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KAU – Rabigh Medical College
5th Year Course of Pediatrics
1434 - 1435
2013 - 2014
Dr Mohamed Hesham
Professor of Pediatrics
Pediatrics!!......Why??
Most children deaths in
developing countries are
preventable
Health Measures in Maternal and Child Health
Pediatrics!!......How??
A Good Student in Pediatrics
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Observer
Social and confident
Listener
Like challenges
Dedicated
Empathetic
Observer
Patient assessment
needs
Social and confident
• Pediatrics has some unique issues
• Working with patients and parents
• If you can not smile, you are in trouble
Listener
• Allow parents to talk, listen to children
• Concentrate on what they say
• Understand their feeling as they speak
• Don’t be judgmental
Like challenges
• Age
• The family unit
• The environment
Dedicated
• Care of babies and young children can
be overwhelming
• Make sure you have the temperament,
personality and dedication required
Empathetic
• Children respond to people who enjoy
and care about them
• Breaking bad news
A Good Student in Pediatrics
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Observer
Social and confident
Listener
Like challenges
Dedicated
Empathetic
Pediatrics is Different….
Children are not small adults!
Newborns are not small children!!
Basic Medical Characteristics
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Anatomy
Physiology and Biochemistry
Nutrition and Metabolism
Immunology
Pathology
Pediatric Characteristics in Basic Medicine
Anatomy
• Appearance: weight, height, circumferences
of head, chest, and arm, and body proportions
• Skeletal development: Anterior fontanel
closes, ossification occurs, primary and
permanent teeth
• Size, position of viscera, skin, muscle, nerve
and lymph system vary in different age.
• Narrow respiratory tract tends to develop
obstructive problems
Changes in body proportions from the
2nd fetal mo to adulthood
Pediatric Anatomy
Pediatric Airway Considerations
Adults
Infants
Pediatric Characteristics in Basic Medicine
Physiology
• Heart rate, blood pressure, routine blood test
results and composition of body fluids are
variable according to age
• Limited kidney's ability leads to electrolyte
and acid-base disorders in children
• More liable to hypothermia, hypoglycemia,
hypoxia and dehydration
Pediatric Respiratory Rates
Infant (birth–1 year)
30–60/m
Toddler (1–3 years)
24–40/m
Preschooler (3–6 years)
22–34/m
School-age (6–12 years)
18–25/m
Adolescent (12–18 years)
12–16/m
Pediatric Heart Rates
Infant (birth–1 year)
100-160/m
Toddler (1–3 years)
90 -150 /m
Preschooler (3–6 years)
80 -140/m
School-age (6–12 years)
70 -120/m
Adolescent (12–18 years)
60 -100/m
Pediatric Characteristics in Basic Medicine
Nutrition and Metabolism
• The dramatic growth of children during early
life demands unique nutrients.
• Unfortunately, provision of these special
nutritional needs is complicated by the
immature digestive and metabolic processes.
• Inborn errors of metabolism causing clinical
manifestations are almost found in the infants
and children stage.
Pediatric Characteristics in Basic Medicine
Immunology
• 3-5 months after birth, the diminished
concentration of immunoglobulin and other
immunologic factors and the decreased
function of neutrophils and other cells
involved in the response to infection put
infants at increased risk for infection.
• SIgA and IgG is not sufficient , thus the
infants are vulnerable to respiratory and
gastrointestinal infections.
Pediatric Characteristics in Basic Medicine
Pathology
Infants
Adolescents or
Adults
Streptococcus bronchopneumonia Lobar pneumonia
pneumoniae
Vitamin D
Rickets
osteomalacia
deficiency
Stress
hematopoiesis
bone marrow
occurs in the yolk
hematopoiesis
sac and liver
Clinical Characteristics of Pediatrics
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Pattern of Diseases
Clinical Manifestations
Diagnosis
Treatment
Prognosis
Prevention
Clinical Characteristics of Pediatrics
Pattern of Diseases
• Neonates : asphyxia of newborn, trisomy 21
• Infant-toddler age: febrile convulsion
• Cardiovascular disorders:
– congenital heart disease in children
– coronary heart disease in adults
• Malignancy: Age of 4 yr and above
– Acute leukemia
– Brain tumors
Clinical Characteristics of Pediatrics
Clinical Manifestations
• Onset of illnesses is very rapid.
