MEDICAL HISTORY TAKING

MEDICAL HISTORY TAKING

“Methods of physicians are like those of a detective, one seeking to explain a disease, other a crime”.

History taking is an art and demands skills of a lawyer, detective and judge. It requires inquisitiveness, persistence and tact. The physician should strive to obtain a lucid chronological story of child’s illness with special emphasis on mode of onset and course of events. Pediatrics has been likened to veterinary medicine because young children cannot express their symptoms. An intelligent and observant mother can provide satisfactory story of illness but may sometimes exaggerate facts due to her anxiety and concern. Father spends little time with the child and is generally ill-informed about child’s problems. School going children can give fair account of their physical difficulties and should always be encouraged to talk and explain their symptoms. The physician must exhibit humility, concern and politeness while recording history. He should be gentle, sympathetic, gracious and kind in his approach but alert and attentive. He must remember that patient is his honoured client and he should relieve the anxiety of the parents and instil confidence in them towards himself during the interview. It is often forgotten that while you are taking history and assessing the attendant and child, you are also being assessed by them on the basis of your behaviour and approach. Even the facial expression, tone of the voice, manner of movements and attitude of impatience, disbelief and reproach can all effect the outcome of communication between the doctor and patient/parents. It is the beginning of the most crucial doctor-patient (parent) relationship, which is essential for developing mutual trust and confidence. Assess the quality of parent-child and parent-parent interaction while recording history and conducting physical examination. Unsatisfactory parent-child or parent-parent interaction may lead to emotional deprivation or psycho-social and behaviour disorder in the child.

MEDICAL HISTORY TAKINGThe consultation room should be well lighted, comfortable, quiet and decorated with toys and pictures to allay the anxiety of the child. Infants and young children should be offered a soft toy or a rattle to establish rapport while taking history. School going children feel at ease when they are directly asked their name, details about school, hobbies and health problems. While taking history, the child should be observed “sneakily” for facial appearance, discomfort, distress and dyspnea. Avoid staring towards the child because children are often scared if you intently look into their eyes. Watch him without yourself being watched by the child. The child must visualise the physician as the friend of the mother and not a frightening figure who prescribes painful pricks and pungent potions. It must be remembered that most common diseases can be diagnosed by good history alone. Elicitation of history should continue during physical examination to seek additional information especially when unexpected abnormal physical findings are detected. History and physical examination should be viewed in continum and one should influence the other. The leads obtained on history should focus the physical examination on certain organs while presence of positive physical findings should encourage the pediatrician to seek more detailed review of certain symptoms/systems. To gain the confidence of parents and child, the pediatrician should maintain a friendly, warm, unhurried, informal and relaxed attitude throughout the assessment.

Basic information

Informant (mother, father, relative, child etc.), name, age (preferably date of birth) and sex of the patient should be enquired. Parent’s name, age, address, telephone number, income, occupation, education and religion should be recorded. The history may be unreliable due to informant’s poor memory, intelligence or education. The origin and ethnic background of the family is important in some genetic diseases. Thalassemia trait and disease are common among migrants from west Pakistan. Glucose-6 phosphate dehydrogenate deficiency is common among Parsis and north Indians while sickle cell disease is seen among tribal population.

Presenting complaints

The chief complaints for which the patient has been brought to the hospital should be recorded in a chronological order according to the sequence of events, e.g. fever 5 days, headache 3 days, vomiting 3 days, convulsions 1 day and loss of consciousness 12 hours. The key symptoms obtained on history should initiate a cascade of logical reasoning, based on the experience and knowledge of physician to consider plausible diagnostic possibilities or hypotheses for further probing.

History of present illness

The mother should be allowed to give details of sequence of events without the help of leading questions. The mode of onset, course of disease and details of treatment already received must be recorded in all cases. The symptoms referable to various body systems should be reviewed in order to identify the site of the disease (system review). The history should provide information whether the disease is localized to a particular body system or is generalised. A detailed information pertaining to various symptoms manifested by the patient should be elicited (symptom review).

