Paediatric HISTORY TAKING & Physical Examination: Summarized

Paediatric HISTORY TAKING & Physical Examination:
                                                                   Dr M Tauseef Omer

Presenting Complaint:        
complaint------duration(2months)
complaint 2 -----duration (10 days)

Complaint 3------ duration (12 hours) 

                       

HOPI:   ___year old (abc) (with Previous medical history significant for _____ ,( or (with no significant previous medical history) was in usual state of health _____days back whe he developed fever which was abrupt in onset , continuous relieved only by medicine and recorded upto 102 degree Fahrenheit …. ( and so on) here you explain and elaborate complaint(s) fully)

Review of Systems: Review all system now regardless of what the complaint is.
From general appetite , weight loss , to CNS symptoms, CVS symptoms, RESP,GIT, Genitourinary, and locomotion.

Previous Medical History: Hospitalizations? Surgeries? ER visits? Hakeen medicines?

ER course:  The condition in which patient was brought in ER.

Birth Hx:
Prenatal Hx(was pregnancy planned, did mother take folic acid, were there regular antenatal visits with ultrasounds from competent radiologist, did mother receive 2 doses of I/M tetanus, did she prepare fore delivery , were there any infections(Premature Prolonged rupture of membranes PPROM >18hrs is significant)/hypertension/diabetes/fits/etc prior to delivery)
Natal history ( born Ft/PT? , SVD, SVD with episiotomy, C/S?, if C/S why c/s done, delivered where (home , maternity centre / hospital, was delivery carried out by trained Birth attendant, or doctor, or DAI , were instruments sterilized, did the neonate have immediate cry, or was blue and limp at birth with no cry , was meconium passed in-utero, was neonate offered breast milk within one hour of birth?did the neonate accept breastmilk(or formula if breast milk not given)adequately? Was pre-lacteal feeding (ghutti) given to neonate? Is the mother well?birth weight ?

Postnatal history (did the neonate thrive well, gained weight,had good activity? Fever? Rash ?fits?bleeding from any site?

Feeding history: ask in detail about Breast feeding, Top feeding with formula or buffalo or cow milk ( ask about method of making of formula, or diluton in cows or buffalos milk done if any), ask about the weaning age , what is given in weaning, how much quantity does the child accept. This is particularly important in  a malnourished child where once must ask details of foods offered to child and those accepted by him , and so the total claories content of those foods.

  

Development: as about Gross motor, Fine motor, Vision+Hearing , and Social development.

Immunizations: Ask about details as to how many injections were given and where injected on body to confirm in case vaccination card is not available. Also confirm if vaccinations are done from govt setup or private clinic(there is a chance that cold chain might not be maintained in private setup).

Allergies:  To foods, drugs, flowers etc

Current Medications:  branded medicines ? or non branded medicines giving by local practitioner? Hakeem medicines ? what branded medicine(name)? Dose ? frequency ? check compliance by asking when was bottle purchased and how many days given and how much is left in bottle (you may look) this will confirm if patient was given right volume and in right frequency.

Family Hx:  Be sure to probe for conditions that may be related to the chief complaint (i.e. history of T.B , allergies, asthma or eczema in a patient with increased work of breathing)

Social Hx: Income & profession of Father , Household members, pets, smokers, recent travel, daycare. In case of a chronic disease, ask about impact of disease on family and how are costs of investigations and medicines of child met.

Physical exam:

Pediatric General Physical EXAMINATION (GPE):

                                     

Get consent from mother/father/caregiver: (do not ask for consent from child, if he refuses to allow you then you ll be stuck no where , or you will surely then make him angry if you against his will)

“Mera Naam Dr _______ hai, or mjhay apkay bachay ka muaina kerna hai. Iss muainay kay doran isay koi dard na hoga or marz ki tashkhees mei madad milay gi”

Shake hand with child, give him something to eat, play, according to his age).Make
friends with him that you know about many good cats and birds.
Now you are safeto proceed:

General Outlook of patient: (sick looking? Healthy looking? Facial Dysmorphism ? Generalize wasting? Sitting/lying, in respiratory distress? Sitting/lying in bed with abnormal posture?havingfacial puffiness? Or Anasarca? Or irritable and crying? Any sound audible as the child breather(STRIDOR? WHEEZE or noisy breathing ? very important. Never miss the sound ).

THEN,

Head to Toe approach

Anterior fontanelle(open/closed/widely open?)

