clinical lecture for undergraduates regarding history taking process.

1. History Taking-1
24.03.2018
Dr Santosh Kumar Singh
Assistant Professor
Department of Pediatrics
Saraswati Medical College, UNNAO
Clinical Lecture-2

2. The attributes of a Pediatrician
 Good physical and
mental health
 Knowledge and skills
 Wisdom
 Confidence
 Patience
 Politeness
 Humility
 Common sense
 Pleasant demeanor
or bedside manners
 Experience and
expertise
 Tact
 Compassion
 Kind and
affectionate look
 Love for children
 Intuition
 Healing touch

3. Building Rapport with Child & Parents
• Wear formal clothing and apron before you address the
child
• Take time ,do not appear hurried.
• Have smile on your face and keep your personal
worries and frustrations away .
• A mother and child feels comfortable when the doctor
displays appreciation of the child.
• Look at the patient and make eye contact , keep your
head at the level of patient
• Touch the baby appropriately
• Avoid distracting movements, like fidgeting or
constantly moving your leg.
• Avoid electing too many personal information like caste
,religious beliefs etc.

4. Objectives of History-taking
 To elicit an accurate account of the
symptoms that represent the clinical
problem
 To help in arriving at a diagnosis
 To develop rapport with the child
and the parents

6. “Methods of physicians
are like detectives, one seeking
to explain a disease , other a
crime”
‘History taking is an art
and demands skills of a lawyer ,
detective and judge.’

7. History Taking
• Pediatrics has been linked to veterinary medicine
because young children can not express their
symptoms.
• An intelligent observant mother can provide
satisfactory story of illness, but may exaggerate
facts due to her anxiety and concern. Father
spends little time with the child and is generally
less informed.
• Most common diseases can be diagnosed by
good history alone . Elicitation should continue
during physical examination to seek additional
information when unexpected abnormal physical
finding is detected.

8. Tips for History-taking
1. Ensure privacy and confidentiality
2. Respect the patient and parents
3. Use simple language
4. Listen actively, let the parents talk
5. Ask open-ended questions
6. Clarify any ambiguous information
7. List the problems and summarize.

9. Do’s
• Listen properly.
• Concentrate on what
the parents is saying
• Observe the speaker’s
non-verbal signals
• Adopt an accepting
attitude
• Express empathic
understanding
Don’ts
• Fake listening
• Interrupt needlessly
• Pass judgment too
quickly
• Argue
• Give advice unless it is
requested
• Switch topic

10. Process of History- taking
1. Place: Privacy and without disturbance
2. Informant : Mother , caretaker , or an
eyewitness to the event
3. Setting : Comfortable
4. Language : Understandable, no ambiguity
5. Sequence : From present to past, and
individual to family to society.

11. The Sequence : History-taking
1. Personal and Demographic details
2. Presenting complaints
3. History of present illness
- Symptoms review
- System review
- Medications received
4. Past history
- Perinatal events
- Significant illnesses and accidents
- Physical growth and developmental milestones
5. Family history
- Genetic diagram
6. Social History and lifestyle
7. Feeding History
8. Immunization status

12. Personal and Demographic details
1. Informant ( mother, father, relative, child etc.)
2. Name
3. Age (date of birth)
4. Sex
5. Parent’s Name
6. Complete address
7. Telephone number
8. Religion / cast (if relevant)

13. Presenting Complaints
• Complaints with duration
• Chronological order

14. 6- Tips for Formulating Presenting
Complaints
1. Describe complaints as described by parents
along with their duration
2. Arrange the complaints in chronological order
3. Avoid use of medical terms as much as possible
4. Try to restrict numbers of complaints to a
maximum of four
5. Use appropriate phrases to describe the nature
of presenting complaints
6. Revisit your presenting complaint , after you
have finished your examination to include
retrospectively all significant findings which
influence the understanding of illness .

15. Chief complaints to be recorded as follows eg.
Chief complaints
• Fever lasting for 5 days
• Rash for 4 days
• Altered sensorium
• Two episodes of left-
sided convulsions
• Not moving the left half
of the body
Duration
10 days back
7 days back
For 5 days
3 days back
For 3 days
Total duration of illness is 10 days. illness started with fever lasted
for first five days only . Rash appeared 7 days back and lasted for 4
days.at present there is no fever& rash. Child had 2 episodes of
left focal seizures on day 8 of illness which were followed by
neurological weakness of the same side. child is having altered
sensorium for last 5 days and not able to move left side of body
for last 5 days

