Pediatric H&P Information
The pediatric history, though essentially similar to that for adults, should contain certain information usually not recorded for the older patient. In addition, some areas of the history require greater or lesser emphasis. These notes are not intended to define the entire pediatric history, but rather to emphasize the main differences from the history for adults.
The age and sex of every patient, at the beginning, are essential for orderly consideration. These facts must be included at the beginning of every write-up.
One of the most important aspects of the pediatric history is that it is usually obtained from a person other than the patient. Thus, identification of the source of the information and an estimate of the reliability of that individual are extremely important. Information may be exaggerated, minimized or withheld by the parent or other individual providing the history. Since the history is usually taken while the child is present, it is appropriate to turn to him/ her occasionally (provided that he/she is old enough to respond) and seek confirmation of the complaint by asking direct questions, such as "Can you show me where it hurts?" For the older child, differences between the parent's assessment of the situation and the child's version may become apparent. This type of information can be very useful to the examiner in his/her evaluation of the family, as can other observations of the interaction of patient and child (excessive dependency, unusual degrees of permissiveness or discipline).
This is the primary reason why the patient or parent(s) is seeking medical aid and should be in his/her own words. Remember that the reason stated by the parent for bringing the child to medical care may not be the real one. The mother who just wants her child to "have a thorough check-up" actually may be seeking help with behavioral problems, school difficulties or other complaints that are uncomfortable for her to discuss.
The "work" of the young child is play, and that of the older child is school. Questions about these activities should therefore replace those relating to work and life style for the adult.
Past Medical History
The past medical history of the child should begin with the pregnancy which results in his birth, with particular attention to its length, any significant illnesses or bleeding, the adequacy of prenatal care, and exposure to any drugs or irradiation. The length of labor, the type of delivery, and the birth weight should be recorded if known. Problems during the neonatal course, such as the need for being in an incubator, of receiving oxygen, or the presence of "mucus", jaundice, or cyanosis should be identified. If the mother's recollection is hazy (which is frequent for this kind of information), two useful clues may be obtained by determining whether the infant was brought to the mother early and regularly, and whether he went home on schedule with her. If a Cesarean section was done, indicate why.
For children in the first two or three years of life, information about early feeding patterns can be important, and should therefore be obtained regularly. Was the infant breast or bottle fed; when were solid foods such as cereal begun; were vitamins or iron given; when was the child weaned from the breast or bottle?
The history regarding communicable diseases is particularly important in children, since the lifelong immunity conferred by most of these diseases is an important consideration in the differential diagnosis in a child with an acute infection. For similar reasons, the immunization status in regard to diphtheria, tetanus, pertussis, varicella, poliomyelitis, hemophilus influenza Type B, hepatitis B, rubeola, rubella mumps, and stretococcal pneumoniae should be obtained for each patient. Some patients may have been immunized against influenza, typhoid or other conditions, particularly if they have underlying heart problems or have been abroad.
Family Medical History
A question about congenital anomalies is warranted, particularly if the patient is being evaluated for an anomaly. ANY DISEASE WHICH IS SUSPECTED IN THE PATIENT MAY NEED TO BE SOUGHT IN THE FAMILY. Remember – This should be reported from the standpoint of the patient. (eg. mom may state that her dad has hypertension but you would write: paternal grandfather with hypertension.)
Review of Systems
The systemic review must be tailored to the age and primary complaints of the patient. A question about urinary or fecal incontinence has little meaning for the small infant! On the other hand, the occurrence of bedwetting after age five years would be of significance and should be recorded. Similarly, subtle complaints such as palpitations or parethesias may not be readily recognized or interpreted by a child.
An extremely important aspect of the review of systems in childhood relates to growth and development. When possible, it is desirable to obtain previously recorded growth data, as are often available from physician's instruction booklets or from baby books kept by the parents; these data may be compared with those obtained at the time of the present evaluation. It is sometimes useful to compare the growth of an individual child with that of his siblings.