Examples:

Fever. Onset (acute or insidious), duration, character (continuous, remittent, intermittent, step-ladder type, Pel-Ebstein etc.) severity, chills and rigors, associated localising symptoms etc. should be enquired. Young children cannot complain of chills (perception of extreme cold) but rigors may be observed by the mother as vigorous shaking movements or tremors. When body temperature never touches normal and daily fluctuations are less than 1°C it is described as continuous fever. When the daily fluctuations exceed 2°C, it is called as remittent or hectic temperature. In intermittent pyrexia, the temperature may touch or remain normal daily (quotidian), every alternate day (tertian) or after every two days (quartan).

Cough. Duration, frequency, character (hacking, brassy, barking, paroxysmal followed by long and deep noisy inspiration i.e. ‘whoop’), dry or productive, postural relationship, diurnal variations and associated features should be recorded. Ask whether cough is dry or associated with “chesty” sound. Infants do not expectorate but they swallow the phlegm and may vomit it out. History of inhalation of a foreign body should always be enquired in any child with sudden onset of cough with breathlessness and in children with recurrent or persistent pulmonary suppuration.

Vomiting. Regurgitation of feeds (possetting) is a common symptom in infants due to aerophagy. Some children are very vulnerable to vomit following a bout of cough or when food is forced or medicine is given. Ask the duration, severity and frequency of vomiting and whether it is associated with nausea or anorexia. The presence of bile or fecal matter is suggestive of intestinal obstruction. Blood-tinged vomitings (hematemesis) is a medical emergency. Aggravating factors and associated symptoms often provide clue to the diagnosis. Association with fever, headache and alteration in consciousness are suggestive of meningitis, presence of abdominal distension and constipation are suspicious of intestinal obstruction and development of diarrhea is indicative of acute gastroenteritis. Episodes of vomiting with fever, ketosis and acidosis are suggestive of cyclical vomiting due to autonomic dysfunction or visceral epilepsy. Ask for symptoms of dehydration such as excessive thirst, absence of sweating or tears, reduced frequency of passing urine or anuria.

Diarrhea. Passing stools after each feed, due to exaggerated gastrocolic reflex, should not be mistaken with diarrhea. Diarrheal episodes are common in children due to intake of contaminated or infected feeds. Ask for history of duration, severity and frequency (purge-rate) of diarrhea and associated symptoms like fever, vomiting and colicky abdominal pain. Assess the bulk (small or bulky), consistency (watery, rice-water, semiloose or semisolid), contents, (undigested, food particles, steatorrhea, froth, mucus, pus, blood), color (yellow, pale, green) and odour (foul smelling, rancid) of stools. Dysentery is characterized by blood and mucus in stools, tenesmus (frequent urge to defecate but with little evacuation) and rectal prolapse. Ask for symptoms and correlates of dehydration e.g. inadequate intake of fluids, excessive crying due to thirst, absence of sweat or tears, oliguria and anuria.

Pain in abdomen. Duration, frequency, timing, site (vague, precise, localised, diffuse), severity, character (burning, piercing, boring, colicky), radiation, precipitating, aggravating and relieving factors, and associated symptoms should be recorded. The child with recurrent abdominal pain, if puts his whole hand vaguely in an unconcerned manner over the centre or whole of abdomen to indicate the site of pain, is most likely having a functional or psychogenic disorder.

It is important to give due credit to all observations of the parents even if they do not fit into your line of thinking or diagnosis. Parents often confuse between pallor and jaundice, hematemesis and hemoptysis, rigors and seizures, breath-holding spells and seizures, pus and wax in the ears etc. and you must try to differentiate between them by asking appropriate leading questions.

History of past illness

Ask for past history of common childhood diseases (exanthemata, pertussis) and whether they ran a normal or complicated course. Details of perinatal history, birth asphyxia, severe neonatal jaundice, meningitis etc. are important in a child with developmental retardation or seizures. Delayed cry at birth if associated with seizures having onset within first 24 hours of life, abnormal neurological behaviour and difficulties in self feeding are suggestive of significant birth asphyxia. In children suffering from asthma, epilepsy, nephrotic syndrome, arthritis, eczema etc., enquiry should be made regarding history of similar attacks and their frequency in the past. Specific enquires should be made regarding previous illnesses which may be related to the present symptoms or illness e.g. past history of jaundice in a child with cirrhosis, joint pains in a child suspected to have rheumatic heart disease, recurrent chest infections in a patient with left- to-right shunt etc.

