Transcript Pediatrics History Taking & Physical Examination

Pediatrics
History Taking
&
Physical Examination
Bassam Y. Abu-Libdeh, MD
Makassed Hospital
&
Al-Quds Medical School
8/9/2012
‫بسم هللا الرحمن الرحيم‬
Approach
Introduce yourself to patient’s
companion (usually the mother)
 Get the respect of the mother in order
to get the confidence of the child.
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Items of Pediatrics History
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Date of history.
Name of patient.
Informant :- Mother, father, grandmother, school
teacher,…..
Reliability:- Good, fair, poor.
History taken by :- Your name and title.
Patient’s profile:Age (including date of birth)
Sex
Address (usually name of city, town or village).
Referred from …….
7.
Chief complaints:-
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Who is concerned (pt., mother, school teacher...)?
When did you notice that your child has changed?
OR
what he is complaining of?
OR
what do you think he is sick with?
Use, when possible, patient’s or patient’s mother
own words.
Arrange complaints according to significance to
child’ health.
Onset / Course/ Duration of each complaint.
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8. History of present illness:
Start with one of the following sentences:
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The patient was doing well until ……..
The history of this child dates back to…..
The patient was in his usual state of health until…..
Analysis of symptoms respecting the
chronological order of symptoms.
Sequence of events.
Any medical advice sought or any medication
given.
Other associated symptoms.
Pertinent negative symptoms related to the
complaints.
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Important complaints in pediatrics age
group:FEVER.
VOMITING.
DIARRHEA.
ABDOMINAL PAIN.
COUGH.
HEADACHE.
9.
Review of systems :Not important in the pediatrics history if
you ask about:* All the complaints in the history of
present illness in details.
* Complete analysis of each complaint.
* All the pertinent negative symptoms
related to the complaints.
10. Past history
a. Birth history: -
(Especially important during the first 2 years
of life).
▪ Antenatal history:Mother’s health (before & during pregnancy).
(Diseases/infections/Nutritional status).
Medications during pregnancy (timing/dose/duration)
Antenatal care: - booked/ un- booked? , where?
frequency of visits.
(If all well; you may write UNEVETFUL after asking all
the questions)
▪ Natal history:
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Place of delivery.
Mode of delivery: - NSVD, assisted vaginal, C/S.
Gestational age.
Resuscitation
Birth measurements (Wt, Lt, HC)
[average at birth:- Wt = 3.25 kg; Lt = 50 cm; HC = 35 cm]
Apgar Score or condition at birth in mother’s words.
Maternal risk factors for sepsis (PROM, maternal UTI, maternal
fever…)
Baby & mother’s blood groups; Coombs test.
▪ Neonatal history:
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When the baby passed urine/ meconium?
Respiratory distress, anemia, jaundice, cyanosis, convulsions,
infection, congenital anomalies
(If all well; you may write UNEVETFUL after asking all the
questions).
b. Past medical history:
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Major illnesses
Recurrent infections
Hospitalizations
Operations
Accidents/ injuries
Current medications
Drug allergy
(if no known drug allergy, may
write NKDA)
11. Vaccination history
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Place of vaccination
What schedule (Palestinian MOH; UNRWA;
Jerusalem area; private clinic)
Additional vaccines
Always ask for vaccination card.
Any vaccine side effects.
12. Feeding history
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Breast feeding or milk formula.
Type and amount of semisolid/ solid foods,
& when added.
Any vitamin or iron supplementation.
Difficulty encountered during feeding.
Any known food allergy.
13. Growth and developmental history
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Growth is increase in the size of the organ.
Development is increase in the function of the
organ.
Ask about physical growth (Wt., Ht, HC) especially
if records available.
Developmental mile stones.
Gross Motor
Social/Adaptive
Fine Motor
Language/Speech
14. Social history:
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Address, home condition (sunny, ventilation,
rooms…)
Health insurance.
Parental education & occupation.
Family income & socioeconomic status
Smoking at home!!!! (advice against it; negative
smoking is as bad as active one).
15. Family history
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Parental age
consanguinity
Siblings
Ill contact in the family
Similar condition in the family
Family tree.
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16. Adolescent history
[ HEADS history]
Home
Education
Activities
Drugs.
Sexual activity.
PEDIATRICS PHYSICAL
EXAMINATION
1. IMPORTANT HINTS
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Avoid irritating the child and prevent him from crying
(if possible).
Examine the child in the most comfortable way
according to his age (exam table, mother’s hands,
mother’s lap, while playing with a toy, while
nursing…).
Postpone the painful and/or irritating examination
(temp/throat/ears).
2. Vital signs
. Temperature.
. Heart Rate.
. Respiratory Rate.
. Blood Pressure.
. O2 Saturation.
. CR time.
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3. Measurements (Wt, Ht, HC).
Always use growth charts and indicate the
percentiles.
Use appropriate scale for age to measure the
weight.
Naked weight (when possible)
Measure recumbent length till 2 years of age and
then standing length (height) after that.
HC is the occipitofrontal circumference and
measures the circumference passing through the
most distal points on the occiput and the frontal
area.
Stadiometers for Measuring Children and
Adolescents
4. General appearance:-
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State of alertness/ level of consciousness.
Awareness to environment
Facial expression
State of nutrition
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Any special decubitus.
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5. Skin, Hair, and nails
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Skin: - Color, elasticity, texture, rash
Hair: - Texture, color, distribution, areas of hair
loss.
Nails: - Color, texture, shape.
6. Head and neck
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Head: - size, shape, fontanelles, sutures, craniotabes
Face: - shape, complexion (pallor, cyanosis, jaundice),
Edema.
Eyes: - degree of slanting, sclera, eyelids, spacing,
epicanthal folds, palpebral fissure, eyelashes, squint,
sunken, sunset.
Ears: - size, position, deformity, discharge, ext canal &
Tympanic membranes (shape, color, position,light reflex).
Mouth: - mandible, size, lips, tongue, gum, teeth, palate,
Throat and uvula.
Neck: - Length, pulsations, thyroid, webbing, LN,
torticollis.
7. Lymph nodes:. Examine all groups (occipital, cervical, axillary,
groin)
. Size, consistency, matting, attachment to skin,
tenderness.
8. Lungs and thorax
(inspection, palpation, percussion, auscultation).
9. Heart
(inspection, palpation, auscultation).
10. Abdomen and genitalia
. (inspection, palpation, percussion, auscultation).
. Examine for ascites.
11. Back and spine
(inspection and palpation)
12. Extremities
(musculoskeletal, joints, and peripheral vessels)
13. Neurological and psychiatric.