Paediatric History Taking

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Taking a paediatric history can at first seem daunting due to the wide breadth of topics to be covered. With experience, there are short-cuts, but it is wise for newcomers to be thorough and work systematically through the history.

This guide provides a general overview of taking a paediatric history in an OSCE setting.


Before the consultation

First and foremost, you should check the child’s age as this information is key in determining what questions you’ll need to ask and what areas you’ll need to cover.

As such, it is imperative to know this information before approaching the patient and family, so that you can prepare a mental model for how you’ll structure the consultation.


Opening the consultation

Introduce yourself including your name and role.

Greet the child, their parents/carers and any other siblings who are present.

Confirm the child’s name and date of birth.

Make sure to maintain a comfortable distance from the child at the beginning of the consultation, whilst trying to build rapport with the family as a whole. Young children generally feel more comfortable and secure in their parent’s arms or lap and may require some time to feel at ease.

Observe how the child is playing and interacting with any siblings and their parents/carers.

Make sure to address questions to the child when appropriate. Depending on the child’s age, they will hold a wealth of knowledge about their current condition and their history – but may feel too shy or embarrassed to add to the conversation you may be having with their trusted adults. Be mindful to allow the child time to answer and do not interrupt.

Negotiating both talking to parents/carers without the child present and talking to the child alone requires tact and consideration. Generally, this is done to avoid embarrassing older children or adolescents and to allow for the imparting of sensitive information. This can be done by talking separately to each in turn, introducing the idea through normalisation – “It is my usual practice to…”. It is a good idea to speak to the parents first, then the adolescent or young adult – to provide some reassurance that the confidential information imparted to the doctor is not going to be immediately disclosed to the parents.


Presenting complaint

Use open questioning to explore the child’s presenting complaint, allowing the parents/carers and child to recount the presenting symptoms in their own words and at their own pace:

  • “So, what’s brought your child in today?”
  • What’s brought you in today?”

History of the presenting complaint

Exploring the presenting complaint

The following questions might be useful to gain more details about the presenting complaint:

  • When did the current problem start? What was it like?
  • Has the problem changed at all? If so, when and in what way?
  • Has medical attention been sought before now? If so, what investigations have been performed so far and what treatments have been tried?
  • Have there been similar episodes in the past?
  • Does anything seem to make the problem better or worse?
  • Do you have any photographic or video evidence (e.g. seizure)?

SOCRATES

If pain is a presenting complaint the SOCRATES acronym can be used to explore it further.

Site

Ask about the location of the pain:

  • “Where is the pain?”
  • “Can you point to where you experience the pain?”

Onset

Clarify how and when the pain developed:

  • “Did the pain come on suddenly or gradually?”
  • “When did the pain first start?”
  • “How long have you been experiencing the pain?”

Character

Ask about the specific characteristics of the pain:

  • “How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
  • “Is the pain constant or does it come and go?”

Radiation

Ask if the pain moves anywhere else:

  • “Does the pain spread elsewhere?”

Associations

Ask if there are other symptoms which are associated with the pain:

  • “Are there any other symptoms that seem associated with the pain?”

Time course

Clarify how the pain has changed over time:

  • “How has the pain changed over time?”

Exacerbating or relieving factors

Ask if anything makes the pain worse or better:

  • “Does anything make the pain worse?”
  • “Does anything make the pain better?”

Severity

Assess the severity of the pain by asking the patient to grade it on a scale of 0-10:

  • “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Ideas, concerns and expectations

A key component of history taking involves exploring the parent’s/carer’s and child’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a child and their parents currently perceive the situation, what they are worried about and what they expect from the consultation. It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the child’s/parent’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the child’s/parent’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the child/parents hope to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

Summarising

Summarise what the child/parents have told you about the presenting complaint. This allows you to check your understanding of the child’s history and provides an opportunity for the child/parents to correct any inaccurate information.

