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Basic Pediatrics: Pediatric History 1 of 5

Lecturer: Dr. Matheus


October 7, 2015

Pediatric history can be divided into two parts:


1. regular pediatric history
2. neonatal history 


GENERAL DATA
Format of pediatric history
• name
• age
I. informant and reliability
• especially important because of presence of
II. general data age-specific diseases
III. chief complaint
• Bronchiolitis, for example, is manifested with
IV. history of present illness classic findings of pneumonia, but is only
V. prenatal history observed with children of less than 2 years old
VI. natal/birth history
• sex
VII. neonatal history
• especially important because of some diseases
VIII. nutritional/feeding records with predilection for sex
IX. past medical history
• Nephrotic syndrome, for example, has a male-
X. adolescence ** [HEADSS FIRST] to-female ratio of 2:1, as far as incidence is
XI. immunization hx concerned
XII. developmental milestones
• area that they live in
XIII. social/personal history
• birthplace
XIV. family history
• manner of delivery, birthdate and APGAR (in
XV. systems review neonatal history)
XVI. regional examination
CHIEF COMPLAINT
• defined generally as the mother’s or guardian’s
words as to why the patient was brought for
INFORMANT AND RELIABILITY consultation
• one of the major differences of pediatric history from • at times, during the process of history taking,
adult history examiner will realize what the chief complaint really
• In general, pediatricians acquire info from the is
parents or caregiver and not directly from the child • for example, patient was brought to consultation
unless we are dealing with an older child (e.g. because of convulsion, but upon interview,
adolescent) who can already verbalize what they are informant states patient have had high grade
feeling fever for already a week
• However, even if these are school children, they • [Di ko gets yung point niya, pero strictest
may not be able to relay crucial information such definition is the caregivers’ words why patient
as chronology of events was brought for consultation]
• Clinicians can gauge reliability of the informant after • particularly important here is that we also need to
talking to the informant specify the duration of chief complaint, 

• typically, we give a reliability rating of 75-100% i.e. c/c: fever, for how long?
• realistically, not even a mother can be given a
100% reliability score HISTORY OF PRESENT ILLNESS
• 80% reliability is good enough • defined as a chronology of events from the onset of
• 60% or lower reliability given if informant has signs and symptoms to the time patient was brought
poor or no idea as to what happened to the for consultation
patient. A. Duration or Onset
• take note that in neonatal history,
Sometimes, other people aside from the mother may have chronology is not expressed in number of
a higher reliabity score if these other people are the days PTA (as in our typical HPI)
primary caregivers of the child. e.g. yaya > mother, if yaya • we express neonatal history by stating the
is the primary caregiver day of life from, for example, time of birth
( 1 week ago) to day of onset of symptoms
Diagnosis is based on physical examination and history (3 days of life, 4 days of life, so on and so
80% of the time. The remaining 20% is based on ancillary forth)
procedures and laboratory examinations • crudely put, narrative is inverse to the way
we do it in our typiccal HPI

• neonatal period is within the 1st 28 days of
life; extended neonatal pd is up to 6th wk of
life.

BAHAGHARI ‘15
Basic Pediatrics: Pediatric History 2 of 5
Lecturer: Dr. Matheus
October 7, 2015
D. General trend
B. Intensity and frequency • in the history, it is typical we place
C. Factors that aggravate or relieve the 
 medications, i.e. paracetamol, for fever,
symptoms then subsequently, state “lysis of fever”
• emphasis is put in the characteristics of the • according to lecture, this is not informative
symptoms; for many clinicians because it is already an
• a major mistake is mentioning symptoms expected result, and therefore may not be
without qualifying or characterizing the mentioned in the history
symptom E. Other symptoms
• character of symptoms help us in ruling in
and ruling out differential diagnoses PRENATAL HISTORY
• para and gravida
• mother’s age at time of birth of child
• age may be associated with some congenital
[in-lec examples] anomalies
• wanted/unwanted pregnancy
Characteristics of fever
• consider congential anomalies may be
• low-grade secondary to medications taken by mother
• high-grade • maternal illness/es during pregnancy
• remittent • rubella, during 1st trimester, is a critical risk
• fever that does not disappear, with temp factor for several malformations of the
that is always above normal developing fetus
• cut-off for normal temp is 37.5, according to • drugs taken during pregnancy
IMCI
• exposure to xray, injurious toxins i.e. tobacco smoke
• intermittent and alcohol
• fever that touches normal values within the • term of pregnancy
day, i,.e. 37.2 deg cel, then 37.8 deg cel,
• closely associated to developmental milestones
then 38.5 deg cel, then goes down to 37.1 and growth parameters
deg cel.
• late developers may be associated to pre-term
• on-and-off fever birth; they may just be catching up from delay
• fever on a particular day, disappears, then
another bout of fever the following day NATAL OR BIRTH HISTORY
• spontaneous breathing of patient at birth
Characteristics of abdominal pain: PQRST
• APGAR
P - precipitation
Q - quality
R - radiation
S - severity
T - time

