HISTORY TAKING

IN PAEDIATRICS
DR(MRS) OLUCHI MILDRED IZUKA (MBBCh, FWACP, FMCPaed)
CONSULTANT PAEDIATRICIAN / HOD
DEPARTMENT OF PAEDIATRICS
FEDERAL MEDICAL CENTRE UMUAHIA / COLLEGE OF HEALTH SCIENCES
RHEMA UNIVERSITY ABA
 LEARNING OBJECTIVES
 At the end of this lecture you should be able
to:
To obtain the symptoms from the patients
description and conversation
To analyze the symptoms elicited from the
patient.
HEADINGS USED IN HISTORY TAKING
 Biodata  Neonatal history
 Presenting complaints  Nutritional history
 History of presenting  Immunization history
complaints  Developmental
 Past medical history history
 Gynaecological &  Family & Social
sexual history history
 Pregnancy & Birth  Drug history
history  Review of system
 THE HISTORY
 Conversation

 Conversational skills
Communication skill
Observational skill
Empathy
Patience
 THE HISTORY
 COMMUNICATION
SKILL  Note taking
 Preliminaries  Exaggeration
 Vocabulary  Controlling the
 Unrelated consultation
information
 Direct questions
 THE HISTORY
 Setting the scene
Offer a greeting and introduce yourself
Seek for permission to interact with them
Pleasant surroundings are very important
White coats frighten and intimidate most
children
Avoid having patients full face in front of you
 THE HISTORY
 Accompanying persons
Identify who is present
The educational level of the accompanying
person
For adolescents consider whether the
accompanying person should also be
interviewed either with your patient or
separately.
 Biodata

 NASART VS NASOMART
Name
Age
Sex
Address
Religion
Tribe
 Informant & reliability of informant’s
history(name documented)
 Child informant (6years & above)
 Date of admission
 Route of admission
 Duration of hospitalization
 PRESENTING COMPLAINTS (PC)
 Arranged chronologically
 Using Informant’s own words as much as
possible
 Prior to presentation vs Ago
HISTORY OF PRESENTING COMPLAINTS
(HPC)
 Opening sentence (apparently well)
 Expand on the symptoms given in the PC
Still in chronological order
Leading questions
CIA VS 5C’s
 Treatment history (out of hospital/ in hospital)
 Present condition as perceived by the caregiver
(with evidence)
 PAST MEDICAL HISTORY (PMH)
 May be part of HPC in neonates & young infants
 History of similar illness in the past
 Previous hospitalization, surgery, accidents,
blood transfusion
 Previous illness e.g. infections (measles etc.)
 Chronic illness e.g. sickle cell disease, seizure
disorder
 The patients age at time of illness, as well as
dates & duration of previous hospitalizations /
surgeries should be stated.
GYNAECOLOGICAL & SEXUAL HISTORY
 Where appropriate
 Adolescents (12 years and above)
 Menarche
LMP, cycle, duration, dysmenorrhea,
menorrhagia
 Thelarche
 Pubarche
 Coitarche
 PREGNANCY AND BIRTH HISTORY
 Was pregnancy desired
 When did she realize she was pregnant
 Was there any attempt at termination
 Parity of mother
 ANC---place and when
 PREGNANCY AND BIRTH HISTORY
 Any illness during pregnancy
 Lab test (viral panel & syphilis)
 Drugs or other treatment
 Chronic illness or developed during
pregnancy
 Duration of pregnancy
 PREGNANCY AND BIRTH HISTORY
 How did labour start
 Duration of labour
 Place of delivery (home, maternity, hospital)
 Mode of delivery
 Was the baby born at term
 Did the baby cry immediately afterwards
 Birth weight
 NEONATAL HISTORY
 Did the baby have any illness in the
immediate neonatal period like jaundice,
convulsion etc.
 Duration of hospital stay before discharge
 Cord clamping and care
 NUTRITIONAL HISTORY
 Was the child put to breast within 30 minutes of birth
 Exclusive breastfeeding
 Age at introduction of complementary feeds & with what,
mode of complementary feeds
 Inquire about FADUS & AFASS
 What was the sequence of introduction of other foods
 Present diet
 NUTRITIONAL HISTORY
 24hr dietary recall
 Total duration of breast feeding
 Who feeds the child
 Does he finish what is offered
 Is the child given his own portion or feeds
off a communal bowl
 IMMUNIZATION HISTORY
When was the immunization commenced
What vaccines has the child received
Are they up to date according to NPI
Did the child miss any vaccines and what
was the reason for it
ASPECTS OF DEVELOPMENTAL HISTORY
 Motor
 Social
 Verbal
 Vegetative (bowels & micturition)
 Secondary sexual maturation
 MOTOR DEVELOPMENT
 Gross  Fine (cognitive)
Head control(2-4mon) Palmer grasp (4mon)
Reach out for
Sitting without object(4mon)
support(7mon) Pincer grasp(7mon)
Crawling(10m) Transfer objects from
hand to hand (7mon)
Standing Banging objects on a
Cruising surface (7mon)
Walking(13mon) Building blocks 2 (15
mon)
 MENTAL DEVELOPMENT
 SOCIAL  VERBAL
Social smile (6wks) Cooing(3mon)
Stranger Babbling(6mon)
anxiety(9mon) Single words (9
Wave bye -12mon)
bye(9mon) jargon
 FAMILY & SOCIAL HISTORY
 Birth order of patient
 Is the child adopted
 Monogamous or polygamous
 Number of siblings alive, ages, sexes, any
illness similar to patients
 Number of siblings dead, age at death &
cause of death if known
 FAMILY & SOCIAL HISTORY
 Fathers age, educational status, occupation,
income
 Mothers age, educational status, occupation,
income
 Number of other wives, if any, &
corresponding number of children
 If the patient lives apart from parents, the
SE level & living standard of the guardian
should also be obtained
 SOCIAL HISTORY
 Home environment (type & size of apartment)
 Living standards
Ventilation, overcrowding, netting
Source of drinking water
Sewage disposal method
Use of ITN
 Amount of support provided by father for family upkeep
 School performance
 DRUG HISTORY
 Chronic drug use e.g. for SCA pts, seizure
disorder etc.
 Drug reactions
 Known drug allergy
 REVIEW OF SYSTEM
 Cardiovascular system
 Central nervous system
 Digestive system
 Endocrine system
 Haematologic system
 Musculoskeletal system
 Respiratory system
 Urogenital system
 IMPEDIMENTS TO HISTORY TAKING
 Language barrier
 Cultural beliefs/ practices
 Conclusion

A detailed determination of all aspects of the