Pedia History - CE-OSCE

History

Framework

1. Demographics (Name, Age, Gender, Nationality, Martial, Residency)
2. Chief of complaint (Cause of hospitalization + days)
3. HOPI (OPERATES NON PAIN | SOCRATES PAIN)
4. B-Symptoms
5. Systemic Review - Inquiry

Journey

1. Neonatal, Nutritional, Immunization, Developmental History
2. Family & Social History
3. Past history (medical, surgical, medication, transfusion, drug, allergies, family, social)

Diagnosis / Management 9. summary 10. differential + justify differential 11. investigations - appropriate 12. treatment - suggestive

Outline of Specific Past Pediatric History

• A. Antenatal
• B. Perinatal
• C. Neonatal
• D. Growth, development, and behavior.
• E. Nutrition
• F. Past illnesses
• G. Immunizations
• H. Allergies and test reactions.
• I. Accidents and injuries.

Wash, Introduction, greet , explain need for history, Permission from both, Assure privacy, chap.

Personal data

• Name, Age, gender,
• Residency/address, nationality,
• Medical condition
• Source of history/informant + reliability: mother, father, brother - good reliability.

Chief of Complaint

What brought you to hospital, whats the issue, And Main complaint

From 1 month to today ask what happened in between

In parent/child words - open question - + Days

• 5D Abdominal pain, fever

Build differential diagnosis based on chief of complaint of child such as diarrhea.

• Pyloric stenosis (less than year)
• Ulcerative collitis/Crohn (Chronic presentation)
• intursceccuption (Jelly stool)
• Severe constipation (may cause diarrhea; functional overflow / fetal incontenence )
• Truama (witness truama vs non witness truama)
• UTI (crying during micturation)

Based upon

• Hematological -
• Infectious - (Hydiated cysts, TB)
• Diseases - ()

Rigors

• Pericarditis
• Pleural effusion
• peritonitis
• pyelonephritis

HLS Malignancy primary treatment with 1st year transplantation

secondary chemotherapy

Leichmenia no chemotherapy

Chest pain Related to Q&A of cardiac and respiratory

other gastroenteritis, ibd, immunodeficiencies, anemias, jaundice

anemia

• pallor
• pain crisis
• exercise intolerance

HOPI

• SOCRATES / OPERATES / RELATED QUESTIONS
• Complete explanation of chief complaint (Abdominal pain)
• If there are two chief of complaint, take full HOPI process to both

Is this disease endemic? Is there anyone in family with chronic cough? occupation of family?

Onset - Course - Duration -Site - Frequency - Severity - Relieving factors - Exacerbating factors - Diurnal or seasonal variation - Relation to food - Relation to exercise e.g. cough - School missing related to the complaint - any associated symptoms

• When
• Where
• Condition
• Followup

Vomiting

• onsent
• frequency
• volume
• content/color - bloody, mucous
• Timing - Fresh, clotted, coffee ground
• Bilious - intestinal obstruction
• Projectile? - Pyloric stenosis if <3M - Increase ICP (ask more regarding ICP questions, headache, seizures…)
• Aggrevating, relieving

Diarrhea

• onset
• frequency
• volume
• content - bloody, mucous
• Pain?
• Color (Pale;Jaundice, Melena)
• Aggravating, relieving
• Tinnismus - sign of collitis

Exclusions

• Dysphagia
• loss apetite
• weight loss

Hidden 2 days vomitting diarrhea - gastroenteritis (fever? other members related?), food poisoning (Last meal? related member same symptoms?)

IBD - Extra-gastrointestinal manifestation - mouth ulcer, joint pain, skin rash

Association

• Vomiting: If projectile, consider increased intracranial pressure (ICP). Bilious vomit may indicate intestinal obstruction; if blood is present (coffee ground, red, clots), further investigation is needed.
• Cough: Nocturnal or exercise-related cough may suggest bronchial asthma. Purulent sputum may indicate suppurative lung disease.
• Pain radiation: Appendicitis may radiate to the umbilicus; pancreatitis may radiate to the back.
• Stool color: Hemolysis, obstructive jaundice, or pyloric atresia may cause white stool.
• Tenesmus may indicate colitis.
• Bleeding per rectum: Consider if it occurs with bowel motion or not, and whether it is painless or painful, mixed with stool or streaks.
• Gastroenteritis and food poisoning may present with 2 days of gastrointestinal symptoms.
• Inflammatory bowel disease (IBD) may have extra-gastrointestinal manifestations.

