How to take History?

In pediatrics

Prepared and Revised by:

Assistant professor Dr.Mohammed Mahir Mushref

Dr.Rana Fahmi Shitran

Dr.Ahmed Abdulkareem

History taking in pediatrics

1-PERSONAL  DATA

Patient name

Age: if<2 years write in months

Sex : Some diseases have sex predilection for example in X linked diseases Males are more commonly and more severely affected than females. Female carriers are generally unaffected, or if affected, they are affected more mildly than males.

Residence: some diseases are common or endemic in certain areas. 

Date of admission : e.g. admitted on the 2nd of march or mention the no of days in hospital

The person from whom history taking

2-CHIEF COMPLIANT AND ITS DURATION :

 Use patient words like frequent bowel motion for diarrhea, yellowish discoloration for jaundice , abnormal body movements for fit .

3-HISTORY OF PRESENT ILLNESS:

 this part include

-Pre-hospitalization history: each symptom should be analyzed regarding ( onset ,nature ,location ,radiation , relieving and aggravating factors , and associated symptoms) . asking  question related to that system.

Any history in pediatrics should ask about ( appetite ,feeding, , activity , sleep)

-What happened before admission  : medications , medical interference ,duration of treatment and response should be mentioned.

-hospitalization  : should include investigation taken, medication, received blood or plasma the progress of illness and any change in activity, sleep, or feeding).

4-REVIEW OF SYSTEMS :

 according to child age

-Gastrointestinal tract :

   1-swallowin difficulties

   2-vomiting or nausea :amount , frequency , duration ,projectile or not, color of vomitus (bile , blood ,associated with clot or not .

   3-Abdominal pain : site , onset , duration, radiation, nature, association ,relieving and aggravating factors .

   4-diarrea:frequency , amount ,consistency ,associated with mucous  ,  blood. malodourous , floating on water ,abdominal pain.

   5-costipation: time and frequency of defecation ,associated with abdominal , rectal or anal pain , associated with vomiting , also describe the appearance , color , consistency and character of feces .

   6-pruritis

   7-jaundice :onset ,color of urine  , color of stool , itching ,associated symptoms ,history of drug ingestion .

   8-rectal bleeding : pain ,blood color ,timing of bleeding with defecation ,severity ,associated with mucous or pus unformed stool or urgency

-Respiratory system:

   1-shortness of breathing :onset , intermittent or persistent ,exercise induced, nocturnal or diurnal , associated with cough, cyanosis, breath holding, severity , aggravating or relieving factor.

   2-cough :type of cough ,dry or moist, accompanied by sputum ( swallowed ,or expectorated, watery ,mucoid , mucopurulent , blood stained). Associated pain , vomitus after cough wheeze and nasal discharge. More severe at day or night . disturb sleep.

  3-chest pain

  4-hemoptysis: frequency , duration, degree of bleeding

-cardiovascular: fainting attacks , cyanosis , squatting ,chest pain , palpitation, breathless on exertion or feeding

-genitourinary: urgency , frequency ,dysuria, nocturnal enuresis, hematuria.

-neurological :fit (preceding fever or not state of patient before and after fit ) ,the type of movement observed , up rolling of eyes, frothy secretion from mouth ,duration stopped spontaneously or by medications, injuries , state of consciousness and incontinence after fit . faint ,headaches ,anosmia ,visual disturbance , parasthesia , weakness , visual disturbance.

-musculoskeletal : limp ,joint pain , swelling , skin rash.

5- PAST HISTORY

  -perinatal history: which include

   *prenatal history : age of mother , antenatal care ,any disease D.M , H.T ,hemorrhage, fever . x-ray exposure ,drug taken , smoking or alcohol consumption .

   *natal : mode of delivery (NVD or CS and the cause of C/S),gravidity, parity , abortion ,types of anesthesia length of labor , complication , duration of rupture membrane.

