How To Take a Paediatrics History

Introduction

This tutorial provides a comprehensive guide to taking a paediatrics history, drawing from the insights shared by Dr. Erwin Kwun. Understanding how to effectively gather a child's medical history is crucial for accurate diagnosis and treatment. This guide outlines key steps and tips to enhance your history-taking skills in paediatrics.

Step 1: Establish Rapport

• Create a Comfortable Environment: Ensure the setting is welcoming and non-threatening for the child and their guardian.
• Engage with the Child: Use age-appropriate language and activities to make the child feel at ease.
• Involve the Parent or Guardian: Address the parent/guardian directly while including the child in the conversation to foster trust.

Step 2: Use Open-Ended Questions

• Encourage Detailed Responses: Start with open-ended questions to allow parents to provide more context.
  • Example: "Can you tell me what brings you here today?"
• Listen Actively: Pay attention to the responses and show empathy, which can lead to more information being shared.

Step 3: Gather Comprehensive Information

• Presenting Complaint: Note the main issue that prompted the visit.
• History of Presenting Complaint: Ask about the onset, duration, and progression of symptoms.
• Past Medical History: Inquire about any previous illnesses, surgeries, or hospitalizations.
• Family History: Gather information about family health issues, especially genetic conditions.
• Social History: Understand the child's environment, including their living situation, school life, and family dynamics.

Step 4: Perform a Systematic Review

• Review Systems: Conduct a thorough review of each body system, asking specific questions related to potential issues (e.g., respiratory, gastrointestinal).
• Document Findings: Take notes on responses for later reference and analysis.

Step 5: Summarize and Clarify

• Recap Key Information: Summarize what you have learned to confirm accuracy and understanding.
• Clarify Any Doubts: Ask follow-up questions if anything is unclear to ensure you have a complete picture.

Step 6: Provide Reassurance and Next Steps

• Reassure the Caregiver: Offer comfort and support, addressing any concerns they may have.
• Outline Next Steps: Discuss potential investigations, treatments, or referrals based on the history taken.

Conclusion

Taking a paediatrics history is an essential skill that requires patience, empathy, and attention to detail. By following these steps—establishing rapport, utilizing open-ended questions, gathering comprehensive information, performing systematic reviews, summarizing findings, and providing reassurance—you can enhance your effectiveness in clinical practice. Continue to refine your skills through practice and seek feedback from experienced colleagues to improve further.