oa GUIDE FOR on HISTORY TAKING, ENRICO EXAMINATION & DIAGNOSIS OF PEDIATRIC PATIENTS : THIRD EDITION d Ze Oa Vv a ecu ee O) au Bi Pee aL @ny FACULTY OF MEDICINE AND SURGERY UNIVERSITY OF SANTO TOMASUNIVERSITY OF SANTO TOMAS FACULTY OF MEDICINE AND SURGERY DEPARTMENT OF PEDIATRICS GUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS (THIRD EDITION) 2013Philippine Copyright@ 2006, 2009,2013 by the Department of Pediatrics, UST Faculty of Medicine and Surgery All rights reserved. No part of this book may be reproduced without the written permission of the copyright holders. Layout and printing by: IES COPY AND PRINTSHOP ~y Oop ope ™ Se eo my mnIn the midst of computerization, we believe that this handbook has its niche in the medical practice. We dedicate this handbook, To All our STUDENTS - the future physicians To All our TEACHERS - the experts in pediatrics, Our inspiration and role models And To the CHILD, our patient and friend - who deserves extra special care because _ -he is not just a miniature adult. '* i 3 The Staff of the Department of Pediatrics a UST Faculty of Medicine and Surgery University of Santo Tomas Hospital 2 2013 22FOREWORD The medical field has been bombarded with a lot of new modalities in the diagnosis and treatment of diseases. Ithas come so fast that literally pushing a button or tapping computer keys would lead one to correct diagnosis and be exposed to a gamut of “How to manage, how to treat, and many similar leads.” As physicians in an under-developed country, we should be more than button-pushers or key-tappers. We should continue to be thinkers or even students of Medicine. We have to make use of our brain and not over-use our fingers. This handbook, the 3" edition aims to do just that - equip the student with the basics and enable them to reach a correct diagnosis using a systematic approach. Additional illustrations were included for easier reference. In this issue, we also included the examination of the critically ill patients. We hope to prepare our younger colleagues in the recognition ofa critical ill childand his problems in the midst of intensive care set-up in most hospitals. Let me express my gratitude to the Chairman of the Department of Pediatrics, Dr. Melinda M. Atienza for believing in this project. 1 am also grateful to the members of the editorial board who have painstakingly reviewed and revised the topics, as well as all the members of the department who have shared their opinions and ideas, I am grateful to the chief resident, all the residents and fellows in training who have helped us the in the printing and publication. I thank our clerk-secretary, Ms Rhenalyn Emata for assisting us in the manuscript and Drs. Dean Dimaano and Hazel David for the cover layout. To all physicians, trainees and students and our dear patients who have helped us achieve our goal, our sincerest thanks. ROF. ROSALINA Q. DE SAGUN, M.D. Chairman, Department of Pediatrics 2002-2008 Head, Editorial Board iv ms = Tat = m= = oe ™EDITORIAL BOARD Melinda M. Atienza, M.D.,MHPed, FPPS, FPSPME Associate Professor and Chairman, UST Department of Pediatrics Section Chief, Section of Endocrinology Agnes G. Andaya, M.D.,FPPS, FPSAAI Professor, Department of Pediatrics Section Chief, Allergology and Immunology Aurora F. Bauzon, M.D.,MSPH, FPPS Professor, UST Pediatrics Christine B. Bernal,M.D., FPPS Instructor, Departments of Pediatrics and Internal Medicine Section Chief, Pediatric Rheumatology Rosalia M. Buzon, M.D., FPPS, FPAM Professor, Department of Pediatrics Section Chief, Ambulatory Pediatrics Rebecca A. Castro, M.D., FPPS, FPSPGN, FPGS Professor, UST Departments of Preventive, Family and Community Medicine and Pediatrics Section Chief, Pediatric Gastroenterology and Nutrition Remedios D. Chan, M.D.,MPHed, FPPS, FPSPGN Professor, Departments of Pediatrics and Physiology Chair, Department of Pediatrics, UST HospitalRosalina Q. De Sagun, M.D., FPPS, FPNA, FCNSP Professor, Departments of Pediatrics and Neurology and Psychiatry Section Chief, Child Neurology Dean Dimaano, M.D. Chief Resident, UST Hospital Department of Pediatrics Josie Niu-Kho, M.D., FPPS, FPSNbM Associate Professor, Department of Pediatrics Agnes Cecille G. Llamas, M.D., FPPS, DAAP Associate Professor, UST Departments of Pharmacology and Pediatrics Maria Philomena G. Lopez, M.D., FPPS Professor, Department of Pediatrics Miguel L. Noche, Jr.,M.D. FPPS, FPSAAI, FAAP Ret. Professor, Department of Pediatrics Member;Professional Regulatory Board of Medicine Remedios Ong, M.D., DPPS, FPSAAI, DABP, ABAI Professor, Departments of Pediatrics and Pharmacology Rhandy Pe Benito, M.D., FPPS, FCNSP, FPNA, FAAP,FAAN Professorial lecturer, Department of Pediatrics, Neurology and Psychiatry Maria Louisa U. Peralta, M.D., FPPS Professor, Departments of Preventive, Family and Community Medicine and Pediatrics Section Chief, Critical Care wi =m = Mm PeAgnes Mary S. Regal, M.D, MPH, Msc, FPPS Professor, Departments of Preventive, Family and Community Medicine and Pediatrics Eustacia M .Rigor, M.D. FPPS Former Dean of the Faculty of Medicine and Surgery And Chair, Department of Pediatrics Edwin Rodriguez, M.D., FPPS, FPSHBT Associate Professor Departments of Pharmacology and Pediatrics Maria Noemi T. Salazar, M.D. FPPS, FPSDBP Associate Professor, Department of Pediatrics Section Chief, Developmental Pediatrics Wilfredo Santos, M.D., FPPS, FPSNbM Asst. Professor, Departments of Preventive , Family and Community Medicine and Pediatrics Carole Lisa C. Sibulo, M.D., FPPS, FPAPP Associate Professor 3, Departments of Physiology and Pediatrics Rolando S. Songco, M.D.,FPPS(deceased) Former Professor, Department of Pediatrics, University of Santo Tomas and University of the East. Chairman Emeritus, Department of Pediatrics, Hospital of the