History taking & management planning (HTMP)

Golden advices for excellence

1. Hx should be goal‐oriented, (based on 'presenting C/O).

a. Comprehensive HT is reserved for training or for
complex, multi‐system disorders
2. Some core knowledge is required to take a tailored
history ‫ﺫﺍﻛﺭ ﻧﻅﺭﻱ‬
a. Know 'topics that frequently came in exam
b. prepare 'tree DD and make a good approach to
get important clues for Δ
3. Technique:
a. Follow 'same rules of communications (eye contact, rapport ... etc.) but don't give
advices, solutions or planes
b. Use a mix of open & closed questions (Poor candidates will take a tick box approach
(shopping list), asking a long list of closed questions).

Types of history
o Acute on top of Chronic problem
 Acute asthma exacerbation
 Asthma in autistic child
o Chronic problem only
 Non-Compliance, complication of the disease or treatment
o Cases with multi-system involvement
Introduction =WIP
 Wash hands, Welcome (memorize name by heart)
 Identify roles (=marks) (‫ﺗﻭﺯﻳﻊ ﺍﺩﻭﺍﺭ ﺍﻟﺗﻣﺛﻳﻠﻳﺔ )ﻣﻳﻥ ﺍﻧﺎ ﻭﻣﻳﻥ ﺍﻧﺕ ﻭﺟﺎﻳﻳﻥ ﻧﻌﻣﻝ ﺍﻳﻪ‬
o Me: I'm Dr/...... one of your child's doctors
o You: You must be Fatma? Hi, nice to meet you, and who's been with you?
o Aim of encounter: to check up how things are going on with your diabetes.
 Permission (consent):

History taking
• Active story
A. Active story: 2 major parts 1
1) Acute problems
a) Active complain (SCOTS EARS) 2
• Search for 'cause & comp
b) Before:
c) During: Associated system S&S • On the run
3
(e.g. in RAP, analyze GI S&S).
d) After: Investigations & Rx • family social psychological
4
2) Chronic problem:

B. Searching for 'Δ, DD & complications: Systemic review

A D
C. On the Run histories (2 chunks)
EL SAM
 COAT TIMA ABD
 Birth to teen: Perinatal, G&D, pubertal history1 U SRY
D. Family, social & psychological history yO
1 Better to take nutritional history as a part of GI symptoms in systemic review. Pubertal history only if appropriate.
I. Active story:
A. Acute complain:
 Say "'golden phrase" could you describe that for me/could you tell you more about
C/O and keep silent after that ('golden minute), allow 'pt to tell his story
 This makes the conversation bidirectional, not a questionnaire.
 You can tailor your language to suit the patient's language
 You gain as much information as you can without need to ask.
 Then you narrow 'spectrum with closed Qs for things he did not tell in his story.

A. Active complain analysis: → SCOTS – EARS e.g. pain for example

o Site & radiation: Where does it hurt? Does the pain go elsewhere up or down?
o Character: What is the pain like? (stabbing, pin‐like, stinging, throbbing, dull?

o OCDF: onset, course, duration

 ONSET: How long has it been bothering you?
 Course: Was it severe from the start or did it worsen with time?
 Duration: How long does it last (mins, hrs, ds)?
 Frequency: Is its constant pain/does it come and go? If Be very clear with
comes and goes: How often does it come on? your questions
o Timing: Allow time for the
 Before: what was he doing before 'events patient to speak
 During: Associated S&S related to the same system
of complain (e.g. upturned eyes & deviation of mouth during seizure)
 After: aborted spontaneously, seek advice? investigations and Rx
 Day/night: Does it occur in a special time during night & day?
o Severity (e.g. scale from 1-10)

o Exacerbating factors: Does anything make it better/ worse?

o Alleviating factors:
o Relation to: posture, feeding, defecation e.g. functional abdominal pain.
o Similar illness: Have you ever had anything like this before?
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
B. Chronic problem:
I. Diagnosis story 2
II. Current F/U & medications3
A. Doctor → are you following with any doctor for short stature?
B. Medicine → Rx (GH, L‐thyroxine …etc.), doses, compliance, SE
III. Control:
A. Monitor
1) V/s → BP in renal disease & HSP
2) lab
a. GHD → IGF1 – hypothyroidism → thyroid panel
b. DM: → RBG, hemoglobin A1c, urinanalysis,
c. Seizure: drug level
3) Self‐monitor: e.g. DM → how frequent you measure blood sugar‫؟‬
Asthma: are you recording PEFR?
L S A MAD
B. complications
Y A BDE
1) Recognize 'symptoms? SR yOU
2
when he was first diagnosed with diabetes? & what happened for him at that time to be diagnosed? did she had to stay in 'hospital at that time? And since that
did, she had to stay in the hospital many times or not at all because of her illness? (No/year, HDU, ICU?)
3
are you following with any doctor for your overweight? what medicine your doctor gave to you? (Doses, SE, compliance, did he make any change to your Rx
plan recently? When was your last visit? Did you gain much weight since this visit?
 2) Ability to deal with it properly?
3) Action plan?
4) Frequency → how frequent is 'breakthroughs?
C. Diary?
D. Control scale 0 → 10

