History Taking - Pediatrics Department PDF

  Pediatrics Department     History taking Tips during history taking 1.   Before the start of the interview, be sure to read...

  Pediatrics Department     History taking Tips during history taking 1.   Before the start of the interview, be sure to read all referral letters and past information. 2.   Introduce yourself. 3.   Determine the relationship of the adults to the child 4.   Do not forget to address questions to the child, when appropriate. 5.   During the interview, observe the child’s play, appearance, behavior, and gait. 6.   Maintain good eye contact with both the child and the informant. 7.   Always be friendly and maintain a respectful manner and pleasant expression 8.   Start with open-ended style questions. 9.   Do not interrupt the informant. 10.   Use silence to encourage the informant to explain things Items for history taking:-   Patient demographics   Chief complaint(s) (presenting complaint)   History of present illness (history of presenting complaint)   Past history:- ü   Birth history ( Prenatal Natal Postnatal and neonatal ) ü   Past medical and surgical history   Medication history   Developmental history   Immunization history   Feeding/dietary history   Family history   Social history   Review of systems Patient demographics It includes: - name, age, sex, nationality, address, date of hospital admission, source of the referral N.B in case of suspected infectious diseases we have to verify history of recent travel to endemic area for this disease.   1      Pediatrics Department     Chief complaint(s) (presenting complaint) tips   The chief complaint may be a symptom, a sign, or an abnormal laboratory test result (or a combination of these items).   To encourage the caregiver to talk start with open questions, such as: “What is the main problem?” “Tell me why you are here?” “Why are you worried?” “How can I help?”   Ask about the duration of each complaint, and put them in a chronological order.   Record the complaints with words said by caregiver. History of Present Illness (History of Presenting Complaint) It is a very important part of the history. Once you know the chief complains you try to put in your mind a differential diagnosis for these symptoms. You need to find out the following:   Type of onset (sudden occur in sec (e.g. foreign body aspiration) or gradual evolving over hours or days)   Duration and timing of the chief complaint   Predisposing factors (e.g.: following ingestions of certain foods or drugs)   Characteristics of the complaint (amount, consistency, and other features, according to the symptom; if pain, ask about its character, e.g., dull, sharp, throbbing, etc.)   Severity of the symptom ( is this symptom sever enough to interfere with the child physical activity )   Frequency of attacks (if there are recurrent attacks)   Course of the condition (improving over time (regressive course ), getting worse with time (progressive course) , or the same( stationary course))   Aggravating and relieving factors   Associated symptoms (other symptoms that could be present in the same illness (e.g. child complain of diarrhea ask about vomiting, fever and bloody stool )   Predicted complications ( complications you know about the current illness e.g. complications of the diarrhea could be convulsion so you ask about if it is present or not )   2      Pediatrics Department       The negative data ( the symptoms related to the differential diagnosis you think about according to the current complaints   Contact with person having same symptoms (e.g. fever ,rash , ….)   Investigations that have already been done and treatments already tried   Current state of the child (eating, drinking, passing urine or stool, sleeping, and activity) Past History:- You should ask about the details of birth history in all children aged less than 2 years or when these details are relevant to the child’s current problem (e.g. the chief complaint is developmental delay). Birth history includes the following: Prenatal History (during pregnancy):- ü   What is the mother’s age? ü   What is the number of previous pregnancies and their outcomes? ü   Were there any problems or illnesses during the pregnancy (e.g. DM, hypertension)? If so, in which trimester? ü   Was the mother exposed to radiation or infection (TORCH, HIV)? If so, in which trimester? ü   Did she take any medication during pregnancy? If so, which medications? In which trimester? ü   How long was the pregnancy? Natal History (event of labor) ü   How did the labor start: spontaneous or induced (why)? ü   Where was the place of delivery: at home or in a hospital? ü   Who conducted the delivery: a doctor, a qualified midwife, or a nonqualified person? ü   What was the mode of delivery: vaginal (assisted or not) or cesarean (why)? ü   What was the duration of the labor? ü   Were there complications during labor (such as bleeding or failure to progress)? ü   Was there maternal fever or premature rupture of membranes? ü   Did the baby have any cyanosis, asphyxia, birth trauma, or meconium aspiration? ü   When did the baby cry?   3      Pediatrics Department     Postnatal and Neonatal History:- ü   What are the birth weight and gestational age? ü   Does the informant know the initial Apgar scores? If so, what were they? ü   Does the child need any resuscitation measures required? If so, what measures? ü   When was the first meconium passed? ü   Is there is need for NICU admission? If yes, what is the cause? For how long? Does there is need for mechanical ventilation? If yes, for how long? What was the age at discharge? ü   What was the infant’s course in the first few weeks? Past Medical and Surgical History:- We should ask the following questions: ü   Any previous similar symptoms or attacks in the past? §   Previous similar attack of the same illness make