PAEDIATRIC HISTORY TAKING

Paediatric history - structure

If a child is unwell then the priority is to assess ABCDE in order to recognise any serious illness and respond immediately.  Once treatments have been started and the child is stabilising then you will need to take a history in order to identify any key points which may lead to a diagnosis and guide treatments.  This is usually performed as part of the secondary survey within the Exposure assessment.

This history will follow a standard approach as you would in any paediatric case.  This chapter is here to help you gain generic paediatric history taking skills, whilst highlighting any changes to this structure when the child is acutely unwell or deteriorating.

Standard Paediatric History - Outline

• Date, time and place (clinic/ward) of history taking
• Demographics (click arrow ↓below for more information)
  ↓

  • Name
  • Gender
  • Age of child  (date of birth)
• Name and relation of accompanying adult(s) giving medical history (e.g. mother, father etc)
• Presenting complaint/problem
• History of presenting complaint/problem
  ↓

  • O (onset)
  • P (progress)
  • E (exacerbating factors)
  • R (relieving factors)
  • A (associated symptoms)
  • T (timing)
  • E (previous episodes)
  • S (severity)
  • + (functional aspects)
• Previous Medical History
  ↓

  • Hospital admissions
  • Childhood illnesses

• BINDS mnemonic (click here)
  ↓

  • B – Birth history
  • I – Immunisations
  • N – Neonatal period
  • D – Development
  • S – Social history

• Birth History and pregnancy details
  ↓

  • Location of delivery
  • Mode of delivery
  • Gestation
  • Birth weight
  • Ante/post-natal problems (including antenatal scans)
  • Neonatal problems (jaundice, Special Care Baby Unit, ventilation, antibiotics)
  • Maternal health
  • Feeding/Weaning

• Immunisations
  ↓

  • For up-to-date schedule (https://www.gov.uk/government/publications/the-complete-routine-immunisation-schedule)

• Neonatal Period
  ↓

  • Jaundice
  • Special Care Baby Unit (SCBU)
  • Ventilation
  • Antibiotics

• Development
  ↓

  • Any concerns regarding development
  • Developmental assessment if required (see below)
  • Personal child health record (red book) for milestones
    • Smiling
    • Sitting unaided
    • Walking alone
    • 3 words with meaning
    • Dry by day/night
  • Health visitor visits
  • General progress at nursery and school.
  • Feeding

• Social
  ↓

  • Housing
  • Heating
  • Mother: Name, Age, Occupation, Health
  • Father: Name, Age, Occupation, Health
  • Siblings: Names, Ages, Health (draw a family tree)
  • Health visitor
  • Social worker
  • Nursery / primary / secondary school
  • Pets
  • Smoking in the home
• Drug history
  ↓

  • Any current medications, route of administration, dosage, frequency
  • Allergies
• Family history
  ↓

  • Conditions with stronger familial disposition: atopy, febrile fits, pyloric stenosis, congenital dislocation of the hips, renal reflux, IDDM
• Review of systems
  ↓

  • General
  • Respiratory
  • Genitourinary
  • Cardiovascular
  • Nervous system
  • Gastrointestinal
  • Musculoskeletal
• Summary and differential diagnosis

If you are seeing an acutely unwell child in a hospital environment then as well as the standard medical history, you should identify:

• Events leading up to the admission
• Events during admission
• Recent investigations or operations