Infant Jesus Ma. Antonia M. Valencia, M.D., FPPS, FPNA, FCNSP Instructor, Departments of Pediatrics and Neurology and Psychiatry ViiCONTRIBUTORS Atienza, Melinda M. Andaya, Agnes G. Bauzon, Aurora F. Bernal Christine Buzon, Rosalia M. Canonigo, Beatrice Cabansag, Rose F Castro, Rebecca Chan, Antonio Chan, Remedios Chiong, Mary Ann Co, Benjamin, Cuaso, Charles, De Leon, Ma.Rhodora Deniega, Lester De Sagun, Rosalina Go, Olivia Hernandez, Emilio Jr. Hernandez, Flerida Kho, Josie Llamas, Agnes G. Lopez, Ma. Philomena G. Olonan, Leoncia Ong, Remedios Peralta, Ma. Louisa Pe Benito, Rhandy Rodriguez, Edwin Rivera, Clara Salazar, Ma. Noemi Santos, Wilfredo, Sibulo, Ma.Carole Lisa Sy, Dolores Valencia, MA. Aurora Villar, Estrella P. Vill mom foal momo = ~ ny moneyPREFACE It is most inspiring and commendable for the Department of Pediatrics to have one of its academic activities, the publication with regular revisions of a Handbook on the Guide to History Taking and Physical Examination. The priceless clinical tools, the fundamentals in making proper diagnosis in many situations will help in the selection of needed confirmatory diagnostic tool/s especially in this era of rapid advancing technology. I congratulate the Department of Pediatrics staff, the editorial Board, the contributors, led by Rosalina Q. De Sagun, M.D., over- all Head, Editorial Board and Committee on Revision and Chairperson, Department of Pediatrics, 2002-2008 and Melinda M. Atienza, M.D., Chairperson, Department of Pediatrics, for this worthy academicaccomplishment. a a EUSTACIA M. RIGOR, M.D. Professor Emeritus Chairperson, Department of Pediatrics, 1984-1993 Dean, Faculty of Medicine and Surgery University of Santo Tomas, 1989-1992PREFACE In 1910, more than 100 years ago, Flexner introduced a curriculum that shaped health science education in the world. This report paved the way to a science-based traditional curriculum. Since then, the curriculum has evolved to become integrated, community-based, and problem-based. With these curriculum changes “mismatch of professional competencies to patient and population priorities emerged because of fragmentary, outdated and static curricula producing ill- equipped graduates from underfinanced institutions". This was the conclusion made by the Commission on Education of health professionals for the 21st century launched in January, 2010 (Lancet Commission Report). This dysfunctional education system, according to the report, has an effect on the functioning ofthe health system, and consequently, patient care. The Philippines has to address the local crisis in health care delivery. The core of health science education, including medical education, stems from a dynamic health system that responds to the needs of the Filipino people. The Lancet Commission has made a worldwide call for transformative curriculum that promotes interprofessional and intraprofessional education as well as professionalism. The Commission on Higher Education is currently preparing to respond to this call. Transformative education, a system-based curriculum, adopts a competency -based curriculum which is an outcome-based education. The outcomes are measurable behaviors or performance such as tests, observations and simulation performance. With these behaviors, based from the samples of case modules/ outcomes of the system, the learners shall be able to “identify / obtain critical physical examination’, " describe the purpose and implications of each of the items in the clinical history “ and “ provide a prioritized differential diagnosis”, among others. These serve to emphasize the critical role of a clinical history, pertinent physical examination and "prioritized” differential diagnosis, all necessary for the clinical impression, whichis essential for appropriate management ofa patient. im PL et eel Par= = Evidently, even if the curriculum in medical education has evolved to become transformative / outcome- based education, data gathering and a "prioritized differential diagnosis” remain important in the care of patients. In this context, I congratulate the conscious effort of the UST Department of Pediatrics to inculcate and develop the most basic and practical skills in arriving at a correct diagnosis. This, they achieve, by publishing and updating this handbook, and makingit easily available to all. I salute Professor Rosalina Quimpo-de Sagun and all the faculty contributors for this pioneering Herculean effortto come up with this publication. The leaders in the department of the medical school and of the hospital have to be recognized : Professors Melinda Millares-Atienza and Remedios Dee-Chan , for their inspiration , monitoring and guidance in the preparation of this handbook. All of your hard work will surely immortalize the legacy of a proper history and accurate physical examination and a logical approach to the diagnosis in this handbook. This process is unique to the UST Department of Pediatrics initiated by Professor Renato Ma. Guerrero carried on by Professor Rolando S. Songco and all the faculty members over the years ! LA Wee PROF. MIGUEL L. NOCHE, JR., M.D Chairman, 1997-2002 UST, Department of Pediatrics xiPREFACE The practice of pediatrics must be based on a strong foundation of fundamentals in the undergraduate curriculum. This link cannot be overemphasized especially since pediatrics is a highly specialized discipline where cues and clues are not obvious and hence requires both knowledge and skills to identify, interpret and correlate medical evidence with appropriate conclusion. The latest revision of handbook “Guide for History Taking, Physical Examination and Diagnosis for Pediatric Patients” was intended to strengthen the art and science of pediatrics in the undergraduate and post graduate medical