Taking a Paediatric History PDF

TAKING A PAEDIATRIC HISTORY Dr Sharvari Inamdar Introduce yourself Confirm child’s details Establish names and relationships of carers present with the child Observe the child Ask questions to the child when appropriate Use an interpreter if necessary Ask open-ended questions P...

TAKING A PAEDIATRIC HISTORY Dr Sharvari Inamdar Introduce yourself Confirm child’s details Establish names and relationships of carers present with the child Observe the child Ask questions to the child when appropriate Use an interpreter if necessary Ask open-ended questions Presenting Complaint F – First Time? O – Onset D – Duration I – Intensity P – Progression A – Aggravating factors R – Relieving factors A –Associated symptoms, Anything else? Systems Review CNS – headaches, dizziness, loss of consciousness, seizures ENT – sore throat, ear pain RS – cough, wheeze, breathlessness CVS – palpitations, chest pain, dizziness GIT – nausea, vomiting, abdominal pain, appetite, stool GUT – urine, dysuria, flank pain, menstruation (when applicable) MSS – joint swelling, joint pain/stiffness, rashes  Additional questions Feeding well? Weeing okay? Pooing okay? Behaviour? Past History Medical conditions? Hospital admissions? Medications? Allergies Perinatal History How was the pregnancy? Birth – term/preterm? Delivery – normal, C-section? Birth weight Any problems during or after birth? Need for neonatal unit admission, resuscitation Need for respiratory support – type and duration Immunization History Developmental History Gross motor Fine motor and vision Screen for a few memorable milestones Speech and hearing Social Growth History Height Weight Red book Family History Any childhood or young adult diseases in the family? Any siblings? Consanguinity? Social History Who else lives in the household? Living conditions? Nursery? School? Pets? Social worker? Questions to ask from an infectious perspective Travel Exposure Contact  Summarize the key points Anything else to add that might have been missed Ask about any concerns or questions Focused history Be thorough Be systematic Thank you!!