In acute appendicites, for example:


• location: RLQ, or much specifically right iliac
region
• pain however usually starts at epigastric, or
periumbilical area
• with subsequent localization at RLQ
• severity will be described as severe abdominal Some comments for APGAR:
pain with loss of appetite, sometimes • taken twice
associated with vomiting • APGAR score at 1 minute
• pain is continuous • indicates need to resuscitate if APGAR is
low, i.e. APGAR score < 3
For chronic constipators, in contrast, pain is on and • “how well the baby tolerated the birthing
off, and not continuous as with acute appendicitis. process” - accgd to medscape (sobrang
ganda ng source ko, haha)
• APGAR score at 5 minutes
• indicates prognostic value
• low APGAR score may mean baby is
suffering from asphyxia, and that neurologic
problems may follow

BAHAGHARI ‘15
Basic Pediatrics: Pediatric History 3 of 5
Lecturer: Dr. Matheus
October 7, 2015
• “how well the baby is doing outside the • gravida and para
womb” • length of stay in the nursery
• Score of 7 and up is normal • complications: infection, convulsion, jaundice
• Score of 9-10 is excellent • phototherapy done?
• blood transfusion done?
• Mothers are generally not knowleddgeable about • presence of bleeding problems?
APGAR. In order to acquire APGAR during history
taking, ask the ff: NUTRITIONAL AND FEEDING RECORDS
• positive spontaneous cry? • type of feeding
• can you describe to me the color of your baby? • quantity of feeding
• was the baby vigorous? • if bottle-fed infant, ask:
• If APGAR is more or less 9, we can assume good • what type of milk is used
pulse, good grimace • preparation done
• Low APGAR more or less if no cry, bluish baby, limp • proper dilution of milk depends on the
manufacturer of milk
According to the lecture, last to go in the APGAR is the • usually 1 scoop:1 ounce or 1:2
cardiac rate. If only pulsation is present (i.e. bradycardia), • how frequent feeding is
more or less APGAR is 1. If without cardiac rate, then • we expect feeding to be done 8x/day, with a
APGAR is 0. [in-lec] cycle of 2-3 hours, especially in the first
week of life
Pink torso with blue extremities ( Appearance = 1) is also
• small, very frequent feeds
termed as acrocyanosis.
• in order to sterilize bottles once a day,
family needs to have more than 8 bottles,
• birthweight assuming we need to have spare sterilized
• apperance of umbilical cord and placenta bottles
• complications such as cord coil and meconium • introduction of solid food
staining • starts at 6 months
• in times of stress, baby may pass meconium • in order for nutritional history to be
intra-uterine adequate, history needs to be extended up
• the clinician may be able to know if stress is of to present age of the patient
prolonged onset or a recent one by observing • assess for
for a positive stain of the cord: • technique
• if prolonged stress: there is yellow • type of foods
discoloration of cord • adequacy of food/milk intake
• if acute or recent stress: there is positive • let patient have a recall of food taken,
meconium, but no staining of the cord noted and preferred food
• manner of delivery
• was the labor induced? reasons for If this is a bottle-fed child with presenting diarrhea, we
inducement? should be very meticulous as far as nutritonal history is
• NSD? CS? Forceps? Indications for non-NSD concerned. We want to know why there is diarrhea. There
delivery? may be problems in the preparation of milk that can be
• presentation corrected, and thefore preventing subsequent episodes of
• presence of oligo-/poly-hydramnios diarrhea. [in-lec]
• oligohydramnios - deficient amniotic fluid
• may indicate renal agenesis (Potter PAST MEDICAL HISTORY
syndrome)
• look for details of any prior illness and
• premature rupture of membranes hospitalizations
(PROM) A. signs and symptoms if remembered
• polyhydramnios - excessive accumulation B. surgery
of amniotic fluid
• diagnosis
• may indicate intestinal atresia • procedure done
• problems at the level of esophagus • when performed
• complications
NEONATAL HISTORY C. accidents
• part of general history of neonatal hx consist of:
• mother’s name ADOLESCENTS
• baby’s name • use HEADSSFIRST assessment tool
• birth weight • sensitive information may be the ff:
• APGAR • sexual habits
• manner of delivery
BAHAGHARI ‘15
Basic Pediatrics: Pediatric History 4 of 5
Lecturer: Dr. Matheus
October 7, 2015
• contraceptives used FAMILY HISTORY
• pregnancies • parents
• venereal diseases
 • names
• health status
Such information are not easy to collect because this • natural parents?
particular age group has issues about privacy and • occupation/educational attainment
independence. As such, such sensitive information may not • siblings
be given to you during the first meeting. Before attempting • number, age, sex
to get these pieces of information, always establish good • illness (past and present)
rapport. Often, sa next few meetings pa makukuha ang • health status
sensitive info, or basta nakapag-build up ka ng good • others
relationship with your patient. Doc says to emphasize the • history of grandparents
need for this info because they are needed for proper • health history of baby sitters
management of patient’s conditions
Family history should always be tailor-made as with the
particular case of the patient. Fashion history in such a way
IMMUNIZATION information is relevant to the case. For example, if the case
• written immunization records are more reliable than is a communicable disease, ask for history of present
informant’s recall illness of family rather than merely focusing on hereditary
disease such as HTN or DM. I.e. If patient is suffering from
pneumonia, family hx is relevant if we ask about another
family member suffering from respiratory tract infection
(RTI) prior to child’s RTI.

