Brucellosis	Any	Raw milk/goat exposure, fever, hepatosplenomegaly, thrombocytosis	Serology/PCR positive; often misdiagnosed as leukemia

Key Clinical Scenario Patterns:

Scenario: 3-year-old male, painful limp + fever

Approach: Right knee swollen, warm, red, tender → Septic arthritis until proven otherwise
Workup: CBC, ESR, CRP, blood culture, X-ray, ultrasound → aspiration for culture
Treatment: Admit, <3 months = Cefotaxime + Flucloxacillin; older = Flucloxacillin/Cefuroxime
Duration: 3-4 weeks (6 weeks if hip involved)

Scenario: 10-year-old obese male, 6 days limp, left hip pain

Approach: X-ray shows posteroinferior epiphyseal displacement → SCFE
Immediate action: Non-weight-bearing status, urgent orthopedic referral
Risk factors: Obesity, adolescent growth spurt, hypothyroidism, steroids/GH therapy
Complication to avoid: Avascular necrosis (emergency if untreated)

Scenario: 10-year-old female, 2 months fever, bone pain, limping

Clues: Contact with goats, moderate hepatosplenomegaly (liver enlarged, spleen 7cm), normal WBC, thrombocytosis
Diagnosis: Brucellosis (not malignancy despite HSM)
Treatment: Doxycycline + Rifampicin for 6 weeks (age >8 years)

Scenario: 10-year-old male, 3 days limp, recent URTI

Clues: Recent cough/runny nose, right hip/groin pain referred to thigh/knee, normal inflammatory markers
Diagnosis: Transient synovitis
Key test: Ultrasound shows effusion; synovial fluid study distinguishes from septic arthritis
Management: NSAIDs, rest, 24-48 hour improvement expected

Febrile Child:

Viral illness (most common)
UTI (most common occult bacterial, <24 months)
Pneumonia (tachypnea, crackles, O2 sat <95%)
Meningitis (bulging fontanelle, neck stiffness, petechiae)
Kawasaki Disease (fever ≥5 days, specific criteria)
Osteomyelitis/Septic arthritis (focal bone/joint pain, refusal to weight bear)

Shock:

Hypovolemic (hemorrhage, burns, diarrhea - cold extremities)
Septic (warm extremities early, cold late, petechiae)
Cardiogenic (hepatomegaly, JVD, pulmonary edema)
Anaphylactic (exposure history, urticaria, wheezing)
Obstructive (tension pneumothorax, tamponade)

HSP:

ITP (thrombocytopenia, no arthritis/abdominal pain, platelets low)
Meningococcemia (sick patient, petechiae, low platelets)
Other vasculitides (rare, requires biopsy)

ALL:

Aplastic anemia (pancytopenia, no blasts)
ITP (isolated thrombocytopenia, normal Hb/WBC)
JIA (joint swelling, no blasts, normal platelets usually)
Infectious mononucleosis (atypical lymphocytes, EBV positive)

Lymphadenopathy:

Reactive (recent infection, tender, <2cm, cervical)
TB (matted nodes, chronic, exposure)
Lymphoma (>2cm, supraclavicular, rubbery, B-symptoms)
Cat-scratch disease (tender, unilateral, cat exposure)
Leukemia (generalized, HSM, pancytopenia)

Key Investigations to Suggest: