HISTORY TAKING IN CHILDREN

INTRODUCTION

History taking is an art that requires the clinician to listen effectively to the complaints of the
patients. It usually begins by asking for the basic information regarding the patient’s medical
history.

GENERAL PRINCIPLES

 Complete history is necessary and it leads to the correct diagnosis in the vast majority of
children 
 Usually is obtained from the parent, the older child, or the caretaker of a sick child
 A short, rapidly obtained history of the events of the immediate past may suffice
temporarily, but as soon as the crisis is controlled, a more complete history is necessary
 A convenient method of learning to obtain a meaningful history is to ask systematically
and directly
 During the interview, it is important to convey to the parent interest in the child as well as
the illness
 Allow the parent/caretaker to talk freely at first and to express concerns in his or her own
words
 The interviewer should look directly either at the parent or the child intermittently and
not only at the writing instruments
 A sympathetic listener who addresses the parent and child by name frequently obtains
more accurate information than does a harried, distracted interviewer 
 Careful observation during the interview frequently uncovers stresses and concerns that
otherwise are not apparent

IDENTIFICATION DATA

NAME

Documentation of the patients name is mandatory for the identification of the patient. In
addition, addressing the patient by name increases the confidence of the patient or attendant and
the examiner.

AGE

Age of the patient is important as certain diseases are more prevalent in children of a specific age
group. Thus the age of the patient can be a clue to the diagnosis of the disorder.

SEX

Many disorders whether genetic or acquired, follow a gender bias

PLACE OF RESIDENCE

The place of residence may give a clue about the disorder because certain diseases are endemic
to certain regions

INFORMANT

The informant is the person who presents the history on behalf of the child .the documentation of
the informant helps to avoid inconsistencies in the history in follow up visits

RELIABILITY OF THE INFORMANT

The reliability of the informant dictates the importance to be given to it. If the informant is not
reliable, then the examiner should spend more time in cross –checking the history of the child.

PRESENTING COMPLAINTS

Presenting complaints include the chief complaints as told by the informant or patient .these
should be recorded in chronological order of their appearance. The complaints should be
recorded in the informants or the patient’s own words. The examiner should refrain from asking
leading questions at this stage. Any diagnosis that is reported by the parents or derived from the
opinion of other medical professionals should not be relied upon to avoid undue bias.

HISTORY OF PRESENT ILLNESS

History of present illness gives a detailed account of the onset, progression and duration of
various complaints in order of their appearance.

 Time of onset
 Mode of onset
 Progression/course of illness
 Duration of the illness
 Precipitating factors
 Relieving factors

Leading questions can be asked at this stage to elicit more details about the illness. The examiner
may also ask appropriate questions to segregate the relevant positive history from the negative
history of the illness.

It is better for the examiner to start asking questions from the time when the child was normal
and enquire about how the first symptom of illness appeared .then the examiner should proceed
in an orderly fashion to elicit a detailed symptom wise and system wise

If the child has never been normal from birth, the examiner should start from the perinatal events
and neonatal history.
If the child is already admitted as an inpatient history of present illness should include the course
during the hospital stay.

If the child has been seen by various practioners, it should be specifically mentioned and the
treatment that the child has received from them must be noted.

HISTORY OF PAST ILLNESS

History of past illness includes episodes of similar or related illnesses in the past.if any such
history is present ,the examiner should enquire in detail about the onset of illness,treatment
received course of the disease ,number of episodes and frequency of relapses.

Treatment history is taken as follows:

 Prior hospitalization (for similar or other illness)

 Nature of treatment given (e.g antitubercular medication)
 Improvement /deterioration with the treatment
 Previous hospitals stay with duration
 Irradiation
 Surgery
 Blood transfusions
 Drug allergy

HISTORY OF CONTACT

The examiner may use leading questions to enquire about recent occurrence of any
communicable disease in the family or in a close contact. For instance,the examiner can ask
whether anybody in the family has chronic cough with expectorations

ANTENATAL HISTORY

Antenatal history includes the series of events that have occurred during the intrauterine
developmental period of the child and may have led to the present illness. This is especially
important for children with congenital defects or disorders.

