Case Taking in Pediatrics
Taking a good history is a vital skill to secure a cure. Sometimes, the history can alone lead to the diagnosis without needing to perform extensive examination or investigations. The history can be taken from-
• care-taker or attendant
The history revealer should also be noted. A typical history should include:
• Presenting complaint —records should be made of the main problems in the family’s own words as they describe them.
• History of presenting complaint —an exact chronology from the time the child was last completely well should be obtained. The family should be allowed to describe events themselves; use of questions to direct them and probe for speciﬁc information may sometimes be useful. An open question —‘tell me about the cough’ rather than ‘is the cough worse in the mornings should be used.’
• Past medical history —in young children and infants this should start from the pregnancy, and include details of the delivery and neonatal period, including any feeding or breathing problems. All illnesses and hospital attendances, including accidents should be noted down.
• Vaccination history —all about immunizations and foreign travel should be noted.
• Developmental history —all about milestones and school performance must be asked.
• Family and social history —who is in the family and who lives at home? Consanguinity as ﬁrst cousin marriages increases the risk of genetic disorders. Emphasis should be made on if there are any illnesses that run in the family including if anyone have special needs and have there been any deaths in childhood.
• Social history —which school or nursery does the child attends? Jobs, smoking, pets and ﬁnancial situation at home are of importance. The social context of illness is very important in paediatrics.
• Drug history —what drugs is the child taking and are there any allergies?
• Systems inquiry —screening questions for symptoms within systems other than the presenting system.
• Anything else that the family thinks should be discussed.
• Finally, a problem list, which allows further management to be planned and targeted should be made.
Approaching the examination
• Child’s cooperation is necessary. It can be done with help of attendants. Physician must be conﬁdent yet non-threatening. It may be best to examine a non-threatening part of the body ﬁrst before undressing the child, or to do a mock examination on their teddy bear.
• Getting down to the child’s level by kneeling on the ﬂoor or sitting on the bed certainly helps. Using a style and language that is appropriate to their age —‘I’m going to feel your tummy’ is good for a small child but not an adolescent.
• Babies are best examined on a couch with the parent nearby. The toddlers may need to be examined on the parent’s lap. Older children and adolescents should always be examined with a chaperone usually a parent but if the child prefers, a nurse. As much privacy as possible is needed when dressing and undressing the child.
• Sometimes it may be needed to be opportunistic and performing what examination can be done, when one can. Unpleasant things must be left until the end, for example, looking in the throat and ears can often cause distress.
• In order to perform a proper examination the child will need to be undressed but this is often best done by the parent and only the region that is being examined needs to be undressed at any one time. They should be allowed to get dressed before moving on to the next region.
• Hygiene is important, both for the patient and to prevent the spread of infection to others.
• Much information can be gained by careful observation of the child. This can be done whilst talking to the parents or taking the history. Does the child look well, ill, or severely unwell, is the child well nourished, are behaviour and responsiveness normal, is the child bright and alert, irritable or lethargic, is the child clean and well cared for, is there any evidence of cyanosis or pallor, does the child look shocked (mottled skin, cool peripheries) or dehydrated (sunken eyes, dry mouth), is there evidence of respiratory distress, what is the level of consciousness?
• Child’s growth i.e. height and weight should be plotted on charts. Head circumference should be measured in infants and in those where there is neurodevelopmental concern.
• The consultation is with the child and the carers and both must be involved.
• History taking is a crucial skill.
• Language and approach need to be adapted to the age of the child and the understanding of the family.
• Consent should be obtained for examination, which must be conducted in a child-friendly manner.
• Observation is often more important than hands-on examination when assessing a child.