2. PRICIPLES OF HISTORY
TAKING:
Encourage the informant to give a spontaneous
account of a child’s illness by using GOOD
COMMUNICATION SKILLS.
- Ask and listen
- Praise
- Advise
- Check understanding.
Ask specific questions to amplify and clarify the
informant’s description.
Older children can provide much history, usually give
an accurate account of their symptoms and answer
questions directly without bias.
You decide before or during the history taking
whether it is desirable for the child to be present.
3. HISTORY COMPONENT’S:
IDENTIFICATION
CHIIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
REVIEW OF SYSTEMS
PREVIOUS HISTORY
- ANTENATAL, NATAL, POST NATAL
- NUTRITIONAL
- IMMUNISATION
- GROWTH AND DEVELOPMENT (DEVELOPMENTAL
MILESTONES)
- PREVIOUS ILLNESSES
- DRUG AND ALLEGIES
FAMILY HISTORY
SOCIAL AND ENVIRONMENTAL HISTORY
4. Identification;
- Name,
- age (date of birth).
- sex,
- residence,
- recent travel
Chief complaints;
- limited number
- duration.
- Relevance
5. HISTORY OF P I:
- The precise order of symptoms including
any repeated episodes (e.g. Asthma or
epilepsy).
- Changes noted since the onset of illness
(contrasting present with previous
condition).
- Relevant, detailed and chorological.
(What, when, where, how, progress,
severity).
- What has been done to the patient
previously (home, OPD, IPD).
6. Symptom
assessment/analysis:
Vomiting:
- Duration, how started – sudden or gradual, frequency,
nature (effortless or projectile), amount, content,
stained with bile or blood, vomiting everything?
- An isolated symptom or associated with abdominal
pain (constipation), pyrexia, or impairment of
consciousness?
7. Abdominal pain:
- Is probably thought to occur much more
frequently than it actually does in babies.
- Toddlers asked frequently if they have a
sore tummy in the presence of any upset, may
use this term for pain at any site.
- With abdominal pain ascertain its duration,
site, nature, timing, constant or intermittent.
- aggravated by breathing or movement
- relation to food, bowel movement or
micturation
- association with anorexia, diarrhea, malena,
constipation, vomiting, sore throat, cough or
purpura.
8. Cough:
Ascertain duration, character dry or moist, paroxysmal,
more severe by day or night, disturbing sleep.
Associated with pain, whoop, vomiting, chest pain,
wheeze, nasal discharge.
Accompanied by sputum swallowed or expectorated,
watery, mucoid, mucopululent or blood stained.
9. Convulsions:
State of the child prior to the convulsions,
any precipitating factor – fever, fall
Any premonitory symptoms – headache,
nausea.
Type of movement – tonic or clonic, up
rolling of the eyes, salaam fits, absence.
Duration of various stages, state of
consciousness, loss of posture,
incontinence, biting of the tongue or
other injury, sleep or headache
afterwards.
Treatment already given must be
ascertained (home, OPD,IPD).
10. Selectivity of questioning:
Not all of the questions will be asked
in every patient, some will be
secondary questions depending on
positive answers to primary questions.
Better ask too many rather than too
few questions.
The more extensive the questioning
the more likely are forgotten points of
history to be uncovered.
11. Previous history:
Antenatal:
- Illness before or during pregnancy
(hypertension, diabetes mellitus,
hydramnius).
- Exposure to drugs or radiation
- Length of pregnancy
- VCT for HIV, serology for syphilis, IPT,
Tetanus toxoid.
- Feeding options in HIV positive mothers.
13. Feeding:
- How soon BF started or Replacement feeding.
- Exclusive BF duration.
- Complimentary feeding, enriched?, preparation, active
feeding, feeding problems identified, counseling and
FU.
14. Immunization and Vit. A supplementation:
- Complete according to age.
- Missed opportunity reasons and solutions
Developmental milestones:
- Time of achievement of gross motor, fine motor,
vision, social/adaptive and hearing/language progress.
15. Family history:
- Ages, state of health, past health
and possible consanguinity?
- Previous miscarriages or stillbirths,
abortions, infant deaths (likely
congenital abnormalities).
Social and Environmental history:
Parents attitudes, separation and
divorce, absence of a parent, illness or
chronic disability, difficulties at
school, occupation, size and condition
of home.
16. REFERENCES:
Swash M. Hutchison’s Clinical methods.
Behman R.E, Kliegman RM,Aron A.M, editors. Nelson
Textbook of paediatrics. 16th ed. W.B Saunders Co, 1984.
Forfar and Arneil’s. editors.Textbook of Pediatrics fifth
edition.churchhill livingstone, 1998.