• Atypical presentations:
– Neonate with severe infection is always weak in
response, apathy, rejects feeding, but has neither
fever, nor increase in WBC counting or other
obvious clinical manifestations.
• May easily miss the diagnosis!
Clinical Characteristics of Pediatrics
Diagnosis
• History given by the parents.
• Varies with age:
– Convulsion in children:
• Neonatal Period--obstetric injuries, asphyxia, congenital
diseases, intracranial hemorrhage.
• <6 mo old--intracranial infection, tetany of Vitamin D
deficiency.
• 6 mo - 3 yr old: high fever, intracranial infection.
• > 3 yr old: epilepsy, intracranial tumor or infection.
Clinical Characteristics of Pediatrics
Treatment
• The pediatric drug dose varies in different age
groups and given according to body weight or
surface area.
• Fluid therapy is critical in amount and
composition.
• Nutritional support is important
• Efficient nursing is essential
Clinical Characteristics of Pediatrics
Prognosis
• The clinical manifestations change rapidly.
• They have good potential for recovery. POSITIVE!
• But when they decompensate they crash
suddenly and rapidly. NEGATIVE!
• Early diagnosis and prompt treatment are very
important.
• Rapid tissue recovery.
Clinical Characteristics of Pediatrics
Prevention
• Prevention in the health care of infants, and
children is at the core of the field of pediatrics.
– Planned immunization (vaccination)
– Genetic consultation and screening test
– Injury prevention
– Parents counseling
– Examples
• Treat urinary tract infection renal dysfunction.
• Treat rheumatic diseases in childhood is to prevent or
reduce organ damage
Pediatrics - Stages by Age
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Fetal period
Neonatal period
Infant period
Toddler age
Preschool age
School age
Adolescence
Pediatrics - Stages of Children by Age
Fetal period
• This period is from formation of embryo till birth.
• First trimester of pregnancy is the first 12 weeks.
– This period is very important for development and
organogenesis . Thus, infection, radiation,
chemotherapy may give rise to congenital
malformation of organs.
• Second and third trimester; fetus increase in size
and get stores.
Pediatrics - Stages of Children by Age
Neonatal period
• From umbilical ligation to 28th day after birth
• Features: beginning of independent life
• The physiological regulation ability and
adaptation to circumstances are challenging.
• The morbidity and mortality are very high
• Health care:
– enough nutrition
– proper nursing care
– prevention of diseases
Pediatrics - Stages of Children by Age
Infancy period
• Rapid growth period.
• Baby weight increases 3 times more than the
birth weight.
• Height increases 1.5 times compared with the
birth height.
• Head circumference increases from 35-47 cm.
• Every organ system continues developing and
completing, most importantly the brain.
Pediatrics - Stages of Children by Age
Toddler period
• From 1 to 3 year-old
• Features:
– growth becomes slower
– more vigorous, contact more objects, intelligence
develops faster
– poor ability of identifying damage.
• Health care:
– enough nutrition
– Prevention of diseases
– Prevention of accident
Pediatrics - Stages of Children by Age
Preschool age
• 3 years old until 6-7 years old
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growth becomes slower,
more mature intelligence.
strong desire for knowledge
imitating adult’s behavior
poor ability to identify damage
• Health care:
– enough nutrition
– prevention of diseases
– prevention of accident
Pediatrics - Stages of Children by Age
School age
• From 6-7 years old until adolescence
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growth becomes relatively steady
more mature intelligence developed
increasing desire for knowledge
decreasing incidence of diseases
• Health care:
– enough nutrition
– prevention of problems in psychology, emotion and
behavior
Pediatrics - Stages of Children by Age
Adolescence
• From 2nd sexual character appearing until sexual
mature and growth stopped
– --Girl: from 11-12 yrs to 17-18 yrs
– --boy: from 13-14 yrs to 18-20 yrs
• Features:
– the second fastest period of growth and development
– neuroendocrine regulation unsteady
– having problems in psychology, emotion, behavior
• Health care:
– enough nutrition
– health care of adolescence
– education
History Taking in Pediatrics
History Taking - 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.
