History taking is an art. In any branch of medicine, especially in child health, the diagnosis mainly comes from the history. For any patient, there can be a diagnosis at three levels. The first diagnosis comes after history, second diagnosis after examination and final diagnosis from investigations.
FORMAT FOR HISTORY TAKING
- Personal data
- Presenting complaints
- History of presenting illness
- Past history
- Antenatal history
- Natal history
- Neonatal history
- Developmental history
- Dietetic history
- Immunization history
- Family history
- Socioeconomic and environmental history
- Summary.
PERSONAL DATA
Name | Age | Sex | M/F |
| AddressInformant – Mother / Father / Grand parents / RelativesReliable / Not reliable | |||
PRESENTING COMPLAINTS
Complaints should be presented in the chronological order
For example: | Fever | 5 days |
Seizures | 3 days |
HISTORY OF PRESENTING COMPLAINTS
One must take a detailed account of history of presenting symptoms, because the diagnosis mainly comes from presenting complaints. One should analyse each presenting complaint in detail.
For exmple: Regarding the first symptom of fever, one should enquire about the
- Type of fever — remittent, intermittent or continuous fever, e.g. intermittent high fever occurs in a child with pyogenic meningitis.
- Diurnal variation of fever, e.g. in adult tuberculosis evening rise of temperature is common, but uncommon in children.
- Associated rigor and chills, e.g. in pyelonephritis, pneumonia, malaria, biliary infections.
- Associated sweating — most of the fevers subside by sweating. If sweating is not there, look for anhydrotic ectodermal dysplasia or hypothalamic syndrome.
- To find out etiology of fever ask for any history, suggestive of symptoms affecting the following system. For exampleCNS—Seizures, altered sensoriumRespiratory—Cough, dyspnoea, chest painGIT—Diarrhoea, dysentery, abdominal painRenal—Dysuria, frequency of micturition, abdominal pain
Regarding the seizure one should ask about,
- Type of seizures— Generalised or focal, if generalised tonic, clonic, tonic clonic, myoclonic.For example: In a child with typical febrile seizure, seizure is generalised. If the seizure is focal may be encephalitis or meningitis.
- Duration of seizure — In a child with simple febrile seizures, duration of seizure is usually less than 10 m.
- Any focal neurologic deficit. If the child develops a focal neurologic deficit like hemiplegia after seizures, it may be encephalitis rather than simple febrile seizures.
- Ask about other symptoms along with seizure like headache, vomiting or altered sensorium which may be seen in children with raised intracranial pressure.
HISTORY OF PAST ILLNESS
In the past illness, ask any relevant history related to the present problem.
For example, in a child with seizure ask for a past history of febrile fits, epilepsy, head injury, recent exanthematous fever or recent immunisations.
ANTENATAL HISTORY
Ask six important points.
- Regular antenatal checkup with special emphasis on nutrition, folic acid and iron supplementation, immunisation, (tetanus toxoid).
- Diseases complicating pregnancy like maternal diabetes, hypertension, bronchial asthma, viral exanthematous fevers like rubella, urinary tract infection.
- Complication of pregnancy like hyperemesis, pregnancy induced hypertension, eclampsia, antepartum haemorrhage.
- Drug intake— History of intake of teratogenic drugs during antenatal period. For example:Thalidomide—Phocomelia, CCHD – TOFAlcohol—Foetal alcohol syndromeDilantin (phenytoin)—Foetal hydantoin syndromeAnti thyroid drugs—Congenital hypothyroidismLithium—CHD-Ebsteins anomaly
- History of radiation — Radiation can lead to teratogenetic, high incidence of chromosomal anomalies and malignancies.
- Trauma during pregnancy can lead to precipitate labour.
NATAL HISTORY
Ask about,
- The type of delivery —Normal, LSCS, assisted labour (forceps or vacuum)
- Where was delivery conducted—Hospital, domiciliary
- Who has conducted delivery—Doctor, ANM
- Duration of labour—Normal, prolonged.
NEONATAL HISTORY
Ask about,
First cry of the child—If asphyxiated intervention, jaundice, cyanosis, pallor, bleeding, respiratory distress, umbilical sepsis, passage of meconium, urine.
DEVELOPMENTAL HISTORY
Take detailed developmental history of the child with emphasis on gross motor, fine motor, language, personal and social development (For details of development, see chapter IV on development and developmental asessment).
