History taking In Pedics Flashcards
History Taking Outline
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.
Before you start History taking……
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?).
DEMOGRAPHICS
—NASMORAN
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?).
Presenting complaints
Please what complaints did you come with to the hospital
— state the duration ( e.g coughing for how long? )
History of presenting complaints
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
On Direct Questioning 🤨
Signs and symptoms relating to the system you think is involved relating to the condition ( diagnosis )
Eg
Fever, chills, headache 🤕,