Paediatric History Taking and HEEADSSS Flashcards
Before the consultation
-what should we be aware of?
Child’s age - will change what areas we need to cover
Introduction
Wash hands, PPE if needed
Hello my name is An, I’m a 4th year medical student. Can I confirm your name and DOB?
Who have you brought with you today?
I’ll start by asking you some questions, but I may ask (family member here) some questions as well, is this ok?
PC, HPC
As usual
Has anyone else in the household had similar symptoms?
Systems review
-key areas to cover
Baseline and changes of
-dietary, fluid intake
-urine, stool output
Vomiting
-frequency, volume, consistency
Fever
-thermometer?
Rash
-location, spread, itchy?
Flu-like sympomts
Cough
-sputum, frequency, triggers
Work of breathing
-wheeze, stridor
-increased RR
Weight change
-gaining or losing weight
-look at growth charts if you have them
Behaviour
-usual self, level of activity, mood, social interaction
Pain
PMHx
-key areas to cover
Scope and detail determined by nature and severity of PC and age
Medical conditions
-how well controlled is it
-treatment
-any complications, hospital admissions?
Surgical Hx
-operations, procedures
-when, why
Allergies and reactions
Prenatal, developmental Hx
-key areas to cover
Prenatal
-any problems picked up during antenatal scans?
-any antenatal problems?
-any medication taken?
Birth
-mode of delivery?
-any problems?
-birth weight and gestation
Neonatal
-admission to SCBU and why
Growth
-did they meet their developmental milestones?
-any concerns about development
-appropriate weight and height centile
Immunisation
-up to date?
Drug Hx
-key areas to cover
Prescribed/OTC
-name, dose, frequency, form, route
Family Hx
-how many generations do you need to cover
-what do you need to do
DRAW A FAMILY TREE
Conditions that run in the family
-who has been affected
-if relevant, ask age of death and why
Social Hx
-key areas to cover
Who lives with the child
Relationship status of parents/carer
Type of accommodation
Education - nursery, school, college?
Smoking status of anyone living with the child
Have you ever received support from social services?
HEEADSSS
-H
Home and relationships
-who lives with you at home?
-who do you get on well with at home?
-who do you not get on with at home?
-who do you turn to when you’re feeling down?
HEEADSSS
-E1
Education and employment
-are you in school/college at the moment
-which year are you in?
-how are you doing at school
-what do you want to do when you finish
-do you have friends at school?
-do you get along with others at school
-do you work? How much?
HEEADSSS
-E2
Eating
-are you worried about your weight or body shape
-have you noticed any change in your weight recently?
-have you been on a diet?
HEEADSSS
-A
Activities and hobbies
-what do you do in your spare time?
-what do you do to relax?
-what kind of physical activities do you do?
HEEADSSS
-D
Drugs, alcohol and tobacco
-does anyone smoke at home?
-lots of people your age smoke, have you been offered cigarettes?
-How many do you smoke each day?
-Many people start drinking alcohol around your age, have you tried or been offered alcohol?
-How much do you drink?
-Some young people use cannabis, have you tried it?
-How much?
-What about other drugs like ecstacy, cocaine?
HEEADSSS
-S1
Sex and relationships
-are you seeing anyone at the moment?
-are they a boy or girl
-Young people are often starting to develop intimate relationships, how have you handled that part of your relationship?
-Are you sexually active?
-What contraception do you use