Key Developmental Milestones—Birth to 5 years
Age | Gross Motor | Fine Motor Adaptive | Personal/ Social | Language |
|---|---|---|---|---|
Birth | Moves head to side asymmetric tonic neck posture (ATNP) | Fixation of face | Sleeps 18 hrs. | Cries |
1 month | Head lags | Visual following 90° | Sleeps 14 hr | Quiets to voice |
2 months | Prone – lifts chin of mattress | Visual following 180° | Social smile | |
3 months | Neck holding ATNR | Hands mostly open disappears | Mother recognition | Cooing |
4 months | Head steadiness | Grasp rattle | Laughs aloud when placed in hands | |
5 months | Rolling over | Bidextrous approach for objects | ||
6 months | Sit with support | Hand to hand transfer of objects. Beginning of mouthing | Smiles at mirror image | Monosyllables ‘Ba’, ‘Ma’ |
7 months | Bounces on standing | Holds object with crude palmar grasp | Stranger anxiety | Response to name |
8 months | Sits without support | Understand ‘No’ | Nonspecific Mama | |
9 months | Crawls, pivots | Explores or objects | Mouthing of objects | Recognizes familiar words |
10 months | Stands with support | Assisted pincer grasp | Plays peek-a-boo waves ‘Bye-bye’ | Specific ‘Dada, Mama’ |
11 months | Cruises around objects | Unassisted pincer grasp | Follows gesture commands | |
12 months | Stands without support. Takes first step | Turns pages of books. Puts objects in container | Play simple ball games | Two, three words with meaning |
13 months | Walks without support. Dances to music. Sits down from standing | Points with fingers. Spontaneous scribbling | Demands attention. Separation anxiety, temper, tantrums | 3, 4 words in addition to ‘Mama, Dada’ |
14 months | Climb upstairs on hands and knees | Co-operates in dressing | Self play. Likes an audience. Fear of changes and darkness | Names of all family members |
15 months | Walks alone in constant motion | Spoon feeds. Marks with pencil. Builds tower with cubes. Puts pellets in bottle | Hunts parents. Indicates need by pointing and when met | Jargon. Follows simple commands. May name a familiar objects |
16 months | Sits on a chair | Like push pull toys | Hunts for missing parents | Enjoys explanation of pictures in book |
17 months | Stands on one foot holding on | Demands personal attention. Afraid of large animal | ||
18 months | Runs stiffly, walks upstairs with one hand held, explore drawers, etc. | Handedness is determined. Imitates scribbling. Put pellets in bottle | Feeds self. Seeks help when in trouble. May complain when wet or soiled. Day time bladder control | 10 words. Uses, ‘No’. Name pictures |
19 months | Kicks ball | Builds 3, 4 block tower. Flushes toilet | Enjoys swing. Pulls wagon with toys inside | 10, 15 words. Likes to be read to. |
20 months | Jumps | Throws ball. Pulls lid on box | Possessive about toys. Puts on shoes Imaginary play‘ Tea party’ | Ask, what is that? Labels action, Pick me up |
21 months | Walks upstairs holding railing | Fold papers | Like bugs and other small objects | Use pronoun ‘ I’. Uses word combinations echolalia |
22 months | Unwraps packages, puts beads together | Starting to co-operate. | Listens to stories, repeat nursery rhymes | |
23 months | Walks up and down steps alone both feet on each steps. Runs all the times. | Likes to fill and empty water | Reads books to self. Easily frustrated | Ask for drink and food |
24 months | Runs all the times. Walks backward | Matches objects. Draws horizontal lines, circular scribbling. Turns pages of book one at a time. | Parallel play. Bowel control. Verbalizes toilet needs | Verbalizes. Puts 3 words together (subject, verb, object) |
30 months | Goes upstairs alternating feet | Makes tower of 9 cubes. Draws vertical, horizontal strokes. | Helps to put things away. Pretends in play. | Refers to self by pronoun‘ I ‘ knows full name’ |
36 months | Rides tricycle. Stands momentarily on one foot. | Copies a circle, imitates a cross. Makes a tower of 10 cubes. Imitates construction of bridge of 3 cubes. | Parallel play with other children. Unbuttons clothing. Puts on shoes. Washes handedness, established. Knows gender | Knows age and sex. Counts three objects correctly. Repeat three numbers or a sentence of six syllables |
48 months | Hops on foot. Climbs well. Throws balls over head. Uses scissors to cut out pictures | Copies cross and square. Draws man with 2, 4 parts besides hands. Name longer of 2 lines | Group play, Role play. Goes to toilet alone. Night time bladder control | Tells a story. Counts 4 coins accurately |
60 months | Skips | Copies a triangle. Names heavier of 2 weights | Enjoys jokes and riddles. Dresses and undresses. Asks questions about the meaning of words. Domestic role playing | Names 4 colours. Repeat sentences of 10 syllables. Counts 10 coins correctly |
DIETETIC HISTORY
Ask about,
- Breast feeding, when was it started and how long breast feeding was continued.