SYSTEMS REVIEW
• pertinent info as regards to per system:
• cardiac: chest pain, easy defatigability, etc.
• respi: apnea, dyspnea, SOB, etc.
• should come from the patient; subjective
• usually done during adult histories
• but not done to all pediatric patients (especially the
very young)
• while children may have these problems
included in the systems review, they may be
unable to verbalize symptoms
• suppose a pediatric patient complains about
dizziness, we are not really certain if it is
dizziness that he or she means
• therefore, we reserve systems reserve for pediatric
patients that are already school age, i.e. 7 years old;
much more so if patients are already in the
adolescent age group.

REGIONAL EXAMINATION
• generally, we do not go from head to foot; as you talk
to the mother, we already do the PE by simply
DEVELOPMENTAL MILESTONES observing the child
• playful touching of the child is already a form of
SOCIAL/PERSONAL HISTORY physical examination
• personality characteristics • a tap on the head is already an assessment of
• personal habits the anterior fontanelle
• feeding • feel for bulge, pulsation, and tension
• sleeping • (Bahaghari: Wait, we’re talking about
• toleting which head again?)
• games • bulge, pulsation and tension may suggest
• cognition (?} meningitis, especially if complaint would be
• sources of support convulsions
• school history • Do inspection first. Do not look at the orifices yet, as
• strengths and weaknesses of child doing so will have you end up having to assess a

BAHAGHARI ‘15
Basic Pediatrics: Pediatric History 5 of 5
Lecturer: Dr. Matheus
October 7, 2015
crying child throughout exam. This makes
auscultation difficult and unreliable.
• calm them down first before proceeding to
assessment if child cries

Chest: 


Inspection
Palpation
Percussion
Auscultation

[in-lec]:
if patient is quiet, go for auscultation before percussion.
Percussion may elicit pain and may therefore cry prior to
auscultation

Abdomen:


Inspection
Auscultation
Percussion
Palpation

• As for neurologic exam, inspection is a strong tool in


pediatric assessment
• In adults, we use series of tests
• CN VII for example is tested by asking
patient to frown, smile, etc.
• In children, we cannot do that.
• We assess CN VII by merely observing the
crying grimace of child
• Patient’s eyes following your movement
across the examining may room will already
help you evaluate CN III, IV, and VI
• Crying with his tongue out helps you
evaluate CN XII
• Crying with uvula going up and down =
CN IX, X
• Crying with lifting of shoulders = CN XI
• Feeding by the bottle with noted swallowing
= CN X
• Sucking motion (i.e. movement of
masseters) = CN V, motor component

Generally speaking, inspection can help us assess cranial


nerve function as far as MOTOR CRANIAL NERVES are
concerned. It’s another story when you assess sensory
components.

Lecture emphasizes neonatal history format is different


from usual format. Neonatal history is a continuous Kindly refer to other sources for more
narration of events from labor of mother, delivery and post- information. Do inform me should you find
natal period errors. Thanks! :D

- END -

BAHAGHARI ‘15