skeleton of history taking in paediatrics

Skeleton of History Taking in Paediatrics

Presented by Dr. Elhadi Mohammed Ahmed

1 -Personal Data:

Name /…………………………………… Age /……………………………………… Sex /……………………………………… Residence /……………………………… Tribe /……………………………………. D.O.A /…………………………………… Informant /…………………………….....

2 -Complain of:

What the child C/O ( in the mother words; avoid medical terms).

Should be in a chronological order. For example: C/O: cough/ 20 days fever/ 10 daysQ: Why you but the symptoms in a chronological

order?.Because it shows the progression in pathology.

3 -History of present illness:

Deeper inquiry about important symptoms must be made. (e.g. time of onset, site, duration, frequency, severity, aggravating &relieving factors, diurnal variations etc.).

Obtain a complete chronological sequence of events, noting especially the mode of presentation and the timing of complications and how they have been treated.

Complete the system involved. Include drugs prescribed, investigations carried

out and operations performed. N.B: If the C/o is chronic one the history of C/O

may overlap with the pass medical history.

4 -Systems enquiry:

Its of especial importance in a chronic multisystem disease otherwise are included for completeness. These in order:

A- Cardiovascular: -Activity (shortness of breath on exertion, or a

baby breathless & sweaty on feeding, or slow to feed).

-Blue episodes. -Squatting. -Chest pain or palpitations (in adolescence). -Dizzy spells or fainting (may confused with fits).

B- Respiratory system: -Sore throat or earache. -Cough (nocturnal or in relation to exercise,

productive/ not & if yes clear or purulent). -Wheezing; (if nocturnal or exercise

induced). -Breathlessness/ game compared to peers. -Frequent chest infections. -Aspiration. -Haemoptysis (in older child, or suspected).

C- Gastrointestinal system: -Weight loss; appetite. -Abdominal pain. -Vomiting; diarrhoea; or constipation

-Blood in the stools. -Pruritis ani.

D- Central Nervous System: Symptoms of increased I.C.P. : -convulsions ( faints or funny turns). -Headaches; vomiting; blurring of vision.*symptom related to cranial nerves: -Loss of smell or taste. -Visual problems. -Deafness or dizziness.* sensory symptoms: -Numbness or unpleasant sensations.*motor symptoms: -Weakness, clumsiness or frequent falls.*others e.g. -Incontinence.

E- Genitourinary system: -Frequency. -Steam. -Dysuria. -Haematuria. -Incontinence. -Nocturia /enuresis (primary/secondary).

F- Rheumatological system: -Limping; joints pain -Joint swelling. -Skin rash. -Others; e.g. dry mouth, hair loss etc.

5 -Past medical history:

This depends on the case e.g. if the case is suffering from anaemia then you ask about:

-Previous hospital admissions (& the circumstances).

-Blood transfusions. -Jaundice. -Similar conditions. -History of pica. -And other related questions.

6 -Developmental History:

Prenatal: pregnancy & gestation. Natal: mode of delivery & birth weight. Postnatal: admitted to special care & why? Milestones.( touch all four areas i.e. gross

motor, fine motor, speech &hearing and social). Schooling (if the child is school age).

N.B:if a neonate, genetic or developmental case, more detail is required.

7 -Nutritional History:

Initiation of breast feeding. Bottle- or breastfed and for how long. Timing of introduction of solids/cereals. Quantity &quality of food. Current dietary intake if relevant to C/o. Diabetic exchanges. N.B: if the child is malnutrition more details is

required.

8 -Vaccination History:

Ask about our routine E.P.I programme. Record the reasons in detail for failure to

uptake. N.B: you must know in detail the absolute and

relative contraindications to all vaccines.

9 -Family History:

Family pedigree.( this an international language to see if there is inherited conditions in the family - read about it).

Ages of parents & their health status. Ages of the siblings & their health status. Number of siblings &their ages range If there is deaths we see the causes of death. Family history of diabetes, atopy or fits. N.B: Pay attention to detailed family history if a

hereditary or infectious disease is involved. (TB)

10 -Social History:

Ask about the following: Housing condition. Parents level of education. Their occupation. And socioeconomic status.

