It is best to start by asking why they have come to see the doctor or nurse. What is worrying them? First let the child or mother tell their story. Give them time to speak without interrupting. In getting an accurate present history make sure that you obtain the following information:
- When was the child last completely well?
- What are the presenting complaints (symptoms)?
- What are the problems which made you bring the child today?
- When and how did they start?
- Are they getting worse?
- Does anything make the complaints better or worse?
- Is any treatment being used?
- Are there any other symptoms (what the child feels) or signs (what you can see)?
- Has the child been in contact with other children with similar problems? Many childhood illnesses are infectious.
It is important to make an assessment about whether you think the information is reliable or trustworthy. Sometimes it can be very difficult to understand what the complaints are.
A symptom is something that a patient complains of. It is usually a feeling like pain, discomfort, nausea or fear. In contrast, a sign is something that can be seen, felt or heard by someone else, such as a rash, lump or heart murmur. Small infants usually only have signs and not symptoms as they cannot speak yet.