HISTORY TAKING

IN PAEDIATRICS
Dr Walufu Ivan Egesa
Lecture series for Resident, Paediatrics & Child
Undergraduate Health Department.
Kampala International University
Medical Students Teaching & Research Hospital.
E-mail: wiegesa@[Link]

Introduction History taking is a skill only acquired through practice.

As an undergraduate student, learning is only effective if you
directly and repetitively interact with patients and their care
givers.
Well taken, the medical history is the most important piece
of information required to deduce a diagnosis, formulate
differential diagnoses, as well as guide clinical examination
and investigations.
History-taking is a dynamic process and can always be
revisited at any point.

Aims of history
To establish rapport with the patient and carer(s).
taking
To get a general overview of the context of a child’s illness.
To establish an appropriate diagnosis and consider
differential diagnoses.
Guide appropriate examination, investigations and make
an agreed management plan.
If the child or carer does not speak your language, please
find yourself an interpreter.

Effective
communication Active listening: helps the doctor/clinician to recognise
what is wrong. Listen and listen!
Carer/patient satisfaction is improved if they understand
what is wrong and what they can do to help.
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 When a patient/carer and a doctor agree on mutual
goals, health outcomes are improved.
Positive support and empathy improve health outcomes
and enhance the doctor-patient relationship.
Medicine taking is improved by clear information about
what a medicine is meant to do.

Differences between Different disease patterns.

history taking in
Even similar diseases seen in adults, are different in
adults and children children because a child is constantly changing and
developing.
In most cases, history taking is obtained second-hand.
Babies can’t talk, and young children are unable to
communicate their ailments precisely.

Major components
1) Personal and socio-demographic data
of the Paediatrics
history 2) Presenting complaint(s)
3) History of presenting complaint(s)
4) Review of other systems
5) Past medical history
6) Past surgical history
7) Antenatal, perinatal and early postnatal history
8) Nutritional history
9) Growth and development milestones
10) Immunisation/vaccination history
11) Family and socio-economic history
12) Summary

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 Personal & socio-demographic Aim for each question to ‘rule in’ or ‘rule
out’ a possible diagnosis.
data
Use a lot of tact; most carers will start
 Name, age (date of birth) with the day when something dramatic
 Sex, tribe, religion happened.
 Address
 School, class Where appropriate, use the carer’s
 Next of kin and relationship words.
 In/out-patient number When and how did it start? How did it
 Date and time of admission develop? Was the child well before?
 Date and time of clerkship Have there been any previous episodes
 If a referral; who referred? From of similar illness? What aggravates or
which health facility? Reason for relieves the symptom(s)? Any contact
referral? with similar illness in others/siblings or
 Source of history (e.g. mother, infectious outbreaks? Any recent
father, aunt, grandmother, etc.) travels? How has the illness affected the
family? Have the symptoms kept the
Presenting complaint(s) child from attending nursery/school?
The presenting complaint is a symptom or Also ask about site, severity, seasonal or
sign (or a collection of symptoms and diurnal variation, frequency, relation to
signs) that have caused the parents or food and any other associated
child to seek medical attention. symptoms.

It is what the carer considers most Which treatment has the child received
important/significant and their durations. since the illness began? Who prescribed?
(Medicines, dose, duration, compliance).
However, be tactful…
Must be documented in a chronological Review of other systems
order. Not more than three (3) complaints. Specifically that which was not covered
For example; in the history of presenting complaint(s).