curriculum. This handbook is to be used as an “aid” in the constructive and collaborative learning of history- taking and physical examination in pediatric patients as well as a quick “reference” in the recognition and application of appropriate diagnosticprocedures requested in common pediatric disorders. The handbook still contains the basic and must-know information on steps involving accurate history-taking and physical examination presented in “learner-friendly” compartments to facilitate understanding, analysis and application. Diagnostics procedures are briefly described including common indications, contraindications and complications. The Department of Pediatrics is grateful to the initiative of its teaching faculty especially led by its Immediate Past Chairperson, Professor Rosalina Quimpo-de Sagun for steering clear the direction and eventual publication of this material. Likewise, the support staff and pediatric residents of the USTH Hospital deserve equal appreciation. The Department of Pediatrics sincerely wishes that all medical learners of different ages use this handbook as a constant companion in their lifelong learning as a medical practitioners and child health advocates. ann MELINDA MILLAR Chairman Department of Pediatrics Faculty of Medicine and Surgery University of Santo Tomas -ATIENZA, MD, MHPEd XI myPREFACE It is known that a physician's ability to obtain a thorough and accurate history and physical examination deepens patient- physician relationships, improves clinical assessment leading to healing and better child care. In 2005, the” Guide for History Taking, Physical Examination and Diagnosis of Pediatric Patients” was published to serve as a valuable reference mainly for medical students. Through the years and after two editions, the handbook also gained wide usage among pediatric interns, aspiring residents and fellows-in-training and pediatric colleagues who needed a quick reference on the correct techniques of physical examination and history-taking, Allow me to extend my felicitations to the UST FMS Department of Pediatrics under the chairmanship of Dr. Melinda M. Atienza, and to Dr. Rosalina Q. De Sagun, Head of the Editorial Board on the revision of the department's handbook, for undertaking the 3rd edition of “Guide for History Taking, Physical Examination and Diagnosis of Pediatric Patients’. With the current updated version, I am confident that this handbook will have a broader and more popular following. — PROF. REMEDIOS DEE-CHAN, M.D. MHPEd Chairman Department of Pediatrics UST Hospital xaTABLE OF CONTENTS Vi. Vil. History Taking.. Physical Examination... ofthe NewlyBorn... Infants and Newborn.. Examination of the Critically Il] Child. Technique in Diagnosis.. Common Pediatric Procedures...... 11 History and Physical Examination 45 Neurologic Examination of the Older child, 63 88 99) 106 VII. Appendix Normal Values of commonlyused tests... 131 Food Exchange of Common Foods... 143 Actual CaloricIntake-Sample Calculation... 143 Recommended Energy and NutrientIntake (REND... Feeding History. Sample Chart. 144 145 148 Developmental Checklist. 149 Denver Developmental Screening Test (DDST).. 152 Red Flags for Developmental Delay. ve Primitive and Developmental Reflexes, Normal Dental Development. And pathological. oe 156 Glasgow Coma Scale in Children. 158 WHO Growth Chartsand instruction foruse.... 159 Tanner's Sexual Maturity Rating (SMR).... 182 Breast Self-Examination.... 184 Blood Pressure Levels in Children 185 Lubchengco Chart. xIV» u | au YI HisToRY TaKNG HISTORY TAKING The mark of an excellent physician is the proficiency with which he takes the ‘history and performs the physical examination and then on the basis of the findings utilizes the laboratory accurately and cost-effectively, when necessary, to approach a final diagnosis and initiate effective therapy. An adequate history is essential for the physician to make a correct diagnosis. To obtain a complete history with data properly recorded chronologically and in appropriate detail is anart whichis acquired only with patience and experience. Children are not miniature adults as such the history taking in pediatric patients is unique and distinctive for the following reasons: 1) Content Variations: a) Prenatal and birth history b) Developmental history c) Social history of family -environmental risks d) Immunization History e) Feeding History 2) Indirect source of clinical information commonly given by Parents a) parent's interpretation of clinical features may affect accuracy of data b) reliability of parent's observation varies ¢) parental behaviors/emotions are important Some basic concepts in obtaining a very good clinical history of the patient: e Go after the symptoms like a ‘hound dog’ and pursue the symptom relentlessly - Failure to keep ‘on track’ lead to error in diagnosis and unnecessary laboratory procedures « DON'Taccept the diagnosis given by parents but pursue the clinical features that enable parents to reach such conclusionGUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS. + Keep an open mind and follow the scent (clue) like an expert detective. + Be flexible in your approach to obtain clinical data especially at the ER or during acute office visit + Start interview with parents or guardians in a positive note since first contact is the most important connection. HISTORY The historian should realize that the information ina pediatric history is usually from a person other than the patient himself. Therefore, it is up to historian to evaluate the accuracy and relevance of the data given by the informant. a General Data Name; age (birth date); sex; race (ethnicity); birthplace; religion; present address; number and date of hospital admissions; name of informantand relation to patient; reliability of informant should be stated; if possible qualify in percentage (%). This should be assessed at the end of history taking. Reliability of the informant depends on the following factors: (1) Relationship of the informantto the patient; (2) Number of hours informant stays with the patient; (3) educational attainment of the informant; (4) involvement of the informant in the care of the patient. 