II. SYSTEMIC REVIEW 4

 General: fever, malaise, exercise intolerance

 CNS: seizures, ↑ ICP, focal deficits

 Head: 4 senses (eye, nose, ear, mouth)
 Neck swellings (LNs, thyroid)

 Cardio: → PP in pain breath FAST

o Palpitation → feel your heart is racing or went crazy?
o Pressure → high BP
o Pain (chest)
o Breath (SOB, dyspnea, orthopnea … etc.)
o FAST (feeding, activity & exercise, sleep, tender liver)
 GI:
A. Symptoms
 Up – vomiting, hurt burn
 Middle
 Pain
 Distention → abd tumour/hepatomegaly,
5 Fs
 Down → (opening bowel) constipations (hypothyroidism),
o Pooing frequency, amount, consistency, colour, smell, incomplete
evacuation (soiling, abdomen is full & still having 'desire despite passing
a loose poo?)
B. Nutritional history detailed only when relevant:
 No of meals & snakes A. Anemic, FFT:
 Amount of meals & snakes B. thin/obese
 Polyphagia (primary obesity, BWS, leptin, C. in children with diabetes:
psychological) D. in children needing high
caloric intake e.g. CHD, CF
 Early sense of satiety → abdominal tumours
 Type of food → fast (junk) foods, ↑ CHO, ↓fruits & vegetables
 Type of drinks → sweetened beverages (soda)
C. Wt, height & charts
 GU: (colour and amount of urine, dysuria, loin pain, urgency, frequency, sphincter control
(wetting, drippling, toilet trained or not)

 Skin:
o Rashes, itching, eczema
o Hypopigmentation "vitiligo as AI association" hyperpigmentation – Addison/CAH
o Back for bed sores in bed ridden pts e.g. CP
 Ms → contractures, proximal myopathy, weakness
M AD
 Bone:
E L SA
o Mobility and mobility problems, gait abnormalities, limb pain A BD
o Fx "osteoporosis", bowing SR Y
o Joint swellings y O U

4
Searching for clues supporting the diagnosis or supporting alternative diagnosis (DD), also searching for 'disease impact on other systems
III. On the run
A. Past medical & surgical history
o Chronic illnesses: do you have any other major illnesses? Like asthma, epilepsy?
o Operation, have you ever had an operation
o Admissions/Accident or
o Trauma

o Team involved in the patient care? Who is the consultant following you??
o Immunization
 has she had her immunizations? that injections given by a doctor?
 Did he receive extra Jabs (shots) especially for premature (e.g. RSV, BCG,
Seasonal flu, nephrotic $ (chicken box)
 Or did he omit vaccination? Such as MMR in non-HIV ID.
o Medications: do you take any other medicines rather than taking a pump?
o Allergies (do you have any allergies to food or medicine?)

B. Perinatal Hx:
A. Screening questions: neonatal H/O is not a concern:
I think, I've to ask your mom bit, bec. you can't remember
1. Was there any problem 'e pregnancy or 'e delivery?
2. Was she born in the normal time??
3. Did she have to stay in 'hospital for a long time after birth? in a
SCBU??

B. Detailed H/O: if you find any +ve findings in screening:

o Prenatal Hx (Maternal obstetric problems)

 This pregnancy
o Infection
 Known e.g. STDs or HIV, or Torch/GBS (from infection
screen)
 Risk: maternal pyrexia, PROM,
o Illnesses e.g. diabetes or hypertension
o Teratogen (Drugs, Alcohol, Smoking)
o Gel scan (what are the results of Gel scan)
 Previous pregnancies (stillbirths, miscarriages, prematurity)

o Natal:
 Delivery mode, GA, birthweight.
 Problems? (bleeding, prolonged labour, need any resuscitation … etc.)

o Post‐natal: whether admitted to SCBU or not?? if yes:

a) Was there any problem with respiration, did he need a breathing
machine? For how long?
b) Did he get jaundice while he was in 'hospital?
c) Was there in problems with eyes (ROP), ears or with the head scan,
yO

that usu done for premature babies??

US

d) Was there any problem in his heart (PDA)?

