CLINICAL HISTORY TAKING - paediatrics.pptx

Brief illustration on how clinical histories are taken for paediatrics

1. PREP CLASS 2026 PAEDIATRIC HISTORY TAKING 10/15/2025 PREP CLASS 2026 1

2. SIGNIFICANCE OF HISTORY TAKING? HISTORY TAKING IS A REQUIRED SKILLS FOR CLINICAL PRACTICE, HENCE POOR HISTORY TAKING SKILLS INDICATES POOR CLINICAL PRACTISE HISTORY TAKING ALLOWS THE CLINICIAN TO COMMUNICATE EFFECTIVELY WITH THE PATIENT ON THE REASON HE/SHE HAS APPEARED AT THE FACILITY. HISTORY TAKING HELPS YOU TO EXPLORE A LOT ABOUT THE PATIENT. HISTORY TAKING DO NOT FOLLOW ANY SPECIFIC PATTERN ASIDE IT BACKBONE. THE CONTENT OF YOUR HISTORY WILL DEPEND ON THE PATIENT’S PRESENTING COMPLAIN. DURING EXAMINATIONS, YOUR HISTORY SHOULD BE AS DETAILED AS POSSIBLE. TO BE ABLE TO ESTABLISH PROPER DIAGNOSIS, IT REQUIRES HISTORY TAKING, PHYSICAL EXAMINATION AND INVESTIGATION. 10/15/2025 PREP CLASS 2026 2

3. CONTENT OF INTERNAL MEDICINE HISTORY TAKING INTRODUCTION(INTRODUCE YOURSELF) DEMOGRAPHY OF THE PATIENT RAPPORT PRESENTING COMPLAINT HISTORY OF THE PRESENTING COMPLAIN ON DIRECT QUESTIONING SYSTEMIC ENQUIRES BIRTH HISTORY IMMUNISATION HISTORY NUTRITIONAL HISTORY DEVELOPMENTAL HISTORY 10/15/2025 PREP CLASS 2026 3 PAST MEDICAL AND SURGICAL HISTORY DRUG HISTORY FAMILY HISTORY SOCIAL HISTORY SUMMARY

4. INTRODUCTION GREETING YOUR NAME YOUR ROLE YOU SEEK FOR CONSENT 10/15/2025 PREP CLASS 2026 4

5. DEMOGRAPHY N – NAME A – AGE S- SEX R- RELIGION OF THE MOTHER O – OCCUPATION OF THE MOTHER A- ADDRESS OF THE MOTHER M- MARITAL STATUS OF THE MOTHER 10/15/2025 PREP CLASS 2026 5

6. ESTABLISH RAPPORT YOU BASICALLY ESTABLISH REPORT BY ASKING HOW THE PATIENT IS DOING, AND ITS ENOUGH FOR EXAMINATION PURPOSES. 10/15/2025 PREP CLASS 2026 6 PRESENTING COMPLAIN WHAT ACTUALLY BROUGHT THE PATIENT TO THE HOSPITAL IT SHOULD BE IN THE PATIENTS’ OWN WORDS , NO MEDICAL TERM THERE SHOULD ALWAYS BE A DURATION E.G COUGH – 3 DAYS 0R 5/7 , 2/4, 4/12, 18/12

7. HISTORY OF PRESENTING COMPLAIN 10/15/2025 PREP CLASS 2026 7 WHAT IF ITS NOT A PAIN? P – PROGRESSION A - ASSOCIATED SYMPTOMS R - RISK FACTORS/ RELEVANT BACKGROUND A - ALLEVIATING AND EXCERBATING FACTORS O - ONSET D - DURATION

8. ON-DIRECT QUESTIONING This depends on the presenting complain. Usually about the affected system. Some things are always common to ask, e.g Headache, Fever, Anorexia, Weight loss, easy fatigue, loss of appetite, irritable cry, pulling of the ear, drooling, squatting more often, jaundice, nasal discharge, difficulty breathing. 10/15/2025 PREP CLASS 2026 8

