- Rationale of the Pediatric History
- History of the Presenting Problem and the Past Medical and Surgical History
- Review of Systems
- History of Pregnancy, Delivery and the Neonatal Period
- Other Components of the Pediatric History
- Clinical Links Relevant to Breastfeeding
- Immunization
- Analysis and Deduction in the Layout of a Complete Pediatric History
The pediatric specialty is unique as it spans across a range of age groups.1–10 Age variation is perhaps its most distinguishing feature. Most patients who are seen in pediatric wards and out-patient departments are babies or young children; hence the history is usually obtained from the parents or guardians of the patient and not directly from the patient. Today, in many countries around the world, an increasing number of families have dual incomes where the mother is expected to work to help support the family. Consequently, children are left in the care of relatives or at nurseries or daycare centers.1–5
Hence, children across the world require meticulous care and universal concern regarding their health and well being and because of this, doctors dealing with children must show interest, be equipped with basic knowledge of childhood illnesses and be empathetic towards their problems. The statistics in some countries indicate that approximately a third of the population importantly consist of young citizens below the age of fifteen years.6
Parents, grandparents, older siblings, extended family members, the babysitter or the social worker will give the history. Consequently, the history is usually one of perception, one that ‘is felt to be’ by reliable observers. The taking of the pediatric history that is often attained ‘second hand’ requires a skill that must be learnt and indeed fostered.
In many countries, children form a large proportion of the population that attend the out-patient clinics
Parents and grandparents are often the best historians
Mothers are often astute observers of their young ones and the maternal history often reveals many clues to the underlying disorder or disease. A good history taker is one who listens attentively and then interjects with appropriate questions.4
Mothers are astute observers
Unfortunately, a small number of parents cannot recall many events pertaining to vital facets in the lives of their children. Dealing with these parents is both difficult and challenging. In these circumstances, a different approach may unavoidably be used; like asking leading questions that directly bring forth events that may otherwise remain untold. These incidents may have vital bearing to the child's history of disorder or illness. In pediatric care, a good clinician uses some special “tools” in history-taking to help parents recall distant events.
When eliciting the history from grandparents and siblings, one needs to ask if they are involved in caring for the child. Obtain all possible information during that visit. Sometimes, one making an appointment with the parents to retake the history or fill in on details is necessary.
If the child is at an age capable of relating his or her own story of himself or herself, it is mandatory to talk to the child, asking the history in a lingo that is simple, practical and understandable. Remember, the first-hand information from the patient is free from the prejudice of perception. Questioning must be uncomplicated and direct. Leading questions are useful in this situation. Tact must be exercised in a non-alarming fashion, neither hurting nor embarrassing the child. Needless to say here too, historical details should also be taken from the parents or guardians present.
In the adolescent, discretion and wisdom is always necessary. Some questions are best left to the last. More detailed information may be ideally explored with the adolescent alone. Beforehand, ask if that is what he or she prefers before raising specifically personal details. Yet other queries may be asked in the presence of the parent or guardian which are alright by the adolescent.
It is thus clear that pediatric history-taking is a skill where versatility in thought, care of the patient and consideration of all matters that relate to the patient are important. Indeed it is a skill to be mastered with diligent practice and patience. Thus, even in an age where many investigative methods are readily available in many parts of the world, the art of history-taking in pediatrics as an essential tool to the accurate diagnosis, clearly cannot be dismissed.
In pediatrics, great reliance is placed on the mother's history. About 70% of the pediatric diagnosis comes from the history. Usually it is the mother who nurses and cares for her sick child, hence great attention must be given to the story she tells. Reflect on the depth of meaning and good clinical sense in this quote by Sir William Osler (1849–1919) the British (Canadian-born) physician.
“Care more for the individual patient than for the special features of the disease. … Put yourself in his place … The kindly word, the cheerful greeting, the sympathetic look — these the patient understands.”
This is perhaps the most important part of the interview. First impressions count. Often they last.
The happy child plays with the cuddly toys (Reprint with kind permission from VRK)
A warm smile and a cuddly toy in one's hand will help in one's approach towards a child. These little objects immediately help to put the child at ease and in good cheer.