Development data may be more difficult to obtain, particularly as children become older; again, baby books may be helpful. Though information about all of the aspects of development (motor, adaptive, language and personal/social) is desirable, it is often difficult to ascertain the precise ages at which the child achieved a specific milestone. Recollections about the following tend to be reasonably accurate:
1. Motor - age when walked alone, rode a tricycle
2. Adaptive - age when learned to button up
3. Language - first words and use of words as short sentences
4. Personal/Social - age when toilet trained
It is also important to develop some understanding regarding the personality and behavior of the child. Inquiry should be made regarding the child's relationship with adults, siblings, and peers. Patients should be asked about overall behavioral patterns, such as "nervousness," hyperactivity, or a tendency to become upset with light provocation. Habits such as thumbsucking, nail biting, and pica should be asked about, as should the common behavioral problems like temper tantrums, sleep disturbances and unusual fears. It is desirable to get information about whether the child is easy or difficult to discipline, and who in the family is responsible for most punishment. Detailed discussions about behavior problems should not, of course, be conducted in the child's presence.
Physical Examination of the Infant and Child
Many students, and experienced physicians, approach the examination of the infant and child with trepidation and lack of confidence. In actuality, the thorough examination of a pediatric patient can be accomplished in only a few minutes if the examiner takes the time to establish rapport with his patient, approaches the task in an organized and logical way, and is familiar with the normal variations in pediatric patients. You are encouraged to use every opportunity for examining the infant or child, for only with experience will you be able to accomplish the task easily and interpret the findings accurately.
Approach to the Child
The normal apprehension of the young patient can often be alleviated by a gentle and friendly approach. Most physicians develop a few "tricks" that fit their style and personality, and help them to achieve a satisfactory examination. It may be useful to allow an infant to have his bottle or a pacifier. An older infant or a young child is often best examined on his mother's lap. Allowing the child to touch or play with the examination instruments may relieve his fear of them. It is often helpful to establish physical contact with the child prior to the examination, such as handing him a toy or even playing with him gently. Above all, carry out first those parts of the examination that would be most interfered with by crying, such as auscultation of the heart or palpation of the abdomen; examination of the ears, eyes, and throat or a rectal examination should be deferred until last! If all else fails, and using a kind and understanding attitude, restrain the child firmly but gently, and get the examination done as expeditiously as possible despite his apprehension and resistance.
NO MATTER WHAT, ALWAYS TELL THE CHILD THE TRUTH ABOUT WHAT IS TO HAPPEN.
Vital Signs and Measurements
The temperature of infants and pre-school children child is best taken rectally since most younger children cannot be trusted to hold the thermometer under the tongue without biting or dropping it. The heart rate of young infants is often easiest to measure by auscultation at the cardiac apex. The respiratory rate should always be counted, especially in infants, since tachypnea may not be appreciated otherwise. Length is recorded for infants and toddlers less than 3 years while supine; height is recorded for the older child who is measured while standing. Measurement of head circumference is done at the time of each visit during the first two years of life, but usually only on the first visit thereafter, unless apparently abnormal.
Head to Toe Exam
The findings of nodes up to one centimeter in diameter in the anterior cervical and inguinal regions is common in children, and of itself should not be considered to be significant. We reiterate strongly the notation in your text regarding the frequency with which normal children have normally large tonsils.
Lack of cooperation of the patient discourages routine funduscopic examination in infants and young children, but at least the presence of a red reflex should be determined. The early diagnosis of strabismus, if present, is essential, and should be determined by identifying an asymmetric reflection of a bright light in the eyes, or by the use of the "cover test." (Cover one eye at a time, and observe for shifts of the uncovered eye, or of the covered one after the cover is quickly removed.)
Otoscopic examination is an essential part of every pediatric evaluation. In the infant, the canal is directed upward, so the auricle should be pulled downward to view the drum, rather than upward and back as in the older child and adult.
Mouth and Throat
This phase of the examination is usually best left until last; even some very "good" children become upset when approached by a physician with a light in one hand and a tongue blade in the other. Every child should be given the opportunity of opening his mouth and extruding his tongue without "assistance"; it is often possible to visualize all structures down to and including the epiglottis in this way. If the child is uncooperative and resistant, assistance of the mother or nurse should be obtained so that the examination can be conducted as expeditiously as possible; the hands and head can be immobilized at the same time for example by "pinning" the raised arms of the supine child against the side of his head.