2. ChiefComplaint The answer to the question "why was the patient brought to the hospital?" expressed in a word or two without describing or qualifying the reply. This may be a single symptom or group of related symptoms; this should not include diagnostic terms or names of diseases; the duration of the symptom may also be mentioned. For OPD patients, one may write for follow-up, CP clearance, well baby care or immunization. *Give the exact words of the informant whenever possible.ee ee ee =a & i mS Gy iy i History Tak History of the Present Illness (HPI): Inquiry as to the HPI should be conducted as follows: A The signs and symptoms should be describedin chronological order, from the start of the illness, with appropriate paragraphing and underlining for emphasis so that the reader may obtain the maximum information in minimum reading time. Use specific number of hours or days or weeks or months, not "last Monday," or "a few weeks ago" for the time of onset. In case of chronic illnesses, state also the date and age at onset. *Ifthe patientis anewborn and/or the present problems are related to the prenatal and perinatal period, the maternal and birth history should be incorporated inthe HPI. Elaborate on the symptoms as to: onset (acute or chronic) intensity of symptoms: how severe the pain is and whether it interferes with activity, its quality, location, duration, extent, severity and frequency; factors that aggravate/relieve the main symptoms, medications (generic and brand names) including actual dose (in mg/kg/day or mg/kg/dose) and duration of treatment; *Brand name of the drugs should be written in parenthesis; Include any outside medical treatment, consultations or hospitalization. Find out where the child is getting their medical care prior to visit and the reason for change. associated symptoms must be described as to: onset, course, chronology, intensity.(GUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS. Ifthe history suggests a particular disease, inquire about signs and symptoms characteristic of this disease. Pertinent negatives are of value in the differential diagnosis. Re-admissions: if previously admitted to this hospital or had Out- Patient Department consultations, obtain these records from the hospital and summarize. Records of any admission to other hospitals should also be obtained and summarized. If these previous hospital admissions appear related to the HPI. summarize the pertinent information (including pertinent laboratory date, final diagnosis); following this comes the Interval History which describes the course of illness since the last hospital admissions related to the present illness and then elaborate of the present symptom(s) and its associated manifestations on this admission. These will all now constitute the HPI. Previous admissions not related to the HPI are placed under Past Illnesses. “If the previous admissions are related to the present illness, these should be written in the first paragraph of the HPI. Based on the History of the Present Illness, the physician should already have an initial impression and differential diagnosis. IV. Review of Systems: This is as elaboration of data in systems not covered in the history of the present illnesses. This will help uncover symptoms in other organs or systems that may be related to the present illness. *Ask only symptoms applicable to the age of the patient General: Weight loss/ gain; activity level; appetite; delay in growth Cutaneous: rash; pigmentation; hair loss; acne; pruritus Head: (include eyes, ears, nose, mouth and throat): headache; dizziness; visual difficulty, lacrimation; hearing; aural discharge, nasal discharge; epistaxis; toothache, salivation: sore throat. Cardiovascular: orthopnea: cyanosis; easy fatigability; fainting spells; etc. a mom H* PH) al am,‘a History Tans Respiratory: chest pain; cough; difficulty of breathing Gastrointestinal: vomiting; bowel movements- diarrhea, constipation; encopresis; passage of worms; abdominal pain; jaundice; food intolerance; pica Genitourinary: color of urine; burning sensation; frequency; discharge; enuresis;, edema of hands and feet; in prepubertal female: ask about discharge and itching; in pubertal and adolescent female-_ get history of menstrual periods (onset, frequency, regularity, pain), date of last period. Endocrine: breast asymmetry, pain or discharge; palpitations; cold/heat intolerance; polyuria, polydipsia, polyphagia Nervous/ Behavioral: tremors; sleep problems; convulsions; weakness or paralysis; mental deterioration; personality or behavioral changes; memory loss; eating problems, school failures; mood changes; temper outbursts; hallucinations Musculoskeletal: pain in bone, joint of muscle; swelling in bone, joint or muscle; limitation of motion; stiffness, limping Hematopoietic: pallor; bleeding manifestation; easy bruisability Personal History: a. Gestational History: age of mother during pregnancy, her parity, health, nutrition, infections, intake of drugs, roentgen exposure, etc; duration of gestation (when pertinent, especially in infants). b. Birth: term or premature or post mature; manner of delivery; persons who attended the delivery; birth weight (especially in infants, or when pertinent). c. Neonatal History: APGAR SCORE: spontaneous respiration or required resuscitation; cyanosis, pallor; cry; jaundice (age of