Pediatric History & Physical Exam

Dr. Romeo Calubaquib | August 25, 2020

Trans by: Deladia, Dela Rosa, Gonzales, Preza

OUTLINE Parent as Historian

1. Parent’s interpretation of signs, symptoms
I. History C. Beginner’s Guide in
 Children above the age of 4 may be able to provide some of
A. Learning Objectives Conducting Physical
their own history
B. Competencies Examination
 Reliability of parents’ observations varies
C. Scope of Assessment D. Differences in
D. Differences of a Performing a Pediatric  Adjust wording of questions - “When did you first notice Johnny
Pediatric History Physical Examination was limping”? instead of “When did Johnny’s hip pain start”?
Compared to an Adult Compared to an Adult Ex: Px: “Masakit po and bewang ng anak ko”.
History IV. Outline of a Pediatric X “Kailan niyo po unang napanisin na
II. Outline of the Pediatric Physical Examination sumasakit ang bewang ng anak ninyo?”
History A. Vitals (subjective)
A. Identifying Data B. General ✓ “Kailan mo napansin na ang anak mo
B. Chief Complaint C. Skin and Lymphatics ay papilay-pilay na maglakad?” (a
C. History of Present D. Head child limping is a sign that he is
Illness E. Eyes experiencing pain)
D. Past Medical History F. Ears 2. Observation of parent-child interactions
E. Pregnancy and Birth G. Nose  Distractions to parents may interfere with history taking
History H. Mouth and Throat  Quality of relationship
F. Developmental I. Neck 3. Parental behaviors/emotions are important
History J. Lungs/Thorax  Parental guilt - nonjudgmental/reassurance
G. Feeding History K. Cardiovascular  The irate parent: causes
H. Review of Systems L. Abdomen
I. Family History M. Musculoskeletal II. OUTLINE OF THE PEDIATRIC HISTORY
J. Social N. Neurologic A. IDENTIFYING DATA
III. Physical Examination O. Genito-Urinary
A. Objectives V. References  Includes name of patient, age, sex, address, admission
B. Competencies VI. Index  *Informant – identify the relationship to patient and reliability
(express in %)
CHILDREN ARE NOT JUST LITTLE ADULTS
B. CHIEF COMPLAINT
I. HISTORY
Brief statement of primary problem (including duration) that caused
History taking is an art, the technique of which is guided by certain family to seek medical attention; not necessarily always the reason
basic principles, but which is developed by the historian himself. for the parent’s bringing the child to the physician.
A. LEARNING OBJECTIVES C. HISTORY OF PRESENT ILLNESS
1. To understand the content differences in obtaining a medical  Initial statement in identifying by the historian, that person’s
history on a pediatric patient compared to an adult. relationship to patient and their reliability
2. To understand how the age of the child has an impact on  Age, sex, race, and other important identifying information
obtaining an appropriate medical history. about patient
3. To understand all the ramifications of the parent as historian in  Concise chronological account of the illness, including any
obtaining a medical history in a pediatric patient. previous treatment with full description of symptoms (pertinent
4. To understand the appropriate wording of open-ended and positives) and pertinent negatives. It belongs here if it is related
directed questions, and appropriate use of each type of question. to the differential diagnosis for the chief complaint.
5. To develop an awareness of which clinical settings it is  Begin with the nature and date of onset.
appropriate to obtain a complete medical history compared to a  Inquire about recent exposure to infectious diseases – date,
more limited, focused history. where, and how.
B. COMPETENCIES
Pertinent positives and negatives
To obtain an accurate and complete history of a pediatric patient in  help you in formulating your differential diagnosis
different age groups (<1 year; 1-5 years; > 5 years). → Pertinent positives- disease-specific; used to “rule in” a
C. SCOPE OF ASSESSMENT particular diagnosis
→ Pertinent negatives- require analytical and creative thinking;
 Comprehensive History- seeing a patient for the first time; function to “rule out” other diagnostic possibilities
includes all different data such as past-medical, pregnancy and
childbirth, developmental, and family history. Guided by “OPQRSTA”
 Focused History- more limited; follow-up of patients or when  Onset- When did the chief complaint occur? Sudden or gradual?
you have seen the patient for several times; includes signs and  Prior occurrence of the problem
symptoms of specific organ system affected.  Progression- Is the problem even worse or better? Is there
D. DIFFERENCES OF A PEDIATRIC HISTORY COMPARED anything that the patient does to make it better or worse?
TO AN ADULT HISTORY  Precipitating Factors- What makes the pain better or worse?
 Quality- Is there pain? If so, what type of pain? How will the
Content Differences patient describe the pain in words?
 Prenatal and birth history  Radiation- Does the pain radiate in other parts of the body? If
 Developmental history so, where?
 Social history of family - environmental risks  Relieving Factors
 Immunization history  Scale- Pain Scale (1-10)