Posterior fontanelle*

HAIR (normal looking and shiny, or coarse and thin)

OFC (must learn the method to measure it, and OFC at birth, 6 month, 1 yr and 5 yr)

Frontal bossing (N=Normal variant)(rickets)(thalassemia)

EYES (cornea,epicanthal folds, JAUNDICE, PALLOR,redness,cataract, KF rings)

Nasal Flaring (the first most sign of respiratory distress)

CHEEKS(prominent as in Cushingoid faces? Or Loss of buccal fat?)(or prominent maxillary prominences as in thalassemia)

Cleft of lips, with or without cleft of Hard palate or cleft of soft palate only?

angular cheilitis (if present caused by deficiency of which vitamin?)

oral cavity exam for (general hygiene(good or poor) , gum bleed, cleft palate, tonsils, posteriorpharyngeal wall) (dentition* ) (tongue position , mass, fasiculations*)

Coated tongue/Oral thrush (candida infection or Enteric Fever or after syp co-amoxiclave use for more than 3 days)(white strawberry or red strawberry tongue) (oral ulcers anywhere, their size ,margins,base and number)

LYMPHNODES (submental, submandibular,jugulodigastric with both hands B/L)

and Unilaterally examine Ant cervical chain and posterior chain of one side , then other side,

and B/L exam anterior parotid,posterior parotid group, and occipital lymph nodes.

Then supraclavicular LN, and Axillary group by SHAKE HAND approach (lymph nodes in ant axilliaryfold, post fold, medial apical , then lateral) (then same on other side).

Now Examine NECK for thyroid swelling. (DO NOT MISS IT).

Then move to ARM (BCG scar on Rt Deltoid) if not present see on leftt arm too. (Rt side same side as you ll be standing for examination for patient)

MUAC* (do in GPE in the end if you have time , otherwise you must know the technique of

measuring the MUAC and its normal values)

Expose the chest to see:

Supra sternal recessions

Intercostal recessions

Subcostal recessions

Substernal Recessions

Pectus excavatum

Pectus Carinatum

Visible pulsations in precordium

Ricketery rosary

Harrison Sulcus

Move further below to see abdomen:

protuberant?normal shaped?sunken?

visible veins, visible scars?

Umbilicus central? & inverted(N) or everted (may be Normal , or due to fluid or mass pushing it outside), may be horizontal slit (as in fluid inside abdomen : ascites) or vertical slit(due to some abdominal mass pushing umbilicus aside)

Now,

Hands lie by side of umbilicus in head to toe approach , so,

Radial Pulse Rate / regularity ? volume ?

Respiratory Rate :

Blood pressure*

Hands(cyanosis,pallor, clubbing, deformity of fingers, simian crease, palmer erythema, tremors,wasting of eminences, koilonychia,splinter hemorrhages “vertical line in nails” , Oslers nodes in pulps of finger tips(these are painful)

WRIST widening (in a child who is in age of crawling 8-9 months, and above) otherwise do not comment.

Then see genitalia(male or female or ambiguous) and testes palpable in scrotum, if not palpable then whether palpable in inguinal canal?

now examine ankles for                  

pitting Edema (must learn method to properly check it)

inward bent feet(talipes feet/club foot)

NOW

turn over and SEE HIS WHOLE BACK and SPINE

AND , take him to weight machine and weigh with attention to CORRECTION error in machine if any, and MEASURE height .(must learn to how to measure from senior residents height using stadiometer ,or using a measuring tape) and in any child who cannot stand up due to his age or disease, we take Length(learn its method from senior residents)

(an infantometer is a length measuring device for little ones who cannot stand up)

(stadiometer for those who can stand)

(and weighing scale for infants is different from those of older children) (see them both in the ward).

GPE is ,therefore, in 3 parts. Do not forget the scheme in table here:

 

Now , proceed forward to systemic examination.

Examining first the most relevant system according to your history.

Redrape the Patient. And Say Thank you to the child and his mother/father.

AND you narrate history to examiner as:

2 Year old M.Ahmed s/o M.Wali resident of Shahdara Lahore was admitted on 10 february at 9pm in

the night through emergency department. The patient had presented with the complaint of fever

and cough from 7 days and breathing difficulty from 3 days, and worsening of breathing difficulty

with reluctance to feed from 12 hours. Patient was in USOH 7 days back when he developed fever,

.......... And so on...
Now proceed to SYSTEMIC EXAMINATION .

Labs:   …….. ………….

Radiology: Think if Ultrasonography or Xray will help you confirm your diagnosis .Or if a  C.T scan is indicated.

Impression:  __ year old F/M with….include all relevant diagnosis (better to be general and write “vomiting” or “fever” if etiology is unknown) as well as pertinent PMH (Down Syndrome, ASD repair 1 month ago)

Differential Dx:  List all possibilities in the order of their preference for the case.

Plan:  PLAN should include:
i) Any New Medication to be given ?
ii) is the patient to be Orally Allowed or NPO ?
iii) any new LABS to be sent ?
iv) Counseling of Parents (sp Father about child’s disease)