Framework for Taking History

Introducing yourself
Patients demographics
Presenting symptoms and duration
History of Presenting Illness
Drug and Treatment history
Drug allergy, adverse drug reaction
Past History
Immunization history
o Up to date on standard schedule?
o How about other optional vaccines
Growth and Developmental history
o Must assess for yourself via developmental hx and not just accept no
developmental issue with my child
o Milestones achieved
o What can the child currently do/cannot do (i.e., threshold)
o Assess growth, determine if normal/abnormal
o Height, weight, head circumference
o Serial data points good to consult health booklet
Menstrual/gynaecological history (in females)
Social history
o Family set up, primary caregiver, school, home situation
Family history
o 3rd generation pedigree
Systems review

In all history, aim to go systematically and show that you have a logical thought process (e.g. now
RO ddx, now doing aetiology)

Symptoms + associated problems

Problem at hand - PC
Differentials TRO by questions, even if the diagnosis is clear
Aetiology
Severity of the problem e.g. GE cx by dehydration -> how badly dehydrated? (e.g. UO in
past 1h)
Holistic view of child family, finances, social, impact of the disease
Previous attempts @ treatment and result outcomes of said treatment -> if abx has been
unable to curb fever etc. different ddx
Expectation why are they actually in the hospital? What are they worried about?

Tip : The order of your questions should be organized, logical in its progression so as to
demonstrate good clinical reasoning/approach to a problem

Student realises the patients symptoms may be due to pallor

The first set of question is thus directed at determining if this is truly pallor
Based on the patients answers, the student concludes that this is indeed pallor
The student then asks a next set of questions aimed at figuring out if this is single cell line or
more than just a single cell line.
Based on the patients answers, the student concludes that this only affects a single cell line,
The student then asks the next set of questions to determine the cause of isolated pallor
....etc
Diet and non-pharm treatment for chronic illness -> should clarify

PMHx in the front only if relevant e.g. Convulsion on B/g CP, UTI on B/g DM1 but NOT UTI on b/g of
convulsion etc.!
Abdominal examination

Rapport
o With child
o With caregiver
Peripheries first observation can tell you a lot of things
Nutritional status/growth - Is the child too small, too fat, too thin?
o Too thin:
Can see the ribs?
Significant LOW:
Look at the gluteal muscles (usually full in well nutritioned kids)
Thigh skin has wrinkles excessive loose skin
Inspection
o Distension
o Visible peristalsis
o Scar old/new
o Striae
o Prominent superficial veins
o Groin for hernias
Rickety rosary (from Vit D deficiency due to inadequate fat soluble vitamin
absorption). Abdominal distension. Scar across abdomen. Chronic liver
disease. Jaundice. Biliary atresia.
Organomegaly (hepatomegaly, splenomegaly), grossly distended tummy.
CLD. Portal htn.
Palpation: DO NOT INFLICT ANY PAIN TO PATIENT
o Superficial
o Deep
Hepatomegaly, splenomegaly, ballot kidneys
Liver:
Is it a liver?
o RHC, cannot get above, moves with respiration, dull to
percussion
Tender
Edge (smooth/irregular)
Surface (smooth/nodular)
Consistency
Rub/bruit
DO NOT SAY LIVER SPAN anything below the costal margin is
considered enlarged
Upper border
Trace over to the left do not confuse spleen and liver
Spleen:
Is it a spleen?
o LHC, direction of enlargement, cannot get above, moves
with respiration, dull, notch
Tender
Edge (smooth/irregular)
Surface (smooth/nodular)
Consistency
Measure size
Kidney
Is it kidney?
o Ballotable, can get above, doesnt move, reasonant
 Tender
Edge (smooth/irregular)
Surface (smooth/nodular)
Bruit
o Check for ascites
o Groin
o PR exam
Auscultate
o Bruit over hepatomegaly (hemangioma), renal bruit
o Ileus in distension
o Borgybmi