Medical History Taking

Question 1

1) Patient

Answer 1

Infant/Child

​Introduction

• Name
• Sex
• ^_Address
• Date and place of birth
• Father’s and Mother’s names and occupation
• Nationality

Ask why and when they were admitted
What has happened/What is the problem?

Question 2

1.1) Present illness

Answer 2

Infant/Child & Mother

Ask why and when they were admitted
What has happened/What is the problem?

Child

SAMPLE history is a mnemonic acronym to remember key questions for a person’s medical assessment.[1] The SAMPLE history is sometimes used in conjunction with vital signs and OPQRST.

• S – Signs/Symptoms (Symptoms are important but they are subjective.)
• A – Allergies
• M – Medications
• P – Past Pertinent medical history
• L – Last Oral Intake (Sometimes also Last Menstrual Cycle.)
• E – Events Leading Up To Present Illness / Injury

Acute illness/Pain

• Onset of the event
  What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain,[2] and whether the onset was sudden, gradual or part of an ongoing chronic problem.
• Provocation or palliation
  Whether any movement, pressure (such as palpation) or other external factor makes the problem better or worse. This can also include whether the symptoms relieve with rest.
• Quality of the pain
  This is the patient’s description of the pain. Questions can be open ended (“Can you describe it for me?”) or leading.[9] Ideally, this will elicit descriptions of the patient’s pain: whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with the pattern, such as intermittent, constant, or throbbing.
• Region and radiation
  Where the pain is on the body and whether it radiates (extends) or moves to any other area. This can give indications for conditions such as a myocardial infarction, which can radiate through the jaw and arms. Other referred pains can provide clues to underlying medical causes.
• Severity
  The pain score (usually on a scale of 0 to 10). Zero is no pain and ten is the worst possible pain. This can be comparative (such as “… compared to the worst pain you have ever experienced”) or imaginative (“… compared to having your arm ripped off by an alien”). If the pain is compared to a prior event, the nature of that event may be a follow-up question. The clinician must decide whether a score given is realistic within their experience – for instance, a pain score 10 for a stubbed toe is likely to be exaggerated. This may also be assessed for pain now, compared to pain at time of onset, or pain on movement. There are alternative assessment methods for pain, which can be used where a patient is unable to vocalise a score. One such method is the Wong-Baker faces pain scale.
• Time (history)
  How long the condition has been going on and how it has changed since onset (better, worse, different symptoms), whether it has ever happened before, whether and how it may have changed since onset, and when the pain stopped if it is no longer currently being felt.[10]
• How and when did the disturbance start?
• When was the patient last entirely well?
• Health immediately before the illness
• Progress of diease: order and date of onset of new symptoms
• Medications given over that period

Question 3

2) Family history

Answer 3

​Infant/Child

• Father and mother age and condition of health
• Marital relationship
• Siblings
• Stillbirths, miscarriages, abortions
• Tuberculosis, allergy, mental health impairment, neurologic disease, diabetes, others

Question 4

3) Social history

Answer 4

Infant/Child

• Family: Income, home (number of rooms, living conditions)
• Whoe else lives in the home beside immediate family

Child/Teenager

• School (public ir private), school progress
• Relation with other children
• Habits, eating, sleeping
• Disturbances, excessive bed wetting, masturbation, thumb sucking, nail biting, smoking, alcohol drinking, sexal activity

Question 5

4) Gestation and labour

Answer 5

​Infant

• Which gestation?
• Which labour?
• Miscarriages?
• Mother’s health condition
• Problems during pregnancy? (e.g., vaginal bleeding)
• Illnesses during pregnancy? (e.g., infections)
• Smoking, alcohol or medicines taken during pregnancy?
• Spontenous or induced onset of labour
• Duration of labour
• Method of delivery
• Problems during labour and delivery
• Medication given to mother?

Question 6

5) Newborn

Answer 6

​Infant (At birth and now)

• Gestational age
• Birth parameters (and their percentiles)
  
  • Weight
  • Length
  • Head cirumcference
  • Chest circumference
• Apgar scale
  
  • 1st min, 3rd min, 5th min, 10th min
• Vitamin K given at birth?

Apgar score attached

Question 7

6) Growth and psychomotor devlopment (milestones)

Answer 7

​​Infant (Toddler)/Child

• First raised head, rolled over, sat alone, pulled up, walked with help, walked alone, talked
• Urinary continence during night and day
• Control of feces
• Any period of failure to grow or unusual growth
• School grade, quality of work

Question 8

7) Nutrition

Answer 8

Infant/Child

• Breast or forumla, duration of eating/drinking, time of weaning
• Vitamin supplements
• Solid foods - when introduced, how taken
• Appetite, food likes and dislikes

Question 9

8) Immunization

Answer 9

Infant/Child

• Hepatitis B
• DTP
• Polio
• BCG (Tuberculosis)
• MMR
• Haemophilus influenzae B
• Blood type of mother and child

Question 10

9) Previous health condition

Answer 10

Infant/Child & Mother

• Diseases
• Operations
• Complications