The most common health problem of children is dental caries; inspection of the teeth and gums should be a routine part of each examination.
During early infancy, and especially in premature infants, respiratory movement may be irregular, intermittent and variable in rate and depth. Pauses between breaths up to 10 seconds, in the absence of cyanosis or other indicators of respiratory distress, are common in normal infants during sleep. Breathing during infancy and early childhood is characteristically abdominal or diaphragmatic in appearance. Thoracic movements with breathing become more predominant around age 7-8 years and older. The normal range of respiratory rates, sleeping and awake is found in your references.
Slight retractions with inspiration are commonly observed, especially during infancy. More pronounced retractions, especially when associated with tachypnea, are seen with important pulmonary disease.
Percussion is performed in infants and children in much the same manner as for adult patients. Auscultation requires a stethoscope with small enough bell or diaphragm to fit closely over the interspaces. In infancy and through age 5-6 years, breath sounds are relatively louder and harsher compared with those in adults. Classify breath sounds as:
Vesicular (loud during inspiration, medium-to-high pitched, and long duration; heard best over the upper lung fields and into the axillae).
Tracheal (heard over the trachea / upper sternal region; more tubular and higher pitched than vesicular breath sounds).
Bonchovesicular (longest during expiration, with high pitch and increased amplitude compared to inspiratory phase sounds; heard best between scapulae and parasternal anteriorly).
Rhonchi (musical continuous sounds; includes categories of wheezing and vibrations).
Rales (crackling or bubbling; fine versus coarse).
Rubs (grating, jerky, leathery, creaking, rubbing sounds which can be intensified with increased pressure on the chest wall with the stethoscope).
Heart and Blood Pressure
Examination of the heart begins with inspection for the normal apical impulse as well as any unusual precordial impulses. These may be difficult to palpate in infants, but by age 4-7 years most children will have a palpable apical impulse in the 5th to 6th interspace within the mammary line. It is best palpated with the child sitting and leaning forward. During this portion of the cardiac exam, it is important to palpate for pathological thrills associated with the louder (grade 4 and louder) murmurs. The determination of heart size by percussion is of limited accuracy for most examiners (malposition of the apical impulse is usually a better indicator of possible cardiac enlargement).
The resting pulse rate should be recorded for comparison with reference values. The normal range of resting heart rates for infants and children is found in your references.
In sinus arrhythmia the pulse rate increases during inspiration and slows during expiration. This is a normal finding in most children above age three. A slow heart rate (relative to the ranges described above) is frequently noted in healthy trained athletes.
Palpation of the femoral pulses should be routinely performed to detect possible coarctation of the aorta, however presence of a normal femoral pulse does not exclude coarctation.
The preferred stethoscope for cardiac auscultation in children is one with a combined bell (for low frequency sounds) and small diameter diaphragm (for mid-to-high frequency sounds). Examine heart sounds with the patient in the following positions: supine, left lateral decubitus, sitting, leaning forward, and standing. In most normal children, S1 is louder than S2 near the apex, and the converse is true near the base. Splitting of S2 is best appreciated using the diaphragm near the base of the heart. The sounds split during inspiration and are almost synchronous during expiration. In the newborn, S2 is either a single sound or minimally split due to the normally high neonatal pulmonary arterial resistance and afterload, plus the relatively fast heart rates in this age group. An apical S3 is often heard during diastole in normal children. When an S3 is present in a tachycardic patient or with other findings suggesting heart disease, it is more appropriate to label it as a gallop rhythm. S4 diastolic sounds are never normal.
Heart murmurs are present in around 50% of children, while the incidence of congenital heart disease is slightly less than 1% in the general population. Clearly therefore, most murmurs will turn out to be innocent. Determining whether a murmur is normal (innocent) or pathological requires more than simply listening to heart sounds. This assessment includes relevant past and family history, other aspects of the physical examination, occasionally laboratory testing (e.g., chest x-ray, electrocardiography, and/or echocardiography), and is frequently made clear simply on the basis of follow-up.
