History Taking and Physical

Examination
Dr George C. Kasonda
Pediatrician
19/10/2017
 Learning Objectives
By the end of this session, students are
expected to be able to:
Describe the components of history taking in
pediatrics and child health
Describe physical examination in pediatrics
List relevant investigations for pediatrics
 History Taking
History Taking
History taking is a medical practice which collects
information from the patient or patient care taker in
order to make a diagnosis and know how to approach
treatment and design appropriate scheme of
management for a patient.
In order to understand each patient, it is necessary to
have his/her history taken considering social, ethnic
and cultural backgrounds.
 The doctor will not only elucidate the problems
posed by disease, but also apply his or her skill
to advise patients and families on how to manage
these problems.
The initial aims of any first consultation are to
understand the patients own perception of
their problem and start or complete the process
of diagnosis.
Appropriate skills are needed to elicit the
symptoms from the patients description and
signs by observation and physical examination.
 Components of a Good Pediatric
History
Components of Good Rapport
History taking is an important part in
management of childhood diseases and
illnesses.
The child is usually brought by his/her mother
or a guardian and it is important for the
health care provider to establish good rapport,
in order to get a well detailed history.
 History Taking
Demographic data
o Childs name
o Sex
o Age
o Place of residence
o Address and telephone number
o Date of taking the history/admission
Note: Report who is the informant
 Chief or main complaints
o Ask for the problem that has caused the child
to be brought to the hospital.
o Probe the caretaker to mention any other
problems and let her/him explain, dont
interrupt (unless critical).
o Ask the duration of each symptom and
arrange the problems (symptoms) in the
chronological order.
This means the symptom with the longest
duration to the shortest duration.
 History of presenting illness (amplification of the chief
complaints)
o Explain in order of occurrence of the symptoms
mentioned in the chief complaints
o Probe the informant to explain further how the
symptoms started
o When asking the questions, look to see how the
symptoms are associated with each other or any
other symptom that a patient has not reported.
o When asking questions, look for complications that
could have already developed but the mother may not
be aware of, write them in the history and remember
them during management/ treatment.
o Ask about any relieving or aggravating factors
o Ask for any treatment (including traditional
treatment) given before coming to hospital.

o Ask for feeding pattern, when last was the

child fed?
Children may come to hospital lethargic or
with impaired consciousness only because
of hypoglycaemia.
 Review of other systems
o Review the systems that have not been
covered in the history of presenting illness,
this should be done systematically to avoid
omissions, the systems to be reviewed are:
Cardiovascular system (CVS)
Respiratory system (RS)
Gastrointestinal system (GIT)
Genital urinary system (GUS)
Ear nose and throat (ENT)
Musculo - skeletal system (MSS)
 Past medical history
o Paediatric history
Ask for previous admissions and their
reasons, diagnosis and treatment given (if
any)
History of previous diseases (if any) that
are associated with the current childs
problems or diagnosis that you are thinking
about.
o Antenatal history
Ask the mother (if present) for any illnesses
and treatment during pregnancy, such
as malaria, syphilis, severe anaemia.
Ask the mother (if present) if she received
Tetanus toxoid vaccine as per EPI schedule.

Number of previous pregnancies and their

results
Serology (for HIV, VDRL), blood grouping and
Hb, their results and any medication
(haematinics, IPT, PMTCT) to the mother.
 Natal history
Was it a hospital or home delivery, was the
pregnancy full term
Mode of delivery, (spontaneous vertex
delivery (SVD), assisted breech
delivery(ASD), caesarean section , vacuum or
forceps delivery)
Rupture of Membranes (timing,
spontaneous or artificial, quality of the fluid -
bloody, clear, cloudy, foul-smelling.)
 Did the baby cry immediately after birth,
or was it after some hours, was the baby
able to suck?

o Post natal history

Any diseases suffered after delivery (e.g.
yellow coloration of the body, bleeding
tendency, sepsis of the cord, convulsions, etc)
Immunization History
o Ask for the RCH card 1, look to see if the child
received all the vaccines and is up to date.

o Note: If the child is not fully immunized, then

arrange for immunization before discharge.
 Dietary history
o Ask about feeding (exclusive
breastfeeding/optional feeding) and
complimentary feeding (age and type of
weaning foods).
o Use the normal feeding recommendations for
the childs age, and if you identify any abnor-
mal practice, give feeding recommendations
as per guidelines.
o Ask if feeding has changed during the illness
Developmental milestones
o Ask for the childs developmental milestones:
Gross motor (movement and posture)
Hearing and speech
Vision and manipulation
Social behaviour
o Ask specifically when the child started to do the above
body functions and what the child is able to do now.

o Compare the above with the childs age and decide if

milestones are normal, delayed or regressed.

