history 3rd year student

8/12/2019 History 3rd Year Student

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"Children are not little adults. Theyare unique."


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History Taking

in Paediatric


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Fundamentals of

Diagnosis

Skillful history-taking

Powers of observation Careful physical exam

Wise selection of Investigations

Good clinical judgment


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More errors are made because of inadequate

history-taking and superficial exam than anyother cause.


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History Taking

Onset

Progression

Duration Severity

Aggravating factor

Relieving factor

Associated factor

Site, Character & Radiation


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After her visits to OPD SARA goes to

South Circular Road (SCR)


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Component of History

Taking

Chief Complaint

HxPI

PMHx & PSHx

Antenatal & post natal history Feeding/dietary

Growth & Development

Immunizations

Medications & Allergies

Family & Social

Summary


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Chief complaint..


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Chief complaint

Sara 1 year 2 month old.. vs Sara 14month old..

Known case of.. vs underlying history of.. Was admitted to hospital on 5thJuly vs

was admitted to hospital 3 days ago


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Chief complaint

Keep it simple

No medical jargon

Implies your working diagnosis..


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Bad chief complaint

Sara a 1 year 7 month old girl fromPuchong, was admitted on 5thof July

complaining of fever, rashes, runny nose& vomiting.

Sara a 1 year 7 month old girl fromPuchong, was admitted on 5thof Julywith 3 days history of fever, vomiting &runny nose and rashes on day 2 of fever.


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Good chief complaint

Sara a 1 !-year-old girl from Puchong,was admitted to hospital following a 3

days history of fever & rashes. Sara a 1 !-year-old girl from Puchong,

was admitted to hospital with 3 dayshistory of facial puffiness and legswelling.


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History of presenting

illness

Simplified

What you have found rather than what

parents say. CHRONOLOGICAL ORDER!

Summarizing, not reporting or story telling

Follow conventional format(OPD SARASCR)

Ask relevant associated symptoms


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Bad reporter

Sara a 1 !-year-old girl from Puchong,was admitted to hospital following a 3days history of fever & rashes.

After day 1 of fever mother brought her tosee a GP where she received PCM &antibiotics.

As fever not settling, mum brought her toanother GP who said she should come

back on day 4 if fever persist.


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Bad reporting


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Good reporter..

Sara a 1 !-year-old girl from Puchong,was admitted to hospital following a 3

days history fever & rashes. She was brought to Serdang hospital after

3 days of persistent fever followingseveral visits to GP & a private hospital.

Her feverOPD SARA

Her rashesOPD SARA


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PMHx/PSHx

Important especially in recurrent/chronic

diseases

Might be related to HxPI

Chronological order!

If many events, summarize


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Antenatal & post natal

Hx

Health and age of mother in pregnancy

Antenatal scans and tests

Birth - Gestation, Mode, BWt, AS(conditionbaby at birth)

Any immediate health problems after birth(Admission to NICU, prolonged stay in

hospital after birth)

Any health problems in first few weeks oflife


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Feeding/Dietary

Breast/bottle fed

How long breast feeding

Bottle feed - what type, how much/24 hr

Weaning what age What type of solid food taken?


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Growth

Assess child physical growth

Parent held record

details/plots of previous weight &lengths/heights

For older children - onset of puberty


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Development

Commonly used developmental milestones

Make a card to carry around

Younger children : ask all 4 domains

Older children :

ask school performance Parent forget :

compare with other siblings


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Immunization

Missed dose - ask why?

Up to date

Completed up to age vs

Last vaccination was at 12 month of age.

No problem occurred after eachvaccination.


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Medications & allergies

Type, dosage, frequency Specific drug allergies or sensitivities

Food allergies


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family hx

Are you and your partner related? -CONSANGUINITY

Family tree - 3 generations ( ages, health,

cause of death)


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Social hx

Who makes up the household?

Size and type of accommodation

Parents occupation

Financial problems

Smoking/Drinking problems in family

Caretaker?

Childs school, school work, friends Problems at school (bullying, teasing)

DIFFICULT & SENSITIVE - practice some clear Q to avoidembarrasement


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can medical studentsgive advice to parents


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SUMMARY


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Bad Summary

In summary, Sara a 1 !-year-old girlfrom Puchong, was admitted to hospital

on 5th

July 2010 with a 3 days history offever & 2 days history of rashes whichappeared on day 2 of fever which isassociated with vomiting, diarrhoea,

cough and poor oral intake. However shedoes not have any abdominal distensionand has no urinary symptoms.


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Summary is not telling story..


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Summary

In summary, Sara a 1 !-year-old girlfrom a dengue endemic area in Puchong,

was admitted to hospital following a 3days history of persistent fever &generalized rashes.

In summary, Sara a 1 !-year-old girlfrom Puchong, was admitted to hospitalfollowing a 3 days history of persistentfever & generalized rashes.


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presenting a history is

an art


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Commentary.


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history 3rd year student

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