11 -Drugs History:

Ask about the following: Chronic medication. Hypersensitivity to any drug (especially penic.) Drugs used now.

Summary of your history:

Summarize your history in a systematic way. highlighting the important positive & important

negative points. (showing the problems of the child).

Do not attempt to present the whole history verbatim.

N.B: the history in the paediatric long case is usually obtained with the help of the parents. A useful list of headings for obtaining and presenting a history is as given above. The most common errors are an inadequate developmental history and an inadequate social history.

Skeleton is skeleton & I mean it; you have to flush it with knowledge.

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Skeleton of Systems Examination in Pediatrics

Presented by Dr. Elhadi Mohammed Ahmed

Introduction :

From the history you should have a good idea of which systems will have abnormal physical signs and therefore plan to concentrate your attention on these systems. (However, there is ample time in the long case to examine every system thoroughly and this is expected).

First know the normal by examining as many normal babies, infants, toddlers & children as possible. The abnormal will then be more obvious.

Examining children is an art and not a science & you should rehearse your examination technique every now and then. The examiner will be impressed by your efficiency and technique even if you do not get everything right.

General advice on examining children:

there are some general rules you have to put in mind:

1- introduce yourself to the child & parents and ask if you may examine the child. Besides:

Ask the child name if you have not been already told --(never refer to the child as it).

Talk to the child as you examine him or her.

Inspection is the most important part of examination in children e.g. assess the speech, colour, RR, signs of distress ,audible respiratory sound ..etc. use all your senses (eyes, ears, smell) before relying on touch.

2- speak quietly to the child but clearly to examiners. -Try to avoid sudden movements.

3- warm your hands and remove a watch or rings which might scratch a child. What about washing hands between short cases??.

4- appear at easy examining children, giving clear instructions, positioning appropriately &adequate expo

5- never hurt a child. Ask about site of tenderness,.etc

6- do not ask a toddler for permission to do something. He will almost certainly refuse!.

7- avoid standing over a small child by getting down to his/her level. If he/she is sitting on his/her mother knee, then be prepared to get onto yours.

8- If at all possible, examine a young child in close proximity to his/her parent. (it is perfectly acceptable to examine a young child on his/her mother lap but tell the examiners you have deliberately chosen to do this).

9- distract the child with a toy if this will help you continue your examination. Or you can choose other distraction tricks e.g. The child may play with your stethoscope, & ..etc.

10- some examiners like running commentary as you examine the appropriate system. We would advice against this unless you specifically asked.

11- The technique for examining the children varies with age:

A- For older children because they are sufficiently cooperative you can do full exam. In order recommended.

B- For the younger child examine carefully (may be in the mother lap) & employ a more opportunistic approach. And again much information must be obtained before distressing the child (by undressing, strange hands, ..etc.).

12- Whatever your approach in examination, organize your information & present it in a logical sequence.

Presenting to the Examiners: Whatever your approach in history & examination, organize

your information & present it in a logical sequence. for example in a long case:

Write the headings of the history &examinations in a paper. present the history in the sequence recommended Then summarize your history -don’t forget the +ve & -ve points Then present the examination in order recommended as: General observation (looks ill, thriving, signs of distress, ..etc) Vital signs (pulse, RR, temp., BP). Anthropometric measurments(Wt, Ht, H.c. & see centiles) Then other examinations in sequence: C.V.S, R.S, Abd. & C.N.S Put differential diagnosis (Common things are common). What investigations needed? What management & follow up required? N.B: i.e. you have to put in mind What questions they may ask?

Approach to different systems examination:

How you examine the C.V.S. ?

How you examine the respiratory S. ?

How you examine the Abdomen ?

How you examine the C.N.S. ?

N.B: the answers to the above questions will be form practical point of view in the coming years.

