PEDIATRIC HISTORY PHYSICAL DIAGNOSIS ICP II

PART I
Raymond C. Baker, M.D., M.Ed. Professor of Clinical Pediatrics Childrens Hospital Medical Center

I.

INTRODUCTION
A. The pediatric history is similar to the adult medical history in format. It is divided into parts: 1. 2. 3. 4. 5. 6. B. Chief complaint History of the present illness Past medical history Review of systems Family history Psychosocial history (just as in the adult history).

Primary differences of adult history and pediatric history: 1. CONTENT OF MANY PARTS OF THE HISTORY DIFFERS FROM THE ADULT HISTORY a. With the possible exception of the adolescent patient, the pediatric history is seldom obtained in as order a fashion as the adult. Children, whose very nature is to be inquisitive, impulsive and demanding, often set the stage for the history and requires the physician to be PATIENT, FLEXIBLE, AND HAVE A GOOD SENSE OF HUMOR. Focus is on birth, growth, and development of the child.

b.

c.

Primary differences of adult history and pediatric history, contd.

d.

Includes: Prenatal Natal Neonatal history Childhood illnesses/operations Immunizations Nutritional history Growth and developmental history Allergies Medications Recent exposures Psychosocial history (childs place in the family) Behavioral elements of the family including parenting practices and lifestyle

2.

METHODS IN WHICH HISTORY IS OBTAINED a. The patient is usually in the room as the history is being obtained from the parent or other caregiver, so DISTRACTION IS THE RULE. Parts of the history are filled in DURING THE EXAMINATION and the short attention span of the child dictates speed, or more commonly, the distractions of the child cause the physician to forget to ask something which is brought to mind during the examination. Even the most seasoned, experienced physician can fall prey to the charms (and vicissitudes) of children. It is the experienced physician who can accept all of these dimensions of the pediatric interaction and find the humor and enjoyment of the experience.

b.

c.

II.

GROWTH AND DEVELOPMENT

A. Distinguishing hallmarks of pediatrics. 1. 2. 3. Growth = increase in physical size (e.g. weight, height, head circumference). Development = the evolution of function (e.g. developmental milestones). Adults have achieved (presumably) their maximal growth and functional development so that adult medicine is primarily concerned with maintaining that level of achievement, preventing disease, and maintaining good health. By contrast, children are growing and developing, and health maintenance issues change with that growth in size and function. Since the anatomy, physiology, behavior, and pathologic states vary according to age and stage of development in pediatrics, the PEDIATRIC POPULATION can be divided into FOUR AGE GROUPS. Each of these age groups requires special considerations during the course of the history and physical examination. INFANCY EARLY CHILDHOOD LATE CHILDHOOD ADOLESCENT Birth 12 months 1 year 4 years 5 years 12 years 13 years 20 years

III. THE HISTORIAN

A. In pediatrics the history is taken from the parent or guardian, a combination or parent and patient, or the patient and parents separately. 1. The NEWBORN HISTORY is often partially obtained from: a. b. c. The infants chart The mothers prenatal record, and labor record, The newborn discharge summery (which the mother was given at discharge from the hospital). This serves as supplementation to history taken directly from the mother.

Historian, contd.

2.

The INFANCY AND EARLY CHILDHOOD history comes mostly from: a. The parent or guardian. However, even a 3 or 4 year old can give you helpful information in response to questions, such as where does it hurt.

3.

The LATE CHILDHOOD HISTORY is obtained from: a. Both parent and child (the child may be absent for sensitive questions).

4.

The ADOLESCENT HISTORY is usually obtained from: a. b. c. The parents and adolescents together Following a separate one from both the parents and the adolescent. The adolescent should be assured about confidentiality at outset (except issues of life and death).

IV.

TYPES OF HISTORIES
1. The COMPREHENSIVE HISTORY (Initial or Intake History) is taken on the first visit to a new provider and is very complete. The child may be sick or well, although it is preferable that this history be taken as part of well childcare. (The student should learn the items from this type of history as it contains all of the elements in the other types of histories discussed below). E.g. Patient being transferred from another health care provider, newborn 2. The HEALTH SUPERVISION HISTORY (Checkup, Well Child Care, Health Maintenance) is taken on subsequent visits. This is an update of interim history and is less extensive than the initial visit. E.g. Well child visits subsequent to the initial, comprehensive visit. 3. The ILL CHILD HISTORY is taken when an established patient comes in for a specific complaint of illness. E.g. Earache, sore throat

Types of Histories, contd.