Once you have summarised, ask the child/parents if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the child’s history and it provides the child/parents with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your child’s symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to discuss your child’s past medical history.”


Systems review

A systems review involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systems review may also identify symptoms that the child/parents have forgotten to mention in the presenting complaint.

Examples of areas to cover in a systems review include:

  • Dietary intake: clarify what the child’s baseline dietary intake is and, if relevant, how this has changed recently.
  • Fluid intake: calculate the child’s fluid intake over the last 24 hours.
  • Urine output: ask if there has been any change in the child’s urine output (in younger children, ask if there has been a change in the number of wet nappies).
  • Stool: ask about the recent frequency and form of the child’s stools.
  • Vomiting: if the child has been vomiting, determine the frequency, volume and consistency of the vomit (e.g. bilious, haematemesis). Ask specifically about projectile vomiting if considering pyloric stenosis as an underlying diagnosis.
  • Fever: ask if the child has had a fever recently and if this was confirmed with a thermometer.
  • Rash: ask if the child currently has a rash, including its location, whether it appears to be spreading and if it appears to be itchy.
  • Coryzal symptoms: ask if the child has recently had a runny nose, or sounded ‘sniffly’.
  • Cough: ask if the child has a cough and if they are bringing up any sputum with it. Gain further details about the frequency of the cough, including associations with particular triggers or times of the day (e.g. nocturnal cough).
  • Work of breathing: ask if the child’s breathing has appeared more laboured recently.
  • Weight change: ask if the child appears to be gaining weight at an appropriate rate and review growth charts if available.
  • Behaviour: ask if the child appears to be their usual self, including their level of activity, mood and social interaction.
  • Pain: ask if the child appears to be in pain and further explore this using the SOCRATES acronym.

Past medical history

The scope and detail of this part of the history are determined by the nature and severity of the presenting complaint as well as the child’s age. For example, if a young child presents with delayed speech, a detailed birth and neonatal history, as well as details of developmental milestones, would be required.

Medical conditions

Ask if the child has any medical conditions: 

  • “Does your child have any medical conditions?”
  • “Are they currently seeing a doctor or specialist regularly?”

If the child does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the child is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Surgical history

Ask if the child has previously undergone any surgery or procedures (e.g. heart valve replacement, appendectomy):

  • “Has your child ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”

Allergies

Ask if the child has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Prenatal history

Key questions:

  • Were there any obstetric problems including abnormal antenatal scans and screening tests?
  • Were any medications taken during the pregnancy?

Birth history

Key questions:

  • Were there any concerns during delivery or interventions required?
  • What was the child’s gestation and birthweight?

Neonatal history

Key questions:

  • Did the child require admission to a special care baby unit and if so, for what reason?

Child development

Key questions:

  • Is the child meeting their developmental milestones?
  • Are there any concerns about the child’s development?

Growth history

Key questions:

  • Is the child currently growing along an appropriate weight and height centile?

Immunisation history

Key questions:

  • Is the child up to take with their immunisations?

Ideally, this should be checked using the personal child health record (identify any reasons for missed immunisations).


Drug history

Ask if the child is currently taking any prescribed medications or over-the-counter remedies:

  • “Is your child currently prescribed medications or are you giving any over-the-counter treatments?”

If the child is taking prescribed or over the counter medications, document the medication namedosefrequencyform and route.


Family history

Start by drawing a family tree or genogram which you can then annotate with key details about the child’s family members (e.g. age, health conditions, social issues, consanguinity).

Ask if any family members or friends have recently experienced similar symptoms to those the child is presenting with:

  • “Has anyone else in the household had a fever recently?”

Ask about conditions which appear to run in the family and clarify who has been affected:

  • “Are there any conditions which appear to run in the family?”
  • “Who has been affected by these conditions?”