- Politely introduce yourself
- Politely request permission from the mother or caretaker
- Gently request permission from the older patient
- Ask keenly what the child is called at home and greet the child by that name (i.e. his pet name or home name)
- Be genuinely interested and concerned when speaking to the parents and patient
- Appear keen to interview both the parent and an older child and show empathy towards the patient and the parents and keenness to make an accurate diagnosis. This is best done by establishing eye contact with the historian
- Allow the mother who has the infant or toddler on her lap to continue to do so as you take the history in her position of comfort. Do not force a change in her comfortable routine unless she herself chooses to do so
- Know that young children may need a little time getting to know you; give a safe toy to the child to allay anxiety lest he or she may be uncomfortable in your presence
- Make the child and parents feel that you have the time, interest and competence to help them. As a consequence of all the above, develop and nurture a good doctor–patient relationship starting from the history-taking. The mother often reveals to you many a hidden secret if she trusts you and has some confidence in you
- Exercise tact and discretion when taking history in front of the child; always weigh the pros and cons of what you say and ask
- Do not forget to give due respect to the child by asking some questions, if the child can understand you. Children aged four years old and above must be included in history-taking
- Allow the child to speak. This is especially important if the child is able to understand and give his or her version of the problem. This will nurture a sense of self-esteem in the young child
- At times where sensitive questions must be asked, and understood by the child, realize that it may be necessary to interview the parents alone
- Likewise, in an adolescent patient and according to the wishes of the patient, it may be necessary to interview the patient alone.
- Use all your senses for observation including your eyes and ears while you take the history
- Observe parent-child interactions which may give you clues to diagnosis
- Recognize specific sounds produced by the pathology in some illnesses (e.g. stridor in upper respiratory diseases) or even be aware of peculiar or distinctive odors that may lead you to ask related questions (e.g. the sweet smell of urine in maple syrup disease)
- Be aware that parental distractions which could practically occur during history-taking can interfere with the quality of the given history; however never show impatience
- Likewise parental feelings of guilt or extreme anxiety may interfere with their perception of some or many historical events
- Be aware that the reliability of parental observation varies
- Start mentally processing the story and truthfully organize the history for clear and succinct comprehension both to yourself as well as to the listener—giving a truthful, clear, chronologically correct meaningful history which conveys the story briefly yet accurately
- You must yourself think maturely and this must be reflected in the history
- You are responsible for the history you take and the message you convey by it.
- Utilize history-taking as an effective and accurate patient management tool.
As mentioned, in taking the pediatric history, the mother or carer is heavily relied upon and trusted as they have the advantage of having spent many hours with the sick child. A large part of the diagnosis depends on their history.
However, in pediatrics, one must also realize that occasionally some parents or carers do not have the child's best interest at heart. This may or may not be a deliberate act of parental unkindness towards their offspring.
For example, when parents are disabled by the “burden” of nurturing as a result of physical, emotional or financial stresses, the welfare of children can be neglected.
When problems within a family are as immense as to endanger the normal physical, developmental, emotional and psychological well-being of their child, various difficulties towards the child can potentially arise. In these instances, the child needs to be protected and doctors, the social worker and child protection agencies must intervene.
In much situations, when the child is unwell and if brought for medical advice, parents or caregivers may not reveal the aspects of the history that may be vital to make a diagnosis of the illness. Important facts are deliberately concealed. In these cases, one must be clear that the duty of the doctor is towards the safety and health of the child. If this is suspected during the process of history-taking, various concerns regarding child protection must be considered.
These include:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Consider these matters too………….
While at the patient's bedside, in the hospital setting, the following issues must be given due thought before you approach the mother for historical questioning and physical examination:1–5,7–10
|
|
|
|
|
|
|
|
|
It is vital to understand symptomatology as your history is entirely based on the patient's symptoms.
What are Symptoms?
Symptoms form the basis and the core of the pediatric history. This commences from the presenting (chief) complaint. Symptoms are clinical expressions of underlying pathophysiology that are vital to the understanding of the patient's illness.
Characteristics of a Symptom
|
|
|
|
|
|
|
|
|
The doctor then enquires in detail about the symptom(s) and asks about other relevant related symptoms. Hence, it is important that your questions are in a language that the mother or caretaker understands and that both you and the historian are speaking about the same thing.
|
|
|
|
|
|
|
|
|
|
|
|
|
Enquiry of Symptoms
Give the patient a chance to talk, be a good and attentive listener : open ended questions and closed ended questions
|
|
|
The establishment of normal patterns and the need for historical comparison
- The enquiry of symptoms must establish the normal pattern of events first.