Systemic review

Category	Symptoms
General	Feeding and appetite (very important), Irritability, Weight loss
Cardiovascular	Breathlessness, Sweaty on feeding, Cyanosis
Respiratory	Breathlessness, Runny nose, Cough, Noisy breathing (wheeze or stridor), Sore throat or earache, Hemoptysis
Gastrointestinal	Vomiting, Abdominal pain, Constipation or diarrhea (frequency and appearance of stool), Jaundice
Genitourinary	Frequency, Dysuria, Nocturia or enuresis, Hematuria, Incontinence, Age of menarche
Neurological	Irritability, Drowsiness, Fits or abnormal movements, Headaches, Numbness or unpleasant sensation, Weakness
Hematological & Oncological	Pallor, Jaundice, Bone pain, Bruises, Bleeding from the nose
Infections	Skin rash, Contact with infectious patients, Recent travel
Musculoskeletal & Skin	Joint swelling, Joint pain, Skin rash
B symptoms	Fever night sweats weight loss

Journey

Medical History

• Previous Disease
• Previous Medications Taken by the Patient:
  • Frequency
  • Dose
• Previous Hospitalization
• Previous Surgery
• Previous Transfusion
• Any Known Drug or Food Allergies

Natal History

Antenatal care: booked/un-booked? Where? Frequency of visits.

• Prenatal exposure to illicit drugs, toxins, or infections; maternal diabetes; acute maternal illness; trauma; radiation exposure and fetal movements. (The prenatal period refers to the period of time from fertilization to birth.)

• Medications during pregnancy (timing/dose/duration).

• Maternal thyroid or seizure disorder.

• Polyhydramnios/Oligohydramnios.

• Maternal severe proteinuria or high blood pressure.

• Bleeding in the third trimester.

• Multiple gestation.

• Chorioamnionitis.

  • Primi or no abortion
  • Maternal blood group/RH status
  • Maternal illnesses or infections (TORCH, HTN, DM)
  • Antenatal screening test results (HAVsAg, blood group)
  • Maternal medication or drug intake

Perinatal period: 22 completed weeks of gestation and ends 7 completed days after birth.

• Place of delivery.
• Presentation of the child (e.g., - Crying immediatly? breech or face presentation).
• Mode of delivery: NSVD, assisted vaginal, C/S. Obstetrical complications. - for what reason?
• Delayed cord clamping (possible polycythemia)
• Gestational age.
• Birth weight and other birth measurements (Lt, HC; 35cm at birth 10cm growth in first year).
• Resuscitation.
• Apgar Score or condition at birth in mother’s words.
• Maternal risk factors for sepsis (PROM, maternal UTI, maternal fever…).
• Baby & mother’s blood groups.
• Apgar score
• Complications prior or during pregnancies
  • Oxygenation, intubation, complications
  • Admissions to NICU

Neonatal

• When did the baby pass urine/meconium?
• Respiratory distress, anemia, jaundice, cyanosis, convulsions, infection, congenital anomalies.
  • If he/she was admitted to the hospital:
    • Length of hospital stay.
    • Complications (e.g., intubation time, presence of intracranial hemorrhage ultrasonogram, feeding difficulties, apnea, bradycardia).

Postnatal

• admission to neonatal? How long? what drugs? - if yes take full history of it.
• Screening test (hypothyroidism) - transucutantous???

Nutritional History

• Breast-fed or Bottle-fed and for How Long?
• If Bottle-fed:
  • Which formula did he receive?
  • How was it prepared?
  • What volume did he take at each feed?
  • And how long did he take it?
  • Frequency of feeds
  • Total daily intake
• Time of Weaning
• Timing of Introduction of Solids and Cereals

Note: Normally, a breast-fed baby might pass up to 6 motions daily.

