1. Pediatrics History Taking & Physical Examination Bassam Y. Abu-Libdeh, MD Makassed Hospital & Al-Quds Medical School 8/9/2012

2. بسم الله الرحمن الرحيم

3. Approach Introduce yourself to patient’s companion (usually the mother) Introduce yourself to patient’s companion (usually the mother) Get the respect of the mother in order to get the confidence of the child. Get the respect of the mother in order to get the confidence of the child.

4. Items of Pediatrics History 1. Date of history. 2. Name of patient. 3. Informant :- Mother, father, grandmother, school teacher,….. 4. Reliability:- Good, fair, poor. 5. History taken by :- Your name and title. 6. Patient’s profile:- Age (including date of birth) Sex Address (usually name of city, town or village). Referred from …….

5. 7. Chief complaints:- Who is concerned (pt., mother, school teacher...)? Who is concerned (pt., mother, school teacher...)? When did you notice that your child has changed? When did you notice that your child has changed? OR what he is complaining of? OR what do you think he is sick with? Use, when possible, patient’s or patient’s mother own words. Use, when possible, patient’s or patient’s mother own words. Arrange complaints according to significance to child’ health. Arrange complaints according to significance to child’ health. Onset / Course/ Duration of each complaint. Onset / Course/ Duration of each complaint.

6. 8. History of present illness:- Start with one of the following sentences:- Start with one of the following sentences:- The patient was doing well until …….. The patient was doing well until …….. The history of this child dates back to….. The history of this child dates back to….. The patient was in his usual state of health until….. The patient was in his usual state of health until….. Analysis of symptoms respecting the chronological order of symptoms. Analysis of symptoms respecting the chronological order of symptoms. Sequence of events. Sequence of events. Any medical advice sought or any medication given. Any medical advice sought or any medication given. Other associated symptoms. Other associated symptoms. Pertinent negative symptoms related to the complaints. Pertinent negative symptoms related to the complaints.

7. Important complaints in pediatrics age group:- Important complaints in pediatrics age group:-FEVER.VOMITING.DIARRHEA. ABDOMINAL PAIN. COUGH.HEADACHE.

8. 9. Review of systems :- 9. Review of systems :- Not important in the pediatrics history if you ask about:- * All the complaints in the history of present illness in details. present illness in details. * Complete analysis of each complaint. * All the pertinent negative symptoms related to the complaints.

9. 10. Past history a.Birth history: - (Especially important during the first 2 years of life). a.Birth history: - (Especially important during the first 2 years of life). ▪ Antenatal history:- Mother’s health (before & during pregnancy). Mother’s health (before & during pregnancy). (Diseases/infections/Nutritional status). Medications during pregnancy (timing/dose/duration) Medications during pregnancy (timing/dose/duration) Antenatal care: - booked/ un- booked?, where? Antenatal care: - booked/ un- booked?, where? frequency of visits. frequency of visits. (If all well; you may write UNEVETFUL after asking all the questions) the questions)

10. ▪ Natal history:- ▪ Natal history:- Place of delivery. Place of delivery. Mode of delivery: - NSVD, assisted vaginal, C/S. Mode of delivery: - NSVD, assisted vaginal, C/S. Gestational age. Gestational age. Resuscitation Resuscitation Birth measurements (Wt, Lt, HC) Birth measurements (Wt, Lt, HC) [average at birth:- Wt = 3.25 kg; Lt = 50 cm; HC = 35 cm] [average at birth:- Wt = 3.25 kg; Lt = 50 cm; HC = 35 cm] Apgar Score or condition at birth in mother’s words. Apgar Score or condition at birth in mother’s words. Maternal risk factors for sepsis (PROM, maternal UTI, maternal fever…) Maternal risk factors for sepsis (PROM, maternal UTI, maternal fever…) Baby & mother’s blood groups; Coombs test. Baby & mother’s blood groups; Coombs test.

11. ▪ Neonatal history:- ▪ Neonatal history:- When the baby passed urine/ meconium? When the baby passed urine/ meconium? Respiratory distress, anemia, jaundice, cyanosis, convulsions, infection, congenital anomalies Respiratory distress, anemia, jaundice, cyanosis, convulsions, infection, congenital anomalies (If all well; you may write UNEVETFUL after asking all the questions). (If all well; you may write UNEVETFUL after asking all the questions).

12. b. Past medical history:- b. Past medical history:- Major illnesses Major illnesses Recurrent infections Recurrent infections Hospitalizations Hospitalizations Operations Operations Accidents/ injuries Accidents/ injuries Current medications Current medications Drug allergy (if no known drug allergy, may write NKDA) Drug allergy (if no known drug allergy, may write NKDA)

13. 11. Vaccination history Place of vaccination Place of vaccination What schedule (Palestinian MOH; UNRWA; Jerusalem area; private clinic) What schedule (Palestinian MOH; UNRWA; Jerusalem area; private clinic) Additional vaccines Additional vaccines Always ask for vaccination card. Always ask for vaccination card. Any vaccine side effects. Any vaccine side effects.

14. 12. Feeding history 12. Feeding history Breast feeding or milk formula. Breast feeding or milk formula. Type and amount of semisolid/ solid foods, & when added. Type and amount of semisolid/ solid foods, & when added. Any vitamin or iron supplementation. Any vitamin or iron supplementation. Difficulty encountered during feeding. Difficulty encountered during feeding. Any known food allergy. Any known food allergy.