onset); convulsions; hemorrhage; respiratory or feeding difficulties, congenitalas (GUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS birth injury (especially in iia or when pertinent). Neonatal History: APGAR SCORE: spontaneous respiration or required resuscitation; cyanosis, pallor; cry; jaundice (age of onset); convulsions; hemorrhage; respiratory or feeding difficulties, congenital abnormalities, birth injury (especially in infants, or when pertinent). *The gestational, birth and neonatal histories should be included only in patients <2 y/o and ifrelated to the illness for children >2 y/o. d. Feeding history: Infancy (<2 y/o): i. Type of feeding: breastfeeding: exclusive or mixed; how many times per day; how long each breast; if not breastfeeding, give reason: formula used, dilution and amount given per day, bottle feeding or cup feeding; ii. Complementary foods: age introduced, foods initially and subsequently introduced, consistency of food (pureed, soft, lumpy, table foods); frequency of feeding per day; iii, Usual food intake for breakfast, lunch, dinner, snacks (am, pm); iv. Assess if the five basic food groups (cereals,/rice, fruits, vegetables (leafy, non-leafy & yellow vegetable, meat/fish/chicken, beans/egg, milk, oil/sugar) are eaten daily; iv. Compute for actual caloric intake (ACI) and compare with Recommended Energy & Nutrient Intake (RENI) or compare both the amountand quality of food intake with the food guide pyramid; v. Food intolerance; vi. Multivitamin and iron supplements: dosage, frequency; rm ‘hel ~-~ = 7 = A= ~~ £iw i History Tang vii. Caregiver: mother, household help, grandparents, siblings. Childhood and Adolescents (2-20 years): Omit early.feeding history unless it is pertinent to the present illness. Assess: i. Appetite: good appetite, picky eater; ii. Usual food intake and amount per day for breakfast, lunch, dinner, snacks (am, pm); iii. Assess if the five basic food groups (cereals, rice, fruits, vegetables (leafy, non-leafy & yellow vegetable), meat, fish, chicken, beans, egg, milk, fats, sugar are eaten daily; iv. Compute for the actual caloric intake (ACI) and compare ACI with the Recommended Energy Nutrient Intake (RENI) or compare both the amount & quality of food intake with the Food guide pyramid; iv. Food likes or dislikes; feeding difficulties. v. Multivitamins & iron supplements: dosage & frequency. (See Appendix for food exchange list and sample calculation, RENI,andamore detailed sample chart for patients with nutritional problems). . e. Development / Behavioral History: 1) Young Children (1-5 years): Inquire about the 1. development using the Modified Developmental Checklist; ii. Dental eruption; iii other behavioral problems: urinary continence, during day and night; toilet training, started and completed; temper tantrums; head banging; phobias; pica; night terrors; sleep disturbances. * If there are indications of Developmental Delay, DO more detailed developmental tests as Denver Developmental Screening Test II (DDST). See Appendix.GUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEOIATRIC PATIENTS. 2) Middle Childhood (6-11 years); Inquire about school performance, And sexual development using Tanner's & Maturity Rating. (See Appendix) be 3) Adolescence (10-20 years): E i, HEADS/S/FIRST: Inquire about: E + Home-Space, privacy, frequent geographic moves, neighborhood. E + Education/School- frequent school changes, repetition of a grade/in each subject, teacher's E reports, vocational goals, after-school educational clubs (language, speech, math, ), learning £ disabilities.( Eating behavior or habits) + Abuse- Physical, sexual, emotional, verbal abuse; t parental discipline + — Drugs- tobacco, alcohol, marihuana, inhalants, ‘club £ drugs”, “rave” parties, others. Drug of choice, age at initiation, frequency, mode of intake, rituals, alone £ with peers, quit methods number ofattempts. + — Safety - Seat belt, helmets, sports safety measures, f hazardous activities, driving while intoxicated. (Suicidal attempts /ideation). t + Sexuality/Sexual identity- Reproductive health (use of contraceptives, presence of sexually transmitted f disease, feelings, pregnancy). + Family/Friends- Family-family constellation, £ genogram single/married/separated/divorced/ blended family, family occupations and shift; £ history of addiction in 1" and 2™-degree relatives, parental attitude toward alcohol and drugs, F parental rules, chronically ill, physical or mentally challenged parent. fi Friends-peer cliques and configuration (‘preppies’, "jocks", “nerds”, “computer geeks’, cheerleaders), gang /cult affiliation. rm + Image- Height and weight perceptions, body ' musculature and physique, appearance (including dress, jewelry, tattoos, body piercing as fashion fi trends or other statement) + Recreation-Sleep, exercise, organized or unstructured sports, recreational activities E (television, video games, computer games, internetee ae ee er ee Hisroay TAKNe and chat rooms, church or community youth group activities . How many hours per day, days per week involved. + Spirituality & Connectedness- Hope or security for the future; organized religion; personal spirituality and practices; effects on medical care and end of life issue involvement. + Threats & violence- self-harm or harm to others, running away, cruelty to animals, guns, fights, arrest, stealing, fire setting, fightin school. (Nelson Textbook of Pediatrics 19" Edition Table 111-3pp.819) ii. For female: Include Menstrual History and self- breast examination ifdone. f. Past illnesses: (state age when contracted; severity; complications) 1. Contagious diseases: measles, varicella, mumps, pertussis, etc. *Describe the clinical course of the illness. 