Paediatric history taking differs significantly from a standard history for a number of reasons, the first being that the patient may not be able to communicate, so a collateral history is often essential. In addition there are a number of extra topics you’ll need to cover, such as immunisation and developmental history. Check out the paediatric history taking mark scheme here. Opening the consultation These questions may need to be addressed at the patient’s parents, depending on their age, so adjust as appropriate. Introduce yourself – name / role Confirm patient details – name / DOB Explain the need to take a history Gain consent to take a history Ensure the patient is comfortable Presenting complaint Give the patient time to explain the problem/symptoms they’ve been experiencing. A paediatric history often relies on collateral information from the parents. It’s important to use open questioning to elicit the patient’s or parent’s presenting complaint. “So what’s brought your child in today?” or “What’s brought you in today?” This can sometimes be difficult when talking to children and you may need to adopt an approach involving more direct questioning. So instead of saying “Tell me about the pain”you may need to ask a series of questions requiring only yes or no answers. “Is the pain in your tummy?” “Is the pain in your back?” Allow the patient time to answer and do not interrupt. History of presenting complaint Onset – when did the symptom start? / was the onset acute or gradual? Duration – minutes / hours / days / weeks / months / years Severity – e.g. if symptom is shortness of breath – are they able to talk in full sentences? Course – is the symptom worsening, improving, or continuing to fluctuate? Intermittent or continuous? – is the symptom always present or does it come and go? Precipitating factors – are there any obvious triggers for the symptom? Relieving factors – does anything appear to improve the symptoms e.g. an inhaler Associated features – are there other symptoms that appear associated e.g. fever / malaise Previous episodes – has the patient experienced this symptoms previously? * Key paediatric questions Feeding – volume of intake / frequency of feeding Vomiting – frequency / volume / timing – projectile? / bilious? / blood? Fever – confirmed using thermometer vs subjectively feeling hot? Wet nappies / urine output – number of wet nappies a day – ↓ in dehydration Stools – consistency / steatorrhoea? (biliary obstruction) / red currant jelly (intussusception) Rash – any obvious trigger? / distribution? / blanching? Behaviour – irritability / less responsive Cough – productive? / associated increased work of breathing? Rhinorrhoea – often associated with viral upper respiratory disease Weight gain or loss – check baby book if the parent has it with them Sleeping pattern – more sleepy than usual? Unwell contacts – often children become infected from unwell siblings Localising symptoms – tugging at an ear/ holding tummy * Pain – if pain is a symptom, clarify the details of the pain using SOCRATES Site – where exactly is the pain / where is the pain worst Onset – when did it start? / did it come on suddenly or gradually? Character – what does it feel like? (sharp stabbing / dull ache / burning?) Radiation – does the pain move anywhere else? Associations – any other symptoms associated with the pain Time course – does the pain have a pattern (e.g. worse in the mornings) Exacerbating / relieving factors – anything make it particularly worse or better? Severity – on a scale of 0-10, with 0 being no pain and 10 being the worst pain you’ve ever felt * Ideas, Concerns and Expectations – often addressed to parents Ideas – what are the patient’s / parent’s thoughts regarding their symptoms? Concerns – explore any worries the patient / parent may have regarding the symptoms Expectations – gain an understanding of what the patient / parent is hoping to achieve from the consultation * Summarising Summarise what the patient / parent has told you about the presenting complaint. This allows you to check your understanding regarding everything the patient/parent has told you. It also allows the patient/parent to correct any inaccurate information and expand further on certain aspects. Once you have summarised, ask the patient/parent if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history. Signposting Signposting involves explaining to the patient/parent: What you have covered – “Ok, so we’ve talked about the symptoms”” What you plan to cover next – “Now I’d like to discuss any previous medical history” Past medical history Antenatal period – illnesses or complications during gestation – e.g. rubella Birth – delivery complications / prematurity / birth weight Neonatal period – illness /admission to special care baby unit (SCBU)? Medical conditions Previous hospitalisation – when and why? Previous surgery Accidents and injuries – remain vigilant for signs of non-accidental injury Drug history Regular medication – e.g. inhalers for asthma Over the counter medication ALLERGIES Developmental history Current weight and height – weight is required to calculate drug doses Developmental milestones (are they on track for their given age?): e.g. sitting up, crawling, walking, talking, toilet training, reading Immunisations Is the child up to date with their immunisations? Dietary history Type of food? – formula / breast milk / solids Intake –e.g. how many ounces of milk? Frequency of feeding – reduced or increased? Special dietary requirements? – cow’s milk intolerance / coeliac disease Family history Family history of disease – e.g. coeliac Genetic conditions – e.g. cystic fibrosis Family tree – useful to draw out if considering genetic disease Social history Living situation – accommodation / main carer / who lives with child? Second hand smoke exposure – risk factor for otitis media / asthma Parent’s occupation Pets – important when considering allergies / asthma triggers Schooling – stage of learning / any issues? Foreign travel – may be important when considering certain diagnoses e.g. TB Systemic enquiry Systemic enquiry involves performing a brief screen for symptoms in other body systems. This may pick up on symptoms the patient failed to mention in the presenting complaint. Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration). Choosing which symptoms to ask about depends on the presenting complaint and your level of experience. Cardiovascular – chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / chest pain GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion Musculoskeletal – Bone and joint pain / Muscular pain Dermatology – Rashes / Skin breaks / Ulcers / Skin lesions Closing the consultation Thank patient Summarise the history Source
