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
HEEADSSS
-S2
Self-harm, depression, self-image
-how do you feel like is going in general
-what do you do when you feel stressed?
-Do you ever feel sad and tearful?
-Have you ever felt so sad that life isn’t worth living?
-Some young people have thoughts of wanting to harm themselves in times of intense distress, have you ever had these thoughts?
-Have you ever tried to harm yourself?
HEEADSSS
-S3
Safety and abuse
-do you feel safe at home/school
-is anyone harming you?
-is anyone making you do things that you don’t want to do?
-have you ever felt unsafe when online or using your phone?
Closing the consultation
Summarise key points back to YP and parent
Ask if they have any questions or concerns
Thank them for their time
Dispose of PPE and wash hands