4.

The FOLLOW-UP HISTORY is taken when a child comes in following treatment for a specific illness. E.g. Ear infection follow-up to determine resolution of effusion or check hearing

V.

THE SETTING FOR THE HISTORY

A. Occurs most commonly in the exam room (clinic or office) 1. 2. Less than ideal: child usually in the room perhaps with one of more siblings, and often interferes with the process. Physician must recognize that there may be no alternative especially with single mothers of caregivers who bring the child to the physician while the spouse is at work and unable to baby-sit siblings. The physician should sit down facing the parent and maintain eye contact to convey to the parent that the physician is concerned and attending only to the parent and child. The atmosphere of the history should be positive, optimistic, and caring. It is important for the physician to introduce him/herself and meet/acknowledge the child.

3.

4.

VI.

COMPREHENSIVE HISTORY A. IDENTIFYING DATA

Name, nickname, birth date, parents names, (last name may be different), telephone number, (work number), address.

B.

CHIEF COMPLAINT
Why is the patient here? It may be because of childs concern, parents concern, or 3rd party (teacher).

C.

PRESENT ILLNESS
Exploration of the present illness (there may be no specific chief complaint with well child care, but the parent usually has some concerns to discuss which should be explored, similarly) with variations and modifications depending on the childs age. E.g. Severity, length, location, associations, how it affects the child/family, etc.

Comprehensive History, contd.

D.

REVIEW OF SYSTEMS
1. 2. 3. 4. 5. Should be age-appropriate. Should be tailored to the visit. Ask a few global questions in each system. Pursue areas of concern for new visit and well child visits. Important areas to include at all ages are bowel and bladder habits, *feeding, and sleeping habits. **These topics are best to be addressed with the adolescent alone. The following list is not meant to be all-inclusive just some suggestions. All do not need to be included at every encounter.

6.

See chart, next page. **In adolescents, dont forget to include smoking, alcohol, drugs, and sexual activity.

a. b. c.

Skin: Head and Neuro: Eyes:

Rashes, scaling, pruritus, bruising, pigmentation Headaches, vertigo, convulsions, syncope, muscle, weakness, or incoordination Discharge, vision, pain, diplopia, tearing, strabismus, squinting, nystagmus, glasses, distance from TV Hearing, earache, discharge Epistaxis, congestion, discharge Teething, state of dental care, soreness of gums, mouth or throat, hoarseness, stiffness of neck/neck mass Coughing, wheezing, SOB, dyspnea Murmurs, cyanosis, able to run and climb as fast as other children, (if infant how long infant takes to take to bottle) diaphoresis, pain, dyspnea Appetite, food intolerance, excessive crying, pain, nausea, vomiting, character, color and frequency of stools, use of suppositories or laxatives, enemas, encopresis, pica (not equal symbol) edible consider development Frequency, dysuria, polyuria, urgency, hematuria, character of stream, enuresis, discharge, sex instruction (all ages). Proper names: penis, vagina Redness, stiffness, swelling, joints or muscles Seizures, syncope, vertigo, paresthesia, hyperactivity depressions, phobias, nightmare, drug or alcohol abuse, excessive nervousness and/or irritability Tremor, heat or cold intolerance, dryness of skin or hair, polydipsia, polyuria History of anemia, easy bruising, Hob SS

d. e. f.

Ears: Nose: Mouth and Throat:

g. h.

Respiratory: Cardiovascular:

i.

Gastrointestinal:

j.

Genitourinary:

k. l. m.

Musculoskeletal: Neurologic: Psychologic:

n. o.