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 Time- When do these symptoms occur? Specific part of the
day: night, morning, or anytime
 Associated symptoms- related symptoms not covered;
important for incidental findings
D. PAST MEDICAL HISTORY
 Major medical illnesses
 Major surgical illnesses-list operations and dates
 Trauma-fractures, lacerations
 Previous hospital admissions with dates and diagnoses
 Current medications
 Known allergies (not just drugs)
 Immunization status - be specific, not just up to date; include
dates given and any reactions.
→ BCG, Diphtheria, Pertussis, Tetanus, Poliomyelitis,
Measles, Smallpox, Cholera El Tor or Cholera
Typhoid, others (tuberculin testing).
E. PREGNANCY AND BIRTH HISTORY
 Maternal health during pregnancy: bleeding, trauma,
hypertension, fevers, infectious illnesses, medications, drugs,
alcohol, smoking, rupture of membranes
 Gestational age at delivery
 Labor and delivery - length of labor, fetal distress, type of
delivery (vaginal, cesarean section), use of forceps, anesthesia,
breech delivery
 Neonatal period - Apgar scores (see index), breathing problems,
use of oxygen, need for intensive care, hyperbilirubinemia, birth
injuries, feeding problems, length of stay, birth weight
F. DEVELOPMENTAL HISTORY
 Ages at which milestones were achieved and current
developmental abilities - smiling, rolling, sitting alone, crawling,
walking, running, 1st word, toilet training, riding tricycle, etc
→ Up to 1 year – smiled, held head, rolled over, sat with support,
crawled, stood with support, spoke single words (be specific),
first tooth.
→ From 1 to 3 years – walked with support, walked alone,
handedness, used sentences, toilet training began and
completed, daily routine (sleep and play), relationship to family,
behavior disturbances.
→ From 4 to 12 years – school placement and adjustment,
specific aptitudes, specific disabilities, daily routine.
 School- present grade, specific problems, interaction with peers
 Behavior – enuresis (involuntary urination or bedwetting),
temper tantrums, thumb sucking, pica (compulsively eat
nonfood items), nightmares, sleeping habits, toilet training,
breath holding, masturbation,
destructive/aggressive/shy/submissive, happy/difficult, etc.
G. FEEDING HISTORY
 Breast or bottle fed, types of formula, frequency and amount,
reasons for any changes in formula
 Solids - when introduced, problems created by specific types
 Fluoride use
*for older children – weight gain, actual dietary pattern
H. REVIEW OF SYSTEMS
 (usually very abbreviated for infants and younger children)
 Weight - recent changes, weight at birth
 Skin and Lymph - rashes, adenopathy, lumps, bruising and
bleeding, pigmentation changes
 HEENT - headaches, concussions, unusual head shape,
strabismus, conjunctivitis, visual problems, hearing, ear
infections, draining ears, cold and sore throats, tonsillitis, mouth
breathing, snoring, apnea, oral thrush, epistaxis, caries
 Cardiac - cyanosis and dyspnea, heart murmurs, exercise
tolerance, squatting, chest pain, palpitations
 Respiratory - pneumonia, bronchiolitis, wheezing, chronic cough,
sputum, hemoptysis, TB
 GI - stool color and character, diarrhea, constipation, vomiting,
hematemesis, jaundice, abdominal pain, colic, appetite
Trans # 2.1 Pediatric History & Physical Exam
 GU - frequency, dysuria, hematuria, discharge, abdominal
pains, quality of urinary stream, polyuria, previous infections,
facial edema
 Musculoskeletal - joint pains or swelling, fevers, scoliosis,
myalgia or weakness, injuries, gait changes
 Pubertal - secondary sexual characteristics, menses and
menstrual problems, pregnancies, sexual activity
 Allergy - urticaria, hay fever, allergic rhinitis, asthma, eczema,
drug reactions
I. FAMILY HISTORY
 Inquire into the mother’s pregnancies in chronological order
and her attitude towards them; inquire into the occurrence of
important diseases in the family.
 Illnesses - cardiac disease, hypertension, stroke, diabetes,
cancer, abnormal bleeding, allergy and asthma, epilepsy
 Mental retardation, congenital anomalies, chromosomal
problems, growth problems, consanguinity, ethnic background
J. SOCIAL
 Living situation and conditions - daycare, safety issues
 Composition of family
 Occupation of parents
Interval History – if the patient had previously been in the hospital
and has had a complete history, write a summary of each
hospitalization. Inquire about the condition of the child from the time
of discharge to the time of readmission.
III. PHYSICAL EXAMINATION
A. OBJECTIVES
1. To understand how the general approach to the physical
examination of the child will be different compared to that of an
adult patient, and will vary according to the age of the patient.
2. 2. To observe and demonstrate physical findings unique to the
pediatric population, and to understand how these findings may
change depending upon the age of the child.
3.
B. COMPETENCIES
1. To obtain accurate vital signs (Temperature, HR, RR, BP) in a
pediatric patient in different age groups and to be able to
evaluate these vital signs compared to age-adjusted Normal
values. To understand the normal variation in temperature
depending on the route of measurement.
2. To complete a thorough physical examination on a pediatric
patient in different age groups.
C. BEGINNER’S GUIDE IN CONDUCTING PHYSICAL
EXAMINATION
1. A keen observation of the child from the beginning to the end of
the consultation, for any deviation from normal is significant.
2. Wash your hands before and after examining the patient to
protect the child from cross infection and to serves as an
example of good hygiene. Rub your hands against each other
