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History taking in children

on May 16 at 01:25 PM
History taking
 
History taking is the foundation on which the 
diagnosis of any clinical condition rests. A skilfully 
elicited history leads to an accurate provisional 
diagnosis, thus reducing the range of investigations. 
Avoiding unnecessary investigations saves a 
considerable amount of time and money. The history 
is usually taken in the following order: 
1. Name of the patient 
2. Age of the patient 
3. Gender of the patient 
4. Place-this includes the area of current 
residence and the area from which they have 
recently migrated (if applicable) 
5. Informant-mother/father/any other 
6. Reliability of the informant-good/fair/not 
reliable 
7. Preaenting complaints-complaint.I as told by 
the informant/patient 
8. History of present illness 
9. History of put illness including the treatment 
history 
10. History of contact with a known communicable 
disease (e.g., tuberculosis) 
11. Antenatal history 
12. Birth history 
13. Neonatal history 
14. Devdopmental history 
15. Nutritional history 
16. Immunisation history 
17. Personal history-this is relevant if the child 
is above 7 years of age. This includes school 
performance, dietary habits and relationship 
with other children 
18. History of allergy-skin, nasal, respiratory and 
gastrointestinal allergies, including allergy to 
food or drugs 
19. Family history 
20. Social and environmental history

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