About pediatric history taking and Physical examination

1. The Art of Pediatric
History Taking &
Physical Examination
MANDAL, AJAY KUMAR
ANSARI, KAISHAR ALAM
Clerkship medical
student
Gullas College of
Medicine

2. Learning
Outcomes
 1. Display the knowledge, skills and attitude
expected of a medical professional
 2. Extract an accurate pediatric history across
different age groups (newborn, child, adolescent)
 3. Construct a complete history based on data
gathered
 4. Review the steps and components of complete
physical examination across different age groups

3. Learning
Outcomes
 5. Demonstrate professionalism and cooperation
with co-learners, academic and non-academic
staff and patients
 6. Develop the desire to gain more knowledge
and skills through continuing medical education
to provide quality care to patients
 7. Develop appropriate attitude & values of a
competent and professional health advocate
with focus on service and love of country

4. SKILLS
expected of a
junior clerk:
History-taking
Physical Examination
Formulate a working Diagnosis
Formulate Differential diagnosis

5. Patient History
and
Physical Examination
n

6. Patient History
and
Physical
Examination
Newborn
Infant and Child
Adolescent

7. The Newborn
History & PE

8. Newborn
History
Maternal/Obstetric History
Prenatal History
Perinatal/Natal History

9. Maternal &
Prenatal
History
 Age
 Prenatal Care
 Illnesses during pregnancy
 Drug Intake
 Exposure to radiation, alcohol, illicit drugs, smoking,
stress
 Prenatal US, progress of growth, presence of
congenital anomalies
 Previous reproductive problems, outcomes of
previous pregnancy/delivery

10. Perinatal &
Natal
History
 Age of gestation
 Was delivery induced & reason for induction
 Mode of delivery including use of anesthesia or
sedation
 Duration of labor and delivery
 Oligo/polyhydramnios
 Premature rupture of membranes (PROM >18hrs
prior to delivery)
 Place of delivery & attendant
 Appearance of cord & placenta
 Presence of meconium stained amniotic fluid

11. Physical
Examination
Timing:
1.soonafterdelivery
2. within 24hours
3.prior todischarge
 Perform UnangYakap or EINC Protocol
(https://youtu.be/AjcoR2tozyQ)
 APGAR SCORING – assessment of the newborn
immediately after birth
 Initial Physical Examination
 Recognize common normal and abnormal
conditions

12. Physical
examination
 Vital signs:
 1. RR: 40 -60 breaths/min
 2. HR: 120 – 160 beats/min
 3.Temp: 36.5 – 37.5 C

13. Physical Exam
of the
Newborn
 Inspect umbilical stump: vein (1) and arteries (2)
single umbilical artery
Observe:
1. Configuration of the thorax; size, shape &
movement of the chest
2. Skin, Abdomen, GU, Skeletal, CV & CNS

14. Anthropometric
Measurement
Weight
Length
Head Circumference
Chest Circumference
Perform physical and neurologic evaluation to
determine neonatal age and intrauterine growth
(BALLARD SCORING)
Lubchenco Chart
- to determine whether AGA, SGA or LGA

15. Lubchenco
Chart

16. The New
BallardScore
(Maturational
assessmentof
gestational age)
https://youtu.be/satiIRd4Vi8

17. Physical
examination
The new Ballard Score - reliable if done within 72 hours;
preterm within the first 12 hours of life
1. Physical features – done once stable
2. Neurological features – quiet and awake state
 Gestational Age:
Preterm: <37 weeks
Term: 37 – 41 6/7 weeks
Postterm > 42 weeks or more

18. Physical
Examination
Form
Items to be coded:
O- No Abnormality
X - Abnormality noted
Code Description of Abnormal Finding
1. General Appearance
Maturity, Activity,Tone,
Cry, Color, Nutrition,
Edema
O
2. Skin O
3. Head & Neck
Molding,Caput,
Carniotabes,
Cephalhematoma
X Cephalhematoma at the right parietal
area measuring 6x8 cm
4. Eyes
Abnormalities
Discharges
X Minimal yellowish discharges in the left
eye

19. Physical
Examination
 Head – shape & size, sutures, fontanel, caput vs
cephalhematoma
 Eyes, Face & Cry
 Eyes: subconjunctival hemorrhages, red orange
reflex, cataract (Congenital Rubella & Galactosemia)
 Face: facies of certain syndromes, facial paralysis or
paresis
 Cry: hoarseness (laryngeal edema ex. after airway
manipulation), high-pitched cry, stridor

20. Physical
Examination
Respiratory &
CVS
 General appearance: color, perfusion, central vs.
peripheral cyanosis
 Head: shape & size, sutures, fontanel, caput vs
cephalhematoma
 Eyes: subconjunctival hemorrhages, red orange
reflex, cataract (Rubella & Galactosemia)
 Face: facies of certain syndromes, facial paralysis or
paresis
 Cry: hoarseness (laryngeal edema ex. after airway
manipulation), high-pitched cry, stridor

