History Taking,

Physical Examination
and
Genetics

Maria Victoria M. Villarica RN, MD, DPPS, FPSECP

Department of Pediatrics
OLFU College of Medicine
Grading System

• Quizzes 20%
• Group Report 10% (CD)
• Performance of History Taking and PE 20%
• Shifting Exam 50%
___________
100 %

Module Grades 70%

Finals (1st sem) 15%
(2nd sem) 15%
History Taking and PE

• Objectives:
 Obtain an adequate and reliable history appropriate for the
developmental age of the patient
Perform an accurate physical examination
Know how to assess growth and development and nutritional status
Know how to apply techniques to arrive at a diagnosis
Discuss the art and importance of communication between the
doctor, the informant and the older child
 Adequate and reliable history

Salient data
(list/prioritize lab examinations)

Thorough PE

Reasonable/accurate working diagnosis
Importance of good
communication skills
• To gain confidence and trust of the child
• To convey concern and empathy
Interviewing methods:

Active listening:
- silence
- maintaining eye
contact
- receptive body stance
Facilitation:
- door opener
- initiate patient to continue (say
something, repeating in form of
questioning)
- open ended or specific question
- repeat what the patient has said
Interviewing methods:

Questioning- open ended on specific question

clarify question and request
explanation

Reflection- response and repeat something the

patient have said, feedback from
patient

Confrontation- focuses on patient attention of his

feelings, behavior (e.g. pain)
 History taking
A. General Data
• Basic information: Patient’s name, age, date and place of birth, sex, race
(ethnicity), religion, present address, and number and date of hospital
admission
• Informant’s name and relation to the patient
• Reliability of the informant (%) – relationship/ amount of time
spent/degree of involvement in the care/ educational attainment
 B. Chief Complaint
“Why was the patient brought to the hospital?”

• Single symptom or a group of related symptoms

• Do not include diagnostic terms or names of diseases
(e.g. vomiting and emesis; dizziness and vertigo)
C. History of Present Illness
(initial impression and differential diagnosis)

• Signs and symptoms should be described in chronological order from the start of illness
• Date and/or age of onset should be stated (chronic illness)
• Specify time of manifestation by period prior to admission
• NB: maternal and birth history
• Symptoms:
 Onset (acute or chronic)
 Intensity of symptoms: quality, location, duration, extent, severity, frequency, change in usual activity
 Aggravating or relieving factors
 Medications taken: generic and brand names, actual dose (mg/kg/day), duration; any outside medication,
consultation or hospitalization should be included
 Associated symptoms (onset, course, intensity)

• If history suggests a particular disease, ask signs/symptoms/characteristics of the disease

(differential diagnosis)
• Interval history- describe the course of illness since the last hospitalization related
to the present symptoms
• Pertinent negatives – valuable in differential diagnosis
D. Review of Systems
Helps UNCOVER related symptoms in other organ or systems
Further ELICIT relevant data about the disease.

• General: weight loss or gain, activity level, appetite, delay in growth

• Cutaneous: rash, pigmentation, hair loss or pruritus

• Head: (eyes/ears/nose/mouth, throat)headache, dizziness, visual

hearing difficulties, lacrimation, aural discharge, nasal discharge,
epistaxis, toothache, salivation, sore throat

• Cardiovascular: orthopnea, cyanosis, easy fatigability, fainting spells

• Respiratory: chest pain, cough, difficulty in breathing

 D. Review of Systems (cont.)
• Gastrointestinal: constipation, vomiting, bowel movements - diarrhea,
jaundice, passage of worms, abdominal pain, encopresis, food
intolerance, pica

• Genitourinary: discoloration of the urine, burning sensation, frequency

of discharge, enuresis, edema of hands and feet; discharge and itching
(pre-pubertal female); history of menstrual period (onset, frequency,
regularity, pain)and date of last period (pubertal and adolescent female)

• Endocrine: breast asymmetry, pain or discharge, palpitations, cold/heat

intolerance; polyuria, polydipsia, polyphagia
D. Review of Systems (cont.)