2. Other medical illnesses: hospitalized? If so, where and for how long? 3. Operations: surgical condition, type and place of operation 4. Allergy, eczema, asthma, food or drug itivities, etc. : include effects if any (verify accuracy of diagnosis by inquiring into signs, symptoms, course of illness). Vi- Immunization History and Tuberculin Test: Include types of immunizations given, including ages when given, place (health center, doctor's clinic,) where given and untoward reactions. Vil - Family History Parents: age, occupation, state of physical and mental health; if not living- age of death, cause and nature of symptoms, history of consanguinity. Siblings: number, ages, state of health; if not living- age of death and cause.(GUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS Familial illness or anomalies: tuberculosis (state contact with patient); diabetes mellitus, syphilis, cancer, epilepsy, rheumatic fever, allergy, hereditary hematological disorders, mental retardation, congenital defects, etc. (verify accuracy of diagnosis by inquiring into signs, symptoms, course, sequelae and treatment given); presence of illness similar to patient's illness in other members of the family or household, family pedigree - if a genetic anomaly is suspected. VIII - Socioeconomic History: Living Circumstances: place and nature of dwelling, number of persons living in the house. Economic circumstances: members of family who work, sources of funds iX - Environmental History: Environmental circumstances: |. exposure to cigarette smoke and other environmental pollutants (*include what pollutants and the duration of exposure); ii. Garbage disposal ( segregation, recycling); iii, Sewage disposal; iv. Water source; drinking, washing. fal Flea!Ca Ue PHYSICAL ExanansiOn PHYSICAL EXAMINATION A good and complete PE largely depends on the approach of the examiner. The usual order in the examination of adults is not often appropriate for young children. In general, itis best to leave the more unpleasant or uncomfortable parts of the PE last. The clinician has to be adaptive to the various situations and circumstances surrounding the examination and yet dothorough examinations, i.e., auscultate the heart and lungs while patient is asleep and inspect throat when patient is crying. The patient is best examined with the minimum of clothing on. Anyone examining a pediatric patient should learn the art of playful interactions and distractions to allay anxiety of the child and to facilitate the examination. Infants and young children can be carried by their caretaker or parent while being examined. In uncooperative patients, the physician should properly immobilize the patient so that certain procedures can be carried outsafely. a. General Survey: Take note of the following: « mental state or sensorium, level of activity + presence of cardiopulmonary distress or not, color e ambulatory or bedridden ¢ nutritional state (well, under, or over nourished) * state of hydration «ill looking * Refer to Table 1, Acute Illness Observational Scale to help determine quickly & more objectively whether the child is well, mildly ill or severely ill. b. Vital Signs: Temperature (T2C), Cardiac Rate (CR)/Pulse Rate (PR), Respiratory rate (RR), Blood Pressure (BP) if >3 yo. + CRand RR should be correlated to the condition in which they were taken to be considered clinically significant, ie, was the child quiet, asleep, active, febrile (~ 5-7 breaths increase/min/2C > 37°C), crying and struggling etc. The ratio of RR to CR is about 1:4. Refer to Table 2 for changes in RRs and corresponsive Clinical implications. 41‘GUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS Table 1. Acute Illness Observational Scale: Nelson Textbook of Pediatrics 18" ed., 2007, p 364 Observation | Normal (NL) Moderate Severe impairment item impairment 1.Quality of | Strong withNL | Whimpering O | Weak Oo cry tone or Or Or Sobbing O | Moaning ao Content & not or crying High pitched 2.Reaction to | Criesbriefly then | Criesoff&on 0 | Continualery 0 parent stops o Or stimulation or Hardly responds 0 Content & not crying 3. State If awake, stays | Eyesclose briefly | Willnot rouse O variation awake O | thenawakes O Or Or Or Fallstosleep 0 Ifasleep & Awakens with stimulated, then | prolonged wakes up stimulation O quickly 4.Color Pink o Pale hands, Pale oO feet Or or Blue Qo Acrocyanosis O | Or Ashen (gray) O Or Mottled o S.Hydration | SkinNL&eyes, | Skin,eyesNL& — | Skin doughy or mouth moist | mouthslightly | tented & eyes may be dry O | sunken & dry eyes & Capillary time mouth O refill (CRT)<2 | CRT2-3sec O | CRT>3sec O seconds Oo 6 Response | Smiles O | BriefSmile O | Nosmile, face O to social or or anxious overtures | alerts O | alertsbriely O | or dull, (s2mo) expressionless O Noalerting 0 + Oral T°C should not be taken in children who are too young and/or are unable to understand instructions. Axillary T2Cs are safer to obtain and are usually 0.5°C lower than oral TSC. Aural or rectal T°C can also be obtained. However, never insert rectal thermometer into an infant who can sit up on his own, especially if it is made of glass with mercury content. 12 PP ele! heal!” ntl! el le ThPasion EXnaonATION Table 2. Changes in RR and corresponding clinical ‘tions. Characteristics | Clinical implications _ “a Bradypnea | RR slower than rologic or electrolyte = normal _ | disturbance, infection or a sensible response to protect against pain as mi — in pleurisy 2 Tachypnea | Fastrespiration | Anemia, exertion, — intoxication, 7 anxiety =a \Hyperpnea | Deep breathing | Exercise, tachypnea, CNS & L.. metabolic diseases _ ea] Kussmaul | Deep & rapid | Metabolic acidosis breathing | breathing rat + The pulse can be described based on: rate (per min), rhythm (regular vs irregular) & volume (full, weak, mn thready or compressible). ; Table 3. Vital signs at various ages. (Source: Behrman et al. Nelson's Textbook of Pediatrics, Saunders, 19" ed, 2011, p. a 280) Age CR /min RR/min BP Preterm 120-170 40-70 55-75/35-45 0-3 mo. 100-150 35-55 65-85/45-55 . 