Perinatal history

It is pertinent to ask perinatal history when dealing with neonates or infants but may be ignored in older children with normal development. Maternal diseases or medications during pregnancy (especially during first trimester), presentation, mode and place of delivery, first cry after birth, feeding difficulties during neonatal period, jaundice, birth weight and gestation etc. should be recorded.

Developmental history

In children suspected to have delayed development or CNS disorder, a detailed developmental screening should be undertaken. Precise timing of social smile, head control, sitting, standing, walking, self feeding and dressing, bladder and bowel control and speech should be enquired. It is useful to compare the development of the index child with other normal siblings. It is easier for the mother to recall differences in the development of index child as compared to other siblings rather than absolute ages for attaining various milestones of development. Identify whether it is global retardation or retardation in a specific field e.g. delayed speech in the presence of normal motor development is indicative of deaf-mutism, while delayed standing and walking with normal social and adaptive development is indicative of protein-energy malnutrition, and congenital dislocation of hips etc.

Family history

Family pedigree should be enquired and genetic diagram constructed.

History of contact with possible infectious illnesses should be sought e.g. viral fever, tuberculosis, leprosy, childhood infectious diseases, infective hepatitis, typhoid fever, scabies, pyoderma etc. The contact may be in the family, neighbourhood or school. History of similar ailment in the family members should be asked when genetic, infective or allergic disorder is strongly suspected. Ask for history of consanguinity among parents. In case a particular disease is manifesting only among male siblings, it is suggestive of X-linked inheritance e.g. haemophilia, pseudohypertrophic muscular dystrophy, G-6-PD deficiency etc.

Social history

Enquire about occupation, education and income of parents. If mother is working, ask who looks after the child at home when she is away or is the child left in a creche. Ask whether the family is nuclear or joint and whether grand parents are staying with the family or not. Calculate per capita income by dividing total income of the family by the number of family members. Housing conditions, sewage disposal and water source should be asked. Harmful social and cultural practices regarding child rearing should be identified e.g. dummy nipple or pacifier, use of kajal, janam ghutti etc. Ask whether child is attending school or not, what is his rank in the class and whether the disease has interfered with his studies or not. Assess the interactive behaviour, habits, hobbies, interests and personality of the child and how he differs from other siblings. Ask about the eating, sleeping and toilet habits of the child. Adolescent children should be encouraged to talk regarding their worries, anxieties, psycho-sexual difficulties and substance abuse tendencies. Ask whether any pets and animals are kept at home or courtyard. Enquiry should be made regarding smoking, intake of alcohol or drug abuse by parent/s which can adversely affect the family dynamics and child rearing practices.

Feeding history

History of dietary intake is of special importance in children because they need food for growth and development. The energy or caloric requirement of infants per unit body weight are atleast 4 times as compared to adults. Ask whether child received breast feeding or not, frequency, type of schedule (time or demand), duration and reasons for discontinuation etc. If top fed, age at starting, nature of formula (dried milk or fresh milk), dilution, amount, frequency, mode of feeding (bottle or spoon) etc., should be enquired in detail. Age at weaning, nature and amount of semisolid food or other supplementary foods or vitamins/minerals given to the child should be asked. Dietary intake just before the onset of illness and during illness should be enquired. Ask in detail the food intake during the last 24 hours to calculate approximate caloric and protein intake per day.

Immunization status

Ask for various immunizations received so far. This information is useful to guide the diagnosis and ensure comprehensive management of the child. Look for scar of BCG vaccination during physical examination. All children must be given advise regarding feeding and immunizations whether they are attending OPD or discharged from the hospital. Outlines the current schedule of immunization.

Modern Trends in History Recording

1. Problem-oriented chart. It incorporates baseline conventional data plus system review with detailed list of problems, plan of management for each problem, auditing and computerziation of data. It is undergoing modifications and its biggest disadvantage is that it leads to depersonalization.

The acronym of SOAP is used to document problem oriented medical record where S stands for subjective, O for objective, A for assessment and P for plan of action.

Schedule of immunization
Age Essential Vaccines Optional Vaccincs
0-7 days BCG, OPVI, HBVI
6-8 weeks DPT II, OPV II, HBV II HIB vaccine I
10-12 weeks DPT III, OPV III HIB vaccine II
14-16 weeks DPT III, OPV IV HIB vaccine III
6-9 months HBV III, Measles, OPV V
15-18 months MMR, DPT booster, OPV VI HIB vaccine booster
2 years or later Typhoid vaccine (Booster every 3 years), HAV 2 doses (6-12 months), chicken pox single dose
4½ to 5 years DPT booster, OPV VII
10 years Tetanus toxoid booster every 5 years, MMR booster, HBV booster ?