• 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 or swelling in bone, joint or muscle; limitation

of motion; stiffness; limping

• Hematopoietic: bleeding manifestations, pallor, easy bruisability

 E. Past Personal History

(Gestational, birth and neonatal histories should be included only for

patients < 2 y/o and if related to the illness for children > 2 y/o)

Gestational History:
Maternal age/parity and duration of gestation
Check up (health, nutrition)
Maternal infections/ accidents/ complications
Cigarette smoking , alcohol intake , drug use
Medications
Roentgen exposure
E. Past Personal History
Birth history:
Manner of delivery
Gestation (term, premature, postmature)
Persons who attended the delivery
Place
Birthweight
Neonatal history
Apgar score
Spontaneous/required resuscitation
Cyanosis, pallor, cry, jaundice (age of onset)
Convulsions, hemorrhage
Feeding difficulties
Congenital abnormalities
Birth injuries
E. Past Personal History
• Feeding History:
Infancy (<2 y/o):
type of feeding: breastfed (exclusive or mixed),
frequency/day, duration; reason why not
breastfed, formula used, dilution, amount given/
day, bottle or cup fed
complimentary foods: age introduced, frequency of
feeding/day, usual food intake, Actual Caloric
Intake (ACI) compared with Recommended Energy
Nutrient Intake (RENI) or the amount or quality of
food intake (food pyramid)
E. Past Personal History
• Feeding history:
Childhood and Adolescence (2- 20y/o)
(early feeding history is not included unless related)
Assess: appetite, usual food intake and amount
Compute: ACI vs. RENI, food pyramid
• Developmental/Behavioral history:
Young children (1-5 y/o): Modified developmental
checklist, dental eruption, urinary incontinence,
toilet training, temper tantrums, head banging,
phobias, pica, night terrors, sleep disturbance
(DDST II – developmental delay)
E. Past Personal History
• Developmental/Behavioral history:
Middle Childhood (6-11 y/o)
School performance
Sexual development (Tanner’s Maturity Rating)
Adolescence (10-20 y/o)
Adolescent –
HEADSS:
Home,education,abuse,drugs,safety,sexuality
(suicide and depression)
FIRST:
Family,image,recreation,spirituality,treats
Violence
Sexual development (Tanner’s SMR), menstrual history
E. Past Personal History
• Past Illnesses (age when contracted, severity, complications) – discuss
clinical course
Contagious diseases
Other medical illnesses (hospitalization)
Operation (surgical condition/type/place)
Allergy, eczema, asthma, food or drug sensitivities
Injuries
F. Immunization History
• Vaccines: type, date, place, untoward reaction
• Tuberculin test: result
G. Family Medical History

Parents/siblings/familial illness or anomalies

 Heredofamilial disease
 Genogram (genetic anomaly)
 Exposure to communicable disease
H. Socioeconomic History

• Living circumstances: place/ nature of dwelling/number of persons

living in the house
• Economic circumstance: working members of the family, source of
funds
I. Environmental/Social History:

Water source
Garbage/sewer disposal
Exposure (cigarette, pollutants)
Travel
others
Physical examination:
Objective:
Perform a thorough and accurate PE

• Depends on the approach of the examiner

• Usual format may not often be appropriate for young adults
• Reserve the more unpleasant and uncomfortable parts until the end of
the physical examination
• Playful interaction and distraction
• Immobilized (when necessary)
Physical examination:

o Introduce yourself
o Wear your name plate
o Explain your purpose
o Seek permission to the
nursing staff, parents or
guardians
o Make child
comfortable
o Adolescent- don’t
perform breast or
genital examination
 Be nice- they have a right to refuse
 Examine in groups *
 See children ASAP- they go home
early *
 Have complete equipment-
thermometer, penlight,
stethoscope, otoscope, tongue
depressor, tape measure
 Ophthalmoscope *
 Infection control – handwashing,
alcohol
* Varies with institution/clinic
 Physical Examination:

Don’t touch patient - observe,

clinical eye
Anthropometric measurement - HC,
CC, AC , weight (Z score) , length ,
height (Plot in growth chart)
Vital signs- HR, RR, BP
A. General Survey
• During history taking  overview
1. mental state or sensorium, level of activity, affect
2. cardiopulmonary distress, color, chest retractions
3. gait (ambulatory); position (bedridden)
4. nutritional state
5. state of hydration
6. well, mild ill or severely ill looking
B. Vital Signs
• Temperature
- Oral: > 5-6 yrs old
- Axillary: safer; 0.5 C lower than oral temperature
- Rectal: not advised in active children
• Cardiac rate (CR), Pulse rate (PR) and Respiratory Rate (RR): taken 1
full minute
• CR to RR ratio: 4:1
• Pulse: rate/min, rhythm (regular or irregular), volume (full,
weak, thread, or compressible)
• Blood pressure (BP) – 3 y/o or any age if relevant to illness
Blood pressure
3 years old , risk factors
Estimate:
Doppler method in infants:
detects arterial blood flow vibrations-
converts to systolic blood pressure