Skeleton of Cardiovascular Examination The cardiovascular system can be examined

systematically as follows: General observation: Look of the child .(looks ill, very ill, unwell, well, ..etc) Signs of distress. (intercostals recessions, acting alae

nasi .etc) General build of the child. (normal growth or emaciated) Apparent dysmorphic features. Hands: Clupping. Cyanosis. Anaemia & Signs of bacterial endocarditis. Pulse. (assess the character of the pulse rate,

rhythm, ..etc). Measure the Blood pressure. (delay it to the end of exam.)

Eyes: Anaemia. Jaundice? (cardiac jaundice). Mouth: Cyanosis. Look at the teeth for dental hygiene (risk of SBE.). Neck: if the child is older i.e. you may neglect in small JVP. What is the difference between JVP & arterial p.? Local chest examination: (inspection, palpation &

auscultation). Inspection (contour, scars, pulsations, apex, others). Palpation: (thrill, apex, LPH., 2nd HS.). Percussion: not useful in C.V.S. examination. Auscultation: (S1 & S2, added sounds & murmurs). Abdomen: tender hepatomegally. (&spleen for SBE). Lower limbs: for oedema. Back of the chest: for p. effusion & murmurs.

Presenting to the examiner Do not look at the patient; look at the examiner. I would like to present the C.V.S. examination of my

child ahmed. General observations (always mention +/- cyanosis,

respiratory distress at rest & dysmorphic features). Pulse (rate, rhythm, character). Local findings (apex, heaves or thrills,

S1&S2,murmur) Signs of heart failure (should be mentioned if +/-). Put your clinical findings together (formulate a

clinical diagnosis). i.e. these features are consistent with VSD.

NB: notes on the C.V.S. examination.

Skeleton of Respiratory System examination

Examination of this system depends on the age of the child. The younger the child, the more important is the phase of inspection, the more difficult are palpation and percussion, and the less informative is auscultation.

Use your ears as well as your eyes . Don’t undress a young child, especially a

sleeping one, until you have answered 4 questions.

What is Respiratory rate? Is there is Signs of distress or not? Is there is cyanosis or not? Is there is audible respiratory sounds or not?

Respiratory system examination systematically as follows:

General observation: Look of the child .(looks ill, very ill, unwell, well, ..etc) Signs of distress. (intercostals recessions, acting nasi .etc) General build of the child. (normal growth or emaciated) Audible respiratory sounds. Others ( restlessness or drowsiness)?? Hands: Clupping. Cyanosis. Anaemia . B.C.G. Scar present or not Eyes & mouth: for what?

Local chest examination: (inspection, palpation,..e)

Inspection: contour scars chest movements Palpation: mediastinal deviation (tracheal position & apex beat) Chest expansion. Tactile focal fremitus percussion: .to define the degree of resonance Auscultation: breath sounds. added sounds: crepitations and crackles or

conducted vocal resonance. Examine the back of the chest: what you do

anteriorly you can do it posteriorly.

Interpretations of physical signs in R.D.

signs disease

Chest movement

Mediastinal shift

Percussion note

Vocal resonance

Breath sounds

Pleural effusion

decreasedTo opposite side

Stony dullness

absentAbsent or bronchial b.

consolidationdecreasednonedullnessincreasedBronchial +/-crackles

collapsedecreasedTo same side

dullnessdecreaseddecreased

fibrosisdecreasedTo same side

dullnessincreasedBronchial +/-crackles

pneumothorax

decreasedTo opposite side

resonantdecreaseddecreased

The musculoskeletal system examination

Examination of the musculoskeletal system is very specialized. As an undergraduate you are only expected to examine a major joint such as knee.

Examination of the knee joint as follows: Observation: for Swelling or redness wasting (look muscle bulk above and below the

joint) Deformity Sinuses Palpate for: (Tenderness, hotness & test for

effusion) Movement: to assess limitations or contractures

Examination of the Reticuloendothelial System How to examine the reticuloendothelial system? General Anaemia Jaundice Lymphnodes:( neck, axillae and groin) Size Position Texture Mobility Look for focus of infection: (throat & limbs … etc) Look for other lymphatic organs: (liver & spleen)

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