1) Fever for 2/7 Cardiovascular system

2) Refusal to breastfeed for Chest pain, breathlessness, palpitations,
1/7 orthopnoea, paroxysmal nocturnal
dyspnoea, lower limb/ ankle swelling,
History of presenting complaint(s) easy fatigability / exertional dyspnoea
(e.g. during breastfeeding, games).
When was the child last well? Mention
whether it is a previously healthy child or Respiratory system
an ill child who has come with the new
present complaints. Cough, shortness of breath, fast
breathing, noisy breathing (e.g. wheeze,
Here, it’s important to get the true stridor), chest pain, chest tightness,
sequence of events, and not what the haemoptysis, nasal discharge and
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 Gastrointestinal system Eyes
Mouth/oral sores, bleeding gums, Use of glasses, visual acuity, eye
appetite and feeding habits, discharges, abnormal tearing, swelling
difficult/painful swallowing, oral thrush, and/or reddening of eyes/eyelids,
nausea, vomiting, diarrhoea, colour of protrusion, ocular injury, prior surgery,
stool (e.g. may be bloody), rectal etc.
bleeding, constipation, painful
defecation, perianal sores, abdominal Endocrine
pain, distention, weight changes, Heat or cold intolerance, change in
yellowing of eyes/skin etc. sweating, excessive thirst (polydipsia).
Central nervous system Past medical history
Headache, dizziness, fainting, Previous admissions: at which health
convulsions, loss of consciousness, facility? Which condition was he/she
numbness, abnormal behaviour or body treated for? How was the child treated?
movements, weakness, abnormal gait, For how long? Did he/she recover? Etc.
visual/hearing problem, neck stiffness,
bulging of anterior fontanel, etc. History of any diagnosed chronic medical
illness e.g. asthma, diabetes,
Genitourinary system hypertension, epilepsy, cancers,
Urinary frequency, urgency, dysuria (or bleeding disorder, sickle cell disease,
crying on micturition), urine colour (clear, HIV, etc.
yellowish, cola-coloured) and quantity, Any drug/food allergies.
stream, bed-wetting (In a child previously
not), abdominal pain (loin pain, Is the patient taking any long-term-use
suprapubic pain), genital/urethral medication? E.g. anti-asthma drugs,
discharge, genital swelling/ulcer, anticonvulsants, antihypertensives,
menarche, prolonged and painful corticosteroids, etc. any use of herbal
erection, etc. treatment?

Musculoskeletal system Past surgical history

Joint/muscle pains/swelling, joint History of fractures, head injury, burns,
stiffness, abnormal mobility. dislocations? Treated from where? How
and by who? Any disability following
Skin previous injury.
History of skin rash/lesions, itching, Previous transfusions with blood or blood
hyper/hypo-pigmentation, etc. products: from where, when and why?
How many units?
Ear nose and throat
History of previous surgeries: Indication
Ear discharge, bleeding, pain, scratching
for procedure? Where it was performed
of pinna, use of hearing aid, nasal
from, when and by whom? Any other
discharge, bleeding or itching, throat
form of treatment-recommendations
pain, anterior neck swelling.
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 If patient recovered; how long did they Perinatal or birth history
take until recovery?
Labour: Gestational age at onset of
Antenatal or prenatal history labour (preterm, term or post-term) and
duration of labour.
Parity and age of mother.
Rupture of membranes: spontaneous or
Mode of conception (natural or
artificially ruptured? Period between
assisted?)
membrane rupture and delivery; colour
Was the pregnancy planned for? and volume of amniotic fluid.

If relevant, establish whether the child is Where did birth take place? at health
adopted or in foster care, with due facility, home, road-side, elsewhere.
sensitivity to the child's awareness of the
Delivery conducted by who: By self,
facts.
midwife or other experienced healthcare
ANC attendance: How many times? professional, traditional birth attendant,
From where? Gestational age at every other.
visit (in weeks), and what was done.
Drugs administered during
Discuss each visit independently. labour/delivery: anaesthetics, oxytocics,
antihypertensives, etc.
Investigations carried-out and results:
e.g. VCT, VDRL, HB, blood group, Rh, Use of herbal medicines (to induce or
U/S scan, etc. augment labour).