16. Analysis of Each Symptom
1. Onset- Time and nature
2. Duration, frequency, and consistency
3. Evolution and severity
4. Aggravating and relieving factors
5. Associated symptoms

17. Assessment of symptoms
• Onset: (exact date and time of onset)
• Nature of onset (acute , insidious or chronic)
• Duration
• Frequency
• Consistency (intermittent , continuous or remittent)
• Severity
• Evolution (progression ,static, or regression)
• Aggravating and relieving factors
• Diurnal variation
• Associated symptoms
• Response to treatment

18. Fever
• Duration
• Type of onset
• Character
• Degree and severity
• Presence of chills and rigors
• Sweating
• Association with cough, loose motions , burning
micturition etc
• Increased , decreased or stationary.

19. Loose motions
• Duration
• Frequency
• Consistency
• Volume of each stool
• Presence of blood , mucus
• color
• Foul smell
• Relation with food
• Abdominal pain
• Worm infestation
• Fluid intake (type & quantity)
• Frequency & quantity of urine
• Associated with fever, vomiting, dehydration ,
electrolyte imbalance

20. Review of Systems
A. General
(i) Growth and development
(ii) Appetite-if poor correlate with weight changes
(iii) Sleep- adequate, remains sleepy in day
(iv) Physical activity-normal, decreased , overactive ,
hyperactive causing disturbance to others.
(v) Behavior-normal, quite, shy ,out-spoken ,
friendly , quarrelsome with siblings
(vi) School performance

21. B. Gastrointestinal tract & Abdomen: Nausea,
vomiting , abdominal fullness , diarrhea.
Constipation, retro sternal or abdominal pain
,pain during swallowing or defecation, jaundice,
worms in stool, bleeding per rectum.
C. Respiratory System: Cough, dyspnea, stridor,
snoring, wheezing, chest pain, family history of
tuberculosis, asthma, eczema ,smoking
D. Cardiovascular System: breathlessness,
cyanosis, palpitation, edema over feet, cough,
recurrent pneumonia, joint pain, pain in right
hypo chondrium , abdominal distension

22. E. Nervous System: seizures, loss of consciousness,
paralysis , speech problems, vision or hearing
problems, abnormal movements, sensory
disturbances , gait abnormalities , bowel and
bladder disturbances, pain in neck, abnormal
posture, headache, vomit, neck retraction.
F. Urinary System: change in urinary frequency and
amount, color of urine, edema, pain in
micturition , frank pain or mass, nocturnal
enuresis
G. Genital System: age appropriate growth and
changes in primary and secondary sex characters
, menstruation in girls, pain discharge, and
swelling related to genitalia.

23. H. Blood anemia : fatigue , dyspnea ,
palpitation, edema , bleeding from (skin , nose
, GIT), swelling in neck , groin etc , dietary
intake , drugs which may cause bleeding, bone
marrow depression, family history of bleeding
disorder, thalassemia, sickle cell anemia etc.
I. Miscellaneous: skin eruption and itching, joint
pain and swelling, frequent falls and fluid
intake.

24. Thank You

25. History Taking-II
31.03.2018
Dr Santosh Kumar Singh
Assistant Professor
Department of Pediatrics
Saraswati Medical College, UNNAO
Clinical Lecture-3

26. Past History
1. Prolonged illness
2. Surgery and injuries
3. Hospitalization
4. Diarrhea dysentery, worm infestation
,vomiting .pneumonia , upper respiratory
tract infection .malaria , otitis media, urinary
tract infections, pertussis , diphtheria,
tetanus, tuberculosis, measles, mumps,
chickenpox, allergies

27. Drug and Treatment History
1. Prescribed and non-prescribed
2. Amount and duration
3. Habit forming drugs
4. Surgical treatment
5. Adverse events following drug intake
6. Compliance to prescription

28. Antenatal History
1. Diet , drugs , and diseases of mother
2. Iron and folic acid supplementation
3. Tetanus vaccination
4. Antenatal check-ups
5. Fetal movements and growth

29. History points to be Elicited in
Antenatal Period
A. First trimester:
Ask for history of
1. Fever with rash (TOTCH infection)
2. Swelling in occipital region (occipital adeno -
pathy for rubella)
3. Drug intake
4. Radiation exposure
5. Alcohol / tobacco/substance abuse
6. Bleeding per vaginum

30. B. Second trimester:
Ask for history of
1. Headache , swelling of feet , blurring of vision,
documented hypertension (P/H)
2. Polyurea , polydipsia , deranged glucose readings
(diabetes mellitus)
3. Fetal movements, bleeding per vaginum, blood
transfusion
4. Weight gain
C. Third Trimester:
Ask the history of
1. Maternal fever
2. Bleeding per vaginum (APH, placenta previa)
3. Leaking per vaginum , foul smelling liquor .
4. Diarrhea / urinary problem ( ascending infection)

31. Natal or Birth History
1. Place and mode of delivery
2. Person conducting the delivery
3. Duration of labour
4. Immediate cry.