9. SYSTEMIC ENQUIRES This explores possible symptoms from all various systems. Cardiovascular System~ palpitations, orthopnoea, chest pains, ankle swelling, paroxysmal nocturnal dyspnoea, and tiredness . Respiratory System~ cough, sputum production, chest pains, haemoptysis, breathlessness and wheeze. Gastrointestinal system~ mouth or bleeding gums, nausea, vomiting, bowel habits and nature of the stools, abdominal pains, difficulty with swallowing, belching, haematemesis, epigastric fullness and flatus, indigestion, the colour of stools (when indicated) Nervous System~ headache, numbness/tingling, muscle weakness, dizziness, vertigo, blackouts, fits, sleep pattern, vision and double vision, syncope, hearing loss. Genitourinary System~ libido, vaginal discharge, urethral discharge, painful urination, freq. urination, sexually active, number of sexual partners. Musculoskeletal System~ muscle pain or weakness, stiffness and swelling of the joints . Integumentary System~ rashes, urticaria, pruritis, bleeding tendencies, scaly or shinny skin, hyper/hypopigmentation, pustules, patches etc. 10/15/2025 PREP CLASS 2026 9

10. BIRTH & PREGNANCY HISTORY Was the pregnancy wanted and planned ? How did she know she was pregnancy? Number of ANC visit Prophylaxis and Immunization during pregnancy Any complications associated with the pregnancy Was the pregnancy carried to term Mode of delivery Did the baby cry after delivery Any other complication after birth Any admissions after birth 10/15/2025 PREP CLASS 2026 10

11. IMMUNIZATION HISTORY 10/15/2025 PREP CLASS 2026 11

12. NUTRITIONAL HISTORY 10/15/2025 PREP CLASS 2026 12

13. DEVELOPMENTAL HISTORY 10/15/2025 PREP CLASS 2026 13

14. PAST MEDICAL AND SURGICAL HISTORY This is to explore any underlying medical conditions, previous surgical and non-surgical procedures, previous traumatic history . MNEUMONIC FOR MEDICAL CONDITIONS – MI THREADCA M I - MYOCARDIAL INFARCTION, T- TUBERCULOSIS, H- HYPERTENSION, R- RHEUMATIOD ARTHRITIS , E- EPILEPSY , A- ASTHMA, D- DIABETES MELLITUS , CA – CANCER OTHERS- SICKLE CELL CRISIS, SEVERE MALARIA ….. Past surgical Procedure – When, Where and on what account. Previous Blood Transfusion- When, Where and on what account 10/15/2025 PREP CLASS 2026 14

15. DRUG HISTORY Any drug the patient is taking. Either supplements, herbal medications, medication for the treatment of an underlying medical condition. 10/15/2025 PREP CLASS 2026 15

16. FAMILY HISTORY Explore any possible medical condition existing in the family. Usually chronic condition, hereditary condition, infectious conditions. MNEUMONIC FOR MEDICAL CONDITIONS – MI THREADCA M I - MYOCARDIAL INFARCTION, T- TUBERCULOSIS, H- HYPERTENSION, R- RHEUMATIOD ARTHRITIS , E- EPILEPSY , A- ASTHMA, D- DIABETES MELLITUS , CA – CANCER AND OTHERS . 10/15/2025 PREP CLASS 2026 16

17. SOCIAL HISTORY & TRAVEL HISTORY Home conditions Playful Parental support Interests, and habits Food Use of ITN Smoking Alcohol consumption. Traveling history 10/15/2025 PREP CLASS 2026 17

18. SUMMARY OF THE HISTORY PRESENTING COMPLAIN WITH DURATION SIGNIFICANT POSITIVE FINDINGS SIGNIFICANT NEGATIVE FINDINGS RISK FACTORS & ASSOCIATED SYMPTOMS PAST MEDICAL & SURGICAL HISTORY. 10/15/2025 PREP CLASS 2026 18

19. IMPRESSION DIFFERENTIAL DIAGNOSIS FOR THE PATIENT AT LEAST 3 10/15/2025 PREP CLASS 2026 19 PLAN INCLUDES VARIOUS INVESTIGATIONS TO CONFIRM YOUR DIAGNOSIS YOUR IMMEDIATE MANAGEMENT FOR THE PATIENT SUBSEQUENTLY YOUR DEFINITE MANAGEMENT FOR THE PATIENT

20. 10/15/2025 PREP CLASS 2026 20

21. REFERENCE T.C ANKRAH HISTORY TAKING AND EXAMINATION HANDBOOK MACLEOD CLINICAL HISTORY AND EXAMINATION TEXTBOOK . 10/15/2025 PREP CLASS 2026 21