Peds History (C FW06)

7/29/2019 Peds History (C FW06)

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Pediatric HistoryAdapted from Davies Pediatric Chiropractic,Ch. 2 & Mosbys Guide to Physical Examination,

6th Ed., Ch. 1


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Fundamentals of

Diagnosis Skillful history-taking

Careful physical exam Keen powers of observation Wise selection of other exams

x-ray, labs, etc. Good clinical judgment

LOOK LISTEN FEEL


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More errors are made because ofinadequate history-taking and superficial

exam than any other cause.


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Tips

Definite No-Nos Never be critical of another practitionersdiagnosis or treatment suggestions

Never allow a child who has been broughtto you for care to leave without it do what you have to do, despite protests from

the child

Never allow a child to be rewarded forbeing sick


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Discussing Difficult

Subjectssexuality abuse

serious disease psychological etiology

suicide

divorcedrug addiction

peer issues


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I need to ask you some personal

questions, is that OK?I know some things are difficult totalk about and I really wish I didnt

have to ask but I need to knowabout, is that OK?

Take all the time you need, I knowthis is difficult for you.


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Be Aware

I want to talk to you about

something, but I want to be surethat you will not tell anyone.


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Recording the Pediatric

History

Reliability of the Historian

Historian is any person providinghistorical data describe by name and/or relationship to

the patient also record reliability


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History

The history for an infant or child will

be modified according to age

The following is just an outline


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Chief Complaint May be taken from a parent orguardian

Note the name, relationship & reliabilityof the person providing the history

The child should be included as much aspossible

Appropriate for his/her age


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Present Problem

Note the degree and character of

the reaction to the problem Both parent and child


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Different aspects of the historyassume or lose importance depending onthe age of the patient or the nature ofthe problem.

Reserve detailed questioning for thoseaspect s most pertinent to the child.


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Past Medical History General Health and Strength


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Past Medical History Mothers Health During Pregnancy General health, extent of prenatal care

Specific diseases or conditions Infectious diseases (gestational month)

Weight gain

Edema, hypertension, proteinuria

Bleeding (approximate time)

Pre-eclampsia


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Past Medical History Mothers Health (contd)

Medications hormones, vitamins, special

or unusual diet, general nutrition status Quality of fetal movement; time of onset Emotional and behavioral status

Attitudes toward pregnancy and children

Radiation exposure Use of alcohol or elicit drugs


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Past Medical History Birth Duration of pregnancy

Place of delivery Labor

spontaneous or induced

duration

analgesia or anesthesia

complications


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Past Medical History Birth (contd)

Delivery

presentation forceps, vacuum extraction

vaginal or cesarean section

complications

Condition of infant, onset of cry, APGARscores (if available)

Birth weight of infant


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Past Medical History

Neonatal Period Congenital anomolies

Babys condition in hospital, oxygenrequirements, color, vigor, cry, feeding

Duration of babys stay in hospital;infant discharged with mother?

Bilirubin phototherapy Prescriptions (antibiotics)


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Past Medical History Neonatal Period First Month of Life

Jaundice, color

Vigor of crying Bleeding

Convulsions

Other evidence of illness


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Past Medical History Neonatal Period Early bonding

Opportunities at birth and during the

first days of life for the parents tohold, talk to, and caress the infant

Opportunities for BOTH parents torelate to and develop a bond with thebaby


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Past Medical History Feeding

Breast or bottle (type of formula)

Reason for changes, if any Frequency of feedings

Amounts offered and consumed

Weight gain


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Past Medical History Feeding (contd)

Present diet and appetite

Age of introduction of solids Age child achieved 3 feedings per day Present feeding patterns Elaborate on any feeding problems

Age weaned from breast or bottle Type of milk and daily intake Food preference Ability to feed self


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Past Medical History Development

Commonly used developmental milestonesNOTE:

Parents my have baby books which can

stimulate recall Photographs may be helpful


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Past Medical History Development (contd)

Age when able to

Hold head erect when in sitting position Roll from front to back; back to front

Sit alone; unsupported

Stand with support; without

Use words

Talk in sentences

Dress self


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Age when toilet trained

Approaches to and attitudes toward toilettraining

Dentition Age of first teeth

Loss of deciduous teeth

Eruption of first permanent teeth


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Growth

changes in rates of growth or weight gain Sexual

Present status, any concerns Female: breast development, sexual hair, acne,

menstruation (description of menses)

Male: sexual hair, voice changes, acne, nocturnalemissions

School Grade, performance, problems


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Past Medical History Illnesses

Vaccinations

Communicable diseases Injuries

Hospitalizations


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Family History Maternal gestational history List all pregnancies

Health status of living children

Deceased children: date, age, and cause of death Miscarriage: dates and duration of pregnancies

Age of parents at the birth of this child

*Review at least 2 generations oneach side of the family.


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Personal and Social

History Personal status

Nail biting, thumb sucking, breath holding,

temper tantrums, pica, tics, rituals, etc. Bed wetting, constipation, or fecal soiling ofpants

School adjustment

A day in the life of the patient is oftenhelpful in providing insights.


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Personal and Social

History Home Conditions

Fathers and mothers occupations

Principal caretaker(s) of the child Daycare?

Parents divorced or separated

Food prepared by whom Sleep habits; sleeping arrangements


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In addition to the usual concerns,inquire about any past medical orpsychological testing of the child

First visit to the dentist? optometrist? Hearing checks? Speech therapist?

Etc.


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Review of Systems Skin Eczema; seborrhea (cradle cap)

Ears Otitis media (frequency and laterality)

Nose Snoring, mouth breathing Allergies

Teeth Dental care


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Adolescents Use open-ended questions Dont force the adolescent to talk

Sometimes, allowing an opportunity

to writea concern may help.


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Adolescents

Common IssuesH Home

E EducationA Activities, affect, ambition, anger

D Drugs

S Sex


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Adolescents

Common IssuesP Parents, peers

A Accidents, alcohol & drugsC Cigarettes

E Emotional issues

S School, sexuality

Peds History (C FW06)

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