PAEDIATRIC HISTORY TAKING
Simwanza webster
Bsc –Cs, Dip-CM, Dip - SLT
Aim
• To get accurate account of symptoms that
represent clinical problem against
background of patient.
• (Holistic understanding of patients clinical
problem and insight into patient’s life)
Aim
• Patient to tell story in own words (parents/
guardian)
• Consultation starts as patient/mother is
walking into room – observe
• Must be communication – 2 way system
between yourself and parents/guardians
and sometimes the patient
• Be a good listener
Vital information -
demographics
• Informant
• Name of patient
• Sex
• Age
• Address
• Religion
Presenting Complaint
• E.g. Cough x 10
• 7
• Fever x 4
• 7
• neck ache x 2
• 7
Development of symptoms
• In chronological order
• Ask informant to tell you their story in their
own words
• Discourage use of medical terms
• Be attentive
• Examine each symptom in detail
• Clarify any unclear symptoms, tactfully
Review of systems ( systemic
review)
(direct questioning)
• General: weight
• sleep
• energy
• GIT: Pain all characteristics of pain – site,
frequency, type of pain, any radiation,
aggravating and localising factors, any other
signs, appetite
Systemic review
• Vomiting – characteristic of vomitus –
colour, when, any blood, frequency
• Diarrhoea – characteristics of diarrhoea –
colour, how many times ( frequency),
consistency – solid, semi-solid, watery.
Any blood, mucus
• Liver/ gall bladder
• Jaundice – are the stools pale or dark
• Does skin itch ( checking for pruritis
which indicates obstructive jaundice)
Systemic review: Genital urinary
system
• Urine – passage frequency during -/day
• - at night
• Dysuria
• Frequency of micturation
• colour
Systemic review -
cardiovascular
• Dyspnoea – exertional, orthopnoea,
paroxsymal nocturnal dyspnoea
• Pain or tightness in chest over precordial
area
• Palpitation
• Cough
• Oedema
• Excessive sweating (in congenital heart
diseases )
Respiratory system
• Cough
• Sputum – colour, smell, frothy, copious, viscid,
time of day, smell?
• Copius greenish sputum, foul smelling-
Bronchiectasis, viscid – cough mostly on waking
up in the morning – broncitis, frothy sputum,
sometimes blood stained – pulmonary oedema.
• Wheeze
• Chest pain in older child: characteristics of chest
pain
Systemic review-
haematological
• Diet
• Past history of loss of blood: gum bleeding,
epistaxis, bruising, rectal bleeding, maleana,
bleeding secondary to trauma, bleeding into
skin; petechiae, purpura, ecchymosis.
• Drug history
• Lassitude, dyspnoea
• Infections
• Skin problems – rashes, change of colour
• Glandular enlargement
Systemic review - CNS
• Fainting attacks (blackouts)
• Loss of consciousness
• Dizziness
• Sleepiness
• Stroke
• Convulsions – age, interval, type, loss of
consciousness, incontinence and
regularity. Is it epilepsy?
Systemic review – muscular skeletal
• Ability to carry out normal duties
Past Medical History
• Any previous major illness
• Any previous admissions and for what
illness
• When?
• Drug History
Birth history
• History of pregnancy – antenatal in
mother
• Baby born Term or premature
• Type of delivery
• Birth weight
• Child cried at birth?
• Mode of feeding shortly after birth
• Did mum have PMTCT during pregnancy
Developmental history
• When did child smile – 6 weeks,
• attain head-neck control – 3 months
• Sit unsupported – 7 months
• Transfers objects - 7 months
• talks: da, ma – 7 months
• Crawls – 10 months
• Walks unaided – 13 months
• walk, talk.
• Refer to developmental lecture: fine motor,
gross motor, social development and speech
Nutritional history
• Feeding pattern: what types of food does
child eat and when?
• How many times a day?
• When stopped breastfeeding?
• When weaned?
• Look at under-five card for growth chart
and relate to nutritional history
Immunization history
• Review immunisation for the child and
ensure all immunisation are up-todate
• Also review any tests for HIV:
• DNA PCR at six weeks – which is piggy-
backed onto immunisation schedule
• HIV Antibody tests
Family history
• No of children in family
• Birth order of child
• No. Of paediatric deaths and of what, when,
age
• Family history of PTB, asthma, SCD,
hypertension, Diabetes mellitus, similar
illness in family
• Health state of parents – mother/father ,
alive or deceased
Socio-economic
• Area of residence
• No of occupants in house
• Size of house
• Income
• Occupation of parents
Summary of history
• Always make a Summary of history –
important positives and important
negatives
