Taking a Paediatric History

Taking a Paediatric History

• Introduction: Clearly introduce yourself, confirming the child’s details and the presence of carers.
• Observation: Observe the child for any signs of distress or abnormal behavior.
• Engagement: Ask appropriate questions directed at the child, utilizing interpreters when needed.
• Open-ended Questions: Encourage more detailed responses rather than yes/no answers.

Presenting Complaint

• Utilize the F.O.D.I.P.A.R.A. mnemonic:
  • F: Is this the first time the complaint has occurred?
  • O: Establish the onset of the symptoms.
  • D: Determine duration of the symptoms.
  • I: Assess the intensity of the condition.
  • P: Inquire about the progression over time.
  • A: Identify any aggravating factors.
  • R: Determine relieving factors.
  • A: Explore any associated symptoms.

Systems Review

• CNS: Document headaches, dizziness, loss of consciousness, seizures.
• ENT: Inquire about sore throat and ear pain.
• RS: Assess for cough, wheeze, breathlessness.
• CVS: Note palpitations, chest pain, dizziness.
• GIT: Ask about nausea, vomiting, abdominal pain, appetite, stool.
• GUT: Review urine issues, dysuria, flank pain, and menstruation if applicable.
• MSS: Inquire about joint swelling, joint pain/stiffness, rashes.

Additional Questions

• Assess general well-being: Are they feeding well? Urinating properly? Bowel movements normal? Any behavioral concerns?

Past History

• Review any medical conditions, previous hospital admissions, current medications, and allergies.

Perinatal History

• Gather information on pregnancy details (e.g., term or preterm), delivery method (normal or C-section), and birth weight.
• Investigate complications during or immediately after birth, including any need for neonatal admission or respiratory support.

Immunization History

• Document vaccination status to ensure vaccinations are up-to-date.

Developmental History

• Review milestones in gross motor, fine motor, vision, speech, and hearing.
• Include social development to assess interaction levels with peers.

Growth History

• Document and compare height and weight, referencing a child's growth chart (e.g., red book).

Family History

• Identify any familial prevalence of childhood or young adult diseases, number of siblings, and consanguinity.

Social History

• Review living conditions, household composition, nursery/school attendance, and presence of pets or social workers.

Infectious Perspective Questions

• Inquire about travel history, exposure to infections, and any known contact with infectious individuals.

Summary

• Ensure all relevant points are covered and clarify any additional concerns or questions from the caregivers outlined.

Focused History

• Maintain thoroughness and a systematic approach throughout the process to gather comprehensive data.