Endocrine: Hemotology:

EXAMPLE OF AN ABBREVIATED REVIEW OF SYSTEMS

(FOR A 2-WEEK OLD INFANT HEALTH MAINTENANCE VISIT)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. General state of health. Skin: any rashes or spots Head: head size or shape, soft spot. Eyes: vision, discharge, or tearing Ears: hearing, or discharge Nose: discharge, shape. Mouth and Throat: character of cry, spots, or masses Respiratory: cough, SOB Cardiovascular: murmur, how long infant takes to take a bottle Gastrointestinal: excessive crying, vomiting, color and frequency of stools Genitourinary: how many wet diapers, character of urinary stream very important in infancy and early childhood Orthopedic: does infant move all extremities equally well, any swelling. Neurologic: tremors, unusual movements. Psychologic: irritability, ability to self-quiet Endocrine: tremor, heat/cold intolerance, newborn metabolic screen results. Hematologic: anemia, results of hemoglobin screening test at birth

VII.

PAST MEDICAL HISTORY

a. Birth History 1. Particularly important the first 2 years of life. May be important in later years, e.g. if the chief complaint is poor school performance, sudden onset of seizures, or deviant development.

b.

Prenatal History 1. Maternal age, G (gravida status number of pregnancies), P (para status number of viable infants delivered) and A (abortus status number of miscarriages or abortions). E.g. G3P3A0 or G3P2A1 Health of mother, medications or drugs, alcohol or smoking, weight gain, vaginal bleeding, duration of pregnancy, parental attitude regarding pregnancy, and parenthood in general, and this child in particular.

2.

c.

Natal and Neonatal History (first month) 1. 2. 3. Nature of labor and delivery, how long, analgesia used and complications. Birth weight. Apgar score, specific problems such as feeding, jaundice, or more significant problems suck as respiratory distress of congenital defects. Apgar score=2 points for each of the following: heart rate, respiratory rate, muscle tone, reflex irritability, and color. Best score=10. Good screening question for neonatal problems: Did infant go home with the mother?

4.

Since the physician features, physiology, behavior, and pathologic states of the newborn vary, they are further divided.

CLASSSIFICATION OF NEWBORNS
Preterm Term Post term AGA SGA LGA d. e. f. g. Significant illnesses Accidents/Injuries Hospitalizations/Operations Current Health: 1. 2. 3. 4. Should begin with a statement of the childs overall health in the opinion of the parent/caregiver 37 weeks (completed) 37-42 weeks > 42 weeks 10- 90 % < 10 % >90 %

Recent exposure to illness. Medicines (including OTC medications) Allergies: Seasonal or food allergies, drug allergies. Type of reaction and remedy. Immunizations: Get past record when indicated

Past medical history, contd.

h.

Nutritional History 1. 2. Important throughout childhood but particularly first two years of life. Should include exploration of major food groups, likes, dislikes, idiosyncrasies.

i.

Growth 1. 2. Physical growth (actual or approximate weight and height a birth and at 1, 2, 5, and 10 years. Any unusual pattern (slow or rapid). It may be necessary to get records from hospital charts, other physicians, or school.

j.

Developmental Milestones 1. Actual or approximate early major milestones in gross motor, fine motor, speech, and language, and personal/social development. Present state of development in these areas. If the child is school age, school performance and childs relationship to family and peers.

2. k.

Screening Procedures 1. 2. These include screening at birth for metabolic disease, hemoglobinopathies, and hearing test. Some routine screening procedures throughout childhood, vision, hearing, tuberculin test, (when indicated), lead test, and hematocrit.

VIII.

PSYCHOSOCIAL HISTORY
a. b. c. d. Parents age, health, education, and job history; siblings age and heath. Type of dwelling, parent work schedules and work type, family support available from relatives, neighbors, and friends. Is anyone else living with the family? Siblings reaction if a new baby in the family. Parents relationship to family members and peers.

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e. f. g.

Safety issues should be age appropriate. Always ask about motor vehicle safety, cigarette smoking the home, smoke alarms. Exposure to object of domestic violence.

IX.

FAMILIAL DISEASES, PEDIGREE

Allergies Anemia/Bleeding Arthritis Cancer Congenital Defects Convulsions/Migraine Diabetes Mellitus Early Cardiovascular Events GI/Liver HIV Infection Hypertension Lung/TB Renal/Enuresis Thyroid Disease Vision/Hearing Other

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