History taking and physical examination

By Adem G
Outline

History taking & physical examination in children

Components of history taking

Components of physical examination

Basic concept of malnutrition

Moderate and sever acute malnutrition

Infant and Young children Feeding

Objectives
• By the end of this session, you will be able to:

Described history taking & physical examination in children

Described components of history taking

Described components of physical examination

Describe basic concept of malnutrition

Manage moderate and sever acute malnutrition

Perform Infant and Young children Feeding

Definition

• History taking can be defined as a systematic inquiry into the patient

or client’s life.

• It is the process of obtaining relevant information from the patient or

patient’s caretaker (such as the mother or father) for the purpose of
making a diagnosis

• About 70 – 80 % of pediatric diagnoses are based mainly on history

Why history taking

• The pediatric history is the foundation upon which the future

physician/ patient/ parent relationship is built.

• The main basis of diagnosis of a medical condition lies in obtaining a

good history and physical examination

• “More errors are made because of inadequate history-taking

and superficial exam than any other cause.”
Goals of the history
• To determine why the patient/parent came to see the physician.
• To determine what the patient/parent is worried about most and why.
• To strengthen the physician/patient/parent relationship and thus the
therapeutic alliance by observing, listening and conveying empathy
• Direct appropriate examination and investigation
• Reach a correct diagnosis (or form a differential diagnosis)
Differences of a Pediatric History
Compared to an Adult History
I. Content Differences
• Peri-natal history
• Developmental history
• Social history
• Immunization history
Differences of a Pediatric History
Compared to an Adult History
II. Parent as Historian
• Parent’s interpretation of signs, symptoms
o Children above the age of 4 may be able to provide some of their own history
o Reliability of parents’ observations varies
o Adjust wording of questions - “When did you first notice Johnny was limping”? instead of
“When did Johnny’s hip pain start”?
• Observation of parent-child interactions
• Parental behaviors/emotions are important
Dealing with pediatric patients requires

• Specific knowledge
• Creativity
• Patience
• Be careful of sarcasm and joking
Listening to Mothers
• A smart mother makes often a better diagnosis than a poor doctor.

August Bier (1861–1949)

A German surgeon and a pioneer of spinal anesthesia
Listening to Mothers
Listening to Mothers
• A good doctor is a good listener.
• History is the vital cornerstone of pediatric problem solving.
• More important information is often gathered from a good history
than from physical examination and laboratory investigation.
Listening to Mothers
Listening to Mothers
• Mothers are excellent observers of their offspring and do know
when the are sick.
• She may not know what’s wrong but she certainly knows something is
wrong.
• No one can replace the mother in providing an accurate and thorough
description of the child and his complaints.
• Other caretakers – grandparents, aunts, will vary widely in their
knowledge of the child.
Listening to Mothers
• Introduce, establish rapport with the mother.
• Get into the habit of quoting verbatim from mother.
• Many have the experience of saying : ‘If only I had listened to that
mother; she was trying to tell me what was wrong’.
Listen to the patient, he is telling you the diagnosis

“Sir William Osler 1904”

Listening to Mothers
• Ask her to define her terms (What do you mean
by . . . ?).
• You need to establish that you are both talking about
the same thing.
• A good opening is, ‘Tell me about your baby’,
and then simply let the mother talk.
• Learn through history taking (receiving) to be a good
listener – to parents primarily, but also to experienced
pediatricians as they elicit clinical histories.
Listening to Mothers
• Always ask the parents to relate the sequence of events
leading to the present complaints.
• A suitable start ‘When was he last well?’
• Patients appreciate a doctor who gives them individual
attention and devoted time.
• Time spent on history taking will be repaid.
• Mothers may, of course, unintentionally deceive.
• A common complaint is: ‘I can’t get him to eat anything’
and a strong overweight toddler!
 Copponents