to warm them up before touching the patient.
3. Spend a little time winning the child’s confidence by starting on
friendly terms. It is the doctor’s concern to gradually correct the
misconception that a doctor is someone to be feared.
4. Examine the child on the examination table. But if the younger
infant feels more secure clinging on to the mother, examine him
in this position.
5. In an infant, remove all clothing. In older child (particularly
adolescents), a thorough examination should be conducted with
due respect to the patient’s privacy and sensitivities.
D. DIFFERENCES IN PERFORMING A PEDIATRIC
PHYSICAL EXAMINATION COMPARED TO AN ADULT
General Approach
 Gather as much data as possible by observation first.
→ 4 Modalities used in Physical Exam:
 Inspection/ observation
 Palpation
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  Percussion → transillumination is performed to detect if the cerebral cortex
 Auscultation is thinned as in hydranencephaly; when the cortex is partially
 Position of child: parent’s lap vs. exam table absent as in porencephaly; or displaced by extra-cortical
 Stay at the child’s level as much as possible. Do not tower!! fluid accumulation as in subdural hygroma.
 Order of exam: least distressing to most distressing → bossing of the frontal and parietal bones may indicate rickets
 Rapport with child  Fontanelle(s)- 2
→ Include child - explain to the child’s level → Anterior fontanel closes between 12 to 18 months
→ Distraction is a valuable tool  Size
 Examine painful area last-get general impression of overall  Tension - calm and in the sitting up position
attitude  Sutures - overriding (sometimes after delivery)
 Be honest. If something is going to hurt, tell them that in a  Scalp and hair
calm fashion. Don’t lie or you lose credibility! E. EYES
 Understand developmental stages’ impact on child’s
Doll’s Eye Test – detects paresis of the abducens nerve and
response. For example, stranger anxiety is a normal stage
weakness of the lateral rectus muscle.
of development, which tends to make examining a
previously cooperative child more difficult.  General
→ Strabismus
Vital signs → Slant of palpebral fissures
 Normal values differ from adults, and vary according to age → Hypertelorism (abnormally large distance between the eyes)
 Temperature or telecanthus (increased distance between the inner
→ Tympanic vs. oral vs. axillary vs. rectal corners of the eyelid)
 Heart rate  EOM
→ Auscultate or palpate apical pulse or palpate femoral  Pupils
pulse in infant  Conjunctiva, sclera, cornea
→ Palpate antecubital or radial pulse in older child  Plugging of nasolacrimal ducts
 Respiratory rate - Observe for a full minute. Infants normally  Red reflex – with use of ophthalmoscope
have periodic breathing so that observing for only 15  Visual fields - gross exam
seconds will result in a skewed number.
F. EARS
Table 1. Respiratory Rate
Respiratory Rate  Position of ears
Age Group → Observe from front and draw line from inner canthi to occiput
(per minute)
Infancy 30-40  Tympanic membranes
Early childhood 20-40  Hearing - Gross assessment only usually
Late childhood (up to 15 years) 15-25 G. NOSE
 Blood pressure  Nasal septum – examined for deviation, perforation or other
→ Appropriate size cuff - 2/3 width of upper arm malformation.
→ Site  Mucosa (color, polyps)
 Growth parameters - must plot on appropriate growth curve  Sinus tenderness
→ Weight  Discharge
→ Height/length
H. MOUTH AND THROAT
→ OFC: Across frontal-occipital prominence so greatest
diameter (Occipital Frontal Circumference)  Lips (colors, fissures, contour, presence of freckles, atrophy,
papules, swelling)
Unique findings in pediatric patients
 Buccal mucosa (color, vesicles, moist or dry)
(See outline below)  Tongue (color, papillae, position, tremors, shape, thickness,
IV. OUTLINE OF A PEDIATRIC PHYSICAL EXAMINATION presence of abnormal mass or lesions)
(Simplified Approach)  Teeth and gums (number, condition)
 Palate (intact, arch)
The order of examination need not to be from head to foot, and will
vary with (1) urgency of the situation, (2) age and cooperation, and  Tonsils (size, color, exudates)
(3) suspected system of involvement.  Posterior pharyngeal wall (color, lymph hyperplasia, bulging)
 Gag reflex (test with tongue depressor)
A. VITALS
I. NECK
- see above
 the shape is noted for anomalies like webbing, and inspected for
B. GENERAL
the presence of hygromas or cutaneous hemangiomas.
1. Statement about striking and/or important features. Nutritional → Thyroid
status, level of consciousness, toxic or distressed, cyanosis, → Trachea position
cooperation, hydration, dysmorphology, mental state (awake, → Masses (cysts, nodes)
drowsy, lethargic, obtunded, stuporous, coma) → Presence or absence of nuchal rigidity- may be a
2. Obtain accurate weight, height and OFC symptom of meningeal infection
C. SKIN AND LYMPHATICS J. LUNGS/THORAX
1. Birthmarks - nevi, hemangiomas, Mongolian spots etc. Inspection
2. Rashes, petechiae, desquamation, pigmentation, jaundice,
texture, turgor  Pattern of breathing
3. Lymph node enlargement, location, mobility, consistency → Abdominal breathing is normal in infants
4. Scars or injuries, especially in patterns suggestive of abuse → Period breathing is normal in infants (pause < 15 seconds)
→ Shallow breathing in respiratory distress of central origin
D. HEAD and alkalosis; deep breathing in peripheral origin and acidosis.
 Size and shape  Respiratory rate
→ microcephaly (slow increase in head circumference) and → in pneumonia and acute bronchitis, it may go as high as 70-
hydrocephalus (excessive increase in head circumference) 80 per minute.

