Depending on the condition of the child, mention the following:.The details of the present illness are recorded in chronological order.It is reported in the patient's or parent's/guardian's own words.The main concern for which the patient or parent/guardian is seeking health care.Informant: the person accompanying the patient and assisting in providing history and their relationship with the patient (e.g., parents, legal guardians, siblings, caretakers).However, this may vary from institution to institution. Age: Pediatric patients generally have their age reported in days until 2 weeks old, in weeks until 2 months old, and in months until 2 years old.Example: For a sample pediatric case, refer to case 7: Toddler with a cough and fever.Ĭhief concern and history of present illness.Pediatric settings: The focus of a pediatric history varies depending on the setting.Observe parent-child interaction, and always be vigilant regarding signs of potential child neglect or maltreatment.Begin the medical portion of the interview by taking the social history before addressing the current health concern.Always open the interview with casual conversation to establish rapport between you and the child or parents/guardian.One of the challenges in pediatrics is that parents/guardians may not have sufficient (subjective and objective) understanding of the child's concerns to report these accurately and reliably.In pubescent patients, it may be appropriate to offer a private interview to discuss sensitive health care issues (e.g., sexual health, recreational drug use, mental health) in a more open as well as private setting.However, the clinician should still rely primarily on the parent's/guardian's report. Children aged > 4 years may be encouraged by the parent/guardian or clinician to report their own concerns.The presence of a parent/guardian generally facilitates taking a child's history.In addition to the details of a general medical history, there are some notable differences to be aware of when taking a pediatric medical history, including certain patient details, the source of information, and modes of communication.
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