HISTORY TAKING AND

PHYSICAL EXAMINATION
IN PEDIATRICS
YASEMİN ALANAY, MD, PhD
The pediatric history ..

¤ is the foundation upon

n future physician/ patient/ parent relationship is built
¤ Conveys interest or boredom
¤ Concern or annoyance

¤ Empathy or lack of understanding

¤ Communicates respect for the patient/parent

¨ The main basis of a diagnosis of a medical
condition lies in obtaining a good history and
physical examination.

¨ In pediatric cases it is the relationship between

the adult parent, patient and the physician
which has to be developed
CHILDREN ARE NOT LITTLE ADULTS..
Goals of the history are:
¤ Todetermine why the patient/parent came to see
the physician

¤ To
determine what the patient/parent is worried
about most and why

¤ Tostrengthen the physician/patient/parent

relationship and thus the therapeutic alliance by
observing, listening and conveying empathy
INTERVIEWING TECHNIQUES
¨ 1. Active listening
¨ 2. Facilitation
¨ 3. Questioning
¨ 4. Reflection
¨ 5. Confrontation
ACTIVE LISTENING:
This involves the use of silence and nonverbal indications
of interest such as nodding, maintaining an open
receptive body stance, leaning forward and maintaining
eye contact.
Particularly effective at the beginning of the interview and
when the patient is upset
FACILITATION
This encourages the patient to continue talking.
Ex: “Tell me more about it”
“ Please go on”
“I’m interested to hear about it “
Rocking - : Yes, Uh huh, umm, I see
Repeating –”It usually happens at night?”
QUESTIONING
Open ended questions are those that require more than a yes/no
response.
2 types of question:
1. Probe –requires more information in a specific area already
mentioned by the patient
Ex: “What else did you notice about the stools?”
“What was the character of the fever?”
2. Clarifying – questions that request an explanation of what has
already been said especially if the interviewer is unsure of what the
patient is trying to say.
Ex: “What do you mean by fretful?”
“Do you mean this . . . . ?”
REFLECTION
This is a response that repeats something the patient just
said. It is a feedback to the patient of the information he
has just given.

Ex: “You sound anxious when you described the fever.”

“You seem worried because the child has a bad
cough.”
CONFRONTATION
This focuses the patient’s attention on a component of
his experience such as feelings, behavior, or statements
The interviewer affirms the patient’s unstated feelings so
as to confront the patient with his emotional condition

Ex: “You seem to be unhappy”

“You look very sad as you say that”
“It sounds like you are angry with the nurse”
The value of the confrontation is in its timing and
helpfulness in giving relief and clarifying them.
PATIENT-PHYSICIAN RELATIONSHIP

¨ The interviewer’s interaction with the patient should be

conducted in a manner that facilitates a helping
relationship.

¨ Medical students should be less directive in their

approach with patients,

¨ The proper rapport with the patient should be established

by showing interest, humanizing the interaction and
providing support
 Five aspects of patient-physician relationship:

1. Try to be relaxed, confident and comfortable.

Do not mumble, hesitate or demonstrate other signs of anxiety.
2. Show interest in the patient as an individual.
Do not focus only in the sick child or only in the illness
3. Maintain objectivity
Don’t intrude own values, become hostile or get involved emotionally
4. Be sincere and honest
Do not hedge, avoid or give incorrect information
5. Maintain appropriate control over the structure of the
interview.
Do not let the patient ramble, do nor shut the patient repeatedly
 Behavioral checklist for assessing patient’s feelings

1. Identify and recognize patient’s feelings like anxiety,

depression and ambivalence
2. Verbally acknowledge patient’s appropriate feelings
3. Verbally acknowledge hostile feelings
4. Encourage ventilation of feelings when needed.
Do not cut off further expression of feelings
Taking history..
Chief complaint / present illness
Past medical history
Family history
Personal and social history
HISTORY OUTLINE
¨ Informant : Relationship to the patient
¨ Reliability : in percentage
¨ General Data : Patient’s initials, age, sex, nationality,
religion, address, admission (1st, 2nd, 3rd, etc), date of
admission

¨ Chief complaint: reason for bringing the child

to the physician
History

¨ The history for an infant or child will be

modified according to age

The following is just an outline…

Chief Complaint
¨ May be taken from a parent or guardian
¤ Note
the name, relationship & reliability of
the person providing the history

¤ The
child should be included as much as
possible
n Appropriate for his/her age
Present Illness:
¨ This should be well organized so that a clear, detailed
and unified profile of the patient’s illness is depicted

¤ Begin with the nature and date of onset, associated

symptoms, location. severity, time of day, character,
and exacerbating or relieving factors.