o Note: Be careful that the milestones used are based on

European standards not African, as you may encounter
ambiguity.
Family and social history
o Ask if the parents are alive, level of education,
economic status, marital status, habits
like smoking and drinking alcohol.
o If the child is an orphan, who takes care of the
child, the relationship to the child and then
cover the above information about the
guardian
o Gather information on the death of the
parents and establish relationship with the
childs current illness.
o If the child is in school, any similar symptoms
with school mates
o Ask about siblings and their well-being
o Ask about family diseases like diabetes
mellitus, epilepsy, hypertensions, sickle cell,
bronchial asthma and important
communicable conditions (like HIV and TB)
Summary
o Age, sex, how many days since admission,
childs status (e.g. orphan)
o Write the chief complaints, important findings
from history that will lead to diagnosis,
and also any complications developed
o Use few words, at most five lines
 Physical Examination
General Examination
Older children will usually cooperate sufficiently to be examined
lying down, and routine physical examination is no different
from an adult examination.
A younger child should be examined sitting on his or her mother's
lap, as any attempt to get him or her to lie down may result in
instant distress.

Always talk to children, however young; do not be afraid of looking

silly if the result is a cooperative child.

Parts of the examination that are painful or unpleasant should be left

until last: if an attempt is made to examine a child's throat at the
outset, the immediate response will be crying.
 Offer the child something to play with; even a stethoscope will be a
source of amusement
to a young child
Children often find it amusing if you examine their toy first
Sometimes a small toy clipped onto the stethoscope is interesting
enough for a young
child to let you examine them without problems
Routine examination will include the following:
o Look to see if the child is ill looking
o Look to see if the patient is dyspnoeic, listen for grunting, wheeze
or stridor
o Do quick assessment of level of consciousness (AVPU)
 Look and palpate for anterior fontanelle
o Look for pallor, cyanosis, jaundice
o Examine the mucous membranes of the mouth (for
ulcers or white patches-oral
thrush)
o Touch the patient and feel for temperature also at
the same time put an axillary
thermometer and assess for temperature and record it
o Measure pulse rate, and decide whether it is normal
or if there is tachycardia, or
bradycardia
 Count the respiratory rate and decide whether it is
normal or if the child has
tachypnoeia or bradypnoea
o Measure the blood pressure (use appropriate cuff for
the child)
o Look for lymph node enlargement
o Look for oedema
o Assess hydration status
o Do the anthropometric measurements
Weight
Height/length
Mid upper arm circumference (MUAC) for age
Head circumference (occipital frontal
circumference)
 Systemic/Regional Examination
In the paediatrics population it is advised to do regional
approach instead of systemic
approach in doing physical examination
The examination may have to be opportunistic, as each
child will dictate the order of the
examination by their reactions to various procedures
In general, start with the least threatening manoeuvres
and we use the following steps:
o Inspection
o Palpation
o Percussion
o Auscultation
 Ear, Nose and Throat
Inspection
o Discharge and lesion, ulcers, obvious
deformity, if uvulectomy has been done
Palpation
o Tenderness, Percussion (Present or none)
Percussion (Present or none)
Auscultation (Present or none)
 Head and Neck
Inspection
o Shape and size of the head (bossed, obvious swelling, hair pattern
and texture, marks,
in newborn examine skull for plagiocephaly, cephalohematoma and
caput
succedaneum)
Palpation
o Fontanelle, if bulging or normal, sutures if are closed well or
abnormal
Lymph node enlargement, and if enlarged you should describe
them by shape ,size,
texture, mobility
Gentle percussion
o For patients with hydrocephalus for a cracked pot sound on
percussion of the skull
Auscultation (may be needed for some swellings/mass)
 Chest (Thorax)
Let the mother undress the child, to expose the
chest both anteriorly and posterioly
Avoid unnecessary exposure in newborn babies
and in children with severe malnutrition,
as they are at risk of hyperthermia
Inspection
o Look for nasal flaring
o Look at the chest for any asymmetry
 o Look at the breasts and nipples, deformity,
lesions, marks, scars or new growths, and
also look for visible pulsations
o Remember you had already counted
breathing per minute, now see if chest moves
symmetric with each respiration, any chest in
drawing
o Precordial bulging and heave
 Palpation
o Lymph nodes of the axilla
o Locate the apex beat normal is at 4th or 5th
(depending on the childs age), palpate for
thrills (palpable murmur)
o Estimate tactile vocal fremitus (older child)
Percussion
o Lung zones following the anatomical land
marks, anteriorly, axillary and posteriorly
o Normal percussion note is resonance
 Auscultation
o Auscultate for breath sounds in each zone,
anterior and posterior, taking note that you
compare the two sides simultaneously
Are they vesicular, or bronchial?
o Auscultate for any added sounds such as
rhonchi, crepitations/crackles, murmurs,
transmitted sounds
 o Auscultate for vocal resonance (older child)
o Count heart rate, use reference range for
normal values
o Auscultate for heart sounds, and report if 1st
and 2nd heart sounds are heard and
normal or you hear a 3rd heart sound (Gallop
rhythm)
o Auscultate the bases of the lungs for
crepitations, (suggestive of congestive heart
failure)
o Auscultate for added sounds, murmurs
 Abdomen
Inspection
o Contour, distension, symmetry, umbilicus, any obvious
lesion, movement with
respiration, dilated vessels, visible peristalsis or pulsations
Palpation
o Tenderness, succession splash, masses, liver, spleen,
kidneys (bimanual palpation),
bladder (describe the texture, size, location)
Percussion (normal percussion note is tympanic)
o Masses, fluid
 Auscultation
o Bowel sounds
Genitalia, groins, anus
o Inspect the penis, scrotum, and female
genitalia if relevant
o Rectal examination when relevant (new born
gently pass rectal thermometer to verify
patency of rectum)
 Extremities/Upper and Lower Limbs
Inspection
o General examination of arms and hands,
legs and feet
Palpation
o Finger nails (clubbing or koilonychias)
o Oedema of feet
 o Pulse rate, rhythm, volume and character
synchronize with other peripheral pulses
(e.g. radial of the other hand, femoral and
dorsalis pedis)
o Note: capillary refill (should be < 2 seconds)
o Muscles (wasting, tone)
o Joint movement, tenderness or swelling
 Neurological
Neck stiffness and Kernigs sign
Cranial nerves
o Optic (2)
o Occulomotor (3)
Extraoccular muscles-normal action, cause
pupilary constriction and muscles of
the eye lids
o Trochlear (4)
Extraoccular muscles-ability of the eye to look
downward and laterally while -the
other look down wards and medially
 o Abducens (6)
Extraoccular muscles-action is to enable the eye to look laterally,
and horizontally while the other moves medially

