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7/29/2019 Peds History (C FW06)
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Pediatric HistoryAdapted from Davies Pediatric Chiropractic,Ch. 2 & Mosbys Guide to Physical Examination,
6th Ed., Ch. 1
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Fundamentals of
Diagnosis Skillful history-taking
Careful physical exam Keen powers of observation Wise selection of other exams
x-ray, labs, etc. Good clinical judgment
LOOK LISTEN FEEL
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More errors are made because ofinadequate history-taking and superficial
exam than any other cause.
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Tips
Definite No-Nos Never be critical of another practitionersdiagnosis or treatment suggestions
Never allow a child who has been broughtto you for care to leave without it do what you have to do, despite protests from
the child
Never allow a child to be rewarded forbeing sick
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Discussing Difficult
Subjectssexuality abuse
serious disease psychological etiology
suicide
divorcedrug addiction
peer issues
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I need to ask you some personal
questions, is that OK?I know some things are difficult totalk about and I really wish I didnt
have to ask but I need to knowabout, is that OK?
Take all the time you need, I knowthis is difficult for you.
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Be Aware
I want to talk to you about
something, but I want to be surethat you will not tell anyone.
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Recording the Pediatric
History
Reliability of the Historian
Historian is any person providinghistorical data describe by name and/or relationship to
the patient also record reliability
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History
The history for an infant or child will
be modified according to age
The following is just an outline
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Chief Complaint May be taken from a parent orguardian
Note the name, relationship & reliabilityof the person providing the history
The child should be included as much aspossible
Appropriate for his/her age
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Present Problem
Note the degree and character of
the reaction to the problem Both parent and child
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Different aspects of the historyassume or lose importance depending onthe age of the patient or the nature ofthe problem.
Reserve detailed questioning for thoseaspect s most pertinent to the child.
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Past Medical History General Health and Strength
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Past Medical History Mothers Health During Pregnancy General health, extent of prenatal care
Specific diseases or conditions Infectious diseases (gestational month)
Weight gain
Edema, hypertension, proteinuria
Bleeding (approximate time)
Pre-eclampsia
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Past Medical History Mothers Health (contd)
Medications hormones, vitamins, special
or unusual diet, general nutrition status Quality of fetal movement; time of onset Emotional and behavioral status
Attitudes toward pregnancy and children
Radiation exposure Use of alcohol or elicit drugs
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Past Medical History Birth Duration of pregnancy
Place of delivery Labor
spontaneous or induced
duration
analgesia or anesthesia
complications
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Past Medical History Birth (contd)
Delivery
presentation forceps, vacuum extraction
vaginal or cesarean section
complications
Condition of infant, onset of cry, APGARscores (if available)
Birth weight of infant
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Past Medical History
Neonatal Period Congenital anomolies
Babys condition in hospital, oxygenrequirements, color, vigor, cry, feeding
Duration of babys stay in hospital;infant discharged with mother?
Bilirubin phototherapy Prescriptions (antibiotics)
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Past Medical History Neonatal Period First Month of Life
Jaundice, color
Vigor of crying Bleeding
Convulsions
Other evidence of illness
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Past Medical History Neonatal Period Early bonding
Opportunities at birth and during the
first days of life for the parents tohold, talk to, and caress the infant
Opportunities for BOTH parents torelate to and develop a bond with thebaby
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Past Medical History Feeding
Breast or bottle (type of formula)
Reason for changes, if any Frequency of feedings
Amounts offered and consumed
Weight gain
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Past Medical History Feeding (contd)
Present diet and appetite
Age of introduction of solids Age child achieved 3 feedings per day Present feeding patterns Elaborate on any feeding problems
Age weaned from breast or bottle Type of milk and daily intake Food preference Ability to feed self
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Past Medical History Development
Commonly used developmental milestonesNOTE:
Parents my have baby books which can
stimulate recall Photographs may be helpful
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Past Medical History Development (contd)
Age when able to
Hold head erect when in sitting position Roll from front to back; back to front
Sit alone; unsupported
Stand with support; without
Use words
Talk in sentences
Dress self
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Past Medical History Development (contd)
Age when toilet trained
Approaches to and attitudes toward toilettraining
Dentition Age of first teeth
Loss of deciduous teeth
Eruption of first permanent teeth
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Past Medical History Development (contd)
Growth
changes in rates of growth or weight gain Sexual
Present status, any concerns Female: breast development, sexual hair, acne,
menstruation (description of menses)
Male: sexual hair, voice changes, acne, nocturnalemissions
School Grade, performance, problems
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Past Medical History Illnesses
Vaccinations
Communicable diseases Injuries
Hospitalizations
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Family History Maternal gestational history List all pregnancies
Health status of living children
Deceased children: date, age, and cause of death Miscarriage: dates and duration of pregnancies
Age of parents at the birth of this child
*Review at least 2 generations oneach side of the family.
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Personal and Social
History Personal status
Nail biting, thumb sucking, breath holding,
temper tantrums, pica, tics, rituals, etc. Bed wetting, constipation, or fecal soiling ofpants
School adjustment
A day in the life of the patient is oftenhelpful in providing insights.
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Personal and Social
History Home Conditions
Fathers and mothers occupations
Principal caretaker(s) of the child Daycare?
Parents divorced or separated
Food prepared by whom Sleep habits; sleeping arrangements
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In addition to the usual concerns,inquire about any past medical orpsychological testing of the child
First visit to the dentist? optometrist? Hearing checks? Speech therapist?
Etc.
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Review of Systems Skin Eczema; seborrhea (cradle cap)
Ears Otitis media (frequency and laterality)
Nose Snoring, mouth breathing Allergies
Teeth Dental care
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Adolescents Use open-ended questions Dont force the adolescent to talk
Sometimes, allowing an opportunity
to writea concern may help.
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Adolescents
Common IssuesH Home
E EducationA Activities, affect, ambition, anger
D Drugs
S Sex
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Adolescents
Common IssuesP Parents, peers
A Accidents, alcohol & drugsC Cigarettes
E Emotional issues
S School, sexuality
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