INSTRUCTIONS FOR USE OF THE SECTION ON PEDIATRIC HISTORY AND PHYSICAL EXAM
The following outline for the Pediatric History and Physical Examination is comprehensive and detailed. In order to assimilate the information most easily, it is suggested that you read through the whole section before examining your first patient to get a general idea of the scope of the pediatric evaluation. Then, as you encounter patients with specific problems, you may return to the individual sections most pertinent to these patients to absorb the information in detail. Repeat practice with a variety of patients of different ages is crucial to the acquisition of skills in data collection. You should use every opportunity possible to evaluate patients in order to develop a sense of normal growth and development and appreciate the variations in patient encounter that is necessary to perform appropriate evaluation children of different ages.
OUTLINE FOR PEDIATRIC HISTORY AND PHYSICAL EXAMINATION
I. Presenting Complaint (Informant/Reliability of informant)
Patient's or parent's own brief account of the complaint and its duration. Use the words of the informant whenever possible.
II. Patient Profile
A good patient profile will eliminate the need for a social history. It should include information relative to the child's living conditions, what the family unit is like, where the patient fits into this unit, background and education of parents, father's work or lack of such, how child spends an average day (plays in house, plays outside with many friends, etc.). In the school age child, information should be checked relative to his functioning in school, and the presence of specific learning or behavior problems. The family's socio-economic situation should be asked about as well as medical insurance. This paragraph is most useful for paramedical personnel as it gives them a summary of the "whole" child.
III. Present Illness
Begin with statement that includes age, sex, color and duration of illness, ex.: This is the first UMC admission for this 8 year old white male who has complained of headache for 12 hours TPA. When was the patient last entirely well? How and when did the disturbance start? Health immediately before the illness. Progress of disease; order and date of onset of new symptoms. Specific symptoms and physical signs that may have developed. Pertinent negative data obtained by direct questioning. Aggravating and alleviating factors. Significant medical attention and medications given and over what period.
In acute infections, statement of type and degree of exposure and interval since exposure.
For the well child, determine factors of significance and general condition since last visit.
IV. Past Medical History
A. Antenatal: Health of mother during pregnancy. Medical supervision, drugs, diet, infections such as rubella, etc., other illnesses, vomiting, toxemia, other complications; Rh typing and serology, pelvimetry, medications, x-ray procedure, maternal bleeding, mother's previous pregnancy history.
B. Natal: Duration of pregnancy, birth weight, kind and duration of labor, type of delivery, presentation, sedation and anesthesia (if known), state of infant at birth, resuscitation required, onset of respiration, first cry.
C. Neonatal: APGAR score; color, cyanosis, pallor, jaundice, cry, twitchings, excessive mucus, paralysis, convulsions, fever, hemorrhage, congenital abnormalities, birth injury. Difficulty in sucking, rashes, excessive weight loss, feeding difficulties. You might discover a problem area by asking if baby went home from hospital with his mother.
D. Growth and Development:
1. Mother and Mental Development
a. First raised head, rolled over, sat alone, pulled up, walked with help, walked alone, talked (meaningful words; sentences), DDST when appropriate.
b. Urinary continence during night; during day.
c. Control of feces.
d. Comparison of development with that of siblings and parents.
e. School grade, quality of work.
1. Breast or Formula: Type, duration, major formula changes, time of weaning, difficulties. Be specific about how much milk or formula the baby receives.
2. Vitamin Supplements: Type, when started, amount, duration.
3. "Solid" Foods: When introduced, how taken, types.
4. Appetite: Food likes and dislikes, idiosyncrasies or allergies, reaction of child to eating. An idea of child's usual daily intake is important.
F. Past Illnesses - A comment should first be made relative to the child's previous general health, then the specific areas listed below should be explored.
1. Infections: Age, types, number, severity.
2. Contagious Diseases: Age, complications following measles, rubella, chickenpox, mumps, pertussis, diphtheria, scarlet fever.
3. Past Hospitalizations: including operations, age.
4. Allergies, with specific attention to drug allergies - detail type of reaction.
5. Medications patient is currently taking.
G. Immunizations and Tests - Be familiar with departmental recommendations for immunizations. List date and type of immunization as well as any complications or reactions.
H. Accidents and Injuries (include ingestions): Nature, severity, sequelae.
I. Behavioral History
1. Does child manifest any unusual behavior such as thumb sucking, excessive masturbation, severe and frequent temper tantrums, negativism, etc.?
2. Sleep disturbances.
4. Pica (ingestions of substances other than food).
5. Abnormal bowel habits, ex. - stool holding.
6. Bed wetting (applicable only to child out of diapers).
V. Family History - use family tree whenever possible
A. Father and mother (age and condition of health). What sort of people do the parents characterize themselves as being?
B. Marital relationships. Little information should be sought at first interview; most information will be obtained indirectly.
C. Siblings. Age, condition of health, significant previous illnesses and problems.
D. Stillbirths, miscarriages, abortions; age at death and cause of death of immediate members of family.
E. Tuberculosis, allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular diseases, kidney disease, rheumatic fever, neoplastic diseases, congenital abnormalities, cancer, convulsive disorders, others.
F. Health of contacts.
VI. Social History
VII. Environmental History
VIII. System Review
A system review will serve several purposes. It will often bring out symptoms or signs missed in collection of data about the present illness. It might direct the interviewer into questioning about other systems that have some indirect bearing on the present illness (ex. - eczema in a child with asthma). Finally, it serves as a screening device for uncovering symptoms, past or present, which were omitted in the earlier part of the interview. There is no need to repeat previously recorded information in writing a Review of Systems.
A. Skin: Ask about rashes, hives, problems with hair, skin texture or color, etc.
B. Eyes: Have the child's eyes ever been crossed? Any foreign body or infection, glasses for any reason.
C. Ears, Nose and Throat: Frequent colds, sore throat, sneezing, stuffy nose, discharge, post-nasal drip, mouth breathing, snoring, otitis, hearing, adenitis.
D. Teeth: Age of eruption of deciduous and permanent; number at one year; comparison with siblings.
E. Cardiorespiratory: Frequency and nature of disturbances. Dyspnea, chest pain, cough, sputum, wheeze, expectoration, cyanosis, edema, syncope, tachycardia.
F. Gastrointestinal: Vomiting, diarrhea, constipation, type of stools, abdominal pain or discomfort, jaundice.
G. Genitourinary: Enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of stream, vaginal discharge, menstrual history, bladder control, abnormalities of penis or testes.
H. Neuromuscular: Headache, nervousness, dizziness, tingling, convulsions, habit spasms, ataxia, muscle or joint pains, postural deformities, exercise tolerance, gait.
I. Endocrine: Disturbances of growth, excessive fluid intake, polyphagia, goiter, thyroid disease.
J. Special senses.
K. General: Unusual weight gain or loss, fatigue, temperature sensitivity, mentality. Pattern of growth (record previous heights and weights on appropriate graphs). Time and pattern of pubescence.