21. Physical
Examination
Respiratory &
CVS
 Chest: RR
Respiratory status
 CVS:
 The presence of a normally split S2 is one of
the most important physical findings to be
mastered as it generally excludes the
presence of a heart defect
 Normal HR 120-160 beasts/min; slowing may
be due to congenital heart block, hypoxia or
intracranial hemorrhage

22. Physical
Examination -
Abdomen
 Abdomen: Globular but not distended
 Abdominal Distention accompanied with vomiting,
absence of meconium stools  intestinal
obstruction
 Diastasis recti, Umbilical hernia, omphalocele
 Liver palpable 2-3 cm below right subcostal arch

23. Physical
Examination -
Abdomen
 Kidneys normally palpable by bimanual
palpation (hydronephrosis, cystic kidney
disease)
 Back: abnormal curvature, evidence of occult
dysraphic state (tuft of hair, sinus, dimples),
skin tag, hemangiomata, subcutaneous
lipoma, etc.

24. Physical
Examination
Extremities: asymmetry, ( ex. Erb’s palsy),
malformations (ex. clubfoot deformity),
joint contractures, hip dysplasia
Genitalia: ambiguity (importance in sex
assignment), testes (descended or not),
hydrocele, hernia
Anus: presence, patency & location

25. Basic
Neurological
Examination
 Cranial nerve examination
 Motor examination – done when baby is alert; take
note of posture, tone, muscle strength, deep
tendon reflexes
 Developmental reflexes -
https://youtu.be/8UhAanlThUE
1. Moro
2. Palmar & Plantar grasp
3. Rooting & sucking
4. Tonic neck
* Sensory testing – rarely done in NB

26. Physical
Examination
https://youtu.be/
cracmPo3iYo

27. INFANT & CHILD HISTORY

28. Components
of Infant and
Child History
General Data
Chief Complaint
History of Present Illness (HPI)
Review of Systems (ROS) – Other
symptoms related to each organ
system not included in the HPI

29. Components
of Infant and
Child History
Past Medical/Surgical History; Medications
Family History including heredo-familial
diseases
Personal & Social History
Birth and Maternal history
Growth & Developmental History
Nutritional/ Feeding History
Immunization History

30. General Data
Full name, age, birth rank, nationality,
religion, date & place of birth, no. of times
admitted, date & time of admission
Informant and % Reliability

31. General Data
Example: Juan de la Cruz, a 3-year old male (1/2), Filipino, Roman
Catholic, born in Quezon City but now residing in Cebu City, is
admitted for the 1st time at VSMMC on 6/30/20 at 5Am.
Informant is the grandmother with 80 % reliability.

32. Chief
Complaint
The most important symptom that
prompted admission
Example: cough

33. History of
Present Illness
(HPI)
Must contain information like onset,
duration, character, severity,
aggravating/relieving factors
Remedies given, relief symptoms
Information regarding consultation/s
done
If medications were given, note the
type, dose, frequency & response
History must build up until the reason
for present consult/confinement

34. History of
Present Illness
(HPI)
 Example:
The condition started 5 days ago with running nose
and occasional cough.Two days ago, the patient
developed moderate to high grade fever thus he was
brought to the outpatient department of the hospital for
consultation. He was prescribed with Paracetamol Syrup
taken every 4 hours for fever 38 C and above and
Salbutamol Syrup 2mg/5ml 5ml 3x/day.
Few hours before admission, he complained of
difficulty of breathing thus was brought to the emergency
room.

35. History of
Present Illness
(HPI)
 Was the chief complaint of cough correct?
 What is lacking in the HPI?

36. History of
Present Illness
(HPI)
 Example:
The condition started 5 days ago with running
nose and occasional cough.Two days ago, the patient
developed moderate to high grade fever thus he was
brought to the outpatient department of the hospital
for consultation. He was prescribed with Paracetamol
Syrup 250mg/5ml 4ml taken every 4 hours for fever
38 C and above and Salbutamol Syrup 2mg/5ml 5ml
3x/day.The mother gave the medication as
instructed but there was no relief of fever and patient
continued to cough.
Few hours before admission, he complained of
difficulty breathing thus was brought to the
emergency room.

37. Review of
Systems (ROS)
Other symptoms related to each organ
system not included in the HPI
Example:
The patient has no changes in
sensorium, rashes, jaundice, eye redness or
discharges, naso-aural discharges, epistaxis,
vomiting, diarrhea, constipation, changes in
urination, easy bruising, limitation of motion,
edema or weakness

38. Past Medical
History
Childhood illnesses, accidents and
injuries, operations, hospitalizations &
allergies
Example:
The patient has no similar illnesses in
the past, no previous hospitalizations, no
surgery. He has a history of allergy to
shrimp and crab.

39. Family History
Illnesses both communicable & non-
communicable present in the immediate
family members and household members
Example:The father has bronchial asthma
and the maternal grandmother has
hypertension. No history ofTB, Hepatitis
nor are there other chronic infections in the
family.