Why??
• 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.”
Objectives
• To understand the content differences in
obtaining a medical history on a pediatric
patient compared to an adult.
• To understand how the age of the child has an
impact on obtaining an appropriate medical
history.
• To highlight the role of parents during taking
pediatric history.
Objectives
• To highlight the fact that modern technology
must be used when appropriate only to
enhance the clinical assessment of the
patient, not to replace it.
• Understand the appropriate wording of
questions in taking a pediatric history, and
appropriate use of questions.
• Children are not just small adults!
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)
Pediatric History is Different?!
Pediatric History is Different
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History is usually given by parents
Developmental level of the child
The age of the patient
Social issues
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
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Specific knowledge
Creativity
Patience
Be careful of sarcasm and joking
Be careful of sarcasm and joking!!
So,
• Taking a history is an art that comes with time.
• Watch how others do it,
• But find what works for you.
Listening to Mothers
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!
A Sample History
About 70 – 80 %
of pediatric diagnoses are based
mainly on history
A good history with the pertinent
points abstracted is the best
pointer to diagnosis in pediatrics
Key areas to cover are
• Presenting complaint -(chief reason for seeking advice)
• History of presenting complaint -(temporal sequence of
events leading to presentation)
• Past Medical History
• Prenatal : drugs, infections, fetal movements, maternal health
• Birth: labor, delivery, Apgar, resuscitation, percentiles.
• Neonatal ; medical and surgical problems
• Feeding, diet, nutrition
• Growth and Development status
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Progress at kindergarten , playgroup, school
Immunizations
Medications
Allergies
Previous medical problems,
Life events , accidents , injuries, surgery
Family History (pedigree) medical and psychiatric, drug and
alcohol
• Impact of child's illness on family/ siblings
• Occupation of parents.
Outline of the Pediatric History
History – General, Personal
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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)
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Pediatrics is a specialty governed by age
Pediatrics is a specialty governed by age
Pediatrics is a specialty governed by age
Pediatrics is a specialty governed by age
Pediatrics is a specialty governed by age
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?'
Presenting complaint - Chief complaint
• In the patient's or informant's words.
• Description of the presenting complaint, in
chronological order.
• Brief statement of primary problem (including
duration) that caused family to seek medical
attention.
• It is important to establish the duration of
each complaint.
History of the Present Illness
• This is the most important part of history.
• Details of the chief complaint are expanded.
– How and when the condition begin
– Progress of the condition, chronology or sequence
– Aggravating and alleviating factors
– Relevant negatives information should be
included if they contribute to the diagnosis or help
exclude other possibilities
History of the Present Illness
• A helpful statement includes when was the
patient last entirely well. "The child was well
until "X" number of days before this visit."
• Review of Systems. A checklist for pertinent
information that might have been omitted.
"Are there any symptoms related to . . .?“
• There is no need to repeat previously
recorded information in writing a Review of
Systems
• If there is more than one complaint, ask which
complaint came first, which was next and
finally, which came last. You should then
present these complaints in order beginning
with the one that came first.
• Always start by “open questions” and leave
“closed questions” ; a “Yes” or “No” questions
till end to complete data.
History of the Present Illness
• Any significant prior laboratory or radiology
studies should be noted here.
• Child maltreatment should be considered if the
history and physical exam are not consistent
with one another or if there is a delay in
seeking care for a serious injury.
History of the Present Illness - Theme
• History of the Present Illness
– (where? what? when? How?...) directed at the chief
complaint(s).
• Review of other systems
– Support a diagnosis
– Exclude a diagnosis
– Assess severity of a disorder
• Negative information should be included if contribute
to diagnosis or exclude other possibilities.