¾ cuff
Respiratory rate
• NB: 30-60/min
• 2-12 months: 50/min
• 1-5 yrs old: 40/min
 Anthropometric Measurements:
Head circumference
 Glabella
(supraorbital
ridge) to occipital
area
(Protruberance)
 Birth to 3 years
 Measures head
growth
 Assess rate of
growth cranium
and brain
• Chest Circumference – mid-inspiration; horizontal; xyphoid notch;
CC<HC until 9-12 mos then CC >HC; AP diameter = transverse
diameter in infancy then > 2y/o, transverse diameter > AP diameter
• Abdominal Circumference – level of umbilicus
• Arm Span – arms stretched sideways, palms supine; middle finger
• Lower (L) segment – umbilicus to tip of toes (feet flexed at 90
degrees)
• Upper (U) segment – subtract L from length or height
Normal values: U/L ratio
at birth: 1.7
1 month – 3 y/o: 1.3
> 3 y/o: 1.0
 Length

Supine length - <3 years (cm):

measure body length -by placing the child supine on
a measuring board or in a measuring tray

Drop in height percentile on a growth curve, may

signify a chronic condition
Height (cm)
• > 3 y/o
• Ruler or measuring board
Weight

 Minimal clothing
 Failure to thrive is inadequate weight
gain for age
 Common scenarios are:
- Growth <5th percentile for age
- Growth drop >2 quartiles in 6 months
- Weight for height <5th percentile
1- Plot length/height-for-age

• Length/height-for-age reflects attained growth in

length or height at the child’s age at a given visit.
• This indicator can help identify children who are
stunted (short) due to prolonged undernutrition or
repeated illness.
• Children who are tall for their age can also be
identified
2 - Plot weight-for-age

• Weight-for-age reflects body weight relative to the

child’s age on a given day

• This indicator is used to assess whether a child is

underweight or severely underweight

• It is not used to classify a child as overweight or

obese

• Cannot be relied upon in situations where the child’s

age cannot be accurately determined

• It is important to note also that a child may be

underweight either because of short length height
(stunting) or thinness or both
3- Plot weight-for-length/height
• Weight-for-length/height reflects body weight in
proportion to attained growth in length or height.
• This indicator is especially useful in situations
where children’s ages are unknown (e.g.
refugee situations).
• Weight-for-length/height charts help identify
children with low weight-for-height who may be
wasted or severely wasted
• These charts also help identify children with
high weight-for-length/height who may be at
risk of becoming overweight or obese
Weight/Nutritional Status
• BMI
= weight (kg)
length or height (m) 2

• Wasting and overweight: weight for length (0-5 y/o) or weight for
height (6-19 y/o)
Anthropometric Definitions of Malnutrition
Stunted: Stunted growth refers to low height-for-age, when a child is short for his/her age
but not necessarily thin. Also known as chronic malnutrition, this carries long-term
developmental risks.

Under-weight: Under-weight refers to low weight-for-age, when a child can be either thin or
short for his/her age. This reflects a combination of chronic and acute malnutrition.

Stunted and Under-weight children are most likely to suffer from impaired development
and are more vulnerable to disease and illness.

