HISTORY AND PHYSICAL

EXAMINATION IN
PEDIATRICS: A GENERIC
APPROACH

Prof Francis E. Onyango

Paediatrics and Child Health

Class: MB ChB V Date: 14 Sept 2016

 BACKGROUND

Important component in diagnosis and

management

Each pediatric patient may need emphasis

on specific areas of history and examination
 Diagnostic Tests: Clinical
diagnosis is based on
History as presented by the patient

Physical Examination as observed by the

clinician

Investigations, which include laboratory

tests
 Diagnostic Tests: Clinical
versus Lab. Test

Most diagnoses are based on good

clinical evaluation than on laboratory
test

Laboratory test may not contribute

anything further to a clinical diagnosis
 Diagnostic Tests:Frequency
of correct Diagnosis
Correct Diagnosis
Reference Based on Based on History
Clinical and Examination
History only - -%
%
Crombie, J.Coll. 88
Gen. Pract. 6:579;
1963
Sandler, Am. H.J. 56 73
100:928, 1980
 Preparation

– Setting
– Informant
– Etiquette and Rapport
HISTORY
 Classify your patient by age
Neonate First 28 days of life

Infant Less than 12 months

Under Five Less than 5 years (60

months)
Preschool age 12 months to 5 years

School age 5 years to 15 years

Childhood 1 year to 15 years

Adolescent 13 years to 19 years

 Components of History
Identification details
Presenting complaints and duration
History of presenting illness
Past medical history including drug history/allergies
Family history
Social History
Birth history
Developmental history
Nutrition history
Immunisation history
Review of systems
 Biodata
Name of patient
Age
Gender
Residence
Informant
Caregiver
 Presenting complaints
The patients own version

Little interference from the doctor

Duration

Documented in a chronological order

Common presenting complaints

 History of Presenting
Complaints (HPC)
In the patients own words (avoid your
interpretation or perceptions)

Taking presenting complaints one at a

time as chronologically presented.
 Past Medical History (PMH)
Details of all illnesses
– Admissions
– Non admissions
– Consultation – provider consulted
– No out of home consultations (home care)
Medications given and how well used
Result of the management
Check on records of previous medical
attendances.
 Family History (1)
Father and the mother (ages)

Siblings (alive and dead)

– Age
– Gender
– Occupation

Any other person living with the family

including the house help.
 Family History (2)

Detailed Medical history of

– Each of the siblings
– Each of the parents
– Each and every other person staying with the
family

Family tree for inherited disorders

 Social History (1)
Marital status of the parents

Living together or not (family relationships)

Education of each parent

Occupation of each parent

Hobbies of each parents (alcohol, cigarettes,

drugs and others)
 Social History (2)
Residence

Water supply

Waste and refuse disposal

Environmental sanitation
 Birth History
Antenatal history

Intra-partum history

State of the baby at birth

Immediate postpartum history

 Growth and Developmental
History (1)

Anthropometrics measurements
– Weight
– Height
– MUAC
– Head circumference
– BMI
 Growth and Developmental
History (2)
Developmental milestones
– Social smile (4-6 wks)
– Head control (1-3 mths)
– Turning towards origin of sound (2-3 mths)
– Extend hand to grasp a toy (2-3 mths)
– Sitting (5-9 mths)
– Standing (7-13 mths)
– Walking (12-18 mths)
– Talking (9-24 mths)
 Nutrition History
First six (6) months
– Exclusive Breast Feeding (EBF)
– Twenty four hour dietary recall
Six to twenty-four (6-24) months
– Complementary Feeding
– Twenty four hour dietary recall
Twenty-four months and above
– Family Foods
– Twenty four hour dietary recall
 Immunization History
Birth

Six weeks, ten weeks and fourteen weeks

Nine months

Others
 Systemic Reviews (1)
Systems
– GIT: diarrhoea, vomiting, nausea, appetite,
difficulty in swallowing, abdominal pain,
constipation, abdominal swelling, nature of
stool,
– RS: cough, sputum, coughing blood, difficulty
in breathing, wheeze, chest pain, nasal
discharge, nasal blockage, itchiness in the
nose, sore throat,
– CVS: cough, shortness of breath, chest pain,
palpitations, tiredness, swelling of the legs,
 Systemic Reviews (2)
– CNS: headache, convulsions, confusion, level of
consciousness, paralysis (weakness of the
limb/s), disturbed sensation (touch, pain,
pressure, temperature,), fatigue (low energy),
dizziness, sleep abnormalities, nervousness,
anxiety (feeling of fear, uneasy state),
depression (sadness), abnormal movements
(tremors, abnormal gait,)
– ENT: ear pain, ear discharge, sore throat, nasal
blockage, bleeding from the nose,
 Systemic Reviews (3)
– MSS: pain in the limbs, pain in the joints,
swollen joints, gait,
– UGT: urine output-nature and amount, colour
of urine, pain on passing urine,
– Skin: colour, wounds, rashes, itchiness,
dryness,
Thanks
 PHYSICAL EXAMINATION