- This is important as:
- There are wide variations to some normal patterns of symptoms in children of different ages.
- The symptoms that are perceived by the guardian to be abnormal must be re-examined (with humility and respect) by further questioning in the light of this wide normal variation in children to better understand the symptoms related to you so that you can ask closed ended questions during history-taking.
So for example,
- You must determine the child's normal bowel pattern before proceeding with a history of diarrhea.
- You must ask what the normal number of changes of nappies is before deciding on reduced urine output.
- Ask whether the infant normally regurgitates his food and differentiate it from the perceived symptom of vomiting.
Compare with Siblings
Comparison with siblings is a form of enquiry that is important in pediatrics. This is particularly important when asking about development, appetite and growth. Comparison gives the mother the opportunity for recall and often enables the discovery of other relevant information in the history.
Comparison with siblings—a form of important pediatric enquiry
An example of the importance of comparison at arriving at a cause for the diagnosis would be:
- If on comparison with siblings of a child who is deemed to be small-for-age other siblings were also small, a familial or genetic cause may be considered. Further enquiry of this would then be necessary.
- The age at which the child walked or said the first meaningful word may not be remembered by the mother but comparison to the siblings may reveal “that they were no different from the others” enabling you to form some impression of the developmental milestones of the patient.
THE CARDINAL TEN (HISTORICAL)
The Cardinal Ten (Historical) describes and enquires into essential features of the history by analysis of important symptoms. The Cardinal Ten (Historical) asks ten important and relevant questions. The enquiry of each of these actually describes the symptom with entirety and clinical significance. Study these points and bear them in mind.1–5,7–10 Use them as a quick reference pertaining to questioning symptomatology.
The Cardinal Ten (Historical)
1. Time of onset | When |
2. Nature of onset | What |
3. Trigger of onset | How |
4. Intensity at onset | How much |
5. Duration of symptoms | How long |
6. Change in intensity | How much less or how much more |
7. *Associated factor(s) | **What else |
8. Exacerbating factor(s) | Worsened by |
9. Relieving factor(s) | Lessened by |
10. Action factor(s) or intervention(s) | What was done? |
| *Associated factors or **what else explores in the clinical history the possible related or relevant links | |
HISTORICAL LINK
This mainly attempts to link the pathophysiological connection that occurs in the human body as a result of interactions of known physiological processes.
The historical link is a bridge between the presenting complaint and many relevant factors that are vital to making an accurate clinical diagnosis:
The historical link links the history to: |
|
|
|
|
|
To elicit questions to form the link of clinical events, remember that these events are often told to the history taker by the mother in one way or the other so listen attentively.
Think, watch, listen, talk and think again.
When asking The Cardinal Ten (Historical) bear in mind that the “what else” can link you to significant events in the history. New events that emerge in the history which may have relevance to the disease or its differential diagnosis may also be elicited.
The associated factor(s) or the “what else” for each symptom is different, base it on your existing knowledge of the pathophysiology of the symptom. Here, you will form a link of related symptoms; the more histories you take the easier this will become.
In any underlying health condition enquire about how the illness has affected the activities of daily living.10
In the history of the more acute presenting complaint, enquire for example if the cough disturbed sleep; if the breathlessness interfered with feeding or if the fever kept the child away from school.
In a chronic problem, activities of daily living are important.
Ask if the repeated cough in a case of chronic cough caused frequent vomiting and if this interfered with weight gain; also ask if the cough was associated with dyspnea or if the dyspnea interfered with the child's attendance at school or playing of games. In an asthmatic child on inhaler therapy, ask if the child could play games like other children and if inhalers were necessarily taken before a game at school. In case of a diabetic child, for example, ask if the child knew to take a sweet in response to dizziness (due to hypoglycemia) and hence was always made to keep a sweet in the pocket.
In chronic diseases, the social impact of the disease and the activity of daily living involving the family are also very important.
