THE PEDIATRIC HISTORY AND PHYSICAL EXAMINATION

By Lewis A. Barness
From: Principles and Practice of Pediatrics, Second Edition. Chapter 6. edited by Frank A. Oski et al. J. B. Lippincott Company, Philadelphia 1994.

HISTORY
Obtaining a complete history on a pediatric patient not only is necessary, but also leads to the correct diagnosis in the vast majority of children. The history usually is learned from the parent, the older child, or the caretaker of a sick child. After learning the fundamentals of obtaining and recording historic data, the nuances associated with the giving of information must be interpreted. For the acutely ill child, a short, rapidly obtained report of the events of the immediate past may suffice temporarily, but as soon as the crisis is controlled, a more complete history is necessary. A convenient method of learning to obtain a meaningful history is to ask systematically and directly all of the questions outlined below. After confidence is gained with experience, questions can be problem-directed and asked in an order designed to elicit more specific information about a suspected disease state or diagnosis. Some psychosocial implications will be obvious. More subtle details often are obtained by asking open-ended questions. Those with organic illness usually have short histories; those with psychosomatic illness have a longer list of symptoms and complaints. During the interview, it is important to convey to the parent interest in the child as well as the illness. The parent is allowed to talk freely at first and to express concerns in his or her own words. The interviewer should look directly either at the parent or the child intermittently and not only at the writing instruments. A sympathetic listener who addresses the parent and child by name frequently obtains more accurate information than does a harried, distracted interviewer. Careful observation during the interview frequently uncovers stresses and concerns that otherwise are not apparent. The written record is not only helpful in determining a diagnosis and making decisions, but also is necessary for observing the growth and development of the child. A well-organized record facilitates the retrieval of information and obviates problems if it is required for legal review. The following guidelines indicate the information needed. If preferred, a number of printed forms are available, which contain similar material, or forms may be modified as long as consistency is maintained.

General Information

Identifying data include the date, name, age and birth date, sex, race, referral source if pertinent, relationship of the child and informant, and some indication of the mental state or reliability of the informant. It frequently is helpful to include the ethnic or racial background, address, and telephone numbers of the informants.

Chief Complaint
After the identifying data, the chief complaint should be recorded. Given in the informant's or patient's own words, the chief complaint is a brief statement of the reason why the patient was brought to be seen. It is not unusual that the stated complaint is not the true reason the child was brought for attention. Expanding the question of "Why did you bring him?" to "What concerns you?" allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying.

History of Present Illness

Next, the details of the present illness are recorded in chronologic order. For the sick child, it is helpful to begin: "The child was well until "X" number of days before this visit." This is followed by a daily documentation of events leading up to the present time, including signs, symptoms, and treatment, if any. Statements should be recorded in number of days before the visit or dates, but not in days of the week, because chronology will be difficult to retrieve even a short time later if days of the week are used. If the child is taking medicine, the amount being taken, the name of the medicine, the frequency of administration, and how well and how long it has been or is being taken are needed. For the well child, a simple statement such as "No complaints" or "No illness" suffices. A question about school attendance may be pertinent. If the past medical history is significant to the current illness, a brief summary is included. If information is obtained from old records, it should be noted here or may be recorded in the past medical history.

Past Medical History

Obtaining the past medical history serves not only to provide a record of data that may be significant either now or later to the well-being of the child, but also to provide evidence of children who are at risk for health or psychosocial problems. Prenatal History If a prenatal interview has been held (see below), this information already may be available. Questions to be answered include those regarding the health of the mother during this pregnancy, especially in regard to any infections, other illnesses, vaginal bleeding, toxemia, or care of animals, such as cats, which may induce toxoplasmosis or other animal-borne diseases, all of which can have permanent effects on the embryo and child. The time and type of movements the fetus made in utero should be determined. The number of previous pregnancies and their results, radiographs or medications taken during the pregnancy, results of serology and blood typing of

the mother and baby, and results of other tests such as amniocentesis should be recorded. If the mother's weight gain has been excessive or insufficient, this also should be noted. Birth History The duration of pregnancy, the ease or difficulty of labor, and the duration of labor may be important, especially if there is a question of developmental delay. The type of delivery (spontaneous, forceps-assisted, or cesarean section), type of anesthesia or analgesia used during delivery, attendance by other family members at delivery, and presenting part (if known) are recorded. Note this child's birth order (if there have been multiple births) and birth weight. Neonatal History Many informants are aware of Apgar scores at birth and at 5 minutes, any unusual appearance of the child such as cyanosis or respiratory distress, and any resuscitative efforts that took place and their duration. lf the mother was delayed in seeing the infant after birth, reasons should be sought. Jaundice, anemia, convulsions, dvsmorphic states, and congenital anomalies or infections in the mother or infant are some of the reasons that viewing or handling of the newborn by the mother may be delayed. The time of onset of any of these abnormal states may be significant. Feeding History Note whether the baby was breast- or bottle-fed and how well the baby took the first feeding. Poor sucking at the first feeding may be the result of sleepiness of the baby, but also is a warning sign of neurologic abnormality, which may not become manifest until much later in life. By the second or third feeding, even brain-damaged children usually nurse well. If the infant has been bottle-fed, inquire about the type of formula used and the amount taken during a 24-hour period. At the same time, ask about the mother's initial reaction to her baby, the nature of bonding and eye-to-eye contact, and the patterns of crying, sleeping, urinating, and defecating. Requirements for supplemental feeding, vomiting, regurgitation, colic, diarrhea, or other gastrointestinal or feeding problems should be noted. Determine the ages at which solid foods were introduced and supplementation with vitamins or fluoride took place, as well as the age at which weaning occurred and the method used to wean. In addition, note the age at which baby foods, toddlers' foods, and table food were introduced, the response to these, and any evidence of food intolerance or vomiting. If feeding difficulties are present, determine the onset of the problem, methods of feeding, reasons for changes, interval between feedings, amount taken at each feeding, vomiting, crying, and weight changes. With any feeding problem, evaluate the effect on the family by asking, "How did you manage the problem?" For an older child, ask the informant to supply some breakfast, lunch, and dinner (supper) menus, likes and dislikes, and response of the family to eating problems.