An antenatal case should get herself registered in the hospital before 12 weeks of the last
menstrual period and should be examined regularly.

The clinician should enquire systematically and ask appropriate leading questions to discover all
the possible antenatal offending stimuli. The offending stimulus may be a maternal disease or
disorder, lifestyle or habit or medication taken during pregnancy.
Important components of antenatal history are as follows:

 Age of mother
 Weight and height of the mother
 Immunization status of mother
 Gravid
 Parity with number of children alive
 History of abortions/still births
 Interval between successive pregnancies and the outcome of each
 History of multiple pregnancies
 History of complications
 History of Rh isoimmunisation
 Diet during pregnancy
 History of any disease during pregnancy
 History of any infection during pregnancy
 History of drug intake with dosage and duration
 Symptoms of maternal malnutrition and vitamin deficiency
 History of first trimester,second and third trimester

BIRTH HISTORY

The birth history covers the series of events that occurred during the birth of the child.

Important aspects of the birth history include the following

 Birth order:the baby born after two or three live children is prone to develop
malnutrition ,especially if the duration between the deliveries is less than 2 years.
 Multiple Pregnancy: the second twin is at high risk of hypoxia,hypoglycemia and birth
trauma,all of which could result in brain damage
 Mode of delivery:Natural birth/caesarean section
 Place of Delivery:Hospital/home/any other
 Person who conducted the delivery-qualified doctor or nurse/trained dai/untrained person.
 Gestational age: preterm/term/post term
  Birth weight:appropriate/small/large for gestational age.
 Birth asphyxia:cried /did not cry soon after birth,if not,then details of resuscitation
 Bluish discoloration of the body(e.g,on crying/feeding)
 Breathing difficulties
 APGAR score at 1, 5 and 10 minutes after birth

NEONATAL HISTORY

Neonatal history includes the events from birth of the baby to 28 days of its life,which are as
follows:

 Feeding problems and duration of feeding

 Neonatal convulsions
 Respiratory distress syndrome
 Jaundice
 Weight gain of the baby
 History of hospitalization with duration and nature of treatment
 Any congenital malformations

DEVELOPMENTAL HISTORY

Developmental history includes the details of various milestones attained by the baby as it
grows. This may vary from child to child

The examiner should enquire about the various age-specific milestones. These should be
compared with the normal values to detect any obvious delay in the attainment of these
milestones.

NUTRITIONAL HISTORY

Nutritional history includes the details of the food intake of the child right from the birth to the
present eating habits. The examiner should enquire about the breastfeeding, additional diet
during weaning and the post weaning diet. Special focus should be given to the diet immediately
before the illness.

IMMUNIZATION HISTORY
The disease –fighting capability of the child depends on his immune status. Therefore it is
important to enquire whether the child has been immunized or not. The examiner should also
note the immunization details of the child.ask whether any optional vaccines were given to the
child

PERSONAL HISTORY

Personal history is relevant if the child is above 7 years of age. It includes various aspects of the
child’s personal habits, attitude and interaction with others. It can be relevant, for instance, in
anticipating vitamin B12 deficiency in a child with strict vegetarian diet. Information about the
attitude and interaction with others may be derived from the child’s school performance or
ability to make friends.

HISTORY OF ALLERGY

The examiner should enquire about the history of allergy in the child. Any allergy to particular
food items or medication should also be documented.