Developmental history

• Primitive reflexed

  • Moro reflex - dissappears 3-6 months
  • Rooting reflex - 3-4M
  • Grasping reflex - 3-4M
  • Parachute reflex - starts 8-10 - never dissappears
  • Extension reflex

• Gross Motor

  • Support head (3-4 months)
  • Sitting (4 months with support, 6-7 months without)
  • Rolling (5-8 months)
  • Standing (8-10.5 months)
  • Walking with support (10- months)
  • Few steps walking then fall w/o support (-15 months)
  • Stairs
  • Stairs two feet w/ support 18m, w/o support 2yrs, w/o support one foot 3 yrs.
  • Bicycle (3 wheels 3 years, 2 wheel/training 4 ys, 2wh w/o tr 5yrs, 3 wh scooter 4yrs, 2wh scooter 5 years)

• Fine Motor

  • Grasping (28 days)
  • Hold things, bringing item close to mouth (3 months)
  • Reaching (4 months)
  • transferring object (6 months)
  • Pencil grasp immature (9 month) mature (1 yr)
  • Spoon use for eating (1 yr)
  • Writing

• Language

  • Crying at birth (-28 d; soft, weak, high pitched, intermittent?)
  • Coo (2-4 months)
  • Babbling
  • Ba, ba (9 months, non specific baba)
  • baba, mama (1 years specific) say 1 word (atta for ex)
  • 2, 3, 4 words sentance (2,3,4 years)
  • Telling stories (4 years)

• Social skills

  • starts smiling - at 2 months
  • responsive smile - 4-6m?
  • How is he communicating with family / peers
  • till engaging with other kids
  • social smiling, responsive smile (more on social skills)

Drawing

• Scribbles: 15 months
• Circle: 3 years
• Cross: 4 years
• Square: 4.5 years
• Triangle: 5 years
• Diamond: 6 years

Cubes

Activity	Age
Passes cubes	More than 6 months
Bangs cubes	9 months
Block in a cup	12 months
Tower three blocks	15 months
Tower four blocks	18 months
Tower six blocks	24 months
Bridge from blocks	3 years
Gate from blocks	4 years
Steps from blocks	5 years

• Visual
• Speech and Hearing
• Social and Play
• Schooling (Level and Performance)
  • If the mother has other children, compare his or her development with his or her other siblings.
  • Some important developmental milestones have been described later on.

Immunization History

• The recommended vaccination in Saudi Arabia is described later on.
• Check immunization card.
• If there is a failure in taking the vaccine, ask for the reasons in detail.
• Any vaccine side effects.

Family & Social History

• Ages of Parents
• Consanguinity
• Number of Siblings and Age Range (any sibling from previous or another marriage)
• Family History of Similar Condition
• Region the Parents Originally Came From (e.g., sickle cell anemia common in southwest and eastern region of Saudi Arabia)
• Neonatal Deaths (e.g., metabolic disease)
• Previous Abortions
• Housing
  • Type of accommodation (rented or owned, house or flat)
  • Number of bedrooms
  • Washing and toilet facilities
  • Air conditions and heaters
• Parents’ Occupation and Income of the Family
• Parents’ Education
• Parents’ Smoking Habit (especially in bronchial asthma cases)
• Contact with Animals
• Recent Travels (e.g., malaria in southwest of Saudi Arabia)

Pedigree chart

• Father is [age], and he’s a [employee of]
• Mother is [Age], [Job]
• No consanguinity between n parents
• patient is having one sister
• no hx of metabolic diseases

no hx of chronic illness in family, similar syndrome, passive smoking, bronchial asthma, allergic rhinitis, allergic conjuctivitis, dermatitits, pets, living in apartment of 5 rooms in neighborhood of … with poor socioeconomic status.

Note:

• Pay more attention to detailed family history if hereditary, allergy, or infectious disease is involved, e.g., sickle cell anemia, bronchial asthma, and tuberculosis.
• Transportation: Ensure there is available transportation for the child to attend any follow-up.
• Try to schedule follow-up appointments suitable for the father’s work schedule.
• If the patient comes from a poor family, contact the social worker to arrange for financial support and airplane tickets between regions if the family is from a distant area.

Related focused past hx Failure to thrive what does he eat? Nutrition?

Neurology Developmental Hx

Immunology Immunization, nutrition, chronic diseases

Jaundice Family history

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Golden Rule: At the end of your history, ask the historian if they would like to inform you of anything else or if they expect you to ask any other questions about their child that were not asked yet.

Closing the consultation

• Summarise the key points back to the child and parents/carers and ask if they feel anything has been missed

• Thank the child and parents/carers for their time

Summary

fever was 40 degrees intermittent for days + operates associate with…

Differential

Depends on clinical findings

Diagnosis

…

Treatment

…