What history questions should be asked for a 3-year-old boy presenting with a 2cm gaping laceration after a fall?

History Questions for a 3-Year-Old with a Head Laceration

When evaluating a 3-year-old boy with a 2cm gaping laceration from a fall, a thorough and systematic history is essential to rule out child abuse, assess for potential traumatic brain injury, and determine appropriate management.

Mechanism of Injury Questions

• Detailed description of how the injury occurred:

  • What exactly happened leading up to the fall?
  • What surface did the child fall onto?
  • What was the height of the fall?
  • What position was the child in when he fell?
  • What part of the head hit first?
  • Was it witnessed? If so, by whom?

• Timing questions:

  • When did the injury occur?
  • How long between injury and seeking medical care?
  • Any delay in seeking care? If so, why? 1

Assessment for Head Injury

• Neurological symptoms:

  • Any loss of consciousness? If yes, for how long?
  • Any vomiting since the injury? How many episodes?
  • Any seizures?
  • Any changes in behavior, irritability, or drowsiness?
  • Has the child been acting normally since the injury?
  • Any complaints of headache or dizziness? 2

• Current mental status:

  • Is the child alert and responding appropriately?
  • Is the child's behavior normal according to the parents?
  • Any confusion or disorientation? 2

Medical History

• Past medical history:

  • Any previous head injuries or concussions?
  • Any history of bleeding disorders or easy bruising?
  • Any chronic medical conditions?
  • Any developmental delays?
  • Any history of premature birth? 1

• Medication history:

  • Is the child on any medications?
  • Any blood thinners or medications that affect clotting?
  • Any allergies to medications? 1

• Immunization status:

  • Is the child's tetanus vaccination up to date? 3, 4

Social History

• Home environment:

  • Who lives in the home with the child?
  • Who was supervising the child when the injury occurred?
  • Who are the primary caregivers?
  • Any recent changes in the home environment? 1

• Risk assessment questions:

  • Any history of domestic violence in the home?
  • Any substance abuse in the home?
  • Any history of mental illness in caregivers?
  • Any previous involvement with child protective services? 1

Wound-Specific Questions

• Wound characteristics:
  • Has there been significant bleeding?
  • Has anything been done to treat the wound at home?
  • Was the wound cleaned? If so, how and with what?
  • Is there any foreign material in the wound?
  • Any other injuries noted elsewhere on the body? 3, 4

Red Flags to Note in History

• Inconsistent history:

  • Different versions of events from different caregivers
  • History that changes over time
  • Mechanism described not consistent with the type of injury
  • Delay in seeking care without reasonable explanation 1

• Concerning social factors:

  • History of previous injuries or ED visits for trauma
  • Inappropriate responses from caregivers
  • Evasive answers to direct questions 1

Additional Assessment

• Observe parent-child interaction:

  • How does the child respond to the parent?
  • How does the parent comfort the child?
  • Is the parent's concern appropriate for the situation?

• Family history:

  • Any family history of bleeding disorders?
  • Any family history of osteogenesis imperfecta or other bone disorders? 1

Documentation Tips

• Document the history using the caregiver's exact words when possible
• Avoid value judgments or interpretations of body language
• Document any discrepancies in the history without accusatory language 1
• Note the time of injury and time of presentation

By systematically gathering this information, you'll have a comprehensive history to guide your physical examination, determine the need for imaging, and develop an appropriate treatment plan for the laceration while ensuring the child's overall safety.