08/17/2015 Pediatrics History Taking & Physical

2:30 – 4:30 Exam; Documentation (Writing &

YL6: 01.15.01 Recording Health History)
Michelle Joy B. De Vera, MD, FPPS, FPSAAI

OUTLINE Fourth principle: A child’s development level affects

I. Assessing Children D. Assessing the the nature of the medical history and physical
A. Principles Adolescent examination
B. Past Medical IV. The Medical Write-up Example: Interviewing a 5 year old is fundamentally
History A. Introduction different from interviewing a 10 year old, or an
C. Developmental/ B. Chief complaint adolescent
Behavioral C. History of Present Tailor physical examination to the developmental
History Illness level of the child
D. Social History D. Review of Systems Compared to adults, you cannot ask closed
E. Family History E. Temporal Profile questions to children
II. Assessing F. Past Medical History One has to tailor how to speak with them and how
Adolescents G. Developmental History one examines them according to these principles.
A. Principles H. Personal and Social
B. HEADSS History Pediatric vs. Adult Patient Interview
III. Physical I. Family History Factors that distinguish pediatric from the adult history:
Examination J. Stakeholder Analysis Depending on the age, primary historian may be the
A. Assessing K. Physical Examination patient and/or another person - the parent
Infants L. Laboratory Data Compared to adults who usually go alone, one is not
B. Assessing the M. Problem List/Statement only dealing with pediatric patient, but also with the
Younger Child V. Review Question patient’s family – father, mother, and extended
C. Assessing VI. Quotation family
Middle One has to establish the reliability of the
Childhood historians – of the different versions of the story
being told, who do I believe?
I. ASSESSING CHILDREN Developmental factors are commonly considered in
pediatric interviews.
A. PRINCIPLES The differential diagnosis of a condition may vary
depending on the age of the patient
Pediatric vs. Adult Development Differential diagnoses for difficulty of breathing
Four principles that differentiate adults from kids:: (DOB) would be very different if it presents in a 3
First principle: Different phases in the development of month old child, versus an 18 year old adolescent.
a child will matter to how you will do your history and Health care maintenance and social issues play a
physical exam. major role emergent and routine care
Child development occurs in an orderly fashion; e.g. immunizations, safety issues
Age-specific milestones: characterize a child’s
development as normal or abnormal according to B. PAST MEDICAL HISTORY
established criteria
Depending on the age of the child, different Pediatric history includes prenatal, birth, neonatal, and
milestones should be achieved. feeding histories
In adults, no more development in the brain as Importance of these items depends on the age of the
compared to the growing brain of a child patient and reason for visit
In contrast, children have observable markers Birth history is not significant for an acute minor
for development trauma visit for an adolescent
It is important to figure out what to ask or look for: Examples:
The physical examination takes place at one If you have an adolescent coming in for acne, you
point in time, you need to learn where the child don’t have to ask if the patient was breastfed or
fits within a developmental trajectory when exactly was his/her first social smile.
Figure out the best way to do your physical exam Getting neonatal score and APGAR for 15 y/o with
because this can be a one-time visit (e.g. ER coming for headache is irrelevant
cases) Using HEADSS in adolescent coming for ankle injury
Second principle: The range of normal development is is inappropriate
wide; it is critical to recognize that children mature at
different dates. Prenatal history
Delay of one month for a specific developmental Relevant to the pediatric interview because of outcomes
milestone may be normal, because of variation that are related to maternal history (e.g. maternal sepsis,
Third principle: A variety of physical, disease-related, fetal alcohol syndrome)
social, and environmental factors affect child Also important for giving breastfeeding advice
development and health Include the mother’s age at delivery, gravidity/parity
Nutrition and outside stimuli, shelter, and family and history of spontaneous abortions (miscarriages)
members may affect child development and Obstetric score (GP, TPAL) – tells problems during
diseases they have. prenatal care
Did the child have risk for certain diseases?