3-6 mo. 90-120 30-45 70-90/50-65 = 6-12 mo. 80-120 25-40 80-100/55-65 1-3y 70-110 20-30 90-105/55-70 a 3-6y 65-110 20-25 95-110/60-75, G12y | 60-95 14-22 100-120/60-75__ = >12 55-85 | 12-18 110-135/65-85 | S . Pediatric Blood Pressure (BP) Monitoring: BP cuff should completely encircle the arm. The inflatable bladder should cover at least 2/3 of the upper arm length and 80-100% of its circumference. A more 4 accurate cuff size is one whose inflatable bladder width is 40% of the arm circumference midway between the = olecranon and the acromion. Using too large or too a small a cuff can lead to falsely low or high BP readings respectively. =a - Method: a4 - Encircle cuff on bare skin of upper arm (right arm z preferably) snugly. Clothing on the arm artificially raises BP. za - Center the inflatable bladder over brachial artery. 13 ](GUIDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS - Patient's arm should be supported and slightly flexed at the elbow. The cubital fossa should be at the level of the heart. The stethoscope bell should be placed over the brachial artery pulse, proximal & medial to the cubital fossa, below the bottom edge of the cuff, about 2 cm above the cubital fossa. BP should be measured after 5 minutes of rest in the seated position. Estimate first the systolic BP (SBP) by palpation method. Inflate the cuff rapidly to level above the suspected SBP then deflate cuff slowly at a rate of 2-3 mmHg/sec. As cuff is being deflated, the onset of the “tapping” Korotkoff sounds signifies the SBP, while the diastolic BP (DBP) is the level at which the Korotkoff sounds disappear. Ideally, BP readings should also be obtained on the left armand one lower extremity. BP should be measured at least twice on each occasion & the average of the systolic and diastolic BP readings be obtained and recorded. BP percentile should then be determined from BP nomograms according to sex, age and height of the patient. (See Appendix) Sources; Nelson Textbook of Pediatrics 19” ed,,p. 1639, Update on task force report on high blood pressure, Pediatrics 1996 Oct; 98:649-58. c. Anthropometric data: 3 major growth parameters include: 1. Weight (wt) in Kg 2. Length (Lt) (for children < 2 y.o.) or Height (Ht)(for 22 yo.) inem 3. Head Circumference (HC) (for <3 y.o.) incm Other measurements for special circumstances: + Chest circumference (CC) in cm, + Abdominal circumference (AC) in cm, + Arm span & U/L ratio for children with growth disorders. Be: eal al hen] ~~ = Pre Dm mm ems mem mee'- = > = = = =e me ome oy @ewenweenaeweenkeankenanaeen Ww PHYSICAL EXABNATION How should anthropometric measurements be done? - Weight is preferably taken with minimal clothing on, using the same scale which has been calibrated before use. An infant weighing scale should be used for children <2y/o. Supine length measurements require 2 observers. Place the patient flat in a supine position on a recumbent length table or measuring board. The crown of the head should touch the stationary vertical headboard. Align the line of vision perpendicular to the plane of the measuring surface. With the shoulders and the buttocks flat on the surface, align them at right angle to the long axis of the body. Extend the legs at the hips & knees flat against the table. Rest the arms against the sides of the trunk, Ensure that the legs remain flat on the the table & shift the movable board against the heels. Extend the legs gently& record the length to the nearest 0.1. cm. Height is measured using a vertical board with an attached metric rule and a horizontal headboard that can be brought into contact with the uppermost pointon the head. With the child wearing little clothing so that body positioning can be seen, stand him on a flat surface, with weight distributed evenly on both feet, heels together and the head positioned so that the line of vision is perpendicular to the body. The arms hang freely by the sides, and the head, back, buttocks and heels are in contact with the vertical board. Anyone who cannot stand straight in this manner should be positioned vertically so that only the buttocks and the heels or the head are in contact with the vertical board. Ask the child to inhale deeply staying fully erect. The movable headboard is brought onto the topmost point on the head with sufficient pressure to compress the hair. Record measurements to the nearest 0.1 cm on the growth chart. (Source: WHO Technical Report Series 854: “Physical Status: The Use and Interpretation of Anthropometry", 1995)(GUIDE FOR HISTORY TAKING, PHYSICAL EXAMI INATION AND DIAGNOSIS OF PEDIATRIC PATIENTS Fig, 1. Measurement of recumbent Fig, 2, Measurement of height length in infants (Source: www.cps.ca) (Source: www.cde.gov) - HC should be measured using a nondistensible plastic tape measure placed over the supraorbital ridge in front and extended circumferentially to include the most prominent part of the occiput giving the largest possible measurement. Chest circumference should be measured in mid- inspiration with the tape running horizontally around the chestusing the xiphoid notchas reference point. Abdominal circumference is measured across the umbilicus in infants. In older children, the subject stands with body wt evenly distributed on both feet, & with feet about 25-30 cm apart. The measurement is taken midway between the inferior margin of the last rib & the crest of the ilium, ina horizontal plane. AC is measured to the nearest 0.1 cmat the end of normal expiration. (Source: WHO Technical Report Series 854: “Physical Status: The Use and Interpretation of Anthropometry, 