Amniocentesis, chorionic villus biopsy Normal or assisted: vaginal or caesarean

results. delivery (indication)? If vaginal, was it
spontaneous or induced? Vacuum
Medicines and vaccinations: T.T, Iron- extraction, forceps delivery, breech
folate, IPT, Mebendazole, HAART, extraction? Episiotomy? Other
antihypertensives, antibiotics, complication?
anticonvulsants, analgesics, others.
How was the cord tied and cut (using
Complications during pregnancy: what? was there any significant bleeding
bleeding, trauma, infections (including from the cord site?)
UTIs, STIs, Hep-B, etc.), hypertension,
diabetes, thyroid disease, immune What the baby was like at birth: cry,
mediated diseases e.g. SLE, etc.) and resuscitation, (Apgar score), birth weight
treatment/medication offered. (relate with G/A), birth injuries,
congenital malformations identified,
Exposure to radiation, cigarette smoking, passing meconium and urine (how long
alcohol use, other addictions, etc. after birth?).
Did the mother sleep under an ITN
throughout pregnancy? Post-natal/Neonatal history
Antenatal health education sessions Ask whether the newborn period was
attended. eventful or uneventful.

Use of herbal medicines and/or self- Breast feeding (time of initiation,

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medication during pregnancy. frequency, any feeding difficulties).
 Presence of jaundice, cyanosis, pallor, Adaptive,
convulsion(s), respiratory distress.
Language and personal social and those
Febrile illness during the immediate related to the special sense organs like
postnatal period. vision, hearing.
Duration of hospital stay. If prolonged, Ask about the child’s developmental
why? milestones: e.g. when did the child first
smile, attain head control, crawl, sit, and
History of procedures like lumbar
walk, talk, run?
puncture, umbilical vein catheterization.
What are the child’s present habits: with
History of phototherapy, blood
regards to eating, sleeping, bowls,
transfusion or exchange transfusion.
micturition?
Any medications administered and any
How does the child compare to
special care given to the baby in the
siblings/friends of the same age?
neonatal care unit.
What sort of child? If school age, which
Attitude of the mother towards the
school, class and how is the child
newborn.
performing at school?
Nutritional history Delay in all the areas of development is
called ‘global delay’. Delay in speech
Was/Is the baby breast fed? How often?
alone, as noted in hearing defect, is
Breastfed exclusively for how long? How
called an ‘isolated delay’.
long was breastfeeding continued?
Any replacement feeds? If so, which Immunisation history
ones? Ask about how they are prepared
Ask for the child’s health card.
and administered.
Which vaccines has the child received?
When were complementary feeds
introduced? Which feeds were used? Which ones the child missed and why?
How often were/are they given?
Which vaccines is the child awaiting to
What is the child feeding on now? receive, and when?
Who prepares it? How is it prepared? BCG scar.
Who feeds the child? (Sibling, mother, Vitamin A.
house-keeper, grandmother, etc.)
Please get acquainted with your
24 hour dietary recall. country’s immunisation schedule.

Growth and development Family & socio-economic history

milestones Birth order, number of siblings, their
Obtain details in all the four areas of ages, sex, and general health status.
development, including; Note any illnesses, drug/food allergies in
Gross Motor, the siblings, relatives, parents.
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Fine Motor, Are both parents alive? Their age?
 Any still births, abortions or genetic Summary
diseases like SCA, DM, HTN, bleeding
disorders, asthma, etc. Please include the following in the
summary of your patient’s history:
Draw a family pedigree (1st, 2nd and 3rd
generation) in genetic/inheritable Name, age sex, address, presenting
diseases. complaint(s).

Any unexplained deaths? Significant/relevant positive and negative

findings in the history of presenting
Details of anticonvulsant therapy, anti-TB complaints, systemic review and the rest
treatment amongst the parents, siblings, of the history.
if any?
Make sure you have the diagnosis at the
Family planning methods considered by end of the summary and have excluded
family (temporary or permanent). the differential diagnoses as well.
Do both parents stay with the child? Any Thanks for reading…
separations?
What are the characters of the parents?
Any smoking, alcohol, substance abuse?
What are the parents’ education levels
and their current occupations? Who is
the bread winner? What are the
relationships between the parents? Any
co-wives and mistresses? What are their
views on child rearing? Childcare (if
parents work)
What does their home look like? Semi-
permanent or permanent house? Rented
or their own? Ventilation, windows,
mosquito barriers? What are the
surroundings like? Swamps, drainage,
bushes, toilets/latrines, domestic water
source, etc. any pets? Birds and other
animals? Preparation and handling of
water for drinking?

Conclude by asking the informant about

anything else he would like to tell you.

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