HISTORY TAKING IN PEDIATRIC CARDIAC PATIENT

Question:
A patient comes to your private practice with circumoral and fingertip cyanosis.
Plis gather information from the patient to conclude the history taking and PE
CC : circumoral and fingertip cyanosis
began since she was 1 years old
getting worse especially after she crying
HISTORY TAKING
Greet patient...plis have a seat
patient identity (mom) : name, age, occupation
• Child) name, age, her father’s occupation
Explain purpose of history taking, aim and take patient’s agreement: I will ask and take information’s
from you regarding your child problem...its actually very important in order to know what actually the
problem of your child. Is that okay with you???
I. Chief complaint III. gestational and natal history
1. what (cyanosis around mouth and (history pregnancy period)
fingertip) 1. Infection??
2. since when 2. Any exposure to radiation or
3. Suddenly or gradually… chemical?
4. Spontaneous or after some specific 3. Take any drug/ medication??
events?? Happen in nursery/ after coming 4. Drinking alcohol??How heavy is it??
home?? How many bottles?
5. What make it worse or better?? 5. Smoking??
6. Can you describe more about the cyanosis 6. Do you have any diabetic or other
episode?? disease during your pregnancy??
Time of appearance? 7. birth weight of your baby after
duration of episode delivery
frequency III. family history
the cyanosis episode appear when 1. Anyone that have similar problem
she holding her breath as your child?
During the episode, did she 2. any similar disease in the family
breathing fast and deep??? like Marfan syndrome, NoOdan's
syndrome
II. postnatal history (after birth until 3. Have congenital heart disease in
now) family??
1. Does she have difficulty in gaining weight?? 4. Anyone with history of hypertension
2. Her development, do you think your child or atherosclerosis in family??
look smaller then her friends?? III. conclusion
3. Feeding pattern (did she eat well??) did she From informations that im get
look too tired to eat/always fall asleep during from you, it shows that
eating?? suka tersedak ngak selepas probably your child had
nyusu??? problem with her heart. To
4. Exercise intolerance (easily gets tired during know the exact problem, I have
doing some activity/walking/running/ get to proceed with physical
tired when sucking mild during examination o your child.
breastfeeding??) The procedure quite simple. I
5. Shortness of breath?? will check several sign on your
6. Have favorite position such as knee-chest child’s body. and if needed, I
position (squatting) when get tired?? will proceed with other
7. Swollen eyelid?? supportive examination
8. Respiratory infection e.g. flu…how frequent Agree to proceed?? tq mum
is it? Could you plis help your child
9. Fever??? lying down on examination
10. chest pain table??
11. nervousness I will wash my hand using
12. feel any pain or hurt while she moves/ antiseptic solution and
redness in her joint water...and make it dry using
13. Neurologic symptoms high pitched cry??? clean and dry towel
Increased irritability recently???Less alert then proceed with PE
with surrounding??