   *post natal :term or pre term, single or multiple  , cry immediately or not , need NCU for any reason  , birth weight , meconium stained liquor , passage of urine or meconium in first day .

  -past medical history : any admission to hospital ,time of admission, for same disease or other disease, length of stay in hospital , discharged well or on medication .history of atopy ( dermatitis, rhinitis) . history of communicable diseases.

  -drug history : name of drug , dose , duration , mode of administration , chronic use or not . drug allergy .history of blood transfusion .

  -past surgical : any operation include circumcision ,date, cause of operation , any complication .

6-VACCINATION HISTORY :

routine national immunization in iraq 2017

  BCG : first week, intra dermal in upper 1/3 of left deltoid .

  DPT:I.M

  OPV: 2-3 drops orally

  HEP B: I.M thigh

  MMR: subcutaneous

7-DEVELOPMENTAL HISTORY (MEDIAN AGE)

  -Gross motor : newborn: limb flexed , symmetrical posture

                              6-8 weeks: raised head to 45 degree

                              6-8 months: sit without support

                              8-9 months: crawling

                              10 month : walk around furniture

                              12 months: walking unsteadily

                              15 months : walk steadily

 -fine motor : 6 weeks :follow moving objects of face by turning head

                          4 m :reach out for toys

                          6 m : transfer object from hant to hand+ palmar grasp

                           10 m : pincer grip

                           14 m :scribbles with a pencil

 Pencil skills : circle (3 y) , cross (4 y) , square (4 and 1/2 years), triangle (5 years ).

  Hand skills : building with bricks : tower of three (18 m) ,tower of six (2 y) ,tower of eight (2 and 1/2 years ).

-social, behavioral and emotional: 6 w: smile responsively

8 m: puts food in mouth

1o m :waves bye bye

12 m :drinks from a cup

18 m: holds a spoon and gets food safely to mouth

2 y :dry by day , pulls off some clothes.

3 y :interactive play.

-speech , language , and hearing:

 newborn : startles to loud sound

3 m :vocalize alone or when spoken to coos and laugh

7 m:turns to soft sounds out of sight.

7-10 m: say dada, mama

12m: 2-3 words other than baba , mama

18m: show four pats of body

20-24 m:use 2-3 words to make simple phrases.

2and half- 3 years: take consistently  in 4-4 word sentence.

8-FEEDING HISTORY:

   -exclusive breast feeding : number of feedings , using both breasts , duration of feeding , difficulties in feeding , baby quiet , calm , sleep .

   -exclusive bottle feeding : no of feeding , no of ounces each feed , type of milk , no of bottle, way of sterilization , source of water used in milk preparation , how long the can of milk lasting , calculate if taking enough calories

   -mixed feeding : bottle and breast feeding

   -solid food : started at 6^th month , one type of food each time to see sensitivity  , not added sugar or salt .

Calculation of total daily requirement  and total amount of milk in a bottle feed infant .

Note : 1 once =28 ml = 20 kcal

The caloric requirement for children up to 1 year =120 kcal /kg/day.

No of feeds : birth -2ws :every 2 hrs

                        2ws – 3ms :every 3 hrs

                        >3 ms :every 4 hrs

9-FAMILY HISTORY :

 Age and state of both parents ,consanguinity (relative or not ) the risk of genetic disorder for offspring of first cousin 6-8% double the risk in general population (nelson textbook of pediatrics 20^th edition p595)

, no. of children , order of this child, health states of other siblings  , history of death in family children and the cause, family history of asthma ,eczema,  Tuberculosis, cardiovascular disease and other diseases .

10-SOCIAL HISTORY :

-occupation of parents , including frequent and prolonged parent absence.

-house hold ( rural or urban)

- socioeconomic state ,crowding in house

- sanity in house and water supply, any animals in house , smoking.

-major life events : divorce ,major illness , death , accident ,separation .

-psychiatric illness: depression

-substance abuse

The family may use the child to seek for help

- poor school performance , excessive crying, and sleep disturbance are common problems .