YL6: 01.15.01 Group 3: Casing, Chan, Cruz D, Cruz M, Lusica, Remudaro, Taguibao, Tiu, Villanueva 1 of 14
 Did the mom get prenatal care, screening?
Maternal past medical history include:
Diabetes or eclampsia/pre-eclampsia
Presence of oligo- or polyhydramnios
Known fetal abnormalities
Results of amniocentesis
Maternal and paternal medications
Occupational exposures at the time of conception and
through pregnancies
Maternal and paternal smoking, alcohol, homeopathic
product, and illicit substance use
Maternal uterine abnormalities
Maternal pet exposure and meat ingestion
Birth and Neonatal History
Duration of labor and pregnancy
Duration of ruptured membranes
Maternal treatment with medications and their timing
(antibiotic and anesthetic agents)
Presentation (vertex vs. breech)
Method of delivery (including forceps or vacuum
extraction)
Birth weight
APGAR scores
Interventions in the delivery room, length of stay in the
hospital after birth, and need for ICU care
Diagnosis of hypoglycemia, hypothermia, anemia,
convulsions, respiratory distress, jaundice, birth injuries
First month of life is extremely important.
Feeding History
Initial feeding by breast or bottle (including frequency
and duration/quantity), quality of latching and suck
Preparation of formula
Introduction of solids (including quality and quantity of
solids, any adverse reactions to foods)
Nutritional supplementation (including fluoride,
important for dental health)
Nutritional balance, meal frequency, fluid intake (including
milk, juice, water, sports drinks)
Allergies
Allergies or adverse reactions to any medications or
homeopathic preparations, herbal supplementations or
medicines
Ask about what the reaction is. It is not enough for the
patient to say that he/she is allergic to penicillin.
Why do you say it is an allergic reaction?
What happened in the first attack?
What happened when the patient took penicillin?
What was the type of reaction? (e.g. hives, emesis,
dystonia)
Why was it prescribed to the patient?
You want to know if the child is allergic to a certain
drug to avoid allergic reactions
Many symptoms are misperceived as allergies:
idiosyncratic reactions or side-effects
Immunization History
Enumerate immunizations and any adverse reactions
Even for adult patients
You want to know what immunization is appropriate
for a particular age
It is not enough to say they “got all the immunizations”
What type of vaccine?
At what age was it administered?
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
How many times?
Are all primary vaccines complete?
C. DEVELOPMENTAL/BEHAVIORAL
HISTORY
There are four domains in developmental history. If no
obvious problems with the patient, pick one of four to
narrow down the problem.
Gross motor
Walking with assistance, sitting without support
Visual-motor / problem-solving
Symbolic thought, object permanence
Language
Vocalization, responding to aural stimuli
Social/adaptive
Social smile, name recognition
Checking for developmental milestones starts with
current age of the child, working backwards
If the child is 10 years old, start with developmental
goals for 10 year olds, then work back
If there are no obvious problems with the patient, you
can pick one of these four domains to focus on in order
to narrow down the problem
General disposition of child - interaction between the
parent and the child.
History of colic, toilet training, temper tantrums, biting,
head banging, phobias, pica, night terrors
Red flags to consider for developmental problems
This is important for health maintenance and
preventive care so that you can advise parents
better.
Sometimes not volunteered by the parent/caregiver so it is
important to ask for this information.
School information – present grades, specific problems,
interaction with peers, methods of discipline
Child interactions with other people – language, body
response etc.
D. SOCIAL HISTORY
Who lives at home with the patient
Includes extended family members and family friends
Occupation of patient or parents’ jobs
Educational attainment
Smoking and alcohol consumption
Sexual history
Reproductive history
Illicit drug use
Parent-child and parent-doctor interaction
Gauge interaction between the child and the parent
and between you and the parent as well.
Because patient is a minor, parents have the right to be
present
If parents are not agreeable to step out, then it’s not
probably going to happen.
Grab the opportunity to interview the patient further in
instances when the parent agrees to step out of the
room; their consent is important
E. FAMILY HISTORY
Construct a family tree that includes the last two
generations
Ask specifically about childhood diseases or adult
diseases with childhood onset
History of consanguinity
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 Ask specific questions about family history related to
patient’s chief complaint.
II. ASSESSING ADOLESCENTS
A. PRINCIPLES
It is important to ask for the following major causes of
morbidity and mortality in adolescents.
Unintentional injuries
Vehicular accidents related to drug or alcohol use
Unwanted pregnancies
STDs
Eating disorders
Mood disorders
B. HEADSS
Home and Environment, Education and Employment,
Drugs, Sexuality, Suicide
1972 - Dr. Harvey Berman developed system for
organizing the psychosocial history, for adolescents
Was refined by Dr. Cohen
Method structures questions to facilitate communication
and to create a sympathetic, confidential, respectful
environment where youth may be able to attain adequate
health care
When asking these things, be sensitive to their needs.
Home and Environment
Education and Employment
Ask about how things are going at home and
school, including current grade level
Activities
Peer group activities
Drugs
Alcohol use, smoking, illicit drug use
Sexuality/ Sexual history
Suicide/Depression
III. PHYSICAL EXAMINATION
General Considerations
To effectively talk to and examine a child, understand
children and their development
You need to be systematic but more flexible
e.g. adjusting if the patient is hungry, sleepy, etc
Depending on what is the developmental level of child
Children are usually uncooperative
You can build rapport to get a more detailed PE in
subsequent visits, if there are any
Children are anatomically and physiologically different
from adults
Many techniques for assessment, physical findings,
and abnormalities in young patients differ
Children display tremendous variations in physical,
cognitive, and social development compared with
adults.
When examining infants and children, the sequence
should vary according to the child’s age and comfort level.
If they are not ready to show you the body part that
you want to examine, don’t force the issue.
Perform non-disturbing maneuvers such as
auscultation first
You start with non-distressing maneuvers first and do
potentially distressing maneuvers (e.g. looking at ears,
nose, throat) near the end of the examination
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
If child reports pain in one area (e.g. chief complaint is
pain in epigastric area), do it last; check other systems
first
Age Group Classifications
Infancy (0-1 year)
Early childhood (1-4 years)
Middle childhood (5-10 years)
Physical examination of adolescents (11-20 years)
A. ASSESSING INFANTS
Start the examination with the infant sitting or lying in
the parent’s lap.
Do as much of the examination as possible with the
infant in the parent’s lap
This position make the child feel secure during the
examination
Approach the older infant gradually. Use a toy or object to
distract the infant.
Make sure there are appropriate toys, a blanket, or other
familiar objects nearby
Appropriate toys are those that the children can
recognize
eg. Barney and Voltes V may not be the relevant
choice today
One can also attach toys in stethoscope to distract the
child
Speak slowly and softly to the infant or mimic the infant’s
sounds to attract attention and to keep infant occupied.
Don’t do baby talk!
Ask parent/s about infant’s strengths to elicit useful