Past Medical History
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Hospitalizations
Surgeries
Medications and drug allergies
Vaccinations
Recent travel
Recent exposure
Injuries
Communicable diseases
Past Medical History
• The 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!
Perinatal history
• Prenatal:
o Length of gestation.
o Age and parity of mother at delivery.
o Any maternal insults [alcohol, smoking] or
illnesses during gestation.
Perinatal history
• Natal:
o Where born: hospital, clinic, home.
o Birth weight, mode of delivery, difficulties in
delivery.
o Resuscitation, intensive care requirement at
birth.
o Apgar score at birth, if known.
Perinatal history
• Postnatal:
o Cyanosis, pallor, jaundice, convulsions,
birthmarks, malformations, feeding or
respiratory difficulties.
o How baby was fed in first few days.
o Whether child went home with mother.
Nutritional history
• Breast-fed vs. bottle-fed
– When breast started, stopped.
– If formula: type, amount, pre-mixed vs
concentrate [and dilution used].
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Vitamin supplements.
Age when weaning started.
Appetite and growth.
Current diet.
Nutritional history
• Present diet and appetite
– Age of introduction of solids
– Age child achieved 3 feedings per day
– Present feeding patterns
– Elaborate on any feeding problems
– Age weaned from breast or bottle
– Type of milk and daily intake
– Food preference
– Ability to feed self
Developmental history
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Gross motor.
Fine motor.
Vision, speech, hearing.
Social.
Developmental history
• Age when able to…
– Hold head erect when in sitting position
– Roll from front to back; back to front
– Sit alone; unsupported
– Stand with support; without
– Use words
– Talk in sentences
– Dress self
– Age when toilet trained
Social History
Social history - Goal
• To build up a picture of the child’s social and
cultural environment to appreciate risks and
stresses at home and school:
• Home: parental attitudes, separated, divorce,
absence of a parent, jealousy of a new baby,
death of a near relative
• School: new school, low educational level,
over rigid discipline, bullying
Social History
Social History
Social history - Items
• Living accommodation
• Who lives at home with the patient, including
extended family members
• Age and parents' occupation
• Level of parental education
• Sibling relationships
• The family's attitude toward the child and toward
each other, the type of discipline used, and the
major disciplinarian
Social history - Items
• School performance (Education history)
• Any others at daycare/ school with same
complaint.
• Travel: where, how lived when there,
immunization/ prophylactic status when went.
• Smokers in the home.
• Pets in the home.
• Nationality and migration of parents [if relevant].
Social History
Family history
• Families share houses, genes and diseases.
• A family tree that includes the last two
generations (prior to the generation of the
proband).
• Childhood diseases or adult diseases with
childhood onset.
• History of consanguinity; unexplained
recurrent miscarriages or SIDS.
Family history
• Neonatal deaths.
• The current complaint in parents/ siblings:
health, cause of death, age of onset, age of
death.
• Parents/siblings: age, health, where living.
• Height and weight of parents.
• Age of parents at the birth of this child
History Tips!!
History Tips!!
History tips
• Use "the father" or "the mother" instead of
"your husband" or "your wife".
• Parents may use lay language. Ask "do you
mean..." for clarification as needed.
• Ask if the temperature was actually measured,
and if so, what it was.
• Great and give pleasant remarks.
• Do not stare at the child!
History tips
• You should not swallow the diagnosis given by
the parents.
• Always use the child’s name.
• Do NOT get the gender of the child wrong!
• During the taking of the history, preferably in
relaxed surroundings, the opportunity should
arise to observe how the child separates from
the parent, how creatively and independently
he plays, and behave.
• Different aspects of the history assume or lose
importance depending on the age of the
patient or the nature of the problem.
• Reserve detailed questioning for those aspects
most pertinent to the child.
• Summarize at the end to check accuracy
History tips
“Don't touch the patient…state first what you
see; cultivate your powers of observation…”
Sir William Osler
Let The Children Speak
Let The Children Speak
• Don’t forget the child!!
