History Taking

History taking in children is likely to be compromised by a variety of factors, not least that the child may be distressed and ill and the parents extremely anxious. This is particularly true where most pediatric histories are taken - that is, in general practice and in an accident and emergency departments. In general practice, such histories will usually be gathered within consultations which are of necessity brief and focused.

Purpose

• To obtain data that is helpful in making a diagnosis, treatment and formulate an individualized plan for care.
• It helps develop a relationship.
• Establish a nurse, parent, and child relationship.
• Gather data about the child's general health status.
• Identify the child's strength.
• Establishing a basis for the nursing process.

Components

• Identification information
• Name
• Sex/age
• Caste/ethnic group
• Date of admission
• Name of unit/ward
• Birthplace
• In-patient number
• Religion
• Bed number
• Telephone number
• Name of informant
• Relation with the children

Chief complaint

• Record the child's and parents' own words as faithfully as possible, using direct quotations if relevant.
• Where there are multiple symptoms set each one out separately with space to document the features of how it developed and the relationships between the symptoms.

History of present illness

• When and how did it start?
• Was the child well before?
• Have there been any previous episodes of a similar illness?
• How did it develop?
• What aggravates or relieves the symptom(s)?
• Any contact with a similar illness in others/siblings, or infectious outbreaks?
• Any recent overseas travel?
• How has the illness affected the family?
• Have the symptoms kept the child from attending nursery/school?

Past medical history

• Previous illness medical/surgical
• Trauma/Injuries
• Previous hospitalization
• History of drug allergies
• Immunization

Prenatal and birth history

History of pregnancy

• Any factors relevant to fetal well-being should be recorded. For example:
• Antenatal infections (for example, rubella).
• Rhesus incompatibility and hemolytic disease.
• Exposure to prescribed, recreational drugs or over-the-counter (OTC) medication.
• Any maternal illness or problems in pregnancy.
• Perinatal history
• Factors pertinent to the child's health should be identified. For example:

Gestation

• Duration of labor.
• Mode of delivery.
• Birth weight.
• Resuscitation required.
• Birth injury.
• Congenital malformations identified.

Neonatal period

Relevant examples include:

• Febrile illnesses.
• Bleeding disorders.
• Feeding problems.

Developmental history

• Parental recall of major milestones will usually give important information (such as sitting up, crawling, walking, talking, toilet training, reading).
• It may be useful to ask how the child's progress and milestones compare with siblings and peers.
• Observations from other carers (school, nursery, and extended family) may be helpful.

Immunization history

Immunization history should include primary immunization and booster doses, complete or incomplete immunization, and find out the causes of incomplete immunization.

Nutritional history

Duration of breastfeeding, weaning, any event during weaning, feeding problem, dietary pattern. If the child is being bottle fed it is important to find out the method of preparation and dilution technique.

Personal history

• Hygiene
• Sleep and rest
• Elimination habit
• Exercise and rest
• Play hobbies
• Special talents
• Relationship with parents and siblings

Family history

• Family history of any disease
• Note whether siblings and parents are all alive and well.
• Consider conditions which may have a genetic component (such as ischaemic heart disease and cerebrovascular disease). Occasionally it is appropriate to address risk factors (such as familial hypercholesterolemia) during childhood.
• Consanguinity occurs more commonly in some cultures and may be relevant to inherited disease (particularly autosomal recessive conditions).
• It can be useful to present findings by using a two-generation family tree.

Social history

• Take care not to offend, when enquiring about the structure of the family unit, by making assumptions about who may or may not be present or 'involved'.
• Be prepared to allow information to come out gradually. Information may come from others (for example, nursing staff, play specialists, and educationalists). Ask about:
• Who lives at home (and any role in childcare)
• Siblings (ages, health, problems)
• Play
• Eating and sleeping patterns
• Schooling and any problems
• Pets
• Housing issues or problems
• Childcare (if a parent works or both parents work)
• Parental occupation(s)
• Smoking in the home
• Child abuse is a common problem. Child abuse comes in many guises and harm is inflicted in many different ways. Any such concerns may emerge from the social and family history and any concerns should be shared with colleagues and Social Services.

General

• Head: a headache, head trauma, swelling, dizziness, fontanels, sutures etc.
• Eye: vision, photophobia, discharge, infection etc.
• Ear: hearing, infection, drainage, pain etc.
• Nose: drainage, nasal patency, smell etc.
• Mouth and teeth: dental carries, chewing, patches, toothache, infection etc.
• Throat: a sore throat, tonsillitis etc.
• Speech: change in voice, hoarseness etc.
• Respiratory: breathing difficulty, common cold, etc.
• Cardiovascular: fainting, cyanosis etc.
• Gastrointestinal: appetite, nausea, vomiting, abdominal pain, etc
• Haematological: bruises, pallor, bleeding, allergy etc.
• Genitourinary: haematuria, dysuria, UTI etc.
• Musculoskeletal: fracture, deformity, etc.
• Neurological: tremor, weakness, loss of memory, a level of consciousness etc.
• Endocrine: sweating, thirsty, etc.
• Lymphatic: swollen lymph, tenderness etc