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 Use of accessory muscles: retraction location, degree/flaring O. GENITO-URINARY
 Chest wall configuration
 External genitalia
Auscultation  Hernias and Hydrocoeles
 Equality of breath sounds → Almost all hernias are indirect
 Rales, wheezes, rhonchi → Can gently palpate; do not poke finger into the inguinal
 Upper airway noise canal
 Cryptorchidism
Percussion and Palpation
→ Distinguish from hyper-retractile testis
 Often not possible and rarely helpful → Most will spontaneously descend by several months of life
 Tanner staging in adolescents- sexual maturity rating
K. CARDIOVASCULAR
 Rectal and pelvic exam not done routinely - special indications
Auscultation may exist.
 Rhythm
 Murmurs V. REFERENCES
 Quality of heart sounds  Lecture of Dr. Calubaquib
Pulses  Del Mundo, F. (1990). Textbook of Pediatrics and Child Health (3rd ed.).
Quezon City, Ph: JMC Press.
 Radial, antecubital, carotid, femoral, tibial pulse
→ Quality in upper and lower extremities
L. ABDOMEN
Inspection

 Shape
→ Infants usually have protuberant abdomens
→ Becomes more scaphoid as child matures
 Umbilicus (infection, hernias)
 Muscular integrity (diastasis recti)