FAMILY HISTORY

The family history has a strong bearing on the disease propensity of the individuals.
Many diseases results from genetic causes inherited from the parents .certain beliefs, customs
and habits are also acquired from the family. Important aspects of family history include the
following:

 Age of the parents

 Consanguinity
 Family tree(pedigree chart)
 Significant illness in the family members
 Family history relevant to nutrition

SOCIAL AND ENVIRONMENTAL HISTORY

The social and environment milieu also dictate the susceptibility of the child to any disease or
condition. The examiner should consider the following aspects while assessing the social and
environmental history:
Socioeconomic status: The socioeconomic status can be classified, according to the occupation,
into the following five classes:

 Class I-executives,judges and collectors

 Class II- professionals such as doctors
 Class III- trained workers
 ClassIV- untrained workers
 Class V-street dwellers

Per capita income

Per capita income of the family is calculated by adding the total income of all the earning
members and dividing it by the number of family members. The examiner should also enquire
about the portion of this income spent on food.

Housing conditions

 Housing type
 Living area per person
 Ventilation facilities

Water source

 Water supply to the house

 Water cleaning facilities

Sewage disposal

 Sanitation facilities
 Hygiene status

Environment

 Pollution due to vehicle smoke predisposes to lead poisoning

 Factories letting out harmful substances such as lead may predispose to lead poisoning
 Contamination of water predisposes to infections and poisoning
CONCLUSION

A careful correlation of the history, clinical examination, radiographic and other investigations
can help in reaching the definitive diagnosis. It should be remembered that careful history taking
plays the most important role in reaching the diagnosis

REFERENCES

 Ghai OP, “Essential Paediatrics”.CBC Publishers, ed. 7th.

 Dutta Parul, “Paediatrics nursing” jaypee publishers, ed.
 Second Sudhakar A,“Essentials of Paediatrics nursing” Jaypee publishers, ed. 1st.
http://www.ijabmr.org
 David Hull andJohnstan D; “Essentials of Paediatrics” Churchill Livingstone
 Blake G, Florence and Wright; “Essentials of Paediatric Nursing”
 Behrman, Richard K and Vaughan;”Nelson,sTextbook of Pediatrics”; WB Saunders
Company
 Achar ST and Viswanathan;“Textbook of Paediatrics; A Clinical Approach Orient
Longman,Mumbai

TOPIC
PRESENTATION
ON
HISTORY TAKING
IN
 CHILDREN

SUBMITTED TO SUBMITTED BY
Dr.Shweta Joshi Jasmine Ouseph
Professor,DYCON F.Yr.MSc Nursing

PERFORMA FOR TOPIC PRESENTATION

TOPIC : History Taking in children

SUB TOPIC : Child Health Nursing

UNIT :I

DATE : 6/4/2021

TIME : 2.30 pm

VENUE : Msc Nursing Classroom

CLASS TAUGHT : Msc Students

METHOD OF TEACHING : Lecture cum Discussion

 AUDIO VISUAL AIDS : PPT

PREVIOUS KNOWLEDGE

OF THE GROUP : the group has some knowledge about the

history taking in children

TOPIC
PRESENTATION
ON
 HISTORY
TAKING
SUBMITTED TO SUBMITTED BY
Dr.Shweta Joshi Jasmine Ouseph
Professor,DYCON F.Yr.MSc Nursing

PERFORMA FOR TOPIC PRESENTATION

TOPIC : History Taking

SUB TOPIC : Child Health Nursing

UNIT :I

DATE :

TIME :10.30 am

VENUE :Msc Nursing Classroom

CLASS TAUGHT : Msc Students

 METHOD OF TEACHING : Lecture cum Discussion

AUDIO VISUAL AIDS : PPT

PREVIOUS KNOWLEDGE OF THE GROUP : the group has some

knowledge about the history
taking in pediatrics

OUTLINE OF THE CONTENTS

SR.N CONTENTS Pg No
O
1 Introduction

2 Identification of the patient

3 Presenting complaints

4 History of present illness

5 History of past illness

6 History of Contact

7 Antenatal history
8 Birth history

9 Neonatal history

10 Developmental history

11 Nutritional history

12 Immunization history

13 Personal history

14 History of allergy

15 Family history

16 Socio and Environmental history

17 Conclusion

18 Bibliography