40. Personal &
Social History
Elicit any concerns in the child ability to
associate with others, living conditions,
influences of community/school
The ethnic & cultural milieu in which the
family lives
Family socioeconomic circumstances (ex.
Income, type of dwelling, and
neighborhood), parental work schedules,
family interdependence, support from
relatives/friends/neighbors

41. Personal &
Social History
Example:
Juan is the first child of Juvy and Edgar.
Mother is a salesclerk while the father is a
security guard. He has a younger sister who is
1 year old. Sometimes, both parents are not
at home during the night so the maternal
grandmother who is staying with them takes
care of the children.
The family rents a one-bedroom space.
The family sleeps in the bedroom while the
grandmother sleeps in the living/dining room.
There are 2 families renting the house.

42. Birth &
Maternal
History
Maternal illnesses and immunizations
received, mode of delivery, complications
of delivery, condition after birth

43. Birth &
Maternal
History
Example:
The pt was born full term to a 25 year old
G1P0 mother at the hospital. Mother had
regular prenatal check-up with an OB-GYN and
was healthy throughout her pregnancy.The
mother did not take any medications during
pregnancy except for vitamins and minerals.
The pt was delivered via vaginal delivery
in a hospital. He had good cry and activity with
birth weight of 3 kg. He was immediately
roomed in after birth.

44. Growth &
Developmental
History
Important during infancy & childhood
and in dealing with problems of delayed
development & behavioral disturbances
Physical growth, weight & height,
history of rapid or slow weight
gain/losses, tooth eruption & loss pattern
Developmental milestones

45. Growth
&
Developmental
History
 Gross motor – rolled over, sat alone, ran well, able
to ride bicycle
 Fine motor – hands not fisted, reached & pulled
objects, linear scribbles, draw circles
 Language – turn to sound, babbled, first words,
spoke 1-2 words, states full name and age
 Personal/Social – smiled responsibly, interactive
games, remove garments, engages in pretend play

46. Nutritional
(Feeding)
History
Concerns in nutritional status contributing to
the present illness
Important during the first 2 years of life & in
dealing with problems of under/over
nutrition
Breastfeeding, artificial feeding preparation
of milk, micronutrient supplements,
complementary feeding and childhood
eating habits

47. Immunization
History
 Vaccines given, number of doses
 Example: Grandmother claimed that Juan
received complete immunization at the
health center.

48. Immunization
History
Example:
Juan was given BCG and 1st dose of Hep
B vaccines at birth. He received 3 doses each
of Pentavalent, Pneumococcal and Oral Polio
vaccines; 1 dose of Measles vaccine at 9
months and 1 dose of MMR at 1 yr at the
health center. No other immunizations
received thereafter.

49. Physical
Examination
General Survey:
The patient was examined awake, coherent, in
respiratory distress with the following vital
signs:
HR _____ RR _____ Temp _____ BP ______
O2 saturation room air _______
with 2 liters Oxygen _____
HC _______
Wt _______ Length/ Ht ________

50. Anthropo-
metric
Measurement

51. Physical
Examination
Skin
HEENT
Chest and Lungs
Cardiovascular System
Abdomen
Extremities
Genital/Rectal Examination
Neurologic Examination

52. Physical
Examination
 Neurological Examination:
Mental status, Motor, Sensory, Cranial Nerves,
Reflexes, Brudzinski and Kernig signs
Glasgow Coma Scale (GCS)
*Assignment: Differentiate Child & Adult GCS

53. Diagnosis
&
Differential
Diagnosis
Initial Impression or Working Diagnosis
Differential Diagnosis – at least 3
Laboratory Examination
Diagnostic Imaging
Treatment Plan

54. Diagnosis
&
Differential
Diagnosis
https://youtu.be/qKrLPY_8
Cyk
 Initial Impression/Working Diagnosis is based on the
facts obtained from symptoms, medical history,
basic laboratory results, and physical examination
 Develop differential diagnosis and one may then
order/perform additional tests to begin to rule out
specific conditions or diseases and come to a
Final Diagnosis

55. The Adolescent
History & PE

56. Adolescent
History and
PE
https://youtu.be/IaXq
43U1t3I
History: Interview with
- Guardian and patient
- Patient alone
- Confidentiality issues

57. Adolescent
History and
PE
 H –Home
 E - Education/Employment
 E - Eating Habits,
 A – Activities
 D - Drugs/Alcohol
 S - Sexuality
 S - Suicide/Depression
 S - Safety and Spirituality

58. Home
● Who lives with the young person? Where?
● Do they have their own room?
● What are relationships like at home?
● What do parents and relatives do for a
living?
● Ever institutionalized? Incarcerated?
● Recent moves? Running away?
● New people in home environment?

59. Education
&
Employment
● School/grade performance--any recent
changes? Any dramatic past changes?
● Favorite subjects--worst subjects?
(include grades)
● Any years repeated/classes failed
● Suspension, termination, dropping out?
● Future education/employment plans?
● Any current or past employment?
● Relations with teachers, employers;
school, work attendance?

60. Physical
Examination
TannerStaging
1 to 5 (Review)
3rd person
should be
present

61. Thank You
“A good physician treats the
disease,
a great physician treats the
patient who has the disease.”