Wasted: Wasted refers to low weight-for-height where a child is thin for his/her height but
not necessarily short. Also known as acute malnutrition, this carries an immediate
increased risk of morbidity and mortality. Wasted children have a 5-20 times higher risk of
dying from common diseases like diarrhea or pneumonia than normally nourished children.
 Physical examination:

Technique:
 Inspection
 Palpation
 Percussion
 Auscultation
Skin:
• Rashes- describe lesions, colour,
arrangement distribution

• Color- mottling, can produce a lattice-

like, bluish mottled appearance (cutis
marmorata), acro/cyanosis, jaundice

• Turgor – wrinkling or loss of elasticity;

hydration, skin pinch
• Birthmarks - size, color, location, hemangioma ,
pigmented , skin tags

• Turgor, hydration, skin pinch

• Acrocyanosis- a blue cast to the hands and

feet when exposed to cold

• Harlequin dyschromia- transient cyanosis of

one half of the body or one extremity; NB;
cutaneous condition; red color change half of
child; body midline demarcation;
hypothalamic immaturity
Head:
• Sutures: Fontanels
anterior: 4cm to 6cm, closes between 4-26 months
of age (90% between 7-9 months)
posterior- 1cm to 2cm at birth and closes by 2
months

• Shape- normal, scaphocephaly, synostosis,

brachycephaly , dolichocephly

• Plot head circumference

A newborn’s head account for one fourth of the body
length and one third of the body weight.
Shapes of head
• A newborn's head accounts for one fourth of the body
length and one third of the body weight

Face:
- assymmetry
- unusual facies
- deformities
Eyes:
o Symmetry
o Swelling, lesions, discoloration, discharge
o Lids
o Epicanthic folds
o Sclera
o Pupils
o Visual acuity- optic blink reflex neonates,
convergence, divergence
o Dolls eye reflex
o Visual fields, diplopia
0phthalmoscope at 0 diopters – 10 inches fr pupil -
red orange reflex (ROR) – up to 24 months
Visual Acuity
• E test: preschool; 3-4 y/o
• Snellen acuity chart: 5-6 y/o (know letters)

• 3 y/o: 20/40 vision

• 4 y/o: 20/30 vision
• 5-6 y/o: 20/20 vision
Nose
• Size, shape, symmetry (nasolabial folds)
• Patency
• Alar flaring
• Position of septum- midline?
• Nasal mucosa- pallor, inflammation, swelling, discharge
• Sinus tenderness
Mouth and Throat
• Lips
• Gums
• Tongue
• Mucous membrane
• Dentition: 20 milk teeth (24 months)
• Drooling : < 18 month old
Tonsils
• Presence
• Size
• Surface color
• Exudates
• Membranes
Ears:

o Position of the pinna

Draw an imaginary line drawn across
the inner and outer canthi of the
eyes should cross the pinna or auricle
if the pinna is below this line, then the
infant has low-set ears.
o External exam
o Tympanic membrane
look for light reflex
o color - pink, gray , red , dull , congested
o Middle ear- discharge, pus, fluid
Ears:

Neonates: 3 yrs: tympanic downward- pull

auricle down and back
> 3yrs old: pull auricle up and back

Acoustic reflex - also known as the stapedius reflex,

middle-ear-muscles (MEM) reflex, attenuation reflex, or
auditory reflex is an involuntary muscle contraction that
occurs in the middle ear in response to high-intensity sound
stimuli or when the person starts to vocalize
Neck
• Short in infant
• Rashes
• Lymphnodes-
measurement, numbers ,
location, matted ,fluctuant,
tenderness, erythematous
• Nuchal rigidity
• ROM- torticollis
• Clavicle
• Masses
• Acanthosis nigricans: insulin
resistance
Chest and Lungs

Inspection:
• Inspiration and expiration
• Chest size and symmetry
• Look for retractions- sternal,
subcostal, intercostal
Palpation:
Percussion:
Auscultate:
• Bell/ diaphragm
• Breath sounds- tracheal,
bronchial, harsh
• Abnormalities- decreased
breath sounds, crackles,
wheeze, stridor
• Wheezes-often audible without the
stethoscope, smaller size of the
tracheobronchial tree, expiratory sound
• Stridor – inspiratory sound; upper airway
obstruction
• Rhonchi -reflect obstruction of larger
airways, or bronchi
• Crackles (rales) -are discontinuous sounds
, near the end of inspiration
Heart and Blood Vessels:
Inspection:
• Precordium (dynamic/adynamic)
• Visible pulsations
• Apex beat: PMI: 4th LICS MCL (<7 y/o)
5th LICS MCL (>7 y/o)
• Pulses Apical pulses
• Rate and rhythm
• Sinus arrythmia, sinus dysrrhythmia,-with
the heart rate increasing on inspiration
and decreasing on expiration
• Functional murmur
• Murmur, location, radiation, thrills, grade
Palpation:
• Thrills – “purring” vibratory sensations felt by the palm of
the hand over the precordium
• Heave- sign of LVH (feels like an abnormally large beating
heart)
• Check pulses

