PEDIATRICS 3B
Some viruses have insidious
Dr. Reynaldo de Vega
*** source: MRA trans and recording
All italicized are from the MRA trans
APPLIED LECTURE
PEDIATRIC HISTORY
- More parts than adult history, but in the latter, more papers
are used (past medical history, long HPI, etc)
- shorter HPI – e.g. patient <1 y/o,
INFORMANT AND RELIABILITY
Pediatric age: 18 years old and 364 days, unless married or
pregnant
Informant – anybody who is knowledgeable of the pediatric
case (mother, grandmother, aunt, yaya)
not always enough that the person living with the child  you
may live under the same roof, but you may not know the
history of the patient.
- How will you know if the parent/guardian is reliable?
- What is your test for consistency?  ASSESS
CHRONOLOGIC ORDER. You ask the patient over and
over, and confirm what they have mentioned. If they give the
same answer over and over again, then that makes them a
good informant. (Consistency, Chronology, Confidence)
- When you see a patient at the ER or OPD initially, what is
the first objective?  ALLEVIATE THE MANIFESTATIONS
or the symptoms of the patient (Alert with Verbal response,
Pain, Unresponsive)  you cannot develop rapport with the
patient if he is not feeling well.  while alleviating symptoms,
you talk to the guardian
Reliability – subjective.
≥90% – believable, no need for further questions
<90% – not entirely believable, need to ask more questions
GENERAL DATA
Non-pedia: 19 y/o and above
Name, age, sex, birthday, religion, nationality, place of birth,
present address, number of times admitted, race, date of
admission, occupation (if adolescent and working)
CHIEF COMPLAINT
Exact reason why the patient came in directly from the words
of the informant or the patient  NEVER A DIAGNOSIS
- example: “Doc, may tonsils po ang anak ko”
Response of a doctor should be “Ma’am, lahat po tayo, may
tonsils. Baka po ang ibig nyong sabihin ay tonsillitis. Bakit
nyo po naisip na may tonsillitis ang anak ninyo?”  Possible
chief complaint: Fever, Refusal to feed/suck
HISTORY OF PRESENT ILLNESS
Duration (gano katagal)
Onset (kailan at paano nagsimula  how – acute or
gradual/insidious and when)
- importance of onset: for example, in fever, if the patient’s
temperature is acutely high, then MOST LIKELY, it is viral in
origin. If the fever is insidious or gradual, then MOST LIKELY,
it is bacterial (e.g. pneumonia: starts from low temp to high
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temp). (This is not always true.
onset, some bacteria have acute onset. So use words like,
most likely, most probably, more often than not, usually, etc)
Intensity(severity), Frequency (how often) - if increasing
severity and frequency, request lab exams
Factors That Alleviate Or Aggravate The Symptom
Example: Abdominal pain due to gastric ulcer  eating
alleviates pain
Example: If an abdominal pain is relieved by pressure on the
site of pain, then the pain is most likely secondary to colic or
spastic origin (Parasite – Ascaris  abdominal pain is on and
off, relieved by pressure).
If the abdominal pain is aggravated by pressure on the area,
then the pain is most likely secondary to inflammatory origin
(e.g. peritonitis)
example: what is the most common cause of ileus?
HYPOKALEMIA, secondary to acute gastroenteritis
General trend (are the symptoms improving or not)
Other symptoms (Pertinent negatives  will depend on
what diagnosis you are thinking at the time of history taking.
Example: Acute Gastroenteritis, usually presents with refusal
to feed, vomiting, diarrhea. Pertinent negative include
headache, fever, dizziness, light-headedness, etc.
Example: 10 month old patient, came in due to bulging
fontanelle, and high fever.  consideration is MOST LIKELY,
it is a CNS infection. negative symptoms include
Indications – ask for kind of drugs, duration and dose taken
Precious diagnosis of doctors – do not write the name of
the hospital and doctor. If the patient is a neonate, start the
history from the time of delivery (consider congenital
problem)
PRENATAL HISTORY – covers the pregnancy of the mother
Gravidity – number of pregnancies regardless of viability
Parity – pregnancy that reached 20 weeks (age of viability)
Obstetric Index – Term, Preterm, Abortion, Number of living
children.
Mother’s age at the time of birth of the child – at extremes
of age (<16 and >35)  malformations of the baby, risk of
prematurity, spontaneous abortion, postmaturity, asphyxia,
hypoxia,
Wanted/Unwanted pregnancy – not asked routinely to the
mother  use “planned or unplanned” – usually malformed if
unwanted due to attempted abortion.
