7.1 HPI, Review of Systems & Social Histories

Domain II.B.1–2 tests whether the CPNP-PC can take the right history for the visit type, not an adult HPI pasted onto a toddler. Pediatric history is a structured interview with a caregiver historian, an increasingly verbal child, and — in adolescence — a confidential second interview. The same chief complaint (cough, limp, abdominal pain) becomes a different problem once you know the household, the last well visit, and who is answering.

Match the history to the visit type

Comprehensive history belongs on a new-patient visit and on health-supervision (well-child) care. You build or fully refresh the database: pregnancy, birth, and neonatal course; past medical and surgical history; medications, allergies, and immunization status; developmental trajectory; family history (sudden death, early cardiovascular disease, lipids, atopy, autoimmune disease, mental health, hemoglobinopathy, heritable conditions); a complete ROS; and a complete social history. A 6-year-old new to the practice is not an interval note, even if the parent says “she is here for shots.”

Interval history is the subsequent well visit or chronic-care follow-up when a database already exists. You ask what has changed since the last visit: new diagnoses, ED or hospital care, new medications, new caregivers or housing, school changes, and a targeted ROS plus age-appropriate social and developmental updates. Interval is not an excuse to skip social history. Households, food security, firearms, and smoke exposure change between September and March.

Focused (problem-oriented) sick visit is driven by the chief complaint. You still take a disciplined HPI, a relevant ROS, and the slice of past, family, and social history that can change the diagnosis. “Quick sick” is a time-management choice, not a license to omit guns, smoke, crowding, travel, or lead when those facts reframe the cough, the limp, or the belly pain.

The high-yield trap is treating social context as well-visit paperwork. Lead, crowding, a new baby, an unlocked firearm, and last week’s travel are diagnostic data.

HPI: OLDCART and PQRST

PNCB items are vignettes; the stem is already an HPI. You still need a method that does not miss time course, function, or treatments already given.

OLDCART: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing (add Severity in practice).

PQRST: Provocation/palliation, Quality, Region/radiation, Severity, Timing.

Use one mnemonic consistently. Pediatric modifications matter:

• Onset includes when the caregiver first noticed versus when the child “got sick.” A toddler cannot date a three-week limp.
• Character in a preverbal child is observed behavior: pulling at an ear, refusing to bear weight, drawing up the legs, inconsolability versus consolable fussiness, tripod posture, drooling.
• Severity is function, not a 0–10 number a 2-year-old cannot give: feeding, wet diapers, play, school attendance, sleep, sports.
• Timing includes relation to feeds, time of day, fever pattern, and whether symptoms are progressive.
• Always ask medications already given (name, milligram per kilogram if known, clock time) and sick contacts.

Worked HPI (focused sick). A 22-month-old is “pulling at the right ear.” OLDCART: symptoms began 36 hours after a cold (onset); parent localizes to the right ear (location); 36 hours (duration); screaming when laid flat, not playful (character/severity); worse overnight, no relief from a 5 mL dose of an unknown product 2 hours ago (aggravating/relieving); fever to 38.8°C last night, then 38.1°C (timing). Relevant ROS: feeding, wet diapers, vomiting, rash, stiff neck, breathing. Relevant social: household smoke (otitis risk), who is the historian, daycare. That is a focused sick HPI. It is not a three-generation pedigree, and it is not “ears look red, here is amoxicillin” without the story.

Always record who is giving the history and whether they were present when symptoms started. A babysitter may not know overnight intake. Invite the older child to contribute: “Does that match what you felt?” If a parent answers every question for a 15-year-old, you have not taken an adolescent history.

Pediatric review of systems

Adult ROS lists miss the domains that diagnose pediatric disease. On a comprehensive or well visit, work through general, skin, HEENT, respiratory, cardiac, GI, GU, musculoskeletal, neurologic, and psychosocial systems — and add the pediatric ROS.

On a focused sick visit you still ask the ROS that can change the differential. A “just a cold” without drooling, stridor, unilateral foul drainage (foreign body), fever pattern, urine output, or travel is an incomplete ROS.

Social history that changes the diagnosis

Bright Futures and Domain II.B.2 expect health and social histories matched to visit type. The CPNP-PC social history is a risk map, not “lives with mom and dad.”

• Household and caregivers: Who lives here, who feeds the child, custody and visitation, kinship or foster care, caregiver mental health or substance use.
• Housing: Stability, crowding, homelessness, mold, pests, pre-1978 housing and peeling paint (lead), well water, working smoke and carbon-monoxide detectors.
• Food security: Running out of food, stretching formula, WIC or SNAP — this is how iron deficiency and faltering growth hide inside a visit for “fatigue” or “constipation.”
• Firearms: Presence, locked, unloaded, ammunition stored separately. Ask on well visits and when mood, aggression, or suicidality appears.
• Smoke and vape exposure: Household and vehicle; this changes asthma, bronchiolitis, and otitis counseling.
• School and sports: Concussion, overuse, weight-cutting, performance pressure.
• Travel and immigration: Recent travel, visitors from endemic areas, unpasteurized dairy, interrupted refugee or newcomer screening.

Exam trap — skipping social history on a “quick sick visit.” A toddler with abdominal pain and pica in a 1950s rental is a lead problem until you prove otherwise. Four children in one bedroom with a coughing relative is crowding and tuberculosis risk, not an automatic viral URI. Fever after a summer trip to visit family abroad needs a travel differential (malaria, enteric fever, hepatitis A) that a local viral script will miss. Crowding, lead, food insecurity, firearms, and smoke are not well-visit-only fields.

Adolescent confidential history: HEADSS and SSHADESS

Starting in late childhood and early adolescence, split the visit. After you explain confidentiality and its limits (active suicidal or homicidal intent, abuse, and other legally mandated reports — state statutes vary; safety overrides secrecy), interview the adolescent alone. Parents hear the agenda; the adolescent hears that sexual health, substance use, and mood stay private unless safety is at stake.

Principles, not a script you must recite in a fixed order:

• Normalize: “I ask every teen these questions.”
• Use a professional interpreter. Do not use a sibling to translate sexuality or substance questions.
• Be specific: vape, alcohol, cannabis, unused prescription pills — not “Do you do drugs?”
• Sexual history is behavior and safety (partners, contraception, STI, consent, coercion), not a morality lecture.
• Document what was confidential versus what was shared, and know your state’s minor-consent rules for STI testing, contraception, and selected mental-health care.

The historian on most pediatric visits is the caregiver. That is appropriate for infants. School-age children should add their own symptoms. Adolescents need a private history. Domain II.B is data collection: if you skip social context, confidential time, or a pediatric ROS, the diagnosis in II.E is guessing.