A complete history is the first investigation
A history should be concise - but contain all the relevant information. It takes a lot of practice to get this right.
It is important to be concise. It is hard for other health care providers to read through a huge amount of irrelevant information. Also try to avoid sentences like "the patient states that she has a headache" - it is more concise to write: "she has a headache."
Young children may well be unable to answer questions themselves - they may not have the language to describe how they feel - they may be too sick. Much of the history is obtained from the parents.
It is important to establish :-
Age of patient
Presenting Complaint: What is the problem (or symptom) that brought them to see the doctor?
To explore the nature of the presenting complaint, ask similar questions to these examples given for pain :-
- When did it start? How long has it been present?
- Where is the pain?
- Does it "travel to" or radiate to another area?
- Is it severe? Ask for a description - how bad it is "out of 10" ? (where 10 out of 10 would be very severe and 1 out of 10 would be very mild indeed).
- Is it there all the time - intermittent or continuous?
- What is the nature of the pain? - sharp, dull, some headaches can be "pulsing."
- Did anything seem to start or precipitate the pain?
- What makes it worse?
- What makes it better?
- With time is it gradually getting worse or better?
- Is the area tender, red or warm? (infection generally causes this)
- Is it getting worse and if so how quickly?
What investigations have been done already?
Children who come to an oncology center for evaluation often have already had some investigation. This is probably an appropriate place to list them. You need to know
- What was the investigation?
- The date of the investigation
- The name of the hospital it was performed at (so the results can be tracked down)
- Does the child seem generally well? Is the child more irritable, crying more frequently or withdrawn?
- Any weight loss?
- Any fevers?
- Any night sweats?
- Any loss of previously attained developmental milestones?
- Any other symptoms - Review of systems.
Review of Systems
- Respiratory - any cough? If so is it productive? What is the nature of the sputum? Any shortness of breath? Any chest pain?
- Cardiovascular - any palpitations? Any ankle swelling? Any difficulty lying flat?
- GI - Any nausea? Any vomiting? Any abdominal pain? Any change in bowel habit? Any diarrhea? Any constipation? Any blood with the stool?
- GU - Any frequency? Any dysuria? Any hematuria?
- CNS - Any headaches? Any seizure like episodes? Any visual changes? Any limb weakness? Any reduced sensation?
- Musculoskeletal - any limb pain or swelling? Any joint pain?
Document any previous serious illnesses or operations.
Previous developmental history - when did the child achieve their developmental milestones?
Allergy - Any known drug or other allergy?
Medications - List drugs the patient is taking now or recently. Dose and how often per day.
Father's occupation? Mother's occupation? Siblings - how many? Are they well? Any social problems? If patient is young, who looks after them during the day? Any illness in the place they spend their day (eg school or day care) ?
Have any members of the family ever had cancer? Family history of any other disorders.