• Children need to be heard and to be noticed.
• Children over 5 years should be asked to give
their account of events with parental comments.
• A bright 10-year-old boy with a proven duodenal
ulcer described his pain as being ‘like a laser
beam going through my stomach’. Brilliant!
• If he does not like to talk, or shy don’t push him
Let The Children Speak
The child should be included
as much as possible
Conclude the History
by Making an Impression
Impression
• A diagnostic impression should be developed.
• A problem list is established
• First describe the anatomy of each abnormality,
then describe the pathologic process (e.g.,
neoplastic, inflammatory, infectious)
Questions
• What is the most important determinant of
pattern of diseases in pediatrics?
A. Weight
B. Age
C. Sex
D. Onset
E. Social conditions
Questions
• What is the most important determinant of
pattern of diseases in pediatrics?
A. Weight
B. Age
C. Sex
D. Onset
E. Social conditions
Questions
• Toddler period is from
A. Birth to one month
B. One month to one year
C. 3 years to 7 years
D. 7 years to 12 years
E. None of the above
Questions
• Toddler period is from
A. Birth to one month
B. One month to one year
C. 3 years to 7 years
D. 7 years to 12 years
E. None of the above
Questions
• Pediatric history is different from adult
history because
A. Parents are the historian
B. Variable developmental stages
C. Perinatal events are important
D. Immunization are given during pediatric age
E. All of the above
Questions
• Pediatric history is different from adult
history because
A. Parents are the historian
B. Variable developmental stages
C. Perinatal events are important
D. Immunization are given during pediatric age
E. All of the above
Case study 1
A doctor is asked to see an ill 9-year-old child
in a hospital outpatient department. He
ignores the child and asks her mother what
the problem is. She gives him the referral
letter, which he does not read. Before she can
give her story he has already started to
examine the child. The child is not weighed.
He tells her that the child has rheumatic fever,
and should stay in bed and take the prescribed
tablets three times a day. He then rushes out
without any further explanation.
1. What is the first mistake the
doctor makes?
1. What is the first mistake the doctor
makes?
• He ignores the patient. A 9-year-old child
should be able to tell the doctor about the
presenting complaints. He also does not
introduce himself to both mother and child.
This is not only bad medicine but it is also
foolish and rude
2. Is this the correct method of
taking a history?
2. Is this the correct method of taking
a history?
• No. He does not pay attention to the mother
and starts examining the child before she has
had a chance to tell her full story. Never
ignore what a mother has to say, as she knows
her child best
3. In a hospital, is it important to
read referral letters?
3. In a hospital, is it important to read
referral letters?
• Yes. Always read the referral letter as it draws
attention to the clinical problem and often
provides important information. The doctor
should have replied to the letter.
A doctor is asked to see an ill 9-year-old child
in a hospital outpatient department. He
ignores the child and asks her mother what
the problem is. She gives him the referral
letter, which he does not read. Before she can
give her story he has already started to
examine the child. The child is not weighed.
He tells her that the child has rheumatic fever,
and should stay in bed and take the prescribed
tablets three times a day. He then rushes out
without any further explanation.
Case study 2
A general practitioner asks about the
presenting complaints and takes a present but
no other history from a mother and her 10year-old daughter. The child has a fever and a
rash. After a quick general inspection, he lifts
the child’s shirt and looks at the rash. After
writing a brief note in the hospital folder he
tells the mother that the child has measles.
1. What mistake has the doctor
made in taking a history?
1. What mistake has the doctor made
in taking a history?
• Only a present history was taken. It is
important always to take a past, social and
immunization history as well.
2. Why is an immunization history
important?
2. Why is an immunization history
important?
• It is important to know whether this child has
been fully immunized, especially against
measles and rubella.
A general practitioner asks about the
presenting complaints and takes a present but
no other history from a mother and her 10year-old daughter. The child has a fever and a
rash. After a quick general inspection, he lifts
the child’s shirt and looks at the rash. After
writing a brief note in the hospital folder he
tells the mother that the child has measles.
