History taking in pediatrics

details on history taking in pediatrics

1. HISTORY TAKING IN PEDIATRICS Dr S hambhavi Sharma

2. History taking Patients particulars Chief complaints History of presenting illness Birth history Nutrition history Immunization history Developmental history

3. Past history Family history Drug and treatment history Socio economic history

4. PATIENT’S PROFILE 1 ) Name 2 ) Age (Date of Birth ) 3 ) Sex 4 ) Address of parents 5 ) Date of admission. PRESENTING COMPLAINTS ( Use parents’ own words + chronological order ) HISTORY OF PRESENT ILLNESS 1 ) Enquire as to when patient was last entirely well ? 2 ) Presenting complaints a)Time (onset , duration , frequency , course ) b ) Place (site ) c ) Quality (character e.g. of pain , composition of vomitus ) d ) Quantity (severity of pain , amount of vomitus ) e ) aggravating and releiving factors f) variations (diurnal or seasonal) g) Associated symptom h)Treatment if any

5. 3) Systemic inquiry General (weight loss , appetite) CVS (shortness of breath on exertion , shortness of breath and sweaty onfeeding , cyanotic spells, squatting, fainting or syncope, cyanosis, edema, chestpain /palpitations)

6. c) Respiratory system (sore throat, earache, cough, wheeze, frequent chestinfections , history of aspiration, hemoptysis ) d ) Gastrointestinal system (abdominal pain, vomiting, jaundice,diarrhea /constipation, blood in stools ) e ) CNS (fits, syncope/dizziness, headache, visual problems, numbness/ unpleasantsensations , weakness/frequent falls, incontinence ) f ) Genitourinary system (stream, dysuria , frequency, nocturia / enuresis,incontinence , hematuria ) g ) Rheumatological system (limp, joint swelling, hair loss, skin rash, drymouth /mouth ulcers, dry or sore eyes, cold extremities)

7. IV. BIRTH HISTORY ( Important in neonatal, genetic or developmental case ) ANTENATAL HISTORY (H/O PREGNANCY ) H & N status (Health and nutritional status of mom duringpregnancy ) Illness during pregnancy (HTN, DM, pre- eclampsia , antepartumhaemorrhage ) Infections during pregnancy (rubella, UTIs, syphilis, T.B .) Drugs (iron, multivitamin, other drugs with dose, duration and at which time of gestation X-ray (h/o irradiation in 1sttrimester) TT (maternal vaccination against tetanus) Past obstetric (problems with previous pregnancies, stillbirths,miscarriages , birth weight of previous children, prematurity, blood transfusions)

8. POSTNATAL HISTORY 1)cry (immediately/cyanosed/ apneic ) 2) Basic problems (need for resuscitation, problem with respiration,sucking /swallowing 3) Birth weight 4) Birth injury 5) Convulsions, cyanosis, jaundice, fever, rash 6) Procedures (exchange transfusion, umbilical artery catheterization,drugs )

9. NATAL HISTORY (H/O DELIVERY) Place of delivery (hospital/home) Conducted by ( dai /trained health visitor/doctor) Sterilization technique for instruments Gestation time (length) Rupture time (time of rupture of membranes) Labour time (duration) Presentation and type of delivery (SVD, forceps, vacuum extractionor C-section) Sedation/analgesics during labour Complications (abnormal bleeding)

10.  V. FEEDING HISTORY ( Significant in child < 2 years , anemic or malnourished ) 1 ) Onset of feeding (after how many hours ) 2 ) Type of feed Breast-fed (duration ) • Bottle-fed (at what age, composition of formula, amount, frequency, dilution ) 3 ) Supplements (vitamin, iron ) 4 ) Weaning (when, what, amount, frequency ) 5 ) Current diet/change in diet during illness

11. IMMUNIZATION HISTORY (check vaccination card) 1 ) Types of Vaccinations given 2 ) Age at which started and by whom 3 ) Doses & adverse effects DEVELOPMENTAL HISTORY 1)Achieving age of various milestones • Smiling• Ability to hold neck• Sit• Crawl• Stand• Walk• Talk• Control of bladder and bowel 2 ) Compared with normal for this age

12. PAST HISTORY 1 ) Significant illness in the past (esp. diarrhea, respiratory infections, fevers, fits, jaundice ) 2 ) History of similar complaints in the past PERSONAL HISTORY Particular habits of child Details of class, school and interest in studies Any missed school attendance Behavior of the child at school and relationship with other children DRUG HISTORY Any medications used (frequency, dose, adverse effects ) 2 ) Allergy to any drug H/o Mom drug usage ** (in neonate or breast fed baby )

13. FAMILY HISTORY (Important in chromosomal, hereditary, infectious diseases) Age of mother and father? How long married? 2) Consanguinity 3) Parents’ health (present and past) 4) Siblings• Number• Age and sex• Illness• Any death (cause if known or symptoms of illness before death)• Stillbirths, miscarriages 5) Grand parents’ health (esp. if living with family) 6) Health of uncles, aunts and their children (if inherited disorder suspected) 7) DO MAKE A FAMILY TREE SOCIO-ECONOMIC HISTORY 1) Parents’ education and occupation2) Family income3) House (made of, persons living, size)4) Cleanliness and general hygienic conditions5) Source of drinking water6) Any pets at home