How To Take Clinical History in Pediatrics by Dr Beena Sharma

by admin on September 26, 2009

Dr Beena Sharma has done MBBS (KGMC-Lucknow), MD, DCH, Pediatrics Neurology New Castle Upontyne United Kingdom, WHO fellowship for teacher’s training, member executive IAP, now as professor at Era’s Lucknow Medical College and Hospital (ELMC&H). According to her history taking is an art, it comes by efforts and practice, Pediatrics is a branch which may be equavalent to vatinary medicine, because child cannot explain his problem, and mother is over concious, history taking becomes still more difficult when mother is also not present or is illitrate.

With this article we have attached the video presentation of  case study of a 3 year old child who is having complains of loose stools, decreased appetite and generalized swelling from last 15 days, the diagnosis goes more in favour of Protein Energy Malnutrition mostly Kwashiorkor, watch video below…

Headings used while presenting clinical history

 

Basic informations: Name, age, sex of the child, from whom you are asking history, his / her realation to child, socio economic status, education, occupation, religion etc

 

Chief complaints: these are the complaints for which patient has come to you must be written in chronological order and in language of patient, no need to use medical terms in it.

 

History of present illness: it includes detailed elaboration of chief complains, their onset, negative history, drug history, each symptom has to explained in details.

 

History of Past Illness: Must ask for history of common childhood diseases like pertusis, rashes, gastro-intestinal infections, respiratory illness, diabetes, jaundice, ingestion or inhalation of foreign bodies.

 

Prenatal History: it includes important intrauterine and perinatal events, must be recorded in child below 5 years,  there is no history of drug intake, x-ray exposure during first trimester or pregnancy.

 

Natal History: full term normal delivery supervised by daes or nurse or doctor,  child cried immediately after birth and was pink in colour.

 

Post Natal History: there is no history of cyanosis, jaundice or convulsions etc

 

 

Developmental history: must ask for milestones in sequence, compare them to other child of the same mother. Developmental History is divided into 4 sub headings

Gross Motor

Fine Motor

Language and

Personal Social

 

 

Family history: ask for genetic diseases, infection in family, see pedigree for inheritance of diseases.

 

Socio Economic status: what is per capita income of family members, educational background, culture practices, schoolings, who looks for child when mother is not at home.

 

Dietary History: Duration of breast feeding, initiation of breast feeding, time of weaning, top feeds, type of milk given if given from outside like cow, buffalo, total calories before illness, calories gap, fluid intake, protein intake etc.

 

Thanks Dr Beena Ma’am And Students of Batch 2004-05 of Era’s Medical College for getting these videos prepared.

For Further Reading :

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{ 2 comments… read them below or add one }

sivaranjini March 8, 2011 at 9:52 pm

dis artical deserves an applaud…thank u mam

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Raminderjit Singh January 8, 2013 at 9:13 pm

surely nice work i really needed this
u desrve an applaud mam
great……..

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