If one of the child’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:

  • “I’m really sorry to hear that, do you mind me asking how old his brother was when he died?”
Family tree symbols
Family tree symbols

Social history

Explore the child’s general social context to gain a more complete picture of their wellbeing including:

  • who lives with the child
  • the relationship status of the parents/carers
  • what type of accommodation the child is living in
  • the child’s preferred play or leisure activities
  • the child’s happiness at home
  • the child’s happiness at school/nursery
  • the smoking status of the parents and anyone else living with the child
  • the impact of the child’s illness on the family

Social services involvement

Ask if the child is currently under the care of social services, subject to a child protection plan or has previously had social services involvement:

  • “Are social services currently involved with the care of your child?”
  • “Is a child protection plan currently in place?”
  • “Have you ever had input from social services?”

HEEADSSS

When taking a history from an adolescent or young adult, it is important to address the health risk behaviours that are more prevalent in this population, as well as the young person’s resilience factors. The HEEADSSS acronym is a useful tool for exploring this area of the history. We have outlined the HEEADSSS structure below with examples of questions to be asked in each section.

It’s important to reassure the adolescent that the content of the conversation will remain confidential and that you will not discuss any aspect of it with their parents/carers without their express permission. However, it’s also important that the young person understands that confidentiality cannot be assured if they’re at risk of harm – to themselves, or others. An opening statement similar may be helpful in establishing this verbal contract:

  • “Anything we talk about today is confidential. That means I cannot tell others, including your parents, about it without your permission. The only exceptions would be if I thought you, or someone else was at risk of serious harm. In that case, I would need to tell someone else.”

Home and relationships

Key questions include:

  • Who lives at home with you?
  • Do you have your own room?
  • Who do you get on with best and/or fight with most?
  • Who do you turn to when you’re feeling down?

Education and employment

Key questions include:

  • Are you in school/college at the moment?
  • Which year are you in?
  • What do you like the best/least at school/college?
  • How are you doing at school?
  • What do you want to do when you finish school/college?
  • Do you have friends at school?
  • How do you get along with others at school?
  • Do you work? How much?

Eating

Key questions include:

  • Are you worried about your weight or body shape?
  • Have you noticed any change in your weight recently?
  • Have you been on a diet?

Activities and hobbies

Key questions include:

  • How do you spend your spare time?
  • What do you do to relax?
  • What kind of physical activities do you do?

Drugs, alcohol and tobacco

Key questions include:

  • Does anyone smoke at home?
  • Lots of people your age smoke, have you been offered cigarettes? How many do you smoke each day?
  • Many people start drinking alcohol around your age, have you tried or been offered alcohol? How much/how often?
  • Some young people use cannabis, have you tried it? How much/how often?
  • What about other drugs, such as ecstasy and cocaine?

Sex and relationships

Key questions include:

  • Are you seeing anyone at the moment?
  • Are they a boy or a girl?
  • Young people are often starting to develop intimate relationships, how have you handled that part of your relationship?
  • Have you ever had sex?
  • What contraception do you use?

Self-harm, depression and self-image

Key questions include:

  • How is life going in general?
  • Are you worried about your weight?
  • What do you do when you feel stressed?
  • Do you ever feel sad and tearful?
  • Have you ever felt so sad that life isn’t worth living?
  • Do you think about hurting or killing yourself?
  • Have you ever tried to harm yourself?

Safety and abuse

Key questions include:

  • Do you feel safe at school/at home?
  • Is anyone harming you?
  • Is anyone making you do things that you don’t want to?
  • Have you ever felt unsafe when you’re online or using your phone?

Closing the consultation

Summarise the key points back to the child and parents/carers.

Ask the child/parents/carers if they have any questions or concerns that have not been addressed.

Thank the child and parents/carers for their time.


References

  • Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
  • Tasker, R. C., McClure, R. J., & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.
  • Fozi & Wood (2016). HEEADSSS Assessment. Nottingham Children’s Hospital. Nottingham University Hospitals NHS Trust. [LINK]

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