Maternal illnesses during pregnancy – German
measles/Rubella – the earlier the trimester, the greater the
chances of congenital malformation; in the third trimester,
less chances of malformation, Chickenpox/Varicella,
Smallpox/Variola, Measles/Rubeola
Herpes – significant during the second and third trimester up
to delivery  predisposes to sepsis if with UTI/ARI
Infection – most common cause of premature labor
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Drugs taken during pregnancy – steroids (can cause cleft
palate), Dilantin (cleft lip and palate), valproic acid (spina
bifida), Thalidomide (Phocomelia – having short limbs;
Amelia – absence of limbs)
Exposure to X-ray, injurious smoking, and alcoholism –
smoking (IUGR, SGA, post-mature, misscarriage),
alcoholism (fetal alcohol syndrome – microcephaly, can
precipitate abortion)
Term of pregnancy –
Preterm: <37 weeks
Full-Term: 37-42 weeks
Post-term: >42 weeks
NATAL/BIRTH HISTORY
- covers the FIRST 24 HOURS OF LIFE
- after 24 hours  neonatal history
Spontaneous Breathing – how long? Was resuscitation
done?
Reasons for delayed/non-spontaneous breathing:
Asphyxiated baby, Airway obstruction, Meconium aspiration,
CNS problem, Mother was given excess anesthesia
- if delayed breathing  hypoxemia  hypoxia  NEC
APGAR score
- to know if there is a need to resuscitate
- the most important is HEART RATE/PULSE
- Interpretation:
<3 – needs resuscitation
4-6 – asphyxiated, observe
>7 – good
Birthweight
- Average birthweight of Filipinos: 3500 g
Cord Coil and Meconium Staining
- Baby is under distress and suffered asphyxia
Cord coil: Umbilical cord coiled around the neck or abdomen
 asphyxia  brain damage  mental retardation
Meconium staining of amniotic fluid  fetal distress,
especially if thickly stained (mild only if lightly stained)
Appearance of the Umbilical Cord and Placenta
- first, describe the SHAPE of the umbilical cord -
cylindrical/rope-like. Gros appearance: gray/grayish-white,
soft and glistening. Cut section: 2 arteries, 1 vein  arteries
have thicker wall, narrow lumen, not collapsed . veins have a
thinner wall, larger lumen, collapsed. FORGET THE COLOR.
- 1 artery, 1 vein  single umbilical artery syndrome 
associated with congenital malformation, affecting the
kidneys  tell the parents to check for the urine output of the
patient, and do routine urinalysis, before sending the patient
home.
Manner of delivery – is it induced?  facilitated delivery
(use of drugs). NSD  normal spontaneous delivery. CS –
Cesarean Section.
Presentation – Most common: Cephalic/Facial/Chin/Brow
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Others: Breech, Shoulder, Footling, Double-footling, Back
Duration of labor – Primigravid: 10-12 hours, Multigravid: 4-
6 hours.
Oligo/Polyhydramnios
NEONATAL HISTORY (>24 hours to 28 days)
Length of stay in NICU – at least 48 hours. If 3-5 day stay,
think of CS delivery. If 1 month stay, think of congenital
problems, or problems during pregnancy/labor
Infection – in first 2 months  sepsis – give antibiotics until
culture is negative
Jaundice – Physiologic: after 24 hours until 5-7 days. If
within first 24 hours, think of HUS  most common cause of
hemolytic disease of the newborn  treatment is
phototherapy, using bililite. Bililite is also used for
hyperbilirubinemia, regardless of age group. If the jaundice
appears in the later weeks of life  neonatal hepatitis,
extrahepatic biliary atresia, breastfeeding jaundice, sepsis
Bleeding problems – earliest clue  bleeding or hematoma
from the site of injection of vitamin K. Acquired prothrombin
complex deficiency  failure to receive vitamin K at birth, and
are common for patients who are purely breastfed 
complications: hematoma and intracranial bleed.
Respiratory problem – Pneumonia – most common
problem. Hyaline membrane disease – lasts 28 days of life,
most common in premature babies. Common cold: 8-10x a
year among the young, 3-5x a year among adults, 2-4 days
in duration.
NUTRITIONAL/FEEDING RECORDS
Type of feeding
Natural Breast feeding
Artificial feeding – any other forms of feeding aside from
breast feeding, including from a dropper, a bottle, through
spoon, OGT, etc.
Mixed feeding – combination of the two
If the patient is bottle-fed - ask what type of milk is being
used, how is it being prepared. If breast feeding, ask the
mother how she prepares her breast before feeding (cleaning
the area of the areola with ordinary bath soap and warm
water)
DON’TS  putting moisturizers in the breast – the patient will
be able to swallow it; also, don’t ALWAYS use soap and
water to clean the breast  soap has drying effect: at the first
cleaning, use soap and water. In the next breast feeding, just
use water. NEVER use alcohol  drying effect, and can
cause cracking of the nipple
Bottle-feeding: example, the patient is 1-month old. What is
the frequency of feeding of a 1-month old? Ideally, the baby
needs to feed 12 times, so you need more than 12 bottles of
milk. How long will you submerge the bottles in boiling water?