- Weaning—Time of weaning and weaning diet.
- Dietary items taken by the child before hospitalization.
Calculate the total amount of calories and protein taken and say whether it is adequate or not.
Recommended Dietary Allowances (ICMR) (1998)
Age | Calories | Protein |
|---|---|---|
0-6 months | 108/kg | 2.05 /kg |
6-12 months | 98 /kg | 1.65 /kg |
1-3 years | 1240 | 22 |
3-6 years | 1690 | 30 |
6-10 years | 1950 | 41 |
10-12 years (male) | 2190 | 54 |
10-12 (female) | 1970 | 57 |
Bed Side Calculation of Calories
Up to 1 year | 100 cal/kg/ (expected weight for age) |
Above 1 year | 1000+ (Age in year - 1x100) |
DIFFERENCE BETWEEN COW'S MILK AND HUMAN MILK
Item | Human | Cows |
|---|---|---|
Non-protein Nitrogen | 0.2 g | 0.03 g |
Protein | 1.1 g | 3.0 g |
Casein | 20%(b) | 80%(a) |
Whey | 80% (Lactalbumin and Lactoferrin) | 20% (Lactoglobulin) |
Lactose | 7g | 4.5 g |
Fat | 4.5 g | 4.5 g |
EFA | 13% | 2% |
P/S Ratio | 1.2: 1 | 1.2 |
Ash / Minerals | 0.25 g | 0.75 g |
Ca: P Ratio | > 2 | < 2 |
Sodium | 0.7 mEq | 2.2 mEq |
Vit.K | 15 mcg | 60 mcg |
Vit.E | 2 mg | 0.4 mg |
Osmolality | 7.9 mOsm | 22.1 mOsm |
Energy Protein Ratio | 70: 1 | 25: 1 |
Calories | 67 cals | 67 cals |
RDA-VITAMINS AND MINERALS
1. | Vitamin A | 1500IU/day(500mcg) |
2. | Vitamin D | 400IU/day(10mcg) |
3. | Vitamin E Vitamin B Complex | 5-15IU/day(5-15 mg) |
4. | B1 Thiamine | 0.5-1.5 mg/day (1 mg/1000 cal) |
5. | B2 Riboflavin | 0.5-1.5mg/day |
6. | B6 Pyridoxine | 0.5-1.5mg/day |
7. | B3 Niacin | 5-15mg/day |
8. | B11 Folic acid | 50-150mcg/day |
9. | B12 Cyanocobalamine | 0.5-1.5mcg/day |
10. | Vitamin C Macro elements | 40mg/day |
11. | Calcium | 500-1000mg/day |
12. | Phosphorus | 800-1000mg/day |
13. | Magnesium Trace Elements | 200-300mg/day |
14. | Iron | 10-20mg/day |
15. | Iodine | 50-150mcg/day |
16. | Copper | 0.5-1mg/day |
17. | Zinc | 5-15 mg/day |
18. | Fluoride | 1-5 mg/day |
19. | Manganese | 1-5 mg/day |
20. | Selenium | 100 μg/clay |
21. | Molybdenum | 200-500 μg/day |
Sample Dietetic History
Detailed history and critical evaluation of diet are important to detect the etiology of protein energy malnutrition, and to provide dietary advice. Enquire regarding the item and time of first feed given, the reason for not breast feeding, duration of exclusive breast feeding and the reason for early introduction of other types of milk, dilution and method of feeding (cup or bottle), details about weaning and family pot diet. The diet prior to the illness by recall has to be entered in a format as shown below. The calorie and protein yield of home made dietary items are to be calculated with the help of a food value chart.