¤ Specify the time of manifestations by period prior to

admission

¤ Accurate description of the symptoms and signs

given, their occurrence, their progress
Negative information should be included if they
contribute to the diagnosis or help exclude
other possibilities.
Inquire about recent exposure to infectious
diseases – date, where and how
Past Medical History
¨ General Health and Strength
Past Medical History
¨ Mother’s Health During Pregnancy
¤ General health, extent of prenatal care
¤ Specific diseases or conditions
n Infectiousdiseases (gestational month)
n Weight gain
n Edema, hypertension, proteinuria
n Bleeding (approximate time)
n Pre-eclampsia
Past Medical History

¨ Mother’s Health (cont’d)

¤ Medications hormones, vitamins, special
or unusual diet, general nutrition status
¤ Quality of fetal movement; time of onset
¤ Emotional and behavioral status
n Attitudes toward pregnancy and children
¤ Radiation exposure
¤ Use of alcohol or elicit drugs
Past Medical History
¨ Birth
¤ Duration of pregnancy
¤ Place of delivery

¤ Labor
n spontaneous or induced
n duration
n analgesia or anesthesia
n complications
Past Medical History

¨ Birth (cont’d)
¤ Delivery
n presentation
n forceps, vacuum extraction
n vaginal or cesarean section
n complications

¤ Condition of infant, onset of cry, APGAR

scores (if available)
¤ Birth weight of infant
Past Medical History

¨ Neonatal Period
¤ Congenital anomolies
¤ Baby’s condition in hospital, oxygen
requirements, color, vigor, cry, feeding
¤ Duration of baby’s stay in hospital;
infant discharged with mother?
¤ Bilirubin phototherapy

¤ Prescriptions (antibiotics)
Past Medical History

¨ Neonatal Period – First Month of Life

¤ Jaundice, color
¤ Vigor of crying

¤ Bleeding
¤ Convulsions

¤ Other evidence of illness

Past Medical History

¨ Neonatal Period – Early bonding

¤ Opportunities at birth and during the first
days of life for the parents to hold, talk
to, and caress the infant
¤ Opportunities for BOTH parents to relate
to and develop a bond with the baby
Past Medical History

¨ Feeding
¤ Breast or bottle (type of formula)
n Reason for changes, if any
n Frequency of feedings
n Amounts offered and consumed
n Weight gain
Past Medical History

¨ Feeding (cont’d)
¤ Present diet and appetite
n Age of introduction of solids
n Age child achieved 3 feedings per day
n Present feeding patterns
n Elaborate on any feeding problems
n Age weaned from breast or bottle
n Type of milk and daily intake
n Food preference
n Ability to feed self
Past Medical History

¨ Development

¤ Commonly used developmental

milestones
NOTE:
n Parents my have baby books which can
stimulate recall
n Photographs may be helpful
Past Medical History

¨ Development (cont’d)
¤ Age when able to…
n Hold head erect when in sitting position
n Roll from front to back; back to front
n Sit alone; unsupported
n Stand with support; without
n Use words
n Talk in sentences
n Dress self
Past Medical History

¨ Development (cont’d)
¤ Age when toilet trained
n Approaches to and attitudes toward toilet
training
¤ Dentition
n Age of first teeth
n Loss of deciduous teeth
n Eruption of first permanent teeth
 Past Medical History

¨ Development (cont’d)
¤ Growth
n changes in rates of growth or weight gain
¤ Sexual
n Present status, any concerns
n Female: breast development, sexual hair, acne,
menstruation (description of menses)
n Male: sexual hair, voice changes, acne, nocturnal
emissions
n School
• Grade, performance, problems
Past Medical History

¨ Illnesses
¤ Vaccinations

¤ Communicable diseases
¤ Injuries
¤ Hospitalizations
Family History

¨ Maternal gestational history

¤ List all pregnancies
n Health status of living children
n Deceased children: date, age, and cause of
death
n Miscarriage: dates and duration of pregnancies

¨ Age of parents at the birth of this child

*Review at least 2 generations on

each side of the family.
Personal and Social History

¨ Personal status
¤ Nail biting, thumb sucking, breath holding,
temper tantrums, pica, tics, rituals, etc.
¤ Bed wetting, constipation, or fecal soiling of
pants
¤ School adjustment

“A day in the life of the patient” is often

helpful in providing insights.
Personal and Social History

¨ Home Conditions
¤ Father’s and mother’s occupations
¤ Principal caretaker(s) of the child
n Daycare?

¤ Parents divorced or separated

¤ Food prepared by whom

¤ Sleep habits; sleeping arrangements

¨ In addition to the usual concerns,
inquire about any past medical or
psychological testing of the child

¤ Firstvisit to the dentist? optometrist?