Describe murmurs on the basis of:
Position in the cardiac cycle (e.g., systolic, diastolic, continuous).
Either ejection or regurgitant in character. Ejection murmurs are generally heard over the base and are frequently normal or innocent. Regurgitant systolic murmurs are always pathological, and are heard closer to the apex. Regurgitant diastolic murmurs are also always pathological in origin.
Transmission (i.e., where does the murmur radiate).
Duration (e.g., early systolic, holosystolic, early diastolic).
Quality (e.g., blowing, rasping, rumbling, etc.)
Pitch (e.g., high pitch or frequency heard best with the diaphragm versus low-pitch heard best with the bell).
Intensity (i.e., grade 1-6)
Response to exercise and/or change of position (e.g., loudest while supine).
Blood pressure determination in the arms and legs should be included in routine well-baby and well-child examinations. Except for infants, the BP should be taken while the child is sitting. Blood pressures recorded with an inappropriately small cuff will be too high, and those with too large a cuff may be falsely low. The proper cuff has a width which is approximately 40% the circumference of the extremity where it is placed. The two measurement methods in most widespread clinical use are sphygmomanometric and oscillometric (e.g., the Dynamap automated BP device). The normal range for blood pressure varies depending upon age, size (e.g., height), and sex of the patient. Tables of normal blood pressures are found in your references.
The liver edge in the infant is often palpable one to three centimeters below the right costal margin; apparent hepatomegaly may be the result of depression of the diaphragm (e.g. due to a lower respiratory infection or asthma) --appreciation of the normal consistency and edge of the liver will help in identifying this problem. The spleen tip may also be palpable in normal young children. Palpation of the femoral pulse should be a routine part of the examination of the young infant, since it may lead to the diagnosis of coarctation of the aorta.
The presence of an inguinal hernia may be detected in the infant and young child by palpating over the inguinal canal for the presence of the sac which is manifested by thickening of the cord structures and sometimes by the sensation of a "silk-glove" beneath the examining finger. A hernia in a female may contain the ovary which can be identified as a small mass within the protruding sac.
The urinary meatus should always be inspected; a tiny round opening instead of the normal slit may indicate the presence of stenosis. Because of the very active cremasteric reflex, small children may appear to have cryptorchidism; if the hands are warm and gentle, the apparently undescended testis can often be milked down the canal and into the scrotum to confirm its normal location.
Tanner staging is important.
Adhesions of the labial mucosa are fairly common in young girls, and probably require no treatment if not extensive. A white discharge is often seen in normal girls during the year or so preceding the onset of menstruation. Inspection of the vaginal orifice for foreign bodies, or the obtaining of vaginal material for laboratory examination, is sometimes facilitated by placing the child in the knee-chest position. Digital or instrumental examinations of the vagina are not done routinely in children, but only on specific indication. Tanner staging is important.
Anus and Rectum
Rectal examinations are not done routinely in children, but should certainly be performed on the slightest indication, including some of those complaints for which a pelvic examination would be done in the adult female. Rectal exam may be helpful in identifying the presence of a vaginal foreign body. INSPECTION IS MANDATORY IN ANY EVENT.
The shape of the legs and feet of infants and young children is determined to some extent by the intrauterine position. Some degree of bowing and inward rotation is common, but external rotation may occur. The foot of the infant tends to appear flat, and the pre-school child's foot is often pronated. In the latter circumstance, having the child stand on his toes may reassure the examiner of the normalcy of the longitudinal arch. Mild degrees of knock-knee and bow-legs are not significant in young children.
The ability of the thigh to be abducted at the hip should be tested throughout infancy, since inability to abduct is the commonest presenting finding in infants with congenital hip dysplasia.