developmental and parenting information
Make sure child is comfortable before doing PE
If the infant is tired, hungry or ill, you might ask the parent
to hold him against the chest. A hungry infant need to be
fed before you can proceed with a complete examination
Watch the parent’s affect when talking about the
infant
Note the parent’s manner of holding, moving, and
dressing the baby, and response to situations that
produce any discomfort for the infant
How the mother deals with temper tantrums, and use
method or parent to sedate child
Same techniques could be used to neutralize the child
B. ASSESSING THE YOUNGER CHILD
General Considerations
Important and unique aspect of examining younger
children - parents are usually watching and taking part
in the interaction
Younger children are more active compared to infants,
although still may be uncooperative
Provide opportunity to observe the parent-child
interaction. Assess the goodness of fit between parents
and children
Careful observation of the child’s interactions with
parents and the child’s unstructured play in the
examination room can reveal abnormalities in
physical, cognitive, and social development
Note whether the child displays age-appropriate behaviors
while you are playing with the child.
Integrate the Hx and PE as you can observe certain
things before doing the formal exam. Be observant.
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 There are questions that you don’t actually have to ask
because they’re quite observable such as if the patient
is walking already.
While abnormal interactions may be due to the unnatural
setting of the examination room, others may be due to
interaction problems.
Tips in Examining Younger Children
First examine the child’s toy or teddy bear, then the child
Some toddlers believe that if they can’t see you, then they
aren’t there. Perform the exam while the child stands on
the parent’s lap, facing the parent
Allow them to touch your flashlight, keys, etc.
Other tips in appendix
Anthropometric Measurement and Vital
Signs
The younger they are the more information you need
because growth is a major way to assess the
development of a child
Growth and development correlate with height and
weight
Include measurement of body size (height, weight,
length and head circumference) and vital signs (BP,
pulse, respiratory rate, temperature and pain)
Height is for children who can’t stand up; if they can’t
stand, the term is length.
Except for body temperature, it is important to
compare the child’s vital signs or body proportions to
age-specific norms, because they change dramatically
as children grow older
Because temperature indicators are independent of
age (i.e. 38 degrees Celsius indicates fever, both for
adults and children)
Growth charts show norms for height, weight, body
mass index (BMI), and head circumference
Measurement of growth is one of the most important
indicators of the health of children
Z score – adopted chart from the WHO
Measured standard deviation from the norm
Basis for international standards: regardless of race,
if you are given proper nutrition, you should be able
to grow at the same rate
Figure 1. Sample of a Weight for Height (WFH) Growth chart
(Source: WHO)
You have to plot on the right chart. If you’re plotting for a
BMI, there’s a BMI Chart for a girl and boy. If it’s height
then get the height for age chart, if the weight then get the
weight for age chart.
Deviations from normal may provide an early indication
of the underlying problem
Not just for nutritional assessment - There may be
diseases that lead to wasting or stunting (TB, Crohn’s
disease)
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
To assess growth, compare child’s normal growth
parameters with respect to normal values according to
age and sex
Check prior readings on the same child to assess
trends. Track over time because one-time
measurement might not give you the whole picture.
To be clinically meaningful, growth parameters
should be measured carefully, using a consistent
technique and, optimally, the same scales to
measure height and weight
Importance of trends: If they were +2SD for all their
life, then suddenly drop to 0, it is a cause of concern
Development of a child follows the curve of the
growth chart
Sutures and Fontanelles
Sutures
Membranous tissue spaces that separate bones of
the skull
Upon palpation: Feel like ridges
Fontanelles
Areas where the major sutures intersect in the
anterior and posterior portions of the skull
Upon palpation: Feel like soft concavities
Clinical significance: certain conditions (e.g.
hydrocephalus will delay closure of fontanelles)
Table 1. Measurement and Closure of Fontanelles
Fontanelle Measurement Age of Closure
at birth
(diameter)
Anterior 4 to 6 cm By 4 to 26 months of
age (90% between 7-
19 months)
Wide range of values
compared to posterior
Posterior 1 to 2 cm By 2 months
Head Circumference
Measured during the first 2 years of life, but
measurement can be useful at any age to assess
growth of the head
Head Circumference in infants reflects the rate of
growth of the cranium and the brain
Measurement:
Place the measuring tape over occipital, parietal,
and frontal prominences to obtain maximal
circumference.
During infancy, this is best done with the infant
supine as they don’t have good head control
Plot these measurements in the growth chart of the
infant.
More than 2 years of life there’s no need to
measure the head circumference. If the growth was
fine on the first 2 years it will proceed normally.
Chest and Abdominal Circumference
Measurements of chest and abdominal circumference
is not clinically useful
Unless current condition calls for it (e.g. abdominal
enlargement
Neck
Palpate the lymph nodes of the neck and assess the
presence of any additional masses such as congenital
cysts
Necks of infants are short, best to palpate the neck
while the infants are lying supine.
Look for size, tenderness. Is it doughy? Hard?
Older children are best examined while sitting
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 It is important to differentiate normal lymph nodes from
the abnormal ones or from congenital cysts of the neck
Lymphadenopathy is unusual during infancy but
common during childhood
Child’s lymphatic system reaches its zenith of growth at
12 years, and cervical or tonsillar lymph nodes reach
their peak size between 8 and 16 years.
Multiple palpable nodes may be normal for children
Focus on quality of lymph node: size, tenderness
and consistency (doughy, hard, etc.)
Not all enlarged tonsils are infected.
Vast majority of enlarged lymph nodes in children are
due to infections (mostly viral; frequently bacterial)
and not to malignant disease
Eyes
Newborns keep their eyes closed except during brief
wake periods. If you attempt to separate the eyelids,
they will tighten even more
You will have to use some tricks to examine the eyes of
newborns and infants. Use small colorful toys as
fixation devices.
Bright light causes infants to blink. Use subdued
light if you awaken the baby gently, turn down the
lights, and support the baby in a sitting position
The eyes of many newborns are edematous from the
birth process
The two most important aspects of the eye
examination for young children:
Test visual acuity in each eye
Determine whether the gaze is conjugate or
symmetric
To test acuity, make their gaze follow the toy;
A lot of children have asymmetric gaze (exotropia, etc.)
so important for you to assess this
Teeth
Timing and sequence of eruption, number, character,
condition, and position
This matters for primary teeth because it can affect
the growth of permanent teeth
Philippines has a poor dental health situation
Physicians can give mothers good dental health
assessment and referral to dentist
Abnormalities of the enamel may reflect local or
generalized disease.
As in most developmental changes of childhood, there
is a predictable progression of tooth eruption and also a
wide variation in the age of eruption
A rule of thumb is that the infant will have one tooth for
