Introduction to

Paediatrics: history taking

and physical examination
SAMUEL N UWAEZUOKE, FWACP (Paed)
PROFESSOR OF PAEDIATRICS & HEAD OF DEPARTMENT
 What is Paediatrics
(Pediatrics)?
• The branch of medicine that oversees the medical care of
o Infants
o Children
o Adolescents
o Young adults
• The term ‘’Paediatrics’’ is derived from two Greek words: pais (‘’child’’) and
iatros (‘’doctor or healer’’)
• Age range of subjects: infants (0-12 months) to adolescents (13-18 years )
• American Academy of Pediatrics (AAP) recommends the age limit of 21 years
What is Paediatrics (Pediatrics)?
• Paediatrics is a medical specialty governed by age

• The child’s age (component of biodata) must first be determined

whenever one considers a paediatric problem: medical,
developmental or behavioural

• The history must be adapted to the child’s age (e.g. the age when a
child first walks is highly relevant when taking the history of a toddler)
The
paediatric
age groups

 Neonate or
neonatal infant (0-
1 month)
Paediatric
age groups

 Infant (1-12
months)
Paediatric
age group
 Toddler (1-2
years)
Paediatric
age groups

 Preschooler
(2-5 years)
Paediatric
age groups
 School-age
child (6-12
years)
Paediatric
age groups
 Adolescent or teenager
(13-18 years)

 WHO definition of
adolescence: 10-19
years (onset of
menarche or
spermarche to 19
years)
Basic feature of the paediatric
age groups

•Growth and development

• Maturation process into adulthood

Parameters of growth
(anthropometric measurements)

• Linear growth length (0-24 months)/height (>24 months)

• Increase in size weight

• Body proportions head circumference (OFC), mid-arm

circumference (MAC), upper/lower-body segment ratio, arm span etc.
Major fields of development
• Gross motor (e.g. head control, sitting, crawling, standing etc.)
• Fine motor and vision (e.g. follows a face, palmar grasp, pincer grasp,
hand transfer etc.)
• Social and skills (e.g. social smile, feeds himself, drinks from a cup
etc.)
• Speech, language and hearing (e.g. startles to loud noises, sound-
distracted, cooing and babbling etc.)
• Bowel and bladder continence or control (response to toilet training)
• External primary and secondary sexual characteristics (Tanner stages
or sexual maturity rating: I, II, III, IV, V)
Tanner stages or sexual
maturity rating (SMR)
Illustration for males Illustration for females
History taking and physical
examination
• History taking and physical examination are the cornerstone or
bedrock of clinical practice
• The first step in gathering information about the paediatric patient
• The history (asking questions) is the single most important method of
establishing a diagnosis
• After a good history, you can be 80% sure of the diagnosis
• Depending on the child’s age, information can be obtained solely from
the parent/informant (child < 7 years), from both the parent and the
child (child 7-12 years) and solely from the adolescent
History taking in Paediatrics:
the format
1. Biodata(basic information): age, sex, ethnicity, parental religion,
domicile/residence

2. Chief complaint/presenting complaint/presenting symptom(s): the

usual response from the patient or informant to the question- ‘’What
brought you to the hospital today?’’ or ‘’Why are you seeing the doctor
today?’’ Should be noted in the patient’s/informant’s own words.
Duration must also be established
History taking in Paediatrics:
the format
3. History of presenting complaint:
• Be open-minded and don’t be influenced by other people’s diagnosis
• Be goal-oriented. While allowing the informant to recount the history, be
ready to ask direct questions based on your perceived likely
diagnosis/differential diagnosis and knowledge of pathophysiology
• Determine the intensity/severity of the primary complaint, if it’s getting
worse, the associated symptoms, aggravating and relieving factors and
previous attempts at treatment
• Both positive findings (e.g. the stool was loose and voluminous) and
negative findings (e.g. there was no blood or mucus in the stool) are
appropriate
History taking in Paediatrics:
the format
4. Past medical and surgical history:
• Previous recurrent history of catarrh/cough may suggest atopy. Thus,
what appears as minor illnesses should not be overlooked
• Any previous hospitalizations?
• If surgery was performed; when, where and why?
• Any complications arising from the surgery?
History taking in Paediatrics:
the format
5. Prenatal, natal and postnatal history:
• Maternal history of drug use and infections
• Delivery route and gestational age
• Cry and weight of the baby at birth
• Jaundice (severity should be noted): phototherapy, exchange blood
transfusion
• Breathing and feeding difficulties
• Prolonged hospitalization
History taking in Paediatrics:
the format
6. Nutritional history:
• Breastfeeding (Exclusive breastfeeding? Predominant breastfeeding?
Mixed feeding?)
• Breast milk substitute (artificial milk) only?
• Complementary feeding (age of introduction and nature of feeds)
• For older patients, typical family menu
• 24-hour dietary recall
History taking in Paediatrics:
the format
7. Developmental history:
• The extent of the information obtained under developmental history
should be age-driven.
• For instance, it is appropriate to emphasize on one gross motor
milestone (head control) in a 2-month old infant but inappropriate to
ask about a fine motor milestone
• Bladder and bowel control should be explored in the preschooler
• Sexual maturity rating should not be missed in the adolescent
History taking in Paediatrics:
the format
8. Immunization history:
• Be familiar with the latest NPI schedule and explore the immunization
status of the patient (dates for primary and booster doses are
important)
• Check the immunization card (if available with the mother)
• Other ways of authenticating the status: be familiar with sites/routes
and age of vaccine administration, check for BCG scar over the left
deltoid
• Note missed immunizations and reason(s)
History taking in Paediatrics:
the format
9. Drug and allergy history:
• Names of current medications (if they can be provided by the
informant)
• Were the medications prescription-based or over-the-counter (OTC)?
• Use of herbal remedies
• Reactions to medications
History taking in Paediatrics:
the format
10. Family and social history:
• Family history of heritable illnesses: in siblings, parents, grandparents
and close relatives
• Social classification of parents (Oyedeji classification uses parental
education and occupation to classify them into I, II, III, IV and V)
• Living conditions/arrangements: overcrowding promotes respiratory
infections, poor sanitary practices promote diarrheal diseases, non-
use of insecticide-treated nets (ITN) promotes malaria transmission
etc.
History taking in Paediatrics:
the format
11. Review of systems:
• Asking a few questions about each of the major systems to ensure
that no problems are overlooked and to obtain important history
about related and unrelated medical conditions
• Essentially a symptom check-list of these major systems: respiratory,
digestive, cardiovascular, neurologic, urogenital, and musculoskeletal.
Other systems can be explored: hematologic, endocrine,
integumentary (skin and appendages)
Physical (clinical) examination:
some tips
• Be flexible in your approach and not stereotypic given the different
psychosocial characteristics of the paediatric age groups
• Obtain the child’s cooperation. Infants and toddlers always show
stranger-anxiety
• Adapt the examination to suit the child’s age (e.g. a toddler is best
examined on his mother’s lap or distracted with a toy)
• Always examine a child with warm smile, warm clean hands and a
warm stethoscope
• Remember to follow the IPPA pattern (Inspection/Observation,
Palpation, Percussion and Auscultation)
Physical