SOME TIPS ON RECORDING A HISTORY AND PHYSICAL EXAMINATION
Perhaps the second most difficult area in the entire process is spelling. We hold to the notion that those who have at least one college degree and will soon have another, should be able to use English with reasonable facility. Some common errors, along with notes of explanation follow. Please understand that this list barely scratches the surface.
|Mucous||This is the adjective and is not to be confused with:|
|Mucus||This is the noun. They are not interchangeable. Nouns are things which adjectives modify.|
|Funduscopic||The only correct way, believe it or not.|
|Inflammation||There are 2 "m's" in this word.|
|Inflamed||There is only 1 "m" here, so save them.|
|Vomiting||Save your "t's", they also may become valuable some day.|
|Enfamil||A proprietary milk product.|
|Organomegaly||One "l" is enough.|
|Microcephalic||With 2 "l's" it becomes an outrageous pun.|
Words to be Avoided and Words to be Used Correctly
There are many lay terms that have no place in a medical document. Others are not words at all and should never be used anywhere. Some of these are:
|Mucousy||The word you are looking for us mucoid.|
|Pussy||Here the word is purulent. No further comment seems advisable.|
|Temperature||We all have a temperature; some of us have a fever.|
|Phlegm||The word is mucus, not to be confused with mucous.|
|To seize||Meaning to have a seizure. To seize is to grab.|
|Matter||A lay term if it means pus in the eye.|
|There is no such thing as an acute abdomen. There may be an acutely inflamed abdomen.|
Strictly avoid the apothecary system at all costs. The most confusing term is grains which may be abbreviated gr. and which in turn may be confused with grams. To protect yourself and to protect your patients, never use this term. Absolutely. It is not difficult to remember that 65 mg = one of those things. Other units in the apothecary system are even more archaic.
Don’t use them!
The organization of your write up should be constructed with the following thoughts in mind.
Please remember that the chief complaint is exactly that--not a complete history.
The present illness should contain all of the information which is germane to the problem which brought the patient into the hospital. This must include both positive findings and pertinent negatives. The review of systems must contain all of the remaining points which may be germane to the case. For example, if the patient is thought to have asthma, then you will wish to include some comments in the present illness or review of systems in regard to symptoms of cystic fibrosis, which always is part of the differential of asthma. But not both. Relative importance is the determining factor; there are no absolute rules. Repeat nothing. Once you have mentioned it once in the history, please feel free to reference it throughout. Always time everything in relation to admission in chronological order. Absolute times and dates are worthless.
Omit nothing in the physical examination. Those parts of the body which you do not invade must still be viewed and described. Specifically, this refers to ear drums, fundi, breasts, genitalia, and the remainder of the perineum. Always fully describe every abnormality. Size, shape, tenderness, color, and so on.
If you admit a patient who has been in several times for the same problem (for example, a patient with a malignancy, hemophilia, myelomeningocele, or some other chronic condition), you may limit your write up to a review of all available information succinctly presented, a description of the present illness or present episode which brought the patient to the hospital, and the usual complete physical examination.
In the family history, be sure that the facts are related to the suspected diagnosis. This will demand a knowledge of genetic patterns which are to be found in textbooks. For example, the questions to be asked, if you suspect hemophilia or cystic fibrosis must be quite specific and different.
The conclusions which you reach are the most important part of the entire write up and of course the conclusions must be based on what has gone before. In other words, the findings should logically lead to the conclusions. You are entitled to at least one diagnosis. Avoid even a very short list of "rule-outs." We wish to know what you think the patient has, not what he does not have and we wish to know why you reached a certain conclusion. The diagnosis is meant to explain the chief complaint, which was the primary reason for admission to the hospital. In every instance where an etiology can be suspected, it must be indicated. Using the term virus or some other generality is not acceptable. When you write out the plan for the patient, do not include any order with which you do not agree. Anything which you think should be done and is not ordered should be listed with the reason given. Do not lump chemistries; do not indicate a “CMP.”. Rather, designate those portions of that study which are indicated in this instance. Always explain any order which is in any way debatable, indicating why you think that order should be written or that study requested.
Please review this paper carefully. If you will adhere to these suggestions, you will find that there will be much more time for advanced learning.
H&P Grading Form