Auscultation
• Heart sounds and murmurs (intensity, pitch, timing,
variation in intensity with respiration, areas and radiation)
• Grades I -VI
Graded on a 6- point scale
- Grade 1 = very faint
- Grade 2 = quite but heard immediately
- Grade 3 = moderately loud
- Grade 4 = loud
- Grade 5 = heard with stethoscope partly off the chest
- Grade 6 = no stethoscope needed

Note: Thrills are assoc. with murmurs

Mitral valve – where the apex beat was felt

Tricuspid valve – on the left edge of the sternum in the 4th intercostal space
Pulmonary valve – on the left edge of the sternum in the 2nd intercostal space
Aortic valve - on the right edge of the sternum in the 2nd intercostal space
• Systolic murmur – midsystolic, < Gr II, asymptomatic: no further
work-up indicated at this time
• Systolic murmur – early, midsystolic > Gr III; late systolic, holosystolic:
< Gr II but symptomatic; diastolic, continuous – refer to cardiologist
Abdomen:
• Divided into 9 parts
Inspection:
• Masses ,lesions, discoloration
• Distention, fluid wave
• Abdominal circumference
Auscultation:
• Listen to bruits, sounds
• High pitched – intestinal
obstruction
• Palpate percussion liver,
spleen, kidneys
• Liver and spleen – 1 -2 cm
bscm
Abdomen:
Percussion:
• Tympanitic except over solid organs (liver, bladder)
• Abnormal dullness: fluid or tumor
• Highly tympanitic: colic, intestinal obstruction or ileus
• Liver span
• Fluid wave

Palpation:
• Liver: hepatomegaly: left lobe over epigastrium to the left subcostal area
• Spleen: not palpable unless 2-3X in size; right to left subcostal margin,
deep inspiration
• Pain
• Kidneys: 2 hands: deep inspiration; CVA tenderness (12th rib and upper
lumbar vertebrae –transverse process)
Liver Exam:
Percussion:
Liver span is determined better by percussion than by palpation in children.
Percuss along the mid-clavicular line to find the upper margin of the liver. The transition from
resonance to dullness indicates the upper liver border

Palpation:
Start palpating from the lower right quadrant and towards the costal margin. Direct fingers inward
upon each inspiration to feel the liver edge.
Spine:
• Lordotic – abdomen sticks out and pelvis curve back
• Scoliosis – adolescent
Musculoskeletal:

• Gait
• Symmetry
• Bulk ,tone
• Strength
• Range of motion Dyskinesia
• Joint swelling

Ortolani test- test for the presence of a posteriorly dislocated hip

Barlow test - the ability to sublux or dislocate an intact but unstable
hip
Extremities:
Check fingers, toes
webbed, syndactyly, polydactyly, skin tags, metatarsus
adductus (inversion)
Inguinal Region
• Hydrocoele
• Undescended testes
• Lymph nodes
Genitalia
Male: preputial folds, meatal opening, tunnel
• Phimosis – preputial sac is narrow and cannot be retracted
• Hypospadia – meatus is in the under surface of the urethra
• Cryptorchidism (undescended testes) – until 3 months
• Hydrocoele – smooth and non-tender; fluid in the tunica vaginalis; <
1 yr. – noncommunicating; patent processus- larger by the day,
smaller in the morning
• Hernia- bulge in inguinal area; failure of obliteration of the processus
vaginalis (7 mos) M>F
Female
• Discharge
• Laceration
Anus and Rectum
• Position: left lateral decubitus with legs flexed
• Patency, fissures (minor lacerations of the anal mucocutaneous
junction)tags, hemorrhoids, pinworms, prolapse (exteriorization of
rectal mucosa through the anus)
Neurologic:

• Level of consciousness
• Mental status- alert
• Cranial nerve
• Sensory- flicking of palms , soles,
pin prick method
• Motor – resistance to passive
movement, flaccid, spastic ,
• muscle tone-increase or decrease
• DTR
Maturity rating

a) staging for breast

development
b) Staging formale genital development
Thank you