History Taking Flashcards
Documentation?
Name
Age
Gender
Source of history (mother /father/other)
Presenting complaint?
- Use their own words
- The parents may actually tell you the diagnosis
History of presenting coplaint?
A complete chronological sequence of events
1. The mode of presentation and timing of complications
2. How they have been managed (drugs prescribed, investigations carried out and operations performed)
3. Include managements on admission for admitted patients
Deeper inquiry about important symptoms under HPC must be carried out regarding?
Time of onset
Site
Duration
Frequency
Severity
Relieving factors
Exacerbating factors
Diurnal or seasonal variation
General systems enquiry?
- Pyrexia and night sweats , weight loss Appetite
- Rashes - site, size, number of lesions, colour, nature, pruritus
- Pain - onset, nature, duration, severity, precipitating /relieving factors, associated symptoms, treatment sort
Respiratory system enquiry?
- Discharge from nose, ear, eyes
- Sore throat or earache – associated pyrexia or other
- Cough – character, duration, exacerbating factors, sleep disturbance, pain, whoop, vomit, sputum
- Stridor – colour change, apnoea
- Wheeze- precipitating factors, diurnal variation
- Snoring
- Dyspnoea- at rest/exercise, intermittent/persistent, cough, cyanosis
- Apnoea – duration, infection, airway obstruction
Cardiovascular system enquiry?
- Breathlessness – at rest, exertion, feeding
- Tiredness and lethargy – exercise tolerance, interest in play
- Slow feeding – associated breathlessness
- Poor weight gain – dietary intake
- 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 (rare, except in adolescent)
Gastrointestinal system enquiry?
- Appetite and feed tolerance and need for special diet - supplements
- Dysphagia – food refusal vs organic
- Thirst - daily fluids input and urine output
- Vomiting – amount, frequency, association with feeds, effortless/projectile, bilious, blood-stained, pain, impairment of consciousness
- Constipation – consistency, frequency, pain
- Diarrhoea – nature of stool, consistency, frequency, blood
- Abdominal pain – site, nature, timing, duration, intermittent/constant, aggravated by breathing or movement, relationship with feeds, bowel movements or micturition, associated sore throat, cough or purpura
- Jaundice - Onset, duration, nature of stool and urine, associated vomiting
Genitourinary system enquiry?
- Incontinence or bedwetting – day and night, deterioration from before or regression in development, urinary symptoms, stress, bullying, treatment sort
- Increased urinary frequency – recent change in pattern, urine volume
- Dysuria – pain, burning, crying
- Change in colour or appearance of urine – urinary symptoms, haematuria
Neurodevelopmental systems enquiry?
- Headaches – site, manner of onset, severity, associated symptoms, aura
- Visual disturbances – fixing and following, myopia, or hypermetropia, colliding with objects, associated symptoms
- Speech – delay in onset, regression, nature, difficult comprehension or expression
- Fits, faints, floppiness – time, duration, frequency, tonic and clonic components, consciousness, triggers, colour change, incontinence, injury sustained
- Abnormal posture, gait, coordination – deterioration or regressing development, falling, injury
- Involuntary movements – nature, aggravating factors, injury sustained
- Changes in mood, activity or behaviour - performance in normal play/activities, interest in surroundings, tiring easily
- School performance - normal or special school, bullying, extra support
Musculoskeletal system enquiry?
Joint swelling
Painful limbs
Past medical history?
- All previous hospital admissions should be documented ( look in the health passport)
- HIV status (also health passport)
- Birth history
Birth history?
Mother’s health during pregnancy (any drugs?, tests)
Gestational age at birth
Mode of delivery and presentation
Birth weight and Apgar score
Place of delivery
Maternal HIV status , PMTCT
Admission to special care and why
If neonatal , genetic or developmental case, more detail is required e.g. miscarriages, terminations, stillbirths, neonatal deaths
Note: Some presentations will, require a more detailed birth history than others. For example developmental regression/delay, seizures, micro/hydrocephalus etc
Family and social history?
Ages of parents and what they both do
Marital status and how long married
Consanguinity
Who lives at home ? Is there contact with both parents ?
Number of siblings and age range
Family history of diabetes, atopy, epilepsy, Tuberculosis
Housing, type of accommodation, rented or owned, number of bedrooms, toilet facilities.
Source of water
Any pets at home
Nutritional history?
Bottle or breastfed and for how long
Timing of introduction of solids/cereals
Current dietary intake if relevant to complaint of an older child