you think about; diseases characterized by remission and relapse e.g. nephrotic syndrome. §   Recurrence of similar attacks help in diagnosis of diseases characterized by recurrence e.g. asthma, epilepsy. §   Think about anatomical or local problem e.g. recurrence of pneumonia on the same side could be FB aspiration or local anatomical problem. ü   Previous hospital admissions to the hospital? If so, when and for what? ü   Are there any allergies? Which are they? ü   Did the child undergo any surgical operations in the past? If so, at what age? For what? What type of operation? Were there any complications? If so, what were they? Medication history:- ü   Is the child on any medication? If so why? ü   What are the current medications? ü   Duration of the treatment? ü   Doses and frequency of the drugs? ü   Compliance of the child? ü   History of drug allergies. N.B:- put in your consideration that the current symptoms could be possible complications for the drug received by the child , poor compliance of the child or incorrect dosing.   4      Pediatrics Department     Developmental History Assessment of the child’s development consists of two parts: Developmental history and observation of developmental progress through physical examination. The current developmental milestones of the child should be matched with his/her age to detect any delay.   Fig.  1  some  key  of  developmental  milestones  in  infants  and  young  children Immunization History:- ü   Is the child up-to-date with his/her immunizations suggested for his/her age (according to the national immunization schedule)? ü   Were there any missed or omitted vaccines? If so, what were they? Why? ü   Were there any adverse events/effects in relation to previous immunization? If so, what were they? When did they occur? To which vaccines were they related? ü   Is there an allergy to any vaccine?   5      Pediatrics Department     Feeding/Dietary History:- It is very important to stress on it especially in infants and if the main concern of the mother about the nutrition of the child For an Infant: _ ü   Is the child breastfed or taking formula? ü   In Breastfeeding Ask the following questions: §   What is the duration of exclusive breastfeeding? §   Is breastfeeding on demand or scheduled? §   What is the frequency of breastfeeding? §   How often does the child feed at night? §   What is the duration of each feeding? §   Does the mother use both breasts for feeding? §   Is the feeding adequate to the child (Adequacy of breastfeeding can be assessed by adequate weight gain, adequate sleeping (2–3 h) after each feeding, voiding of urine six to eight times/day, and passage of loose yellow stool at least four times per day (by 5–7 days). N.B exclusively breastfed babies may stool only once every 3–5 days, which is still normal. §   Are there any feeding difficulties (e.g., choking, regurgitation, or vomiting)? §   Are there any worries regarding breastfeeding (e.g., anxiety regarding the adequacy of milk supply, return to work, or breast pain/discomfort due to sore nipples, mastitis, or thrush)? §   Did the child receive vitamins or mineral supplements? §   Did the mother start complementary feeding? If so, what? At what age? In Formula Feeding ü   Why and when start formula feeding? ü   Does it complementary or substitutive for breast feeding? ü   What type of milk is used? ü   How is it prepared? Is it diluted? ü   How much milk does the child consume in each feeding? ü   What is the frequency of feeding? ü   What is the average duration of each feeding? ü   Are there any feeding problems (e.g., allergies, diarrhea, or colic ü   Is the feeding adequate for the child (sleeping after feeding, weight gain, and passing urine)?   6      Pediatrics Department     Weaning ü   When complementary foods were first introduced? ü   What is the type of weaning foods given to the child? ü   How were weaning foods administered (i.e., by spoon or in a bottle)? ü   What is the amount of food given to the child per day? ü   What is the frequency of food intake? ü   Did he/she have any preference? ü   Were there any known allergies to weaning food? If so, to which food? Family History:- ü   The degree of consanguinity between the parents. ü   Siblings: Number, age, sex, illnesses, disabilities, and significant medical history of all siblings. ü   Birth order of the child in the family. ü   Similar problem in the family. ü   History of death among the parents or siblings; if so, ask about cause, age, and date of death. ü   Illnesses that run in the family. ü   Diseases that affect more than one member of the family. ü   Drawing out of a family tree.   Fig.2  example  of  family  tree   Fig.3  pedigree  symbols Social history:- ü   Parents : education level, occupation and smoking ü   Who lives with the child at home? ü   Ask about housing and living conditions?   7      Pediatrics Department     ü   How many rooms in the home? Is there is overcrowding? ü   History of travelling in relation to the current symptoms? ü   Is there is any animals at home? Review of other systems:- ü   General: - general health, activity, rash, fever, decrease appetite. ü   Respiratory system: - cough, breathing difficulty, noisy breathing. ü   Ear, throat and nose:-earache, ear discharge, snoring, rhinorrhea, throat pain. ü   Cardiovascular system: cyanosis, fainting, exercise intolerance, tachycardia. ü   Gastrointestinal tract: - vomiting ,constipation, diarrhea , abdominal distention ,jaundice. ü   Genitourinary: - frequency, dysuria, change color of urine, wetting in toiled train. ü   Neurological: - development, hearing, vision, headache, change in behavior. ü   Musculoskeletal: - gait, limb pain, joint pain, joint swelling or stiffness ü   Pubertal development References: Illustrated textbook of pediatrics Essential clinical skills in pediatrics   8