each month of age between 6 to 26 months, up to
the full complement of 20 primary teeth
In general, lower teeth erupt a bit earlier than upper
teeth.
C. ASSESSING MIDDLE CHILDHOOD
Usually you will find little difficulty examining children after
they reach school age
Most children will respond well when the examiner is
attuned to their level of development
More responsive and cooperative like adults and
adolescents
The order of the examination now begins to follow that
used for adults
Head-to-toe assessment can be done
As at any age, examine painful areas last, and forewarn
children about areas you are going to examine
If the child resists part if the examination, you can return
to it at the end
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
Be as flexible as you can when examining children.
D. ASSESSING ADOLESCENTS
Key to successfully examining adolescents is a
comfortable, confidential environment - privacy is the
key!
Consider the cognitive and social development of the
adolescent when deciding issues of privacy, parental
involvement, and confidentiality
The sequence and content of the PE are similar to that of
an adult
Pay particular attention to issues unique to adolescents -
puberty, growth, development
Use Tanner staging to gauge development
Gauge appropriateness when to assess (e.g. chief
complaint is acne)
Adolescents may be reluctant to reveal sensitive parts
of their body to the doctor
If for tanner staging, you may simply ask them to
point out their developmental stage from the Tanner
chart
Look for delayed and precocious puberty
Figure 2. Tanner Staging System for Females (Source:
transactiveonline.org/resources)
It is important to have a chaperone (parent or nurse)
present during the genital examination of adolescent
females
Ask for consent from the adolescent
Ideally, chaperone who is same sex of patient
Parents can be chaperone if adolescents consent
IV. THE MEDICAL WRITE-UP
After doing the patient history and physical exam, you
have to write everything down. Why?
You will always be a part of a team especially in the
hospital setting. You need to document correctly. If you
don’t document well, the rest of the team gets lost
To avoid legal issues
For regulatory, insurance purposes etc.
Most important reason: You want to make sure that
you understand the case really well (if you have a lot of
patients, you might forget the details)
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 A. OBJECTIVES
Should give the audience (e.g. doctors, nurse, student in
your group) a vivid picture of the patient and the patient’s
medical problems
Should be made to inform other members of the health
team even without seeing the patient
For legal purposes: documentation, supporting
document
Tell the patient’s story in a clear, chronological and
concise fashion
Should make a strong case for your assessment and
plan
Based on history and PE
When you get a good history, it gives good logic to your
diagnosis. It gives sense to your plan.
4 Essential Components:
The database
Problem list
Problem assessment/analysis and detailed plans
Structured progress notes dealing with each identified
problems
The Database
General body information collected on most patients
The database includes:
Usual history and PE
Carefully reviewed records of all previous medical
encounters
Any other information pertinent to the patient’s
medical
condition and management. If your patient came
from another hospital, that’s part of the history of the
present illness.
It can also include a core of required laboratory data
which might be defined differently for patients of
different ages, sex, and potential risk factors
If they have laboratory tests when they come to you
(from a different hospital)
Laboratory tests coming from you is not part of the
database.
There’s a format when writing it down. Your version of
the conversation is already an edited version of the
medical conversation.
The Problem-Oriented Approach
The way you approach a patient, do history, do physical
exam
make assessment and get the plan done will be based
on the problem
Not based on systems (e.g. cardiac, respiratory,
circulatory)
Not the same for all institutions and schools
A. INTRODUCTION
There is an art of writing and of reporting a physical exam
Always put things in the perspective of each case
What is the write up about?
When it is reported to a particular audience who hasn’t
seen the patient, it will give a picture of the medical
patient
It is written after the PE and history-taking have been
conducted
General Rules
Adhere rigidly to the H&P format
Chief Complaint → History of Present Illness → Past
Medical History, etc.
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
In Bates’, ROS comes last but follow the format in
the handout instead
Do not disturb the order so the reader will not be
confused
Write it down in the same format even though your
patient is
Giving information in different sequence
Make the transition between each section very clear and
do not cross-pollinate.
Do not put your PE in the HPI; do not put
conclusions or interpretations in the primary data
because it should be part of the assessment
Place headings and space the write-up content well
Don’t discuss physical exam findings in the history or
the review of systems. The history and the review of
systems should contain only information the patient
tells you.
Don’t introduce elements of the history into the PE
Don’t put conclusions or interpretations in the primary
data section (which includes the history, the physical
exam, and the tests)
Stick to the patient’s story, do not add anything else;
keep your language precise.
K.I.S.S. – Keep It Simple, Stupid!
Use positive statements rather than negative statements
Chest x-ray shows normal heart size” is better than
“Chest x-ray shows no cardiomegaly“
In summary, this patient’s problem is acute dyspnea” is
better than: “The patient’s problem is rule-out
pneumonia” Try to get out of the rule-out mentality.
Do not rationalize or editorialize as you present, just tell
the “facts” as they were obtained by you. It is a medical
document of facts. Do
Do not use flowery words. This is not poetry.
Remember! Tell the patient’s story, not your own.
Don’t put your own conclusions into the HPI.
Example, at the end of the HPI, you would not put: “I
would have gathered more information but the patient’s
breakfast came but the nurse kept interrupting to
change the patient’s dressing, administer medications,
and check vital signs.”
Identifying Information
Includes primary data of the patient such as name,
gender, age, marital status, religion, address, etc.
Begin with a one-sentence description of who the patient
is
“MJ is a 26-year old female, single, a Roman Catholic,
residing in Pasig City”
B. CHIEF COMPLAINT
May quote patient’s own words but should still be stated in
short, formal terms or phrases
You can translate Filipino words into English (if there’s
a translation for the term)
You can also add duration if this is helpful
“Shortness of breath for 3 days”
Sometimes there is no direct translation
Example: “Pasma?” There is no direct translation for
that. Put descriptions because things might mean
differently to different people.
Do not invent words!
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 C. HISTORY OF PRESENT ILLNESS
The fundamental part of your story
Based on a narrative and concise description of the
patient’s chief complaint, associated symptoms and
the impact these have had on the patient’s life
Should be sufficiently detailed that the reader will be
able to understand and picture the patient as if they had
talked to the patient themselves
Detailed enough so when somebody else reads it, they
understand. They don’t have the luxury of actually
asking the patient.
Avoid irrelevant information in your HPI
Edit your work – tell a coherent story
Should be problem-based. The dominant problem serves
as the center of the story.
If there is more than one problem, try to link them
when appropriate; if not, just describe them separately.
