Obtaining and Presenting a Patient History
Joseph J. Zorc
M. William Schwartz
(3rd Edition)
This chapter presents a guide for obtaining a history of a pediatric patient and presenting a case on rounds or to an audience. Not every item described in this chapter is necessary in every write-up or presentation. The goal is to communicate key information about a patient; and the reader should not be overwhelmed with details that do not tell the patient’s story.
HISTORY
Chief Complaint
Always ask the patient or the parents to describe their concerns, and record their actual words. Starting in an open-ended way may uncover concerns that can be missed if the clinician focuses too early on problem-oriented questions. The age and sex of the patient, as well as the duration of the problem, should be noted when presenting the chief complaint.
HINT: Experienced pediatric clinicians state that most of the key evidence leading to a diagnosis is obtained through the history of the patient. Often, the physical examination and laboratory tests serve to confirm what the history suggests.History of Present Illness
Indicate the person who provided the history (e.g., patient, parent, or guardian). Provide a clear, concise chronology of important events surrounding the problem—when did the problem start, how has it changed over time, and what tests and treatments were performed. Include key negative findings that may contribute to the differential diagnosis.
Medical History
Prenatal history—mother’s age and number of pregnancies; length of pregnancy; prenatal care, abnormal bleeding, illness, or exposure to illness; and medications or substances used (alcohol, drugs, tobacco) during pregnancy.
Birth history—birth weight; duration of labor; mode of delivery, use of induction, anesthesia, or forceps; complications; and Apgar scores, if known.
Neonatal history—length of stay, location (nursery vs. intensive care); complications such as jaundice, respiratory problems; and feeding history.
HINT: Details about birth history are included in a write-up when they are relevant, but generally should be included for all children younger than 2 years.
Developmental history—milestones for smiling, rolling over, sitting, standing, speaking, and toilet training; growth landmarks for weight gain and length. If delays are present, determine the approximate age at which the child functions for motor, verbal, and social skills.
Behavioral history—proceed from less to more sensitive areas. The mnemonic SHADSSS can help structure the interview with an adolescent: School: grades, likes/dislikes, and plans for the future Home: others present and relationship with family Activities: friends and hobbies Depression: emotions, confidants, and suicidal thoughts/acts Substance abuse: exposure or use of drugs, tobacco, and alcohol Sexuality: partners, contraception use, and history of sexually transmitted diseases (STDs) Safety: violence and access to weapons
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