Developmental History

Estimation of physical growth rate is important. Attempt to ascertain the birth weight and the weights at 6 months, 1 year, 2 years, 5 years, and 10 years. Lengths at similar ages are desirable. These data are plotted on physical growth charts. Any sudden gain or loss in physical growth should be noted particularly, because its onset may correspond to the onset of organic or psychosocial illness. It may be helpful to compare the child's growth with the rate of growth of siblings or parents. Ages at which major developmental milestones were met aid in indicating deviations from normal. Some such milestones include following a person with the eyes, holding the head erect, smiling responsively, reaching for objects, transferring objects, sitting alone, walking with support and alone, speaking the first words and sentences, and experiencing tooth eruption. Ages of dressing self, tying own shoes, hopping, skipping, and riding a tricycle and bicycle should be noted, as well as grade in school and school performance. In addition, note should be made of the age at which bowel and bladder control were achieved. If problems exist, the ages at which toilet teaching began also may indicate reasons for problems.

Behavior History
Amount of sleep and sleep problems, and habits such as pica, smoking, and use of alcohol or drugs should be questioned. The informant should state whether the child is happy or difficult to manage, and should indicate the child's response to new situations, strangers, and school. Temper tantrums, excessive or unprovoked crying, nail biting, and nightmares and night terrors should be recorded. Question the child regarding masturbation, dating, dealing with the opposite sex, and parents' responses to menstruation and sexual development.

Immunization History
The types of immunizations received, with the number, dates, sites given, and reactions should be recorded as part of the history. In addition, it is helpful to record these immunizations on the front of the chart or in a conveniently obvious place with a lot number for future reference when completing school physical examinations or when determining need for booster immunizations or possible reactions.

History of Past Illnesses

A general statement should be made about the child's general health before the present encounter, such as weight change, fever, weakness, or mood alterations. Specific inquiry is helpful regarding the results of any screening tests and regarding any history of roseola, rubeola, rubella, pertussis, mumps, varicella, scarlet fever, tuberculosis, anemia, recurrent tonsillitis, otitis media, pneumonia, meningitis, encephalitis or other nervous system disease, gastrointestinal tract disease, or any other illness, as well as specific treatment, results, and residua. The history of each past illness should include dates of onset, course, and termination. If hospitalization or surgery was necessary, the diagnosis dates, and name of the hospital should he included. Questions concerning allergies include the occurrence and type of any drug reactions, food allergies, hay fever, and asthma. Accidents, injuries, and poisonings should be noted.

Review of Systems
The review of systems serves as a checklist for pertinent information that might have been omitted. If information has been obtained previously, simply state, "See history of present illness" or "See history of past illnesses." Questions concerning each system may be introduced with a question such as: "Are there any symptoms related to . . .?"

Head (e.g., injuries, headache) Eyes (e.g., visual changes, crossed or tendency to cross, discharge, redness, puffiness, injuries, glasses) Ears (e.g., difficulty with hearing, pain, discharge, ear infections, myringotomy, ventilation tubes) Nose (e.g., discharge, watery or purulent, difficulty in breathing through nose, epistaxis) Mouth and throat (e.g., sore throat or tongue, difficulty in swallowing, dental defects) Neck (e.g., swollen glands, masses, stiffness, symmetry) Breasts (e.g., lumps, pain, symmetry, nipple discharge, embarrassment) Lungs (e.g., shortness of breath, ability to keep up with peers, cough with time of cough and character, hoarseness, wheezing, hemoptysis, pain in chest) Heart (e.g., cyanosis, edema, heart murmurs or "heart trouble," pain over heart) Gastrointestinal (e.g., appetite, nausea, vomiting with relation to feeding, amount, color, blood- or bile-stained, or projectile, bowel movements with number and character, abdominal pain or distention, jaundice) Genitourinary (e.g., dysuria, hematuria, frequency, oliguria, character of urinary stream, enuresis, urethral or vaginal discharge, menstrual history, attitude toward menses and opposite sex, sores, pain, intercourse, venereal disease, abortions, birth control method) Extremities (e.g.. weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps) Neurologic (e.g., headaches, fainting, dizziness, incoordination, seizures, numbness, tremors) Skin (e.g., rashes, hives, itching, color change, hair and nail growth, color and distribution, easy bruising or bleeding) Psychiatric (e.g., usual mood, nervousness, tension, drug use or abuse)