History taking In Pedics Flashcards

1
Q

History Taking Outline

A

Introduce yourself , Establish rapport, Explain Why you’re taking history

DEMOGRAPHICS— NASMORAN

Presenting Complaints and duration

History of presenting complaints

On Direct Question

Systemic review

Pregnancy 🤰 and Birth History

Developmental history

Immunization 💉 history

Nutritional history

Past medical / Surgical / Drugs/Allergies.

Family history

Social history

ICE: Ideas, concerns and expectations.

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2
Q

Before you start History taking……

A

Introduce yourself (my name is Ama a level 400 physician assistant student
- establish rapport— please may I know your name?
- explain procedure—as part of my clinical assessment I have been asked to ask you some questions concerning the reason you’re here
- seek consent—please do I have your permission?).

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3
Q

DEMOGRAPHICS
—NASMORAN

A

Name
Age
Sex
*Marital status— not relevant cause patient is a child
Occupation— student is the only option here if the child is one year and above. ( skip below one year)
Religion
Address
NHIS— Do the child have an active NHIS( if yes is it active or not?).

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4
Q

Presenting complaints

A

Please what complaints did you come with to the hospital
— state the duration ( e.g coughing for how long? )

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5
Q

History of presenting complaints

A

Should be in a story form
Should be chronological
Onset and duration
Agreviating and relieving factors
If there is pain— SOCRATES
(( vomiting 🤮/ Diarrhea 💩🚽— volume, content, color, odor/ smell.
Eg
Patient was well until 3 day ago started feeling pain in the abdomen

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6
Q

On Direct Questioning 🤨

A

Signs and symptoms relating to the system you think is involved relating to the condition ( diagnosis )
Eg
Fever, chills, headache 🤕,

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