If the child is still breast fed the approximate quantity of breast milk has to be stated. A healthy mother will have 500–600 ml of breast milk up to 6 months after delivery, and thereafter decreases to 30 to 60 ml per feed. The approximate quantity can be calculated by knowing the number of breast feeds given to the baby, daily, as reported by the mother. Advice regarding feeding should be given after evaluation the diet.
Comparison with recommended dietary allowances (RDA) for the age and sex from ICMR chart or by bed side calculation is necessary to find out the dietary gap. The statement on diet may be made as follows. The diet reveals a gap of—calories and—proteins as per ICMR recommendation.
FORMAT OF SAMPLE DIETETIC HISTORY
Time | Item | Quantity | Calories | Protein (g) |
|---|---|---|---|---|
6 AM | Cow's milk | 1 glass | 120 | 6 |
8 AM | Iddli | 1 | 50 | 2 |
10 AM | Plantain | 1 | 50 | 0.5 |
12 Noon | Cooked rice, fish, cooked dal, vegetable curry | ½ cup ½ ounce 2 tsps 2 tsps | 87 40 20 - | 2 3 1 - |
3 PM | Vada | 1 | 50 | 1 |
5 PM | Cow's milk | 1 glass | 120 | 6 |
7 PM | Cooked rice, fish, cooked dal, vegetable curry | ½ cup ½ ounce 2 tsps 2 tsps | 87 40 20 - | 2 3 1 - |
Total | 684 | 275 | ||
Nutritional Value of Home Made Food Items
Items | Quantity | Calories | Protein |
|---|---|---|---|
Cow's milk | 1 glass | 120 | 6 |
Cooked rice | 1 cup | 175 | 4 |
Ragi flour | 6 tsps | 100 | 2 |
Egg | 1 | 80 | 6 |
Fish | 1 ounce | 80 | 6 |
Mutton | 1 ounce | 50 | 6 |
Dosa | 1 | 70 | 2 |
Iddali | 1 | 50 | 2 |
Chappathi | 1 | 70 | 2 |
Appam | 1 | 70 | 1 |
Bread | 1 slice (1 ounce) | 70 | 2 |
Poori | 1 | 35 | 1 |
Vada/Bonda | 1 | 50 | 1 |
Cooked dal | 1 tsp | 10 | 0.5 |
Plantain | 1 | 50 | 0.5 |
Upuma | 1 cup | 250 | 6 |
Sugar | 1 tsp | 20 | - |
Jaggery | 1 tsp | 20 | - |
Ghee/Butter | 1 tsp | 40 | - |
Mashed potato | 1 tsp | 40 | - |
Ground nuts | 10 | 20 | 1 |
Pappadom | 1 | 20 | 0.5 |
Biscuit | 1 | 20 | 0.5 |
Tapioca | 100 gm | 157 | 0.7 |
Green vegetables | 100 gm | 46 | 3.6 |
Measures | |||
1 Ounce | = 28.4 gm | 1 Teaspoon | = 5 ml (5 gm) |
1 Gm | = 1 ml | 1 Teacup (large) | = 180 ml (180 gm) |
IMMUNIZATION HISTORY
Ask about,
Immunisation taken — time, number of doses according to National Immunisation Schedule and IAP Schedule.10
NATIONAL IMMUNIZATION SCHEDULE
(a) | For Infants | |
At Birth | BCG and OPV ( zero dose) | |
At 6 weeks | DPT −1 and OPV −1 | |
At 10 weeks | DPT −2 and OPV −2 | |
At 14 weeks | DPT −3 and OPV −3 | |
At 9 months | Measles | |
(b) | At 16 ∗ 24 months | DPT and OPV |
(c) | At 5 ∗ 6 years | DT −2nd dose |
(d) | At 10 ∗ 16 years | Tetanus toxoid |
(e) | For pregnant women | |
Early in pregnancy | TT −1 or Booster | |
One month after TT-1 | TT −2 |
IAP IMMUNIZATION TABLE
Vaccine | Age recommended | |
|---|---|---|
Primary | Booster | |
BCG | Birth - 2 weeks | No Booster |
OPV | Birth 6, 10, 14 weeks | 16–18 months, 5 years |
DPT | 6, 10, 14 weeks | 16 ∗18 months, 5 years |
Hepatitis B | Birth 6, 14 weeks | No Booster |
Hib. Conjugate | 6, 10, 14 weeks | 16 ∗18 months |
Measles | 9 months plus | No Booster |
MMR | 15 months | Booster at 5-6 year |
Typhoid WC (or) | 6 months, 2 doses | Once in 3 years |
Vi (polysaccharide) | 2 years, 1 dose | Once in 3 years |
(or) Ty 21a | 6 years, 3 doses | Once in 3 years |
TT/ Td | 10, 16 years | Once in 5 years |
TT ( Pregnant ) | 2 doses | Once in 5 years |
ADDITIONAL VACCINES
Varicella ** | Above 1 year and ≤ 12 years – 1 dose > 12 years – 2 doses ( 1 month apart ) | No booster |
Hepatitis A ** | Above 2 years 1 dose on elected date | 6 months later |
Conjugate pneumococal vaccine | 3 dose 6,10,14 | 18 months |
Note:
- Newborns who miss BCG, OPV and Hepatitis B vaccines at birth should receive the same, latest at the completion of 6 weeks.
