History-and-exam.ppt - Taking a Paediatric History Dr E...

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Taking a Paediatric History Dr. E. Roche & Dr. S. Khalaldeh
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Differences Birth history and impact of children’s growth and development Often distracted by presence of the child Need to be flexible Maintain a sense of humour
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Chief Problem/Presenting Complaint Who is Giving the History? Listen to the mother, What are her worries? What does she think is the problem? Ask her to define her terms Quote verbatim what she says. Understand her idioms.
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Presenting Complaint & History of Presenting Complaint Presenting Complaint use patient’s/parents own words History of Presenting Complaint Sequence of events - what happened next? when was he last well? - what was the first thing you noticed wrong? Follow-up enquiry , eg pain - site, nature, frequency, radiation, aggravating & relieving factors, associated features eg seizure – onset, characteristics, duration, post episode
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Taking a Paediatric History Previous History - Medical & Surgical Neonatal History Nutrition History Developmental History Vaccination History Family History Social History Medications & Allergies
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Natal / Neonatal History Neonatal History - pregnancy/antenatal complications - gestation, mode of delivery – Why? -birth weight, (AGA, SGA, LGA) Apgar scores Neonatal problems, -jaundice, transfusions, sepsis Feeding Respiratory problems, -ventilated – why & how long for? Congenital defects Did the baby go home with you?
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Nutritional History Nutrition/Feeding History - breast /bottle, -weaning (when?, amount & type of feeds) Major food groups - likes, dislikes -idiosyncrasies Special diets - why? Adherence/compliance, e.g diabetes- diabetic exchanges,PKU, Coeliac disease
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Development & Growth Developmental History - major milestones achieved i.e age smiled, sat, crawled, walked, first words - vision, hearing speech, motor skills, social skills - comparison with sibs - school performance Growth - does mother think child is growing - ask about puberty if appropriate to child’s age
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Vaccinations Vaccination History - BCG, - 5 in 1( dip, pertussis, tetanus, Hib, ipv) and Meningococcus C ( 2, 4 and 6 months) - MMR ( 12 – 15 months) - Boosters -special cases e.g pneumococcal vaccine, varicella vaccine, Hepatitis A & B * if no vaccinations always ask why
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Taking a Paediatric History Family History Asthma, eczema, diabetes, cystic fibrosis specific enquiries from pc
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Family History (I) Useful to draw family tree (pedigree) Siblings – age and health Any deaths ( incl SIDS, recurrent miscarriages) Specific enquiries related to presenting complaint ( parental heights, head size etc.) Level of education achieved by parents ( useful in developmental histories) Consanguinity
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ASTHMA TRIGGERS
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Taking a Paediatric History Social History marital status, supports, occupation siblings age & health any pets, smoking carers - who cares for the child by day
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