If there are four problems and two are related, link
two and list the others separately.
If after review of your patient’s case, you believe the
chief complaint (diarrhea) may be a direct extension of
his ongoing chronic problem (ulcerative colitis).
Therefore, the HPI begins with the chronic problem.
Information about the chronic problem should include:
Original diagnosis – date of diagnosis, presenting
symptoms and signs, diagnostic test
Current management and control of symptoms
Complications
Most recent objective measure of disease
Pertinent positives and negatives should be included:
All positive elements (what occurred) precede all
negative elements (what was absent)
Positive statements (what occurred) are presented in
chronologic order and are attentive to detail
Aspects to consider in HPI:
Whether intermittent/constant, duration
Whether changing over time (progressive, stable,
improving)
Aggravating/alleviating features
Associated symptoms
Prior episodes
Attributions (i.e. patient’s own interpretation of his/her
symptoms)
Quality, location, depth, radiation, severity
If the current problem is a direct extension of a previous
ongoing active medical problem, the HPI begins with a 1-2
sentence summary of that ongoing medical problem,
using key words
If the patient is coming in for diabetes/ uncontrolled
sugar:
Chief Complaint: Uncontrolled sugar.
HPI: State that the patient was already diagnosed
with diabetes (this is also part of past medical history
but placing this in the HPI will make it easier for the
reader to interpret)
Date of diagnosis?
How was diagnosis made?
Current symptoms and treatment?
Are any complications present?
Are any objective measures of the chronic
problem available? (e.g. Hgb A1c for diabetes,
FEV1 for COPD)
Negative Statements: findings that, although absent, are
important to mention
Constitutional complaints (fever, sweats, weight
change)
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
Symptoms relevant to organ symptom (if the patient
has chest pain, report here which chest symptoms were
absent: cough, dyspnea, sputum, hemoptysis,
dysphagia)
Important risk factors (what could my patient have
been exposed to cause this problem?)
The CC is the only part of history that you need to put
using the patient’s words. HPI can be interpreted,
translated and used with medical terms
Parts of the Past Medical History:
Family History, Social History that are pertinent (to the
present illness)
[1] “Ms. J was in her usual state of health until one
week prior to consult when she developed upper
respiratory symptoms including sore throat,
rhinorrhea and cough. The cough was initially dry
but, over the last 3 days became productive of
yellow green sputum. During the same period of time
Ms. J noted subjective fevers and chills. She also
developed progressive shortness of breath and
tightness in her chest, not relieved by the use of her
inhaler. On the night of the consult at the ER, she
was using her inhaler every 2 hours without relief. In
addition, Ms. J has been feeling weaker, has had
loss of appetite and mild nausea.”
[2] “Ms. J has been asthmatic since childhood. She
has been admitted multiple times for asthma
exacerbations but has never been intubated. Her last
admission was a year ago. She states her asthma is
usually well controlled. On average she uses her
albuterol inhaler 3-4/week. She denies night time
symptoms. She is not a smoker and doesn’t have
pets. She denies any ill contacts or new exposures.”
If you just included the first statement - confusing,
a lot of differentials (shortness of breath)
Adding the second statement - you already have
an idea (this case might be an asthma
exacerbation)
If the same patient has been diagnosed with
hypertension, you do not put it here (1st statement
does not have anything to do with 2nd paragraph
regarding hypertension)
Be as specific as possible when describing
symptoms, using the patient’s own words whenever
possible and quantifying whenever possible
“Ms. J could walk a mile one month ago without
getting SOB, but over the past month his SOB has
gradually progressed to the point that he cannot walk
50 feet without stopping to catch her breath.”
Put context (e.g. Before I could run a kilometer.
Now, I’m breathless after 20 steps)
Avoid burying important information in a mass of
excessive detail, to be discovered by only the most
persistent reader
Wrong: “After that, Ms. J went to her office then went
to the bank and then she became worried because the
shortness of breath wouldn’t go away. So she drove to
the ER.”
Correct: “4 hours prior to consult, she had shortness of
breath, wouldn’t go away, went to the ER”
Prior work-up to date (e.g. if the patient is transferred
from another hospital), and status on transfer
Information obtained from a chart review, outside records,
or a referring MD
If a patient comes in with a clinical abstract, it is still
part of the HPI.
Any treatments and the effects they had
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 Any pertinent prior laboratory or radiology studies,
information obtained from a chart review, outside
records, or a referring MD
It is acceptable to refer to diagnoses made by other
physicians in your HPI
“Dr. X had this assessment Z so she got treated this
way" put it in the HPI
However, you should reserve your diagnostic
impression to the impression portion of the write-up (not
HPI)
Do not readily assume that another doctor’s diagnosis is
correct.
Conclude the HPI with an explanation why the patient
came to the hospital that day.
HPI should always be written in paragraph (all the other
parts can be written in bullet form)
D. REVIEW OF SYSTEMS
Catalogue of symptoms
Findings critical to the main problem have been
mentioned as part of the HPI
All other positive findings should be listed
You do not need to list all the negatives. All pertinent
negatives would be in the HPI already
Do not repeat information you already included in the
HPI or PMH in the ROS as it is redundant
Common Errors in the ROS:
Some PE findings are found in the ROS
Some details of the HPI are repeated in the ROS
“No exertional dyspnea, no orthopnea with audible
wheezing with decreased breath sounds”
E. TEMPORAL PROFILE
Gives a visual representation of the significant
symptoms of the patient
A check and balance mechanism to ensure that:
The different symptoms of the patient are presented in
a sequential manner
No “time holds” present
The changes in severity and frequency of symptoms
are accounted for
Do not use very unusual shapes in the temporal profile.
When you do a family tree, you need to use the accepted
symbols
There are no standard symbols – you can make your
own
Figure 3. Temporal Profile Sample (2018 Trans)
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
F. PAST MEDICAL HISTORY
Patient’s significant past medical problems are
delineated
Major medical illnesses
Major surgical illnesses: list operations and dates
Trauma: fractures, lacerations
Previous hospital admissions with dates and diagnoses
If the patient cannot remember, you can put ‘patient
cannot recall’ or ‘date unrecalled’ instead of inventing
dates or keep pressuring the patient for dates.
Some medical conditions should have some further details
provided
For example, for patients with Chronic Heart Failure
(CHF), it is very helpful to know when they had their
last ECHO and what it showed.
Current medications:
Include over the counter cold medications, and
homeopathic preparations/herbal/supplements,
since some parents do not consider these to be
medication
Write the generic name instead of brand name. If you
want to put the brand name, enclose it in a parenthesis.
Put the dose, how they’re taking it.
Past use of a specific medication may be a useful
indicator
E.g. Use of Salbutamol for episodes of respiratory
problems
Allergies should always include a brief description of the
reaction
Ask for severity and triggering factors. If unsure of
patient’s allergy, write it down as ‘patient claims that...’
Recent history of travel or visitors from other countries