1995) Arm span is measured by asking the patient to stand straight with arms outstretched sidewise parallel to the ground and palms facing front. Measure from the tip of the right to the tip of the left middle finger. Lower (L) segment of body is measured as follows: * 0-3 y/o: with child supine, measure from umbilicus to tip of toes with feet flexed 902 at heel. * >3y/o: with child standing, measure from anterior superior iliac spine to the floor - Upper (U) segment = Lt or Ht minus lower segment- Normal values for U/L ratio: * At birth: 17 *1monthto3y/o: 13 *>3 y/o: 1.0 7“~= en nmene ene | eenrnvscan Exnuanaion, - With dataonWt& Ltor Ht, calculate for body mass index (BMI) using the following formula: BMI = Wtin Kg + (Lt or Ht in meter)’ | The Wt, Lt/Ht, Wt for Lt or Ht, BMI and HC should be plotted on 2006-2007 WHO growth charts and z-scores (standard deviation scores) determined for nutritional assessment, Assess for the following: * wasting & overweight for 0-5 y/o by determining z- scores on Wt for Lt or Ht z-score charts, or for 0-19 y/o, from BMIz-score charts. * stunting in children 0-19 y/o by determining z- scores on Lt or Ht forage z-score charts. "See Appendix for WHO Growth Charts for infants & children, their proper use & interpretation. d. Skin: color, tissue turgor (wrinkling or loss of elasticity), loss of subcutaneous tissue, rash or eruptions, hemorrhages, scars, edema, jaundice. + Skin turgor can be used to assess dehydration by pinching the skin over the anterior abdominal wall. In the presence of dehydration, the skin does not fall back quickly and remains in folds or tented. This sign however cannot be used in malnourished children because of the loss of subcutaneous fat in these children. e. Head: hair, shape or contour, scalp, fontanels, sutures + Hair should be observed for the ff: - Quantity: increased or decreased, generalized or localized - Color: blonde hair in phenylketonuria, albinism, flag signin kwashiorkor - Texture: dry coarse hair in hypothyroidism, fine thin hair in malnutrition Surface characteristics: look for presence of lice and nits Strength: fragile hair in many congenital syndromes and fungal infections 7GUDE FOR HISTORY TAKING, PHYSICAL EXAMINATION AND DIAGNOSIS OF PEDIATRIC PATIENTS * Abnormal swelling may indicate: hematoma, abscess, tumors, cephalhematoma, caput succidaneum + Sutures: overlapping, gaping + Fontanels: There are 2 major fontanels at birth, the anterior (AF) and the posterior fontanel (PF). The AF is normally slightly depressed and pulsatile and is best evaluated when an infantis held upright while asleep or feeding. Table 4. Characteristics of anterior vs posterior fontanels. Anterior fontanel Posterior fontanel \Tocation | Midline at junction of Midline, between | coronal & sagittal intersection of occipital and | sutures parietal bones Shape Diamond ‘Triangular | Size at ~2x2em Very small or appears birth | - | closed Closure 9-18 months 6-8 wks Table 5. Clinical correlation of the fontanel findings (PE finding Glinical implication _ Small fontanel Microcephaly, craniosynostosis Late closure or large Hypothyroidism, hydrocephalus, rickets, Trisomy 18 syndrome (Tense/ full/ elevated @ intracranial pressure Depressed Dehydration + Auscultation of the skull is important for detecting bruits which may indicate the presence of A-V malformation or may be normal in children < 4 years old with febrile illness. f. Face: + Inspect face for symmetry, expression, unusual facies, deformities, lumps & bumps. « Adenoid facies: Term used to describe child with long face, short upper lip, pinched nose & open mouth, often associated with pharyngeal tonsillar & adenoid hypertrophy and chronic upper airway obstruction. g. Eyes: lids, conjunctivae, sclerae, pupils, extraocular movements, vision, strabismus, opacities, discharge, red orange reflex (ROR) up to 24 mo, corneal light reflex, cross-cover test. 48 me hl lal lel” baa La FrPryscat Exavenarion Table 6. Lids’ findings & correlates © Findings Clinical implication Narrow palpebral fissure Ptosis | Wide palpebral fissure (Short horizontal length Exopthalmos, hyperthyroidism Trisomy 18 Lids slanted upwards Down's syndrome Dennie-Morgan folds* allergic shiners” | Atopy, A slanted downwards Treacher Collin syndrome jergic rhinitis (AR) eho} oOBy oR ORR OR oR os = = om aS ee & & & & & Ge ke = ay = * These are skin folds extending from inner canthi below the lower lids. coThese refer to the blue-gray to purple discoloration beneath the lower lids due to venous stasis. Note also for periorbital edema, drooping lids, scaliness, crustings of eyelashes, hypertelorism. Conjunctivae: note for pallor, hyperemia, pterygium, subconjunctival hemorrhages, opacities (plaques) from keratinization in Vit. A deficiency (Bitot's spots) Sclerae: ictericiae, unusual color like blue Pupils: size & reaction to light Vision: use Snellen's chart or E chart if the patient is unable to read. Red orange reflex (ROR): an orange color is normally seen when flashing ophthalmoscope light through the infant's pupil. Absence of ROR or its replacement by a “white reflex” should alert the clinician to the following possibilities: ~ congenital cataract ~ retinoblastoma + infestation with toxocara - retrolental fibroplasias Corneal light reflex (Hirschberg test): This maneuver screens for the presence of strabismus and describes the corneal reflections of alight held in front ofthe child. A target object should be used to keep the child's vision fixated in a forward gaze. Position the child so that the penlight, target object and the examiner's line of vision are at the same level as the child's eyes. The distance between the penlight, target object and the child's eyes should be about 14-16 inches. Have the patient focused his eyes on target 19