- In addition to ‘Routine OPV doses’ the recommended ‘Pulse OPV doses’ are also mandatory during PPI campaigns.
- Apart from the earliest age indicated, MMR, typhoid, varicella and hepatitis A vaccines can be given for older children, adolescents and adults.
- Td (Tetanus/diphtheria toxoid) should be preferred to TT (Tetanus toxoid) where available.
- Varicella ** and Hepatitis ** A are additional vaccines as recommended by Indian Academy of Pediatrics.
IAP ADOLESCENT IMMUNISATION TIME TABLE
Vaccine | Age recommended |
|---|---|
Tetanus toxoid | Booster doses at 10 and 16 years. Booster every 5 years |
Rubella vaccine (As part of MMR vaccine or Monovalent formulation) | For Girls at 12 ∗13 years of age. One dose if not given earlier |
MMR Vaccine | Both for boys and girls, one dose at 12 ∗13 years of age if not given earlier |
Hepatitis B vaccine | 3 doses, any age at 0, 1 and 6 months, if not given earlier (0 being elected date). |
Typhoid vaccine TA (Whole cell) V1 or Oral Ty21a | Every 3 years |
Varicella vaccine Hepatitis A vaccine | 10 12 years, one dose, 13 years two doses at 4 weeks interval 2 doses at 0 and 6 months ( 0 being elected date). |
- 2 doses of MMR vaccine are recommended for those travelling to USA # Combined Hep. A+ Hep. B vaccine adult formulation can be given at 0,1 and 6 months (0 being elected date).
FAMILY HISTORY
Ask about,
- The age of father, mother, number of siblings with age, their health status.
- Draw a pedigree chart, in any inherited disorders, e.g. hemophilia
- Familial diseases
- History of consanguinity.
Socioeconomic history and Environmental History
Social history | —Type of housing, sanitation, water supply |
Economic history | —Job of father, mother, monthly income |
Environmental history | —Over crowding —Environmental pollution —Passive smoking —Pets in the house – Dog, cat, love birds —Source of energy – Electricity, wood, charcoal, gas —Flooring, cow dung, cement, marble —Type of bed, bed sheet —Ventilation in rooms |
Modified Kuppuswamy's Socioeconomic Scale
Item | Score | |
|---|---|---|
A. | Education of Family head | |
1. Professional degree, Postgraduate or above 2. Graduate 3. Intermediate, Post high school diploma 4. High school certificate 5. Middle school completion 6. Primary school or literate 7. Illiterate | 7 6 5 4 3 2 1 | |
B. | Occupation of Family head ( Last occupation if retired) | |
1. Professional 2. Semi professional 3. Clerical, shop owner, farm owner 4. Skilled worker 5. Semi skilled worker 6. Unskilled worker 7. Unemployed | 10 6 5 4 3 2 1 | |
C. | Per capita Income ( Rs per month ) | |
1. 800 or above 2. 400 − 799 3. 300 − 399 4. 200 − 299 5. 120 − 199 6. 40 − 199 7. Below 40 | 12 10 6 4 3 2 1 | |
Total Score A+B+C | ||
Total Score | Social Class | |
26 − 29 16 − 25 11 − 15 5 − 10 Below 5 | I II III IV V |
SUMMARY
Summarise the history, highlighting the positive points. Analyse the most important symptoms and try to arrive at provisional diagnosis—two or three.