History of recent exposures (other sick people or to
environmental factors)
E.g. Asthma as described: “On average she has 2-3
exacerbations/year that require steroid use. She denies
any new exposures or changes in environment”
Seasonal allergic rhinitis – no regular medication
used.
Pneumonia – admitted to hospital in 1998.
No surgeries
Medications:
Fluticasone (Flovent) MDI 2 puffs BID
Salbutamol MDI 2 puffs q 4-6 hours prn
Flonase nasal spray 2 sprays daily
Fexofenadine 120 mg po QD prn
Ampalaya capsule
Allergic to penicillin-1992 developed swelling of
face and avoided penicillin from then
Other items to include in the pediatric PMH are prenatal,
birth, neonatal, feeding and immunization histories
Relative importance of these items depends on the age
of the patient and the reason for the visit
In general, the birth history is not significant for an
acute minor trauma visit for an adolescent.
Prenatal, birth and neonatal, feeding history, allergies,
immunization history, developmental, personal and social
history
Refer to part IB. Past medical history
J. STAKEHOLDER ANALYSIS
Tool to analyze the various positions of people involved
and their level of influence in the context of a case or
problem:
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 In the doctor-patient context, stakeholder analysis is a
tool to help you understand who has influence over
the patient and who could support a patient’s journey
towards healing, i.e. the treatment plan
You have to ask stakeholder analysis during next visits
Level of influence might change when disease gets
worse
You can decide how to approach people involved your
plan " know how to “manipulate” them " in the end, you
want your patient to adhere to your prescription and get
well
Identify stakeholders who could influence the patient,
negatively or positively
Understand how other people shape a patient’s
behavior
Find levers for changing a patient’s attitude and
behavior
Stakeholder analysis helps you gain handles from
which to anchor change. Leadership is not about
working from a position of power or authority, but about
influencing others.
Who can I change? Who can I work with?
Figure 4. Example of Stakeholder Analysis (ASMPH Clinical
Encounter Handout 2012). Larger version in appendix
Figure 5. Explanation of the Columns (ASMPH Clinical Encounter
Handout 2012). Larger version in appendix
Focus on those who are neutral, easier to convince
than those who are already at extreme
The physical exam, history and stakeholders analysis
should be able to help you; To figure out assessment,
diagnosis, and treatment plan
If you don’t have enough information, you can make
some assumptions and try to validate them based on your
interaction with the patient and relatives who may be
present
You need to put down your plan as well
The sample stakeholder analysis highlights the need for
you to go beyond the usual clinical encounter and
YL6: 01.15.01 Pediatrics History Taking & Physical Exam; Documentation (Writing & Recording Health History:
Principles and Perspectives
reach out to people around the patient. This may require
you to encourage your patients to bring to the consultation
their close relatives and friends.
K. PHYSICAL EXAMINATION
A record the examination in an organized system-based
approach
More organized if systems-based
Cranial nerves – HEENT (technically) → put it in
neurologic exam
Describe the positives and abnormal findings
Diagrams of abnormalities are helpful (e.g. masses,
rashes)
Do not say “patient is positive for rashes. There are
many kinds of rashes. Be specific.”
Document physical findings in the order that you do them:
usually Inspection, Palpation, Percussion,
Auscultation
You do this in order, you write these in order as well
Document all findings relevant to each system together,
even though you may have performed some of the
physical exam components at another time
Auscultation for aortic bruits should go in the
Cardiovascular system section even though they are
done during the abdominal exam
Cranial nerves should go to the neurological section
even though they are done with the Head and Neck
exam
Only document findings that you personally detect; not
findings recorded in the patient’s chart by other people
If you do not hear a murmur but it is in the previous
chart, you don’t write positive for murmur
List examinations you omitted to do and explain why you
didn’t do them
“Lower limb reflexes omitted as legs in traction.”
“Could not examine the leg because it was in a cast.”
“Could not do cranial nerves because patient was in a
coma.”
Always begin with a general description of the patient
You should also include pertinent observations related to
the patient’s presenting complaint when applicable
If patient presents with shortness of breath, it is very
useful to know right away whether he is: “lying flat with
unlabored breathing” or “sitting forward in the bed
breathing rapidly through pursued, blue lips using
accessory muscles.”
Common Errors in the PE Write-Up:
Do not provide just an adequate description of findings
Write “normal” or “WNL” or “benign” without even
specifying to which specific part of the exam they are
referring
“HEENT-normal” – Should one assume that this
includes a fundoscopic exam? Which one is normal?
Occasionally, it is acceptable to describe something as
normal if it doesn’t beg further description
Perform “the same” exam for every patient.
Ex. Shortness of breath – attempt to do a focused
exam so you don’t check the abdomen → You can
do a focused exam (i.e. spend 30 minutes listening
to the lungs) but make sure you give time to other
systems
Do not cut and paste
Every patient is different, every PE is different
PE should be tailored to the individual patient
If a patient is jaundiced or has known cirrhosis, you
should specifically seek out stigmata of chronic liver
disease and note their presence or absence; but for a
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 patient with syncope, you don’t need to do that; rather,
you should perform a very thorough cardiac and
neurological examination.
L. LABORATORY DATA
Like the physical exam, describe your findings rather than
give a diagnosis
NOT: “CXR-RLL pneumonia with small pleural effusion”
– do not interpret
INSTEAD: “CXR-slightly underpenetrated PA/lat with
patchy alveolar opacity in the RLL with blunting of the
right CP angle”
L. PROBLEM LIST/STATEMENT
The purpose of our problem solving is diagnosis and
treatment
The problem list is often forgotten and omitted. But if
you make space for it in a history, you will find that it is
very, very useful.
Therefore, the objective of our problem solving and
identifying problems is to eventually evolve diagnoses
(which are problems at the highest stage of resolution)
and treatment
It is a ranked list of all a patient’s active health problems
from most to least important
e.g. smoking versus MI, which would you put first?
Primary problem can be the most chronic illness
It should be complete, prioritized, and specific without
being overly redundant
A problem is anything that:
Requires further diagnostic work-up
Requires other medical or therapeutic management
Interferes with the quality of the patient’s life, as
perceived by the patient
Include medical and non-medical concerns
Or, in the opinion of the physician, may be potentially a
matter interfering with the quality of the patient’s life
You cannot put in the problem list something you’re not
sure of
A problem may be:
An equivocal and established diagnosis (carcinoma of
the lung)
Person comes in with a diagnosis of lung cancer →
#1:
Carcinoma of the lung (work up is done, already
established, no question about it)
But if the patient comes in with a lung mass →
Problem: Lung mass
Patient has diabetes → Problem: Diabetes, not
elevated blood sugar
If the patient comes with dyspnea, fever, rash →
Problem: Dyspnea, fever, and rash (because you
cannot come up with a diagnosis with these 3
symptoms)
If the patient has cough, fever, tachypnea, crackles
→ Problem: pneumonia (no other disease that has