• Personal • Developmental History

• The Chief complaint • Feeding History

• History of the present illness • Family History

• Past medical history • Social

• Pregnancy and Birth History • Review of Systems

History – General, Personal
• Date
• Patient's name
• Birth date……..Age
• Gender, be careful to use the correct gender
• Residence
• Person giving the history (relationship to patient and perceived
reliability)
Note that Pediatrics is a specialty governed by age
• Pediatrics stretches from newborn infants to adolescents.
• Whenever you consider a pediatric problem, whether medical,
developmental or behavioral,
• First ask, 'What is the child's age?'
The Chief complaint

• Brief statement of the primary problem (including duration) that

caused the family to seek medical attention

• is the symptom the patient presents himself with

• It can be stated briefly as e.g. fever, cut wound, or vomiting, etc.

History of the present illness

Any treatment and response to

• this is a chronologic description and duration

of the chief complaint treatment

• We try to answer the following questions;  History of contact with a similar illness

Duration of disease onset  Relevant pediatric history (like the

Severity history of immunizations) related to
 Aggravating and alleviating factors chief complaints or history of present
 Associated symptoms illness
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

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, breathing problems, use of oxygen, need for intensive
care, hyperbilirubinemia, birth injuries, feeding problems, length of stay, birth weight
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 (see developmental charts)

• School-present grade, specific problems, interaction with peers

• Behavior – enuresis, temper tantrums, thumb sucking, pica,

nightmares, etc.
Feeding History

• Breast or bottle fed, types of formula, frequency and amount, reasons

for any changes in the formula

• Solids - when introduced, problems created by specific types

• Fluoride use
Family History

• Illnesses - cardiac disease, hypertension, stroke, diabetes, cancer,

abnormal bleeding, allergy and asthma, epilepsy

• Mental retardation, congenital anomalies, chromosomal problems,

growth problems, consanguinity, ethnic background
Social

• Living situation and conditions - daycare, safety issues

• Composition of family

• Occupation of parents
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
Review of Systems cont...
• 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

Review of Systems cont...

• GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of the 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
Physical examination

• Objectives

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

 To observe and demonstrate physical findings unique to the pediatric

population, and to understand how these findings may change depending on
the age of the child
Competencies

• To obtain accurate vital signs (Temperature, HR, RR, BP) in a pediatric patients
in different age groups and to be able to evaluate these vital signs compared to
age-adjusted normal

 To understand the normal variation in temperature depending on the route of

measurement

• To complete a thorough physical examination on pediatric patients in different

age groups. Two of these should be supervised by the attending staff in Clinic
Chronological steps of physical examination
1. General appearance
• The general physical state of the patient
This is what you observe while examine
general state of health
your patient The mental state of the patient
 weight and body build
 is he acting normally?  colors
 is he confused?  respiration

 is he drowsy, stuporous or even  signs of dehydration

comatose? etc.  edema

2. Vital signs

• These are:

Temperature

Pulse rate

Respiratory rate

 Blood Pressure
The temperature
• All sick children should have their temperature measured (rectally, orally, and axially)

• The normal temperature is about 37• C

• A temperature below 36• C is abnormally low and may be a sign of infection in a

small baby

• A temperature above 37.5• C is fever

• When there is a fever it usually means an infection is present and you must try to
locate the site of the infection and decide whether it needs treatment and with what
The pulse

• The pulse can be felt and count in children radically for fifteen
seconds multiply by four

• In the infant it is sometimes easiest to count the heart rate with the
stethoscope apically
Normal pulse rate

• babies 100-140 beats per minute

• children 80-100 beats per minute

In fever the pulse rate generally rises

 In dehydration the pulse rate may be very rapid and weak.

