Paediatric History Taking PDF

05.12.2024 Children are not just little adults, newborns are not just smaller...

05.12.2024 Children are not just little adults, newborns are not just smaller children Paediatric history taking Maciej Szczukocki 1 2 A good student in paediatrics Paediatrics is specific… Observer Working with patients and parents Social and confident If you can not smile, you are in trouble Listener Like challenges Dedicated Empathetic 3 4 Content Differences Prenatal and birth history Developmental history Social history of family - environmental risks Immunization history Differences of a Pediatric History Compared to an Adult History 5 6 1  05.12.2024 Parent as Observation of parent-child interactions Historian Distractions to parents may interfere with history taking Parent’s interpretation of Quality of relationship signs, symptoms Children above the age of 4 may be able to provide some of their own history Reliability of parents’ observations varies Adjust wording of questions - “When did you first notice Johnny was limping”? instead of “When did Johnny’s hip pain start”? 7 8 Parental behaviors/emotions are important Listening to mothers Parental guilt - nonjudgmental/reassurance A smart mother makes often a better diagnosis than a poor doctor. The irate parent: causes August Bier (1861–1949) A German surgeon and a pioneer of spinal anesthesia 9 10 Listenig to mothers Mothers are excellent observers of their offspring and do know About 70 – 80 % of pediatric diagnoses are based mainly on history when they are sick. She may not know what’s wrong but she certainly knows something is wrong. No one can replace the mother in providing an accurate and thorough description of the child and his complaints. Other caretakers – grandparents, aunts, will vary widely in their knowledge of the child. 11 12 2  05.12.2024 Listening to mothers Ask her to define her terms (What do you mean by... ?). You need to establish that you are both talking about the same thing. A good opening is, ‘Tell me about your baby’, and then simply let the mother talk. *…but: a common complaint is: ‘I can’t get him to eat anything’ and a strong overweight toddler Learn through history taking (receiving) to be a good listener – to parents primarily, but also to experienced pediatricians as they elicit clinical histories. Outline of the Pediatric History 13 14 I. Chief Complaint I. Chief Complaint Brief statement of primary problem (including duration) that caused Always identify the patient by name, age and gender. For the chief family to seek medical attention complaint, use the informant's own words if possible. Identify any Examples: crucial identifiers of the patient that are pertinent to the diagnosis. "The rash in his diaper area is getting worse.„ Example: "This is a 6 year old boy with SS disease who presented with fever of one day duration." Parent brings fourteen month old female (Amy) to the PNP with complaints of intermittent vomiting, occurring for past 2 weeks which has increased in frequency this week. 15 16 II. History of Present Illness II. History of Present Illness Initial statement identifying the historian, that person’s relationship A good HPI can frequently identify the diagnosis. Begin with a to patient and their reliability statement that summarizes the recent past medical history and the Age, sex, race, and other important identifying information about patient's current health. patient Example: "Wayne was in his usual state of health, characterized by Concise chronological account of the illness, including any previous well-controlled asthma, until two days prior to presentation when he treatment with full description of symptoms (pertinent positives) and began to..." pertinent negatives. It belongs here if it is relates to the differential diagnosis for the chief complaint. 17 18 3  05.12.2024 II. History of Present Illness II. History of Present Illness The signs and symptoms should be described in chronological If the history suggests a particular disease, inquire about signs and order with appropriate paragraphing and underling for emphasis so symptoms characteristic of the disease. that the reader may obtain maximal information in minimum reading Include all pertinent positives and negatives, as they are of great time. Include all recent outside medical treatments and the name of value in differential diagnosis. the physician who saw the child. Note similar illness in the family and always inquire about recent exposure to contagious diseases. Include how the disease is affecting the patient's vital life functions, i.e., level of activity and intake and output. 