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23 APRIL 2010
NO 1568
Taking a history
The first and cardinal skill taught to clinical medical students applies also to all other professions – namely history taking – structured and active listening not physical examination or biochemical tests. Other disciplines have their own or the equivalent devices or procedures. History taking in itself can be powerfully therapeutic and is one of the core skills of all professions – but is not mastered by all. There are certain aspects to this craft which are often overlooked:
With older children address the questions directly to them, let them answer in their own words and watch whether their parents feed them answers or put them in to their minds.
Ask structured questions in a set order so that one does not leave out relevant areas.
Make accurate and legible records: always write in precis the gist of what the patient actually said: if they say 'I have pain doing number two's, do not write 'bowels'! If the child actually says 'migraine' they may have heard an adult with a headache using the word and there can be no guarantee that the child actually has this problem.
Beware the leading question. All too often the amateur asks a question that suggests only one answer: a child has a large mark probably caused by a whip over the back – 'What did daddy hit you with?' That is a typical leading question. Try again: 'I see you have a red mark on your back. Can you tell me how it happened?' Record the answers you get. If you ask leading questions you are very likely to get the answer that the interviewee thinks you want!
The standard way that medical students are taught to take history could with profit be applied to other professions concerned with child care. The universal first question is: 'Why have you come to see me?' – then the History of the main presenting problem followed by the: Previous (medical) history then the:
Family history
Including the health of the mother, father, siblings. It is important that you as well as the patient decide what is relevant and that all deaths and possibly inherited disorders in the family are disclosed.
Social history
The housing, where the family live, their moves, how far from relatives, who is in work and what do they do, are there major social problems? Transport, amenities, even sometimes the name and breed of the dog! There is a fine line between being gratuitously nosy,and getting vital and relevant information.
Some additional information is particularly relevant in medicine but should also be relevant to any professional worker:
Childbirth and development
The mother's health in pregnancy – did she have a straight forward or difficult pregnancy and delivery? A bad experience can colour her attitude to the child for better or worse.
Where was the child born, birth weight, health as a new baby, feeding and behaviour patterns?
The ages at which the child did things such as walking, talking, nursery and school experience and grades.
It is only when this stage is concluded that
doctors should want to start a medical examination: With any luck by now
the child will be playing or drawing. Note if they separate from a
parent or not, whether their behaviour is age-appropriate. Do child and
parent interact, talk to each other, reassure each other, cling or seem
indifferent? Does the parent speak ill of the child in their hearing?
Does the child speak ill of the parent?
EUAN M. ROSS
Ross, E.M. (1996). Learning to listen to children. In
Davie, R., Upton, G. and Varma, V. (Eds.). The Voice of the Child: A
handbook for professionals. London. The Falmer Press. pp. 100-101.
