How to Take History in Paeds?
How to Take History in Paeds?
History taking in Paeds or paediatrics is somewhat different from medicine because the patient we dealing here is more innocent one and has some distinguished needs. So we have to cover some extra topics like birth history, feeding and developmental history etc to make a good diagnosis. So coming to the protocol of history, key points are as;
- Patient profile or Bio-data
- Presenting complaints (PC)
- History of present illness (HOPI)
- Past Illness History (PH)
- Birth History
- Feeding History (Breast feeding + Weaning)
- Immunization History
- Developmental History
- Personal History
- Drug History
- Family History
- Socio-economic History
Biodata / Patient Profile
- Son / Daughter of
- Mode of Admission (MOA)
- Date of Admission (DOA)
Presenting Complaint (PC)
Presenting complaint merits only those which the parents complain about and use the parent words only (not your medical terminology) and care the chronological order.
(Parent words only + Chronological order / Order of Importance)
History of Present Illness (HOPI)
- Ask the parents when the patient child was completely well? (Time)
- Ask now about the presenting complain in following order;
- Site (where or which part of body is affected?)
- Time (onset, duration, course and frequency)
- Quality (character e.g if pain is the complaint, composition and consistency if vomiting)
- Quantity (Severity e.g of pain, amount / cup of vomits)
- Periodicity (complaint reoccurs after some days e.g diurnal or seasonal)
- Aggravating factors / Relieving Factors
- Associated factors
- Systemic Inquiry (SI)
- Respiratory System
- Gastrointestinal System
- Genitourinary System
- Rheumatological System
Birth history covers three aspects i-e antenatal (h/o of pregnancy), natal (h/o of delivery) and post natal history.
Birth history is important in cases involving neonatal, genetic and developmental problems.
1. Antenatal History (History of Pregnancy)
- Health and nutritional status of mother
- Ailment during pregnancy like PIH, GDM, pre-eclampsia
- Infections during pregnancy (TORCH infection)
- Drug intake and time (vitamin supplement, iron tablet and especially drugs affecting fetus)
- Tetanus vaccination of mother
- X-ray exposure and time
2. Natal History (History of Delivery)
- Place of delivery (home or hospital)
- Assisted by (dai or trained professional)
- Sterilization of instruments done or not?
- Gestation time length (term or preterm)
- Membranes rupture (preterm rupture or not)
- Labour duration
- Presentation and mode of delivery (SVD, forceps assisted, ventouse assisted or C-section)
- Anaesthesia during labour
- Complications of birth like PPH
3. Postnatal History
- First cry (time, method to elicit cry)
- Birth injury
- Birth weight
- Basic problems and ailment (cynosis, respiration difficulty, jaundice, rash etc)
- Treatment or procedures
Feeding History (Breast Feeding + Weaning)
Feeding history is important in children < 2 years, anemic or malnourished.
- Onset of feeding
- Type of feeding
- Breast feeding (duration of feeding)
- Bottle feeding (when, composition of feed / milk and dilution, amount, frequency)
- Supplement of iron or vitamin
- Weaning (when, what, amount, frequency)
- Current diet
Vaccination card should be checked if available.
- Which vaccines have been administered and when?
- Age of vaccination and by whom or where?
- Any adverse effects?
- Achieving various milestones for that age;
- Ability to hold neck
- Control of bladder and bowel habits
- Compare with normal for that age
Past Illness History
Past illness history covers the diseases experienced in the past like diarrhoea, respiratory infections, fever etc.
Past history mainly focuses on diseases that has been resolved and treated for. The current ongoing disease or ailment besides primary complaint is considered as co-morbidity.
Personal history covers the habits, social attitude towards others (other than parents especially mother) and is compared with children of same age. The points considered significant are;
- Particular habit of child (not seen in routine)
- Interest in school or studies (if the child is of school going age)
- Behaviour and relationship with other children at school
Drug history involves any treatment for a diseases that may affect the child thereafter. Questions usually asked are;
- Any drug used (for what, when, dose, frequency, any adverse effects)
- Allergy against any drugs or substance
- Drugs abuse of mother (during pregnancy or breast feeding)
Family history taking is important in cases of genetic or hereditary abnormalities and infectious diseases.
- Age of mother and father
- Time of marriage (When and how long been married?)
- Relation of parents before marriage (cousin marriage or not?)
- Any genetic disease or abnormality in the family members
- Ask details about siblings (if genetic disease is suspected)
- Age and gender
- Any illness or disease
- Death (do ask about the cause of death)
- Any sibling been miscarriaged or aborted
- Grand parents or uncles etc. and their health status (may be the source of infection)
- Parents education
- Family income (per person, total earning members)/li>
- House (owned or on rent, made of, on area of)
- Environment and surrounding hygiene
- Any pet in the house (may be source of infection for child)
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