Auscultation

Palpation
 Tenderness - avoid tender area until end of exam
 Liver, spleen, kidneys
→ May be palpable in normal newborn
 Rebound, guarding (contraction of the abdominal wall muscles
during palpation)
→ Have child blow up belly to touch your hand
M. MUSCULOSKELETAL
 Back
→ Sacral dimple
→ Kyphosis, lordosis or scoliosis
 Joints (motion, stability, swelling, tenderness)
 Muscles
 Extremities
→ Deformity
→ Symmetry
→ Edema
→ Clubbing
 Gait
→ In-toeing, out-toeing
→ Bow legs, knock knee
 “Physiologic” bowing is frequently seen under 2 years
of age and will spontaneously resolve
→ Limp
 Hips
→ Ortolani’s sign (sensation of the dislocated hip reducing)
and Barlow’s signs (unstable hip dislocating from the
acetabulum)
N. NEUROLOGIC
 most accomplished through observation alone
→ Cranial nerves
→ Sensation
→ Cerebellum
→ Muscle tone and strength
→ Reflexes
 DTR
 Superficial (abdominal and cremasteric)
 Neonatal primitive

Trans # 2.1 Pediatric History & Physical Exam 4 of 5

 VI. INDEX

APGAR SCORE CHART

SIGN 0 1 2
Appearance (Color) If the infant is pale or If the infant is pink, but If the infant is entirely pink,
blue, the score for color the extremities are blue, the score for color is 2
is 0. the score for color is 1.
*Note: most infants will score 1 .
for color as peripheral cyanosis is
common among normal infants.

Pulse (Heart rate) If there is no heartbeat, If the heart rate is less If the heart rate is more
the heart rate score is than 100 beats per than 100 beats per minute,
0. minute, the heart rate the heart rate score is 2
*Note: heart rate is evaluated score is 1.
with a stethoscope, and it is the
most critical part of the score in
determining the need for
resuscitation.

Grimace (Reflex irritability) If there is no response If there is grimacing in If the infant cries, coughs,
to stimulation, the response to stimulation, or sneezes on stimulation,
reflex irritability the reflex irritability the reflex irritability
response score is 0. response score is 1. response is 2.

Activity (Muscle tone) If the muscle tone is If the infant demonstrates If the infant is in active
loose and floppy some tone and flexion, motion with a flexed muscle
without activity, the the score for muscle tone tone that resists extension,
score for muscle tone is is 1. the score for muscle tone is
0. 2.

Respiration (Breathing effort) If the infant is not If respirations are slow If the infant is crying
breathing, the and irregular, weak or vigorously, the respiratory
respiratory score is 0. gasping, the respiratory score is 2.
score is 1.

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