The respiratory rate

• Normal respiratory rate:

 < 2 month < 60 breath per minute

 2-12 months < 50 breath per minute

12 month-5years< 40 breath per minute

• A rapid respiration of 60 or more in a small, feverish child is a very good

indicator of pneumonia
Anthropometric measurement

• Weight

• Height/Length

• head circumference

• mid-arm circumference

• Chest circumstances
Weight
• The best way to assess nutritional status is to • The middle shows the lowest weight that is still

take body weight considered to be within limits of normal and the

• The weight should be charted on a weight weights on this line are 80 % of the weights on

chart the upper line

• Most weight charts have three curves • The lower curve shows 60 % of the ideal

• The upper line shows the average weight of weight

healthy well nourished children and this is an • According to Gomez classification any child

ideal growth curve whose weight is below this line is marasmic

Height
• Height (length) is also used but more difficult to measure than weight
especially in infants
• It is a less sensitive measure than weight because it does not
decrease during malnutrition, it only stops increasing.
• This means that height is not affected much for the first six months in
malnutrition and is therefore more a measurement of longstanding
malnutrition
Evaluation of various body system

• eyes for inspection

• hands for palpation

• ears for auscultation

• HEENT (hair color and texture, pallor, oral lesions, ear discharge, eye discharge,
neck swellings…) inspection.

• Chest (Inspection, Palpation/ Percussion, Auscultations)

• CVS (Inspection, Palpation/, Auscultations )

Evaluation of various body system cont...

• Abdomen(Inspection, Palpation/ Percussion, Auscultations )

• GUS (Costo-vertebral angle (CVA) tenderness, Suprapubic tenderness, and

inspection of external genitalia)

• Musculoskeletal system( joint swelling or tenderness or deformity, bone swelling

or tenderness, muscles)

• Integumentary /skin ( color, lesions )

• CNS( Level of consciousness, reflexes,(motor and sensory )and meningeal Sign

Example

• Date and Time of H&P: 9/6/16, 15:00

• Historian The history was obtained from both the patient’s mother and
grandmother, who are both considered to be reliable historians

• Chief complaint: "The rash in his diaper area is getting worse."

History of Present Illness
• Cortez is a 21-day-old African American male infant who presented to LBCH with 1 day of

worsening rash on his abdomen

• Cortez’s mother stated that her baby seemed to be healthy since his discharge from the

nursery until 1 day prior to presentation, September 5th, when she noticed a raised

erythematous rash on Cortez's abdomen

• She also noticed that her baby vomited her breast milk after three feeds. Consequently, she

switched to formula, which he handled without vomiting. There were no rashes anywhere

else on his body

•
History of Present Illness cont...

• On the morning of the presentation, she noticed the rash had become

fluid filled and had spread throughout the anterior diaper area

including the inguinal region and upper right and left thigh

• No intervention was attempted to treat the rash and nothing was noted

to worsen the rash besides the passing of time

History of Present Illness cont...

• Both mother and grandmother did not note any changes in Cortez's temperature, stool or
urine quality or quantity, or appetite

• In addition, there were no symptoms of increased work of breathing, cough, or lethargy

• However, the grandmother did say that Cortez was slightly more irritable today

• This was Cortez's first medical visit following discharge after birth

• The patient’s family denies any illness within their current household and visiting relatives

• The patient does not attend daycare

Review of the system
• CONSTITUTIONAL: No fever, weight loss. The grandmother reported increased irritability

• EYES: Seems to have difficulty focusing at distances EARS, NOSE,

• MOUTH/THROAT: No otorrhea, no congestion, Mom noticed a white dot on the roof of his
mouth since birth

• CARDIOVASCULAR: No history of heart murmur, no cyanosis

• PULMONARY: No cough or increased work of breathing, but mom did notice that he
occasionally breathes fast then stops for a few seconds, then starts up again. It’s most
noticeable when he sleeps
• GI: Mom says Cortez passes a lot of gas. When he was breast-fed, he had a soft stool after every feed
– sometimes 8-10 a day. He has only had two stools in the last 24 hours. His umbilical cord fell off
three days ago

• GU: Cortez displays a strong stream of urine when he voids

• NEUROLOGICAL: Cortez was very shaky after birth but that’s slowly resolved

• MUSCULOSKELETAL: No edema or trauma

• HEMATOLOGY: No ecchymosis or bleeding

• DERMATOLOGY: see HPI