BCG: Bacille Calmeue-Guerin, OPV: Oral polio vaccine, HBV: Hepatitis B vaccine, DPT: Diphtheria, pertussis and tetanus toxoid, HIB: H. influenzae type B vaccine, MMR: Mumps; measles and rubella vaccine, HAV: Hepatitis A vaccine

Rahul 2 years old boy from Ballabgarh township presented with

S
1. History of high grade, continuous fever of one week duration.
2. Semiloose stools without any blood and mucus with a purge rate of 5-6 stools/day, was treated with concentrated ORS and injectable antibiotics. Urine out put was adequate.
3. Vomitings for 2 days with a frequency of 5-6 times/d
4. One episode of generalised tonic-clonic seizures 12 hours ago.
5. Altered sensorium for 12 hours.

O
Toxic sick looking semi-comatosed child with stable vital signs. Temperature 40°C. No evidences of dehydration or meningeal irritation. Liver 3 cm and spleen just palpable. Deep tendon jerks were exaggerated with bilateral extensor plantars but no focal neurological signs. Fundus examination was normal.

A
1. Enteric fever with encephalopathy
Prolonged fever with diarrhea, splenomegaly and altered sensorium. Seizures may occur but are uncommon.
2. Shigella encephalopathy
Fever preceded the onset of diarrhea which was non-invasive in character.
3. Pyogenic meningitis
History is rather long and there are no signs of meningeal irritation.
4. Hypernatremic dehydration
The onset of dehydration is often delayed and use of concentrated ORS is well known to produce hypernatremia and seizures. However, high grade fever and splenomegaly cannot be explained.
5. Reye syndrome
The presence of high grade continuous fever and onset of vomitings later during the course of disease are against this possibility.
6. Brain abscess
The absence of any focal neurological signs and lack of any predisposing conditions like head injury, otitis media and congenital cyanotic heart disease are against this possibility.

P
1. Complete hemogram, serum electrolytes, blood glucose, liver function tests, stool microscopic examination and culture, Widal test, blood culture, CSF examination and contrast enhanced CT scan of head.
2. Administer IV fluids, appropriate antibiotics and anticonvulsants.

2. Flow sheet analysis. It has been proposed to simplify diagnostic approach for community health workers by use of algorithms.
3. Diagrammatic summary is useful to ascertain and assimilate the information at a glance.

Maintain an accurate record of history, physical examination and followup both in the hospital and ambulatory practice in view of the increasing incidence of medical litigation.

Scheme for Presentation

Basic Information:  Name, age and sex of the child, informant and his/her reliability, socio-economic status, education, occupation, religion, ethnic and geographic background etc.

Presenting complaints:  The main complaints and worries which compelled the parents to seek medical aid.

History of present illness:  Present a lucid chronological story with special emphasis on the onset and evolution of disease process, effect of drugs already taken and a detailed symptom and system review.

History of past illness:  History of common childhood illnesses (exanthemata, pertussis, acute respiratory and gastro-intestinal infections), episodes of similar disease in the past, occurrence of other serious or significant diseases in the past, ingestion, inhalation or insertion of foreign bodies.

Perinatal history:  Intrauterine and perinatal events constitute important past events and relevant details must be recorded especially in infants and under-five children.

Developmental history:  Developmental mile stones and differences between the development of the index child as compared to other siblings.

Family history:  Family history of infectious, developmental, genetic and chromosomal disorders, family pedigree for two generations to assess the nature of inheritance.

Social history:  Socio-economic and educational background, ecological considerations, child rearing cultural practices, who looks after the child when mother goes to work, schooling, interactive behaviour, habits and personality of the child.

Feeding history:  Duration of breast feeding, time and type of weaning, dilution of formula feeds, mode of top feeding, food intake before illness, effect of the disease process on the appetite and dietary intake, actual intake of food by recall in the last 24 hours for calculation of approximate caloric and protein intake.

Immunisation status:  Timing of various primary and booster immunizations received so far, any adverse Or unusual reactions, presence of BCG scar.