Case study 3
An infant is seen by a physician at a follow-up
appointment at a local clinic. She is unable to
read the long and confused notes made at the
previous visit and does not ask the mother for
the Health Card. The mother cannot help her,
as she was not told what the problem was.
She thinks the child has a heart problem.
During the examination the infant cries
because the physician’s hands are cold. As a
result she cannot hear the heart sounds and
refers the child to hospital.
1. Why is she unable to read and
make sense of the patient’s notes?
1. Why is she unable to read and
make sense of the patient’s notes?
• Because they were not written clearly in a
logical order. This is a very common finding.
With good notes she should be able to quickly
find out what the previous problems and
management were.
2. Why should she have asked for the
Health Card?
2. Why should she have asked for the
Road to Health Card?
• There may be a summary of the previous visit
in the Card. The Card would also indicate how
the child has been growing, whether the
immunization schedule is up to date and what
previous health problems have occurred. It is
a serious error not to review the Card at each
visit
3. Why was the mother not told what
the problems were?
3. Why was the mother not told what
the problems were?
• There was poor communication between the
health professional and the patient. This is a
common problem. This can be partially
addressed by making a note in the Health
Card. The parents and the child should always
be fully informed after a consultation.
An infant is seen by a physician at a follow-up
appointment at a local clinic. She is unable to
read the long and confused notes made at the
previous visit and does not ask the mother for
the Health Card. The mother cannot help her,
as she was not told what the problem was.
She thinks the child has a heart problem.
During the examination the infant cries
because the physician’s hands are cold. As a
result she cannot hear the heart sounds and
refers the child to hospital.
Case study 4
• A child from a very poor home presents with
scabies at a clinic. His weight is below the 3rd
centile. The mother also says that he has
coughed for the past month. The doctor takes
a full history and completes a physical
examination. She writes SOAP notes in the
patient folder and also writes a summary in
the Health Card.
1. What are SOAP notes?
1. What are SOAP notes?
• This is a system of writing clinical notes, which
includes the story (history), observations
(physical examination), assessment and plan
of action.
• All initial or follow-up examinations should be
recorded this way
1. What are SOAP notes?
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S ….the story, subjective (history)
O….observations (physical examination)
A….assessment and
P….plan of action.
2. Is it necessary to write notes in
both the clinic folder and Health
Card?
2. Is it necessary to write notes in both
the clinic folder and Health Card?
• Yes. The clinic folder should hold the detailed
notes while a summary should be written in
the Health Card.
3. What is a problem list?
3. What is a problem list?
• This is a clear & simple list of the patient’s problems.
• The problem list is drawn up during the assessment
at the end of the complete examination.
• The problem list is the most important part of
summarizing the findings of the history, physical
examination and investigations.
• A problem list must always be made even if the
diagnosis is not known.
4. What would be the problem list for this
child?
• A child from a very poor home presents with
scabies at a clinic. His weight is below the 3rd
centile. The mother also says that he has
coughed for the past month. The doctor takes
a full history and completes a physical
examination. She writes SOAP notes in the
patient folder and also writes a summary in
the Health Card.
• A child from a very poor home presents with
scabies at a clinic. His weight is below the 3rd
centile. The mother also says that he has
coughed for the past month. The doctor takes
a full history and completes a physical
examination. She writes SOAP notes in the
patient folder and also writes a summary in
the Health Card.
4. What would be the problem list for
this child?
• Poor social circumstances
• Failure to thrive, with a weight below the 3rd
centile
• Scabies
• Chronic cough
An action plan is needed for each of the
problems. Some problems, like scabies, needs
treatment while others, like the chronic cough,
need investigation. It is important that social
problems are also recorded and addressed
History Taking - Summary
• Personal History: Name, age, sex and address
• Complaint: Main symptom(s) that necessitate
medical advice
• Present History: Onset, course and duration
including medical care given (if any)
• Past History: Perinatal, developmental,
nutritional, vaccinations,….
• Social History: Home and school
• Family History: Consanguinity, siblings,
similar conditions
Thank You