R

e) GIGU
Y
AB

 For how long did he stayed on TPN? "if relevant"

D


Did they insert a catheter in his tummy? And for how long
EL

they keep it in place? >> (a clue for hematemesis scenario in 21 mo old boy)
SA

 Did he have any problem with sucking, swallowing, NGT use,

M
AD

GERD?
 o Post discharge:
 Home Rx e.g. oxygen, medicines. Did he was on any support after being
discharged? Like oxygen or medicine
 Extra jabs: Did he take any extra Jabs?
 NB screen: What about 'results of NBS? was that normal?
 F/U: Did he follow in any clinics after that?

C. Developmental Hx: → only if relevant (e.g. CP patient) → Cover '4 aspects: gross, fine
motor, hearing & speech, social skills
o General questions: → what he is able to do himself?
o Easy to remember milestones
o Gross motor: 1st Head control, 1st sitting unsupported, first crawling, first
What is he able standing, first step
to do himself? o Fine motor & vision: reach for objects, CCS (cubes, cryon (writing, and
what are 'things drawing), scissor)
you need to help o Hearing & speech:
him with? o 1st word, 3 words with meaning (1 yr)
o 2 ward sentences (2 yrs), 3-word sentence (3 yr)
o Social:
o 1st smile (8 weeks),
o fear of strangers (8 mo),
o feed himself with spoon (18 mo),
o play (symbolic 1.5, interactive 3.5),
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
IV. Family, social & psychological history

 Family history:
1. Consanguinity, siblings & sibling's health.
2. F/H of
 Similar illness, or
 Related illness (Deafness in Pendred synd or LQTS)
 Illness that run in 'family

 Social history:
1. Home:
 Place: "only if relevant"
 Describe to me your house; floor, bedrooms, New home?
 Home modification: because of disability?
 People:
 People problems affecting 'child/possible solutions
o Financial
 Problems: parents not working, no medical insurance.
 Solution → income support: is the family on any income support? (e.g.
disability living allowance "DLA")
o Psychological
 Family problems affecting 'child:
 Do you have any family problems that can affect 'child's e.g. divorce,
separation, recent deaths, moving to a new house/school?
M AD
 Anyone in 'family has a psychological problem?
L SA
 Solution → did you asked advice for that? E
 Family problems from 'child? A BD
 Coping: Could you cope comfortably with it‫؟‬ S RY
U
 Care for other children? yO
  Solution:
 Respite care: Are you in any respite care plan?
 Support groups: Are you a member of any support group?
2. School: → ABESS = psychological history
 Academic
o School details → type (main stream or special needs school) & grade
o Impact of illness
 Achievement:
 How he is doing? – if she said good, no need for next Q
 Learning difficulties (LD)? Has he ever been evaluated for LD?
 Missed days: How many ds/wks did he miss school because of his illness?
o School role in 'child illness
 School knows about illness? Have they action plan for emergencies?
 Any plans to compensate absence days.
 Behaviour:
o Interaction with peers & family?
 Not interacting e.g. ADHD & autism
 Aggression e.g. oppositional defiant disorder, ADHD
 Isolation and separation 2⁰ bullying
 Do his peers understand his illness, bullying him?
o Habits
 Enuresis, temper tantrums, thumb sucking, pica, nightmares
 Smoke, drink, illicit drugs? Do you smoke or drink5? Do you take any kind
of drugs (only if relevant, only in adolescent)?
 Emotions:
o Anxiety, depression, emotional lability
o Low self esteem
 Sport/ activities
o Video games or TV viewing >2 hr/d
o Sports
 Type (walking, biking, football, …etc)
 Hours/wk
 Is he always relactant to be involved in sport?
o Yes, he always has Limited activity
o No, he was fine & playing before getting obese?
o Disability interfering 'e activity?
 Sleep problems "only if relevant"
o Inadequate sleep hours "watching TV all the night"
o Insomnia, somnolence
o nightmares 'in hypoglycemia" M AD
o OSA: night time snoring, day time somnolence
D E LSA
3. Safety: → BEAT Y AB
R
a. Bracelet: Are you wearing bracelet
y OUS
b. Exposure to harm
 Smoke, Drink, illicit drugs "if not done before"
 Animal exposure "of importance in asthma, lymphadenopathy"
 Travel: endemic area, travel vaccine?
c. Action plan: Did your parents, teachers & colleagues knows how to deal with emergencies?
Do they have a written action plan?
d. Transportation esp in disabled child e.g. CP

5 This needs preparation before you ask, you can say, nowadays some of your colleagues are smoking or trying to drink or to use some drugs; did you ever tried such things?