15. 13. Growth and developmental history Growth is increase in the size of the organ. Growth is increase in the size of the organ. Development is increase in the function of the organ. Development is increase in the function of the organ. Ask about physical growth (Wt., Ht, HC) especially if records available. Ask about physical growth (Wt., Ht, HC) especially if records available. Developmental mile stones. Developmental mile stones. Gross Motor Fine Motor Gross Motor Fine Motor Social/Adaptive Language/Speech Social/Adaptive Language/Speech

16. 14. Social history:- Address, home condition (sunny, ventilation, rooms…) Address, home condition (sunny, ventilation, rooms…) Health insurance. Health insurance. Parental education & occupation. Parental education & occupation. Family income & socioeconomic status Family income & socioeconomic status Smoking at home!!!! (advice against it; negative smoking is as bad as active one). Smoking at home!!!! (advice against it; negative smoking is as bad as active one).

17. 15. Family history 15. Family history Parental age Parental age consanguinity consanguinity Siblings Siblings Ill contact in the family Ill contact in the family Similar condition in the family Similar condition in the family Family tree. Family tree.

18. 16. Adolescent history 16. Adolescent history [ HEADS history] [ HEADS history] Home Home Education Education Activities Activities Drugs. Drugs. Sexual activity. Sexual activity.

19. PEDIATRICS PHYSICAL EXAMINATION 1.IMPORTANT HINTS 1.IMPORTANT HINTS Avoid irritating the child and prevent him from crying (if possible). Avoid irritating the child and prevent him from crying (if possible). Examine the child in the most comfortable way according to his age (exam table, mother’s hands, mother’s lap, while playing with a toy, while nursing…). Examine the child in the most comfortable way according to his age (exam table, mother’s hands, mother’s lap, while playing with a toy, while nursing…). Postpone the painful and/or irritating examination (temp/throat/ears). Postpone the painful and/or irritating examination (temp/throat/ears).

20. 2. Vital signs 2. Vital signs. Temperature.. Heart Rate.. Respiratory Rate.. Blood Pressure.. O2 Saturation.. CR time.

21. 3. Measurements (Wt, Ht, HC). 3. Measurements (Wt, Ht, HC). Always use growth charts and indicate the percentiles. Always use growth charts and indicate the percentiles. Use appropriate scale for age to measure the weight. Use appropriate scale for age to measure the weight. Naked weight (when possible) Naked weight (when possible) Measure recumbent length till 2 years of age and then standing length (height) after that. Measure recumbent length till 2 years of age and then standing length (height) after that. HC is the occipitofrontal circumference and measures the circumference passing through the most distal points on the occiput and the frontal area. HC is the occipitofrontal circumference and measures the circumference passing through the most distal points on the occiput and the frontal area.

22. Reasons/Benefits to Breastfeeding

25. Stadiometers for Measuring Children and Adolescents

27. 4. General appearance:- 4. General appearance:- State of alertness/ level of consciousness. State of alertness/ level of consciousness. Awareness to environment Awareness to environment Facial expression Facial expression State of nutrition State of nutrition Any special decubitus. Any special decubitus.

28. 5. Skin, Hair, and nails 5. Skin, Hair, and nails Skin: - Color, elasticity, texture, rash Skin: - Color, elasticity, texture, rash Hair: - Texture, color, distribution, areas of hair loss. Hair: - Texture, color, distribution, areas of hair loss. Nails: - Color, texture, shape. Nails: - Color, texture, shape.

29. 6. Head and neck 6. Head and neck Head: - size, shape, fontanelles, sutures, craniotabes Head: - size, shape, fontanelles, sutures, craniotabes Face: - shape, complexion (pallor, cyanosis, jaundice), Face: - shape, complexion (pallor, cyanosis, jaundice), Edema. Edema. Eyes: - degree of slanting, sclera, eyelids, spacing, Eyes: - degree of slanting, sclera, eyelids, spacing, epicanthal folds, palpebral fissure, eyelashes, squint, epicanthal folds, palpebral fissure, eyelashes, squint, sunken, sunset. sunken, sunset. Ears: - size, position, deformity, discharge, ext canal & Ears: - size, position, deformity, discharge, ext canal & Tympanic membranes (shape, color, position,light reflex). Tympanic membranes (shape, color, position,light reflex). Mouth: -mandible, size, lips, tongue, gum, teeth, palate, Mouth: -mandible, size, lips, tongue, gum, teeth, palate, Throat and uvula. Throat and uvula. Neck: - Length, pulsations, thyroid, webbing, LN, torticollis. Neck: - Length, pulsations, thyroid, webbing, LN, torticollis.

30. 7. Lymph nodes:- 7. Lymph nodes:-. Examine all groups (occipital, cervical, axillary,. Examine all groups (occipital, cervical, axillary, groin) groin). Size, consistency, matting, attachment to skin,. Size, consistency, matting, attachment to skin, tenderness. tenderness. 8. Lungs and thorax 8. Lungs and thorax (inspection, palpation, percussion, auscultation). 9. Heart 9. Heart (inspection, palpation, auscultation). (inspection, palpation, auscultation).

31. 10. Abdomen and genitalia 10. Abdomen and genitalia. (inspection, palpation, percussion, auscultation).. (inspection, palpation, percussion, auscultation).. Examine for ascites.. Examine for ascites. 11. Back and spine 11. Back and spine (inspection and palpation) (inspection and palpation) 12. Extremities 12. Extremities (musculoskeletal, joints, and peripheral vessels) (musculoskeletal, joints, and peripheral vessels) 13. Neurological and psychiatric. 13. Neurological and psychiatric.