4 A pediatric history is a systematic and

PEDIATRIC HISTORY

1. PEDIATRIC HISTORY PRESENTER: LINDA MOGAMBI RN, BSc, MSc .

2. Introduction Look for environmental clues/ explanation of injuries Observe child interaction with parent/care giver Give the child a chance to trust you Use age appropriate language Involve the parent and the child Provide a toy for distraction purposes

3. Source of data Parents/ care taker Referral notes Child if old enough . Note time client arrived at point of service, condition of client, any medical management initiated and who accompanied the patient. If treatment had been initiated, ensure proper documentation is done before receiving the patient.

4. Biographic Data Age Sex / Gender Name of parents/ guardian Religion Residence Contact information: Address, mobile number

5. Chief complaint The client’s answer to the question “What brought you to the hospital?” or “What is troubling you?” is expressed in the client’s own words Reason why the client is seeking medical help

6. History of Presenting Illness This includes the history of onset, and sequence of symptom(s) in the present illness i.e. When the symptoms started If development was sudden or gradual Severity and frequency of occurrence Site or location of distress Character of the complaint, its intensity or quality Activity of the client which may be involved in the development of the problem Phenomena or symptoms associated with the chief complaint, and the factors that aggravate or alleviate the problem

7. HPI cont…. List items in order of appearance Write in a narrative fashion (tell the “story” why the patient is there). It is important that you gain a clear idea in your mind of the chronology of the problem, so make sure you have done so by ‘playing back’ the history to the family.

8. History of Presenting Illness Example; S tarting from when the child was last ‘100%’ or ‘their normal self ’: Client was well until…… 4 weeks ago: onset of cough; 3 days ago: sore throat; Today: convulsion. Relieving and exacerbating factors Action taken by parents, including medication given. If possible ask mother to show container of meds and give brief description of the same.

9. Past Medical History The referral letter is often helpful in determining previous visits to the doctor’s surgery and details of any medication the child has been given. Ask about all admissions to hospital, surgeries or blood transfusion . Ask about any congenital, chronic illnesses diagnosed Enquire about any drug allergies and determine how severe any previous allergic reactions had been . Ask specifically about childhood communicable diseases: measles, diphtheria, chicken pox etc. Ask mother for well baby clinic card and confirm incidence of childhood infections.

10. History of pregnancy and birth - Perinatal Antenatal Duration of pregnancy Enquire about any problems during the pregnancy such as hypertension, smoking, drug ingestion , influenza-like illnesses (TORCHES ). ANC attendance and interventions

11. History of pregnancy and birth - Perinatal Natal : Labor & Birth history Gestational age Duration of labor Type of delivery - If caesarean section was done, indication for this Place of delivery Any significant event during delivery (injuries, excessive bleeding etc ) Birth weight Condition of baby and mother after delivery

12. History of pregnancy and birth - Perinatal Post-natal Mother and Baby’s condition in post-natal period. Maternal complications: infections, medical conditions in peuperium e.g. puerperal psychosis. Newborn problems: Admission into nursery: prematurity , resuscitation, respiratory distress, jaundice and infections .

13. Nutrition and Immunization History Nutritional history Infants: breastfeeding/formula, Age of introduction of solids Assess adequacy of current diet History of food allergies Food preferences and conflicts Older Child: Variety of diet (appropriate source of Fe +,Ca +, etc.), “junk food’’ intake. Adolescent: Food preferences, dieting, purging, body image, calcium and iron intake in girls

14. Nutrition and Immunization History Immunization History Ask mother vaccines the child has received Review immunization card if available Check for presence of BCG scar

15. Developmental History Age of acquisition on milestones in the four aspects of development Motor Cognitive Social & emotional Moral

16. Family Social History Family History Age and health status of all 1st degree relatives. In case of death of any family member, inquire into the cause of death. Risks for genetic disorders: history of premature/unexpected deaths, stillborns, consanguinity. History of chronic medical conditions , mental illness, suicide

17. Family Social History cont… Social History Household composition and any other caregivers. Residence H/o violence, substance abuse, etc in the home. Parental occupation (risk for toxin exposure). Child’s school performance Child’s relationship with family members and significant others

18. Family Social History Cont … Health maintenance Access to clean water for domestic use Use of mosquito net to prevent malaria Provision of safety needs for the child Hand hygiene Well ventilated house Adherence to health appointments In current illness: Knowledge of child’s condition, management

19. Review of Systems A system review will;  Bring out symptoms or signs missed in collection of data about the present illness.  Direct the interviewer into questioning about other systems that have some indirect bearing on the present illness (ex. - eczema in a child with asthma).  Serve as a screening device for uncovering symptoms, past or present, which were omitted in the earlier part of the interview.  Skin :  Ask about rashes, hives, problems with hair, skin texture or color, etc. Eyes :  Have the child's eyes ever been crossed?  Any foreign body or infection, glasses for any reason. Ears, Nose and Throat :  Frequent colds, sore throat, sneezing, stuffy nose, discharge, post-nasal drip, mouth breathing, snoring, otitis, hearing, adenitis. Teeth :  Age of eruption of deciduous and permanent; number at one year; comparison with siblings.

20. Cardio respiratory:   Frequency and nature of disturbances. Dyspnea , chest pain, cough, sputum, wheeze, expectoration, cyanosis, edema, syncope, tachycardia. Gastrointestinal :  Vomiting, diarrhea, constipation, type of stools, abdominal pain or discomfort, jaundice. Genitourinary :  Enuresis, dysuria , frequency, polyuria , pyuria , hematuria , character of stream, vaginal discharge, menstrual history, bladder control, abnormalities of penis or testes.         Neuromuscular :  Headache, nervousness, dizziness, tingling, convulsions, habit spasms, ataxia, muscle or joint pains, postural deformities, exercise tolerance, gait. Endocrine :  Disturbances of growth, excessive fluid intake, polyphagia , goiter, thyroid disease. General:   Unusual weight gain or loss, fatigue, temperature sensitivity, mentality.  Pattern of growth (record previous heights and weights on appropriate graphs).  Time and pattern of pubescence.

21. Functional health patterns Gordon’s system of functional health patterns provides an excellent format for data collection. It groups human responses into 12 domains based on human response patterns: Health perception-health management pattern. Nutrition-metabolic pattern. Elimination pattern

22. Functional patterns cont… Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Self perception-self concept pattern Role-relationship pattern Sexuality-reproductive pattern Coping-stress tolerance pattern Value-belief pattern