these characteristics)
Problem: Rash and fever →so do not put “rule out
dengue”
Abnormal physical findings or signs (hepatomegaly)
Abnormal laboratory values (positive stool guaiac)
Behavioral aberrations, including social and psychiatric
problems
Socioeconomic problems (inadequate income for
family size)
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Because if you prescribe beyond the capability of the
patient, it will be useless
Prior surgery (s/p cholecystectomy)
Things that have long-term impact. Do not put medical
procedures w/o impact
e.g. IV insertion 3 years ago
Any factor which will significantly influence the patient’s
medical welfare should be listed
Never use the term “rule out” on a problem list. Rather, list
the actual finding as the problem and then processed to
seek its etiology:
Example: It is better and more useful to list “pyuria” as
just that, rather than “rule out urinary tract infection” and
miss the vaginal discharge when the urine culture
returns as negative and the problem is forgotten
Advantages of systematic problem list approach are as
follows:
Saves time (focuses on major problems, counter
checks treatment options)
Serves as trigger for remembering clinical history,
physical findings and laboratory
Fosters holistic care (includes non-medical issues in
the problem list)
Forces doctors to analyze and commit to a diagnosis
or develops prioritization skills
Gives an organized quick overview of patient’s
present
Condition for continuity of care, esp. for multiple
physician situations
After identifying and listing down all the possible problems
and sub problems of a patient, the five main steps in
creating a systematic problem list are the following:
Clustering problems – the problems are grouped
together according to related conditions. After you put
down the list, you need to assess it: every problem
needs to be assessed
e.g.. (1) Pneumonia (diagnosis) → assess etiology
(bacteria or viral), assess severity (category A or B)
(2) Asthma → controlled or uncontrolled
Checking for completeness of problems- the list is
checked for completeness, including possible cause of
the chief complaint
All problems should be included: past or present,
“important” or not
Major differential diagnosis should be included. If
there are too many, “etiology?” can be used
Medical and non-medical problems should be
considered
Separately list recurrences of acute disease
Only procedures with permanent effect should be
included
Prioritizing the problems – the clustered diagnoses
are prioritized according to the urgency of treatment,
magnitude and severity of the problem
Dating the problems – each problem and sub-problem
is date according to the date of onset for acute
conditions, or data of diagnosis for chronic conditions
Updating the problem list – the problem list is
updated regularly depending on the clinical course of
the patient. This is usually needed when new problems
arise, old problems are resolved or priority problems
change
Table 2: Example of Problem List
Case: “A diabetic patient presents with chest pain
and bibasilar crackles, JVD, and an S3 on exam;
has anterior ST elevation on ECG; interstitial
infiltrates on CXR; and a Hct of 30 with an MCV of
75, troponin T of 5.0, and a glucose of 200.”
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INCORRECT Chest pain Many of these problems may be related to prior
WAY. While JVD diagnoses and, therefore, do not need a differential
it is complete S3 diagnosis and your detailed thought processes.
and Abnormal ECG They should be listed as diagnoses with a brief
somewhat Abnormal CXR comment about acuity. Example: “HTN-well-controlled,
prioritized, e. Elevated troponin T 7. Low type 2 DM with poor control, hypercholesterolemia-
& f. are not hematocrit untreated”
specific and Low MCV Each problem assessment is followed by a statement of
it is very the initial plans covering 3 specific categories for that
Hyperglycemia
redundant. problem:
Incorrect because no attempt
Some of Diagnostic Plans – outline the specific tests or
to put things together to reach a
the findings procedures necessary to elucidate that specific
diagnosis
can be problem that are not already available in the defined
grouped data base.
Therapeutic Plans – define the specific drugs,
CORRECT Acute anterior MI – chest pain, dosages, and therapeutic procedures to be
WAY. This list S3, abnormal ECG, elevated undertaken
is complete, troponin Patient Education Plans – define what the patient
prioritized,
Congestive Heart Failure and the family have been told about the problem and
secondary to #1 – JVD, the plans for further education
Bibasilar crackles, S3
Microcytic anemia – Low Table 3: Example of Problem List, Assessment and Plan
hematocrit, low MCV Problem list Acute asthma exacerbation
Type 2 DM – glucose of 200 Acute respiratory distress with
hypoxemia secondary to Problem #1
Problem List Construction Upper respiratory tract infection
The key to successful problem illustration is to learn the History of asthma (since childhood) –
skill of being complete and specific without being persistent, not controlled
redundant Allergic rhinitis - stable
Assessment “Acute respiratory distress: the
The Assessment and Plan symptoms and physical findings,
especially with her past history of
Each numbered/ identified problem should have an
asthma are consistent with a moderate
Assessment and a Plan
asthma exacerbation likely triggered by
The assessment should include: the viral upper respiratory tract
Diagnosis, severity, etiology infection.”
Acute M.I. – you have nothing to assess “The differential diagnosis for her
CHF – severity respiratory distress is quite extensive
Microcytic – etiological (i.e. iron deficiency, chronic (pulmonary and cardiac causes, anemia,
disease, acute blood loss) etc). However, her presenting HPI,
Type 2 diabetes – controlled or uncontrolled association of diffuse wheezes on exam,
Differential diagnosis lack of crackles or focal findings in a
State which diagnosis is most likely and why, drawing patient with known history of asthma
on information from your recorded history and physical, makes this the most likely diagnosis in
and state why other diagnoses in the differential are the case. Congestive heart failure could
less likely also present with SOB, cough and
The organization is flexible because each patient has a diffuse wheezes, but one would expect
different number of active medical issues and a different bilateral crackles on exam aswell as
level of complexity other signs of volume overload (elevated
When you are unsure of the exact diagnosis, you JVP, edema, etc.)”
should still commit to what you think is most likely and Her symptoms and physical findings are
why the result of diffuse bronchospasm as
Good rule of thumb: provide specific comment about well as airway inflammation. Her
anything in your differential that you are planning to hypoxemia is the result of impaired gas
evaluate or address in some way exchange as a result of both of these
Do not include things in your differentials that you know pathologies.
the patient does not have. Plan Treat with inhaled bronchodilators
e.g. Patient has fever and rash → do not put shingles (Salbutamol nebulization) to reverse
For patients with multiple active problems, you need to bronchospasm, intravenous steroids to
address each problem diminish inflammation and oxygen via
This is not the same thing as your problem list. You are nasal cannula to keep O2 saturation
synthesizing and prioritizing the information from your greater than 95%.
problem list; often you can combine much of it into 1-2 Obtain chest x-ray to confirm the leading
diagnoses diagnosis of asthma exacerbation
Do not organize notes by systems no matter what (hyper-inflated lungs) and rule out the
you see others do presence of a superimposed pneumonia
Problems that are unlikely to be active during the (focal infiltrate)
hospitalization can also be omitted from the Close monitoring with frequent dosing of
assessment. inhaled breathing treatments until her