o Trigeminal (5)
o Facial nerve (7)
Asymmetry of face when baby cries
o Vestibulocochlea (8) - for hearing
o Glossopharyngeal nerve (9) and Vagus (10)
When baby cries look at symmetry of the uvular for cranial nerve
9 and
swallowing without nasal regurgitation for cranial nerve 10
o Accesory (11) (lift shoulders for older children)
o Hypoglossal nerve (12th cranial)
Look when the baby protrudes the tough for symmetry of the
tongue
 Muscle bulkiness
o Normal or reduced
Muscle tone
o Check by lifting the child and feel for the
resistance
Muscle power (not easy for a baby)
Examine for obvious abnormal movements such
as choreiform, tics, etc
Coordination
o Can be checked by watching a child playing or
tying shoe laces or pointing at
something and touching without missing
 Examination of the back for spinal deformity, swelling
or mass
Primitive reflexes
o Moro reflex
o Grasp
o Stepping
o Rooting
o Sucking
o Tonic neck
o Trunk incurvation
o Crossed extension
o Parachute
o Landau
 Refer students to Handout 2.1: Primitive
Reflexes
 Diagnosis and Investigations
Note: Definitions and formulation of
provisional and differential diagnosis are
covered in the
Clinical Skills module and the same definitions
apply to paediatrics.
 Specimens Specific to Paediatrics
Sickling test
Gastric aspirate:
o Appearance
o For Acid Fast Bacili (AFB)
o For Gram staining
o Culture and sensitivity
Note: Specimens to be collected are covered in
the Clinical Skills module
 Diagnosis
After thorough history taking and
appropriate examination, in 80% of cases a
diagnosis
should be reached
The details of how to reach a final diagnosis
are covered in the Clinical Skills module
 Key Points
History taking is a medical practice which collects
information from the patient or patient
care taker in order to make a diagnosis and know how to
approach treatment and design.
Involvement of the child in the conversation of history
taking is important, provided that
the child is old enough to understand.
In conducting physical exams, avoid of unnecessary
exposure of the neonates and
children with severe malnutrition, because of hypothermia.
Start with the least threatening manoeuvres avoiding
annoying the child before finishing
your examination.
 Evaluation
What is important to remember during history
taking in paediatrics?
List components of general physical
examination in paediatrics.
What specimens are collected in
paediatrics?
 References
Beattie, J., Carachi, R. (2005). Practical
Paediatric Problems (International student
Edition) London: Hodder Arnold.
Behrman, R.E., Kliegman, R.M. (2002).
Nelson Essentials of Paediatrics. (4th Ed.)
Pennsylvania: Saunders Company.