¤ Hearing checks?
¤ Speech therapist?
¤ Etc.
Review of Systems
Review of Systems
¨ Skin
¤ Eczema; seborrhea (“cradle cap”)
¨ Ears
¤ Otitis media (frequency and laterality)
¨ Nose
¤ Snoring, mouth breathing
¤ Allergies

¨ Teeth
¤ Dental care
Adolescents
¨ Use open-ended questions
¨ Don’t force the adolescent to talk
Sometimes, allowing an opportunity
to write a concern may help.
Adolescents
Common Issues

H Home
E Education
A Activities, affect, ambition, anger
D Drugs
S Sex
Adolescents
Common Issues

P Parents, peers
A Accidents, alcohol & drugs
C Cigarettes
E Emotional issues
S School, sexuality
Physical Examination
PHYSICAL EXAMINATION
¨ Physical examination of an infant, child or
adolescent must be individualized and
purposeful.
¨ Assessment begins as soon as the physician
sees the child and parents
¨ The order of examination need not be from head
to foot and varies according to many factors :
urgency of the situation, age and
cooperativeness and suspected system of
involvement.

¨ Invasive procedures may be saved for last in a

child that is anxious and frightened
¨ Vital signs: HR RR BP Temp
RR: newborn 30-40 at rest or
asleep
Early childhood 20-40
Late childhood 15-25
15 years adult levels
¨ Anthropometric measurements : Percentile
Height Weight
HC –done in the first 2 years because 70%
of post natal growth occur during this period
¨ Head and neck: head shape, anterior fontanel,
masses, tenderness
Ears : position and shape : ear drums
Eyes : normal red or orange reflex
pupillary size and reaction to light
color of conjunctivae
Nose : patency, nasal septum
Mouth, tongue, throat –color of lips; teeth
eruptions
Neck – note for anomalies , webbing,
cutaneous hemangiomas, cervical
adenopathy, thyroid gland, abnormal
pulsations
¨ Breasts – sexual maturity rating, symmetry,
masses, nipple discharge, retraction,
ulceration
¨ Chest – inspection, palpation, percussion and
auscultation
By 9th month chest circumference more or
less equal with head circumference
Normal RR is ¼ of cardiac rate
Breathing is shallow in respiratory distress of
central origin and alkalosis
Breathing is deep in peripheral respiratory
distress and acidosis.
Inspiratory rales – bronchiolitis,
bronchopneumonia or atelectasis
Expiratory rales – bronchiolitis, asthma,
presence of foreign body and aspiration
pneumonia
¨ Heart – auscultation usually gives a better count
of the cardiac rate than palpation at the wrist in
children.
Murmurs should be described as to location,
time, quality, intensity and transmission
Distant heart sounds – pericardial fluid
Poor heart sounds – severe heart disease,
myocarditis, heart failure
Gallop rhythm – indicative of failing heart
Pericardial friction rub – tuberculous or
rheumatic pericarditis
¨ Abdomen – normally flat when child is in
supine position
Peristalsis visible during examination is a sign
of obstruction until proven otherwise
Palpation – begin from LLQ LUQ

RLQ RUQ
¨ Genitalia – bloody or mucoid discharge in a
newborn is normal
ambiguous genitalia, hernia,
hydrocele,epispadia, hypospadia,
undescended testes
Sexual maturity rating
¨ Anus/rectum
¨ Musculoskeletal system – muscle, bones,
joints
¨ Skin and integumentary system
Plan tests
Selection of laboratory tests should be
based upon adequate analysis of the
pathophysiologic process
PROBLEM ORIENTED MEDICAL
RECORDS (POMR)

The POMR consists of 4 phases of medical

activity:
1. Establishment of data base
2. Formulation of a list of problems
3. The initial plan for each problem
4. Progress notes on each problem
 DATA BASE – initial collection of information about
the patient which consists of 6 basic elements

1. Chief complaint –should be concise statement of the

reason the patient seeks medical attention, preferably in the
patient’s own words.
2. Patient profile –explicit account of how the patient spends
his routine day
3. Present illness or illnesses
4. Past history and system review –should be based on a
series of explicit and logically arranged questions in a
branching pattern
5. Physical examination – should be clear precisely what was
examined and what was not
6. Baseline laboratory examination
Formulation of a list of problems
¨ S –subjective data –
¤ qualitative and quantitative description of the
symptoms appropriate to the problem

¨ O- objective data –
¤ actual clinical findings, x-ray results or laboratory
findings appropriate to the problem, preferably in
the order and context designated in the original
plan
The initial plan for each problem

¨ A – Assessment
¨ P- plan

¨ What is a problem? – defined as something

that concerns the patient, or the physician or
both
¨ Problem List –
¤ list in numerical order all the problems extracted
from the data base.
¤ It is an expression of the physician’s analytical and
synthetic thinking.
¤ Initially, problems may be symptoms , signs or
abnormal test results.
¨ Progressive investigations of such problems
may disclose interrelationships and specific
diagnosis may replace initial listings of problems
by symptoms or signs.
¨ New problems may be added as
identified and old problems may be
resolved.

¨ No. Problem Date identified Date resolved

1 RHD
a. MI
b. Atrial Fib
c. CHF
OBSERVE & PRACTICE
¨ Observe, observe, observe

¨ Practice, practice, practice