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Principles and Perspectives
 symptoms improve and the hypoxemia 2. A part of HEADSS system of psychosocial history of
resolves. adolescents
Regarding her persistent asthma that a. Health and well-being
appears to be uncontrolled, she will be b. Social functionality
educated about the regular and proper c. Sexuality
uses of her medications as well as d. Existential perceptions
avoidance of asthma triggers. 3. Which of the following does not belong in a PE?
a. Systems-based examination
b. Positive PE results from previous records
Tips for a Clear and Accurate Write-up c. Personally omitted examinations
d. General description of patient
Write as soon as possible, before data fade from your 4. The following should be compared to age-specific
memory standards, except
At first, you will probably prefer to take notes; later, work a. Height
towards recording the History of Present Illness, Past b. Weight
History, Family History, Personal and Social History, and c. Body Temperature
ROS in final form during the interview d. Middle-upper arm circumference
Leave spaces for filling in details later 5. What does not belong in an HPI?
During the PE, make note immediately of specific a. CC
measurements, such as BP and heart rate. b. Social History
Pay special attention to the order and degree of detail as c. Aggravating factors
you record d. Risk factors

Order of the Write-up Answers: c, c, b, c, b

Order should be consistent and obvious so that future
readers (including you) can easily find specific points of FREEDOM SPACE
information.
Keep subjective items in the history, and do not let them
stray into the PE
Offset your headings and make them clear by using
indentations and spacing to accent your organization.
Arrange the present illness in chronologic order, starting
with the current episode and then filling in the relevant
background info
If a patient with long-standing DM is hospitalized in a
coma, for example, begin with the events leading up to
the coma, and then summarize the past history of the
patient’s DM. REFERENCES

1. Doc De Vera’s powerpoint and supplementary medical

Checklist for your Patient Record
write up guideline
Is the order clear?
Do the data included contribute directly to the
assessment?
Are pertinent negatives specifically described?
Are there overgeneralizations or omissions of important
data?
Is there too much detail?
Are phrases and short words used appropriately?
Is there unnecessary repetition of data?
Is the written style succinct?
Is there excessive use of abbreviations?
In general, do not use abbreviations, write the whole
word
Are diagrams and precise measurements included where
appropriate?
Is the tone of the write-up neutral and professional?
Do not be judgmental
Ex. Do not say, unfortunately my patient is a smoker →
correct: smoker

REVIEW QUESTIONS

1. Which of the following does not belong in a PMH?

a. Drugs currently being taken
b. Previous hospital admissions
c. Associated symptoms to CC

d. Drugs previously taken

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 APPENDIX

Sample Stake Holder Analysis, (ASMPH Clinical Encounter Handout 2012)

Explanation of the Columns (ASMPH Clinical Encounter Handout 2012). Larger version in appendix

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 Sample Z-Score Growth Indicators. (www.WHO.com)

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