15-20 minutes. Never boil rubber nipples/pacifiers – just soak
it in warm water. If you boil it, it becomes jelly.
Introduction of solids – PREFERRABLY 6 months, but you
can start as early as 4 months. (Answer 6 months if asked in
the exam!). Disadvantage of patients given solid foods earlier
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than 6 months  if they become adults, they become picky
eaters, obesity, early manifestations of hypersensitivity
reaction. Tell the mother to watch out for these if she plans
to start early solid food feeding.
Adequacy of food/milk intake – Short term assessment:
The baby sleeps after feeding, gets quiet after feeding, plays,
and smiles. Long term assessment: Weight-gain
Expected Weight Gain
600g for the first 6 months (20g expected wt gain x 30days)
2kg per year for the first 5 years of life
8kg – expected minimum weight of a 1 year old child
Formula:
Age in mo x 600/mo + BW (3000g) – 1st 6 months – 20 g/day
Age in mo x 500/mo + BW (3000g) – next 6 months – 15g/day
Age in years x 2 + 8 if older than 1 year old
PAST MEDICAL HISTORY (same as adult history)
Details of prior illness or hospitalization
Surgery
Allergy
Accidents – appropriate to the age group.
Certain accidents are age-appropriate. Example: 1 year old
who fell from the stairs, and a 10 month old swallowing a
foreign body.
Adolescents – ask about sexual habits, contraceptives,
teenage pregnancies and venereal diseases. Act and speak
with authority, especially when talking about these things. (If
not, the adolescent will think twice about telling you these
things, because it’s as if you know nothing of what they’re
talking about. Others will try to test you). Don’t put malice.
IMMUNIZATION
Know the vaccines that should have been given, and what
vaccines should still be received by the patient
DEVELOPMENTAL MILESTONES
Most awaited milestone: SMILING.
Emphasize on the more important milestones:
Social Smile – 2 months
Vocalization – 2-4 months
Standing – 10 months
Walking – 15 months
Toilet training – 18 months, completed at 3 years
Supine to prone – 7 months
SOCIAL AND PERSONAL HISTORY
Check on the personality characteristics, personal habits,
sleep pattern, feeding pattern, toileting, games and play,
living conditions, sources of financial and psychological
support, school history. In the younger and toddler age
group, focus on the feeding history – what does the patient
like to eat?
Example: The mother is complaining that the patient does not
want to eat vegetables  ask if the people in the household
are eating vegetables too. What type of vegetables are being
prepared? How do you cook the vegetables?
Example: The mother is complaining that the sleeping time
of the patient is at 1 am  ask where do they live, and what
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type of house do they live in (maybe they live in a one-room
house)
FAMILY HISTORY – exactly the same as the adult, except
the history of the caregiver, or anybody directly involved in
taking care of the patient  grandparents, aunts, yayas.
SYSTEMS REVIEW – just like in adult history
REGIONAL EXAMINATION
Inspection, Palpation, Percussion, Auscultation – follow
this sequence as long as the patient is very cooperative. If
not, then there can be variation of this sequence.
Example: 2 year old patient as he entered the OPD started
to cry. He was kicking and struggling. How will you do your
PE? You can still proceed with the PE. You don’t need the
patient to be quiet for inspection. Proceed to palpation – the
head, neck, extremities, axilla, inguinal area, except the
abdomen, which is affected by crying (increased
intraabdominal pressure may give false positive results). You
can also proceed with percussion  you don’t need the
patient to be quiet to elicit dullness, resonance, etc. You can
isolate the sound from crying and the sound you want to hear
from the PE. Auscultation will be difficult. But, with repeated
auscultation to patients, both noisy and quiet ones, you will
be able to differentiate the sounds from the cry from the
breath and heart sounds. If the patient is struggling and
crying, the best PE you can do is the examination of the
ORAL CAVITY – it’s already open, you don’t need to use a
tongue depressor. You can also start PE of the EAR and
other ORIFICES of the body, except the anus – the patient
will cry anyway once you start your exam, so just do it.
Do NOT stop the patient from crying (the more he will cry),
because eventually, he will get TIRED. You can then
examine the abdomen.
If your patient is adolescent, HEADS FFIRST
Home life – space privacy, neighborhood
Education – school transfer, grades after school activities
Abuse – physical, sexual, verbal, emotional
Drugs – includes tobacco and alcohol, age of initiation,
frequency, done alone or in a group
Safety – sports and motor vehicle safety measures,
hazardous activities, sexuality/sexuality identity, reproductive
health issues
Family – family genogram, structure, history of
addiction/alcohol/drug abuse, parenting concerns
Friends – peer group, gang, cult
Image – body perceptions, appearance, fashion trends
Recreation – sports, recreational activities, how often, social
networking
Spirituality and connectedness – faith beliefs, importance
and influence of faith community support
Threats and Violence – self harm or harm to others, running
away, cruelty to animals, fights, arrests, stealing
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