19 20 III. Past Medical History III. Past Medical Major medical illnesses History - Prenatal Major surgical illnesses-list operations and dates Pregnancy planned or unplanned; Trauma-fractures, lacerations duration; any complications including bleeding, Previous hospital admissions with dates and diagnoses edema, hypertension, glycosuria, Current medications illness (when?); Known allergies (not just drugs) unusual exposures (radiation, etc.); Immunization status - be specific, not just up to date medications taken during pregnancy; onset of prenatal care; serology results; Rh and blood type 21 22 III. Past Medical History - Birth Date, place weight duration of labor complications during labor type of delivery (spontaneous, c-section, forceps) presentation (vertex, breech) Apgar score 23 24 4  05.12.2024 III. Past Medical History - Neonatal III. Past Medical History - Feeding complications (convulsions, cyanosis, jaundice, rash, vomiting, bleeding, infection, congenital anomalies, resuscitation or oxygen required) Breast - entirely, partially, not at all. How long? good suck and cry Artificial - when started, formula type, current formula, # feedings qd and quantity did baby go home with mother and if not, why not? usually taken Solids - when started, how tolerated. Vitamins - type, amount, when started Present diet - cereal, vegetables, fruit, egg, meat, amount of milk Feeding problems - type, time of onset (emphasis depending on age and chief complaint) 25 26 III. Past Medical History – Growth & Developement Weights at various periods plus linear growth. Milestones: age when smiled, held head, rolled over, sat without support, crawled, stood with support, walked, began teething, spoke words, spoke sentences. Left or right handed. Toilet training begun, completed. 27 28 III. Past Medical History – Specific Illnesses Contagious: note age, complications. Measles, German measles, mumps, chicken pox, pertussis, scarlet fever, polio. Recent exposures Other medical: dysentery, meningitis, pneumonia, rheumatic fever, renal problems, tuberculosis, anemia, asthma (exposures), etc. Operations, accidents: any difficulties (bleeding, transfusions etc.) Hospitalizations: in chronological order; when, where, dx, tx 29 30 5  05.12.2024 III. Past Medical History – Immunizations Diphtheria, pertussis, tetanus (DPT); polio; measles, mumps, rubella (MMR); BCG. Dates, boosters, complications. Last PPD /purified protein derivative – Tb skin test/ placement 31 32 https://www.cdc.gov/vaccines/schedules/ IV. Medications List all, including specific regimens for asthma, seizure, etc. 33 34 V. Allergies List specifics of any untoward reactions to medications or foods (rash, gastrointestinal, sleepiness, irritability, etc.) VII. Review of Systems Do not repeat information found elsewhere. 35 36 6  05.12.2024 VII. Review of Systems – 1. Skin Rashes Petechiae Jaundice Infection 37 38 VII. Review of Systems – 2. HEENT VII. Review of Systems – 3. Respiratory Frequency and nature of complaints Otitis, nasal discharge, colds, sore throats, coughs, nosebleeds, swollen glands, snoring, coughing or choking with feedings Frequency and nature. Chest pain, difficult H E E N T breathing, wheezing. H N E E T Head Eyes Ear Nose Throat 39 40 VII. Review of Systems VII. Review of Systems – 4. Cardiovascular – 5. Gastrointestinal Appetite "Heart trouble" abdominal pain Murmur vomiting (onset, type, color, Dyspnea frequency, relation to feeding) Cyanosis bowel habits (constipation, diarrhea, number, color and Edema character of stools, bleeding) Easy fatiguability pruritus ani Parasites Pica 41 42 7  05.12.2024 VII. Review of Systems VII. Review of Systems – 6. Genitourinary – 7. Musculoskeletal Urinary control Infection Joint or muscle pain Hematuria joint swelling enuresis (diurnal, nocturnal, "growing pains" age of onset) Weakness vaginal discharge menstrual history (if Deformities appropriate) limp or gait abnormalities Circumcision 43 44 VII. Review of Systems VII. Review of Systems – 9. Special senses – 8. Neurologic Vision Convulsions (febrile or afebrile, onset, Hearing type, frequency, how controlled) Syncope Speech Paralysis Tics staring spells head trauma Headache changes in personality motor coordination 45 46 VIII. Family history IX. Social history Familial diseases, including diabetes mellitus, rheumatic fever, allergy, blood dyscrasia, Living situation and renal problems, epilepsy, conditions - daycare, safety mental illness, congenital issues anomalies, tuberculosis, Composition of family syphilis. Causes of death for close relatives Occupation of parents (grandparents, other siblings, etc.) 47 48 8  05.12.2024 Tips Tips Use "the father" or "the mother" instead of "your husband" or "your Don’t forget the child. wife". Children need to be heard and to be noticed. Parents may use lay language. Ask "do you mean..." for clarification as Children over 5 years should be asked to give their account of events needed. with parental comments. Ask if the temperature was actually measured, and if so, what it was. If he does not like to talk, or shy don’t push him Great and give pleasant remarks. 49 50 Summary Summary Eight-year-old boy. Eight-year-old boy. Recurrent chest infections particularly in winter. Recurrent chest infections particularly in winter. Nocturnal cough. Nocturnal cough. Persistent runny nose. Persistent runny nose. Past history of eczema. Past history of eczema. No physical findings today. No physical findings today. Impression: Asthma 51 52 53 9