History Taking 3rd year Lecture. Thembi Katangwe 1st March 2011

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Transcription:

History Taking 3rd year Lecture Thembi Katangwe 1st March 2011

Objectives To understand that the parent / guardian is the historian Build a rapport with parent/guardian as well as older children To understand the appropriateness of open ended questions Content differences between paediatric and adult histories

Parent as a historian Depend on parent to interpret symptoms of the child Look through referral letters and health passport books Observe child and parent / guardian interactions

Rapport Importance Allows you to gain trust of the parent/guardian as well as the older child To build a rapport Always introduce yourself Avoid an interrogation Look interested and smile Maintain eye contact with the child & guardian Avoid scribbling in notes while you or the parent is talking

Open Ended Questions Do not lead the guardian on It allows you to keep your differentials open Example: When did you notice that Mary was limping? Instead of, When did Mary s hip begin to hurt? When did Grace start convulsing? instead of When did Grace develop meningitis?

Content differences between paediatric and adult histories Prenatal and birth histories Developmental history Social history of the family environmental risks Immunization history

Outline of paediatric history Background information Presenting Complaint History of presenting Complaint Review of systems Past medical history Pregnancy and birth history Developmental history Family history Social history

Background information Patient s name Date of birth Age Sex HIV status Source of history (relationship of child & informant very important ) Referral source ( include reason for referral & working

Presenting Complaint (s) Main reason (s) for coming to hospital e.g vomiting, cough, diarrhea Duration of symptoms e.g. cough 1/52, vomiting 3/7 Be systematic, start with the earliest symptoms, it helps in organizing your history of presenting complaint. In cases of long histories, still ask the reason for seeking health care services at that time

History of presenting complaint (s) Tell a story Include details of the presenting complaints in chronological order. E.g. the child was well until 2 wks prior to admission (explaining how it started) Use patient or guardian s own words ( no medical terms) e.g. mum noted that the child was pale instead of mum noted that the child was anaemic Include progression of symptoms, aggravating and relieving factors

History of presenting complaint (s) Associated symptoms, relevant positives and negatives ( relevant systemic review) Medical attention sought, medications given, over what period and their curative effects Patient s general state during the illness, e.g. appetite, school performance, sleep, sleep, and change in urine and stool output

Systemic Review Get information about complaints from systems not represented in the history of the presenting complaints Serves as a checklist for pertinent information that might have been omitted Do not do a systemic review of a system that has already been discussed in the history of presenting complaint

Systemic Review Neuro Headaches, Visual disturbances, Speech Fits, faints, dizziness, floppiness Abnormal posture, gait Involuntary movements, numbness Changes in mood, activity or behaviour Respiratory Discharge from nose, ear, eyes Sore throat, hoarseness Cough, coughing blood (haemoptysis), whistling sound when breathing (Wheeze), Snoring

Systemic Review Cardiovascular Breathlessness, Exercise intolerance, Tiredness and lethargy feeding difficulties associated breathlessness / sweating Pallor and cyanosis intermittent (blue episodes)/persistent, associated with crying or straining Dizzy spells or fainting (may be confused with fits) Chest pains or palpitations Oedema Gastrointestinal Appetite and feed tolerance, difficulties in swallowing,thirst

Systemic Review Genitourinary Incontinence or bedwetting Increased urinary frequency Painful urination (Dysuria), blood in urine (haematuria) Change in character of urinary stream or appearance of urine Urethral / vaginal discharge Menstrual history Sexually- active Sexual abuse

Systemic Review Musculoskeletal Trauma, Joint swelling, Painful limbs Weakness, Deformities Difficulty in walking / moving extremities Muscle pains or cramps Weight loss Skin Rashes, itching, colour change & distribution, hair & nail growth bruises or bleeds easily Night sweats

Past medical history All previous hospital admissions with dates, diagnoses and prognoses Major surgical illnesses HIV status, blood transfusions Chronic illnesses eg TB. Drugs and allergies

Pregnancy and Birth history Mother s health during pregnancy HIV status, PMTCT, any other drugs, vaccinations Gestational age at birth Labour and delivery length of labour, place and mode of delivery, presentation Neonatal period- birth weight, whether child cried soon after birth, admissions to nursery (reasons) If neonatal, genetic or developmental case, more detail is required e.g. miscarriages, terminations, stillbirths, neonatal deaths

Developmental history Ask age at which major milestones were achieved - smiling, sitting alone, crawl, walking, run, first word, toilet training Cover all areas of development : Gross & fine motor- head control, sitting independently, crawling, walking, reaching for objects Hearing & vision - turning to sound, obeying commands, fixing and following Speech & language - age at first spoken word Social - smiling responsively Deviations from normal because of illness.

Nutrition and immunization history A nutritional history can be included at this point : Bottle or breastfed and for how long Timing of introduction of solids/cereals Current dietary intake if relevant to complaint of an older child Know the current immunisation schedule & ascertain that the child is immunised fully to date : BCG and polio at birth DPT Polio Hib HepB at 6 weeks DPT Polio Hib HepB at 10 weeks DPT Polio Hib HepB at 14 weeks

Family history of diabetes, atopy / allergy, epilepsy, Tuberculosis Family History Ages of parents and what they both do Marital status and how long married Consanguinity Number of siblings, sex & age of each

Social History Housing: type of accommodation, rented or owned, number of bedrooms, toilet facilities Source of water Usual meal composition, how may times a day? Any pets at home. Usage of mosquito nets?

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