32. Postnatal History
1. Birth weight
2. Preterm or full-term or post-term
3. Resuscitation requirement
4. Initiation of breathing
5. Respiratory difficulty, cyanosis, jaundice,
feeding difficulty

33. National Immunization Schedule 2017
Age Vaccine
Birth BCG,OPV (0),Hep B (0)
6 weeks DPT (1),OPV (1),Hep B(1) ,HiB (1)*, IPV intradermal
10 weeks DPT (2),OPV (2),Hep B(2) ,HiB (2)*
14 weeks DPT (3),OPV (3),Hep B(3) ,HiB (3)*. IPV intradermal
9-12 months Measles vaccine (1)
16-24 months Measles vaccine (2)**
16-24 months DPT (booster 1),OPV (4)
5 yrs DPT (booster 2)
10 yrs TT
16 yrs TT
In addition,Japanese encephalitis (JE), vaccination is provided in endemic districts, in two
doses schedule (Ist) dose: 9-12 month age: 2nd dose 16-24 month age.
* Hib (given in pentavalent vaccine containing Hib + DPT+Hep– B) in selected states. **
Second dose of measles vaccine can also be given as MMR ( measles, mumps, rubella )
vaccine

34. Immunization History
• To ascertain whether child is fully immunized
• Vaccinated child is unlikely to suffer from that
disease
• Presenting problem may be related to recent
vaccination e.g., axillary lymphadenitis after BCG,
Mild rash & fever after measles vaccination , high
fever, convulsion following DPT,
• Write down name of vaccine administered, when
by whom, any missing dose and adverse reaction
• See BCG scar ,New vaccines received, OPV during
pulse polio immunization.

35. Developmental History
• Ask for developmental milestones the child
has achieved.
• Assess in 4 fields:
(i) Motor (gross motor & fine motor)
(ii) Adaptive
(iii)Language
(iv)Personal-social fields.

36. Nutrition and Dietary History
1. Breastfeeding
2. Complimentary feeding
3. Quality and quantity of feeds
4. protein and caloric intake per day
5. Diet balanced or not
6. Fast food
7. Vegetarian or mixed
8. Food beliefs fads, and allergies

37. Nutrition and Dietary History
Newborns and infants below 6 months
Time of initiation of breastfeeding , frequency and
duration of feeds, exclusive breastfed or not ,
expressed breastmilk , weather started top feeds.
Infants above 6 months-24 months:
Time of initiation, quality, thickness ,frequency
,quantity of complimentary foods .breastfeeding
continued or not.
From 2 yrs onwards:
Record all food taken in 24 hrs. Calculate total
proteins and calories consumed

38. Family History and Pedigree Charting
1. Type of family
2. Total members with relation
3. Age of mother and father
4. Name ,age , and sex of siblings
5. Health and diseases in members
6. Abortion, stillbirths
7. Death in close relatives
8. Tuberculosis , diabetes mellitus
9. Obesity, hypertension, heart disease
10.Pedigree up to 3 generations

39. Degree of consanguinity
Degree of
consanguinity
Percentage of
shared genes
Relationship
First degree 50% Parents;
Children and
Siblings
Second degree 25% Grandparents
Uncles , aunts
Nephews, nieces
Half-siblings
Third degree 12.5% First degree cousins
Second degree cousins

40. Social History
• Useful determinants of Socioeconomic status
are education and occupation of the family head
and monthly income,
• Nuclear or joint family
• Per capita income,
• Housing conditions, toilet facilities , sewage
disposal, water source,
• School attending ,rank in class
• Interactive behavior ,habits ,hobbies , interests,

41. Kappuswamy socioeconomic status scale
Parameter Scale
Education of family head
Illiterate to Professional 1-7
Occupation of family head
Unemployed to Professional 1-10
Income of family head per month
<1800 to above Rs. 36017 1-12
Total score ( A+B+C) (Socioeconomic class)
26-29 UPPER (I) 5-10 UPPER LOWER (IV)
16-25 UPPER MIDDLE (II) <5 LOWER (V)
11-15 LOWER MIDDLE (III)

42. Thank You