HISTORY TAKING AND PHYSICAL

EXAMINATION

• History taking and approach

1. A) The Chief complaint is the symptom the patient presents

himself with. It can be stated briefly as e.g. fever, cut wound, or vomiting etc.

1. B) History of the present illness: this is a chronologic description and duration of the chief complaint. We try to answer the following questions;

• Duration of disease onset
• Severity
• Aggravating and alleviating factors
• Associated symptoms
• Any treatment and response to treatment
• History of contact with similar illness
• Relevant pediatric history (like history of immunizations) related to chief complaints or history present illness
• C) Past medical history: this is made up of the illness the patient has had in the past. Past medical history section of paediatrics contains (Past illness, childhood illness, Prenatal history, birth history). Find out if your patient has been hospitalized previously and for what conditions. Do the symptoms he/she has now resemble the one he had in connection with these past conditions, if so then they might be due to the same illness.

In the case of children ask about what childhood diseases they have had. If a child has a rash now which resembles measles you do not have to worry about this condition if he has already had measles or if he has been immunized against measles.

1. D) Social and family history:

The social history should include the parents’ occupation as well as the current living condition. Poverty and ignorance are major sources of ill health. You may have to educate a poor mother with a malnourished baby that the best treatment for her baby is to be breastfed exclusively until the age of one or more. If a mother feeds the baby food containing unbilled water the baby may get diarrhoea. Teach the mother to boil water used for preparing food to infants.

1. E) Immunization status:

Immunization is a way of protecting children against the major diseases of childhood, which harm, cripple or kill thousands of children. Ask the mother about immunization status and if he/she is not properly immunized, take the opportunity of a minor illness to prevent major diseases by advice and vaccination.

1. No proper history can be obtained without observation of the child and the mother.

Some rules in history taking:

Be an intelligent observer (while you are waiting for the undressing of the child or while you are taking with the mother)

Situation

The very sick child your action in history taking try to find out quickly what is causes

The Symptoms of disease (e.g. respiratory distress, dehydration, pain, anxiety). This will direct your history taking. The healthy looking child whose mother believes he is ill. See how the proposed illness affects the general wellbeing or growth of the child. History taking does not have to be long if he looks well. An inappropriate reaction of the mother the recent history may be irrelevant. Social history may be more important to get.

ƒ Abnormal reaction of the child towards

What is happening around him history may be directed towards CNS

2. Listen to the mother’s description of the complaints carefully and get the main symptoms.

• How did the disease start, which symptoms followed?

• Get the time factor. When does the disease start? Has the child had the same kind of symptoms before?
• Ask about the condition of other members of the family?
• How is the child eating at present? How was his appetite in the last month?
• How is he doing between the attacks of illness? Is he weak and inactive or strong and active?
• It may be necessary to obtain the social history in certain conditions such as malnutrition.
• Get the ‘story’. Where has the child gone for help before?What sort of local treatment has he had? What are the mother’s beliefs about his illness/disease?

• Always try to evaluate the weight progress of the child. This is best done by looking at the weight chart which the mother preferably should have and bring to outpatients’ department at every visit.
• Ask about vaccinations done.
• When the symptoms are vague and nonspecific, e.g. tiredness, abdominal pain etc. review the different systems of the body.
• Review of Systems:

The review of the system is essentially the same as in the adult history. It is best organized from the head to down to the extremities. In the child, however, there should be increased emphasis on the symptoms related to the respiratory, gastrointestinal, and genitourinary systems. The high incidence of symptoms and diseases related to these symptoms obligate the interviewer to focus in this area.

To get the important points:

The patient usually comes with his mother and the task is to pick out from all the different information the mother is giving what is important.

• Try to make good contact with her and with the child
• Treat them as human beings who have come for help and advice and do not look upon them as ‘cases’ only.
• Always believe what the mother tells, but try to be realistic about the importance the symptoms she is mentioning.
• If he is not well nourished and not properly immunized, take the opportunity of a minor illness to prevent major diseases by advice and vaccination.
• Use communication skill (APAC: Ask, Praise, Advice and check one’s understanding)
• Physical Examination:

1. A) Principles and techniques of physical examination:

The principles and techniques of physical examinations in the case of small children you should make it habit to undress the child and examine the whole child. To examine the whole body we start with the head and end at feet in older children and adults. In order not to frighten small children it is best to examine things that are uncomfortable or frightening to them last so as not to lose their cooperation. This means the last thing to do in a child is auscultation of the heart, inspection of the ears with an auriscope and inspection of the throat with a throat stick. We use our eyes, ears and hands in addition to a few special items of equipment to perform the physical examination.

1. Chronological steps of physical examination: This consists of three parts:
2. General appearance:

This is what you observe while examing your patient The mental state of the patient

• is he acting normally?
• is he confused?
• is he drowsy, stuporous or even comatose? etc.
• The general physical state of the patient
• the general state of health

• weight and body build
• colours
• respiration

• signs of dehydration
• oedema

1. Vital signs:-These are:

• Temperature
• Pulse rate
• Respiratory rate
• Blood Pressure

The temperature:

All sick children should have their temperature measured

(rectally, orally, and axially) The normal temperature is about 37

• C. A temperature below 36

•C is abnormally low and may

be a sign of infection in a small baby.

A temperature of 37.5

•C is the fever. When there is a fever it

usually means an infection is present and you must try to locate the site of the infection and decide whether it needs treatment and with what.

The pulse:-

The pulse can be felt and count in children radically for fifteen seconds multiply by four. In the infant, it is sometimes easiest to count the heart rate with the stethoscope apically.

Normal pulse rate:

• babies 100-140 beats per minute
• children 80-100 beats per minute

In fever, the pulse rate generally rises. In dehydration, the pulse rate may be very rapid and weak.

The respiratory rate:-

Normal respiratory rate:

• < 2 month ,< 60 breath per minute
• 2-12 months < 50 breath per minute
• 12 month-5years< 40 breath per minute

A rapid respiration of 60 or more in a small, feverish child is a very good indicator of pneumonia

Anthropometric measurement:

• Weight
• Height/Length

• head circumference

• mid-arm circumference • Chest circumstances

Weight:

The best way to assess nutritional status is to take body weight. The weight should be charted on a weight chart. Most weight charts have three curves. The upper line shows the average weight of healthy well-nourished children and this is an ideal growth curve. The middle shows the lowest weight that is still considered to be within limits of normal and the weights on this line are 80 % of the weights on the upper line. The lower curve shows 60 % of the ideal weight. According to Gomez classification, any child whose weight is below this line is marasmic.

Height: Height (length) is also used but more difficult to measure than weight especially in infants. It is a less sensitive measure than weight because it does not decrease during malnutrition, it only stops increasing. This means that height is not affected much for the first six months of malnutrition and is, therefore, more a measurement of longstanding malnutrition.

1. Evaluation of various body system:

• For various body system evaluation, we use our
• eyes for inspection
• hands for palpation • ears for auscultation
• HEENT (hair colour and texture, pallor, oral lesions, ear discharge, eye discharge, neck swellings…) inspection.
• Chest (Inspection, Palpation/ Percussion, Auscultations) • CVS (Inspection, Palpation/, Auscultations )
• Abdomen(Inspection, Palpation/ Percussion, Auscultations )
• GUS (Costo-vertebral angle (CVA) tenderness, Suprapubic tenderness, and inspection of external genitalia)
• Musculoskeletal system( joint swelling or tenderness or deformity, bone swelling or tenderness, muscles)
• Integumentary /skin ( color, lesions )
• CNS( Level of consciousness, reflexes,(motor and sensory )and meningeal Signs