General Examination

Systemic Examination
 General Examination (1)
General Condition – good/fair/poor,
AVPU
Vital Signs – Temperature, Respiratory
Rate, Pulse, Blood Pressure
Nutritional Status
– Weight, Height, MUAC (Head Circumference)
– Well nourished, Malnourished (Skin, Hair,
Muscles)
Hydration Status – Eyes, Skin, GC,
Drinking
 General Examination (2)

Skin – head, neck, upper limbs, trunk,

lower limbs and perineum

Mouth – ulcers on lips and mouth cavity,

thrush, teeth, jaws
 General Examination (3)
Anaemia – eyes (conjuctiva), mouth, palm, nail
bed
Jaundice – eyes (cornea), under the tongue,
skin
Cyanosis – eyes (conjuctiva), lips/buccal
mucosa, tongue (central cyanosis), fingers, nail
bed (peripheral cyanosis)
Lymph Nodes – cervical, axilla, epitrochleal,
inguinal
Clubbing – fingers, toes
Oedema – feet, legs (pitting? non-pitting?),
sacral, face/cheecks
 SYSTEMIC EXAMINATION
Cardiovascular System (CVS)
Respiratory System (RS)
Gastrointestinal System (GIS)
Nervous System (NS)
Muskulo Skeletal System (MSS)
Ear, Nose and Throat (ENT)
Genito Urinary System (GUS)
Systemic Examination: General
Principle
Inspection

Palpation

Percussion

Auscultation
 Cardiovascular System (1)
Pulses
Blood Pressure
Inspection
– Chest Wall - ?Normal, Abnormal, Sternum
(Pigeon Chest Deformity)
– Pulsations
Palpation
– Apex Beat, Parasternal Heave, Thrills,
 Cardiovascular System (2)
Percussion
– Cardiac dullness

Auscultation (Mitral Area, Tricuspid Area,

Aortic Area and Pulmonary Area)
– Heart Sounds I and II (Normal, Loud, Muffled)
– Other heart sounds
– Murmurs (Systolic, Diastolic, Grade)
 Respiratory System (1)
Inspection
– Respiratory Rate
– Lower Chest wall In-drawing
– Chest Cage
Configuration – normal, deformity (pigeon chest,
Harrison sulcus, kyphosis, scoliosis)
– Skin
– Pulsations
– Moving with respiration
 Respiratory System (2)
Palpation
– Trachea
– Apex Beat,
Percussion
– Note – resonant, hyperresonant, dull, stony
dull
Auscultation (all lung fields)
– Air entry – normal, reduced
– Breath Sounds – Vesicular, Bronchial
– Added Sounds – Crepitation, Rhonchi
 Gastrointestinal System (1)
Examination of Abdomen
Nine Areas of Abdomen – vertical and
horizontal landmarks
Inspection – shape (normal, scaphoid,
distended:- general, localized), skin (scars,
blood vessels, movements, moving with
respiration
 Gastrointestinal System (2)
Palpation:
– Light palpation - areas of tenderness,
masses, guarding,
– Deep palpation – organs (Liver, Spleen,
Kidneys, Bladder), masses,
Percussion – note (resonant, hyper-
resonant, dull), shifting dullness, fluid thrill
Auscultation – bowel sounds (normal,
increased, absent)
 Nervous System
Level of consciousness (AVPU)
Orientation – person, time and space
Meningeal irritation (neck, Kernig’s sign,
Brudzinski’s sign)
Cranial Nerves
Motor System – muscle bulk, tone, relexes
(deep tendon, superficial, primitive), power,
co-ordination
Sensory System – touch, pain, position,
temperature, vibration.
 Musculo Skeletal System
Bones – deformities, point tenderness,

Joints – swellings, pain, range of

movements,

Soft tissues - swellings, tenderness.

 Ear, Nose and Throat
Ears – shape, size, position, pinna,
external meatus, ear drum,

Nose – shape, nasal bridge, skin,

discharge,

Throat – pharynx; colour, tonsils (size,

membrane).
 Genito Urinary System

Genitalia – normal, abnormal (describe),

male (testis descended), female (labia,
clitory).

Kidneys – renal flanks tenderness,

bimanual palpation, size.

Urinary Bladder – distended, tenderness,

WORKING DIAGNOSIS
DIFFERENTIAL DIAGNOSIS

MANAGEMENT PLAN
Treatment
Laboratory Tests
Thanks