A young boy enjoys cycling which is an activity of daily living. Remember that the activities of daily living are as important to the child as they are to the adult. Emphasize its relevance and reflect it in your good clinical history. (Reprint with kind permission from VRK)
The links in history-taking through observation and pathophysiology (observe the things around the patient as you take the history)
As the first example……. The link to activities of daily living reflects the severity of disease
During history-taking from the mother, you must also observe the surroundings and the patient. While taking the history you notice that the young child is sitting up in bed looking comfortable but on nasal oxygen. The mother tells you that he has a congenital heart disease. You notice the child looking very pale. In this case you must enquire on all symptoms of heart failure at that age, attempt to deduce the cause of the condition knowing that cyanotic and acyanotic heart diseases can cause heart failure at that age. Additionally, due to the striking pallor observed, the dietary history including all questions on type and amount of feeding and difficulties during feeding must be elicited. Details of growth and developmental milestones must be asked. Be aware about pathophysiological processes like the expression of cyanosis: if the hemoglobin is less than 5 g/dl, the cyanosis will be difficult to clinically detect.
The links are:
- To ascertain all historical details of heart failure, the underlying cause of heart failure. The past history of illnesses and chest infections will be important in forming a diagnosis.
- Peripheral vasoconstriction in heart failure can make a child look pale. Bearing this in mind, you will later examine the cardiovascular system thoroughly to exclude this. But in this comfortable child, do not assume that the pallor is only due to heart failure. Determine the cause of the pallor by asking about difficulties in feeding and in going into the nutritional history. Remember also that poor nutrition includes not only intake but all conditions that interfere with absorption and assimilation of nutrients.
- Enquire about the activities of daily living like playing, getting up and down stairs, attendance to nurseries and many others. Ask about how this illness has affected the family. Appreciate how activities of daily living give you a clue to severity of the underlying condition. The social history of the family also gives you an idea of how the disease has impacted living activities of the family.
A second example ……. The link to the onset of the disease helps narrow the diagnosis
During history-taking of a child with stridor, you must enquire from the mother about its onset, whether sudden or insidious and the child's activity prior to the episode. Enquire also if accompanied by other symptoms like choking, vomiting or cyanosis. This may reveal the cause which may be acute bacterial in origin with the history of drooling of saliva, being very ill or of refusing to feed or on the other hand, of a slightly more insidious viral etiology. A sudden onset in a previously healthy child must immediately alert one to possible foreign body inhalation. In foreign body aspiration, quickly ask, if the child was playing on the carpet with small toys. The age and developmental history would tell you if the child has already developed a pincer grip.
Notice how the mode of onset links you to other questions to determine the etiology of the stridor. Appreciate in the above examples how knowledge of the pathophysiology of the disease helps in forming a chain of relevant questions which are clues for an informed clinical guess and with the physical examination, basis for a sound clinical diagnosis.
PERTINENT NEGATIVES IN THE HISTORY
Pertinent negative history has often not been emphasized enough. During history-taking you ask many questions that you feel can directly take you to a possible diagnoses or a list of differential diagnoses. You ask questions and may find that the patient is experiencing illness in one particular system. You proceed to ask important questions of that system. You also ask about related symptoms. You ask more questions on the diagnosis considered while asking to exclude symptomatology that could overlap with other diseases. The negative responses or the absence of such symptoms helps you reaffirm the positive answers and make a case in strengthening your provisional diagnosis.
When you have got a fair idea of the problem, you may also ask many closed ended type questions which are more focused, where you limit choices to the answers and patients or parents may answer “yes” or “no”. Usually, during closed ended type questioning, positive symptoms and negative symptoms are elicited. These negative symptoms have as much diagnostic value as the positive ones.
Pertinent negatives |
|
|
|
|
Remember that in linking an important clinical symptom to another based on pathophysiology and pattern of diseases, you will have to ask many direct questions. The mother too may volunteer much vital information which you understand by attentive listening. This is the importance of the historical link and it elicits many questions that are answered in the affirmative. This line of questioning strengthens your most probable diagnosis.
While the astute mother herself may have told you many things that did happen in the history, she cannot tell you things that did not happen but may be deemed highly relevant. Hence you ask these questions, by direct questioning, whether such important events occurred. When armed with sufficient knowledge about diseases that occur in children these questions will help in excluding the more unlikely differential diagnosis. They give weight to the diagnosis that you feel is most likely. Hence given the importance of these events (or the lack or absence of such events), these pertinent negatives must be written down and narrated to the listener who can then make his or her own clinical judgment.
Remember that when a good history is taken, the need for superfluous and sometimes unnecessary investigations is reduced. A good clinician asks sharp important questions that quickly eliminate unlikely diagnoses.
As an example…….. The link of a symptom to other systems with similar symptomatology
A child of three years and who is not thriving well, has a cough of two weeks’ duration. The child has a history of rhinorrhea and fever and other family members have any history of an upper respiratory tract illness. You mentally formulate that the problem involves infection of the respiratory system. You ask about how the cough started, the precipitating factors and relieving factors. If the mother says that the cough worsens when the child lies down, you may think of a postnasal drip. But in view of the poor growth of the child, you may also want to exclude “orthopnea”. You ask if there is exercise intolerance, a history suggestive of paroxysmal nocturnal dyspnea. These questions are asked to exclude cardiac failure as a cause of the cough. You later review the relevant systems well. If these questions have negative answers, you decide that a cardiac cause of the cough is unlikely and consolidate your opinion of a respiratory problem. You continue to ask other relevant questions to focus the pathological and etiological diagnosis.
You proceed to ask if the fever was high grade or low grade to determine an etiological diagnosis. You ask if there were chills. The absence of chills in an active child with fever supports a viral etiology whereas high grade fever with chills in an inactive child suggests a bacterial etiology.
You may ask about travel or immunization. Based on the history of travel to endemic regions for some diseases, or the absence of specific immunization, a more specific etiological cause may be suspected and you further narrow down the differential diagnosis.
Another example is the links in the history to search for an etiological cause
In a child diagnosed with bronchial asthma, the mother may tell you that the child usually has an attack of cough and wheezing when he or she has flu or a running nose. You must also ask about other precipitating factors like animals, furry toys, cigarette smoke, aerosol sprays, exercise, cold weather, excitement and fizzy drinks. Even if the answer is “no” to all these triggers, it tells you importantly that the asthma attack is triggered by infection and not due to allergens, irritants exercise, excitement, colored or fizzy drinks. These trigger factors are important to elicit and to eliminate by the history. Your knowledge of etiology and a spectrum of variable disease triggers may prompt you to bring these possible triggers to the attention of the mother when counseling about management, treatment and prevention of such diseases.
- History-taking. Available at http://medicaltextbooksrevealed.s3.amazonaws.com. Accessed April 2013.
- Goel KM, Gupta DK. Hutchinson's Pediatrics (1st edn). India: Jaypee Brothers Medical Publishers (P) Ltd; 2009.
- Marcdante K, Kliegman RM, Jenson HB, Behrman RE (Eds). Nelson's Essentials of Pediatrics (6th edn). Saunders Elsevier, 2010.
- Pediatric history and physical examination (Children are not just little adults). Available at http://www.ped.med.utah.edu. AccessedApril 2013.
- The pediatric history. Available at http://www.patient.co.uk/doctor. Accessed April 2013.
- Website of Ministry of Health, Malaysia. Available at www.moh.gov.my. Accessed April 2013.
- Mason S, Swash M (Eds). Hutchinson's Clinical Methods (17th edn). A Baillere Tindall Book Published by Cassell Ltd; 1980.
- Milner AD, Hull D. Hospital Pediatrics. 3rd edn. ELBS with Churchill Livingstone. 1998.
- Richard E. Behrman (comps). Robert M Kliegman, Waldo E Nelson, Victor C VaughanIII(eds).Nelson's Textbook of Pediatrics (14th ed). Philadelphia:WB Saunders; 1992.
- Stephenson T, Wallace H (Eds). Clinical Pediatrics for Postgraduate Examinations. UK: Churchill Livingstone; 1991.
The essence of the relevant chapters in the following books have also been numbered as references in this chapter. We recommend for further reading, the rich text in these books for greater integration and deeper understanding.
- Goel KM, Gupta DK.Hutchinson's Pediatrics, 1st edn.Jaypee Brothers Medical Publishers (P) Ltd, India. 2009.
- Marcdante K, Kliegman RM, Jenson HB, Behrman RE (Eds). Nelson's Essentials of Pediatric, 6th edn.Saunders Elsevier. 2010.
- Mason S, Swash M (Eds). Hutchinson's Clinical Methods, 17th edn. A Baillere Tindall Book Published by Cassell Ltd. 1980.
- Milner AD, Hull D. Hospital Pediatrics, 3rd edn. ELBS with Churchill Livingstone. 1998.
- Behrman RE (comps), Kliegman RM, Nelson WE, VaughanIIIVC(Eds).Nelson's Textbook of Pediatrics, 14th edn. Philadelphia:WB Saunders. 1992.
- Stephenson T, Wallace H (Eds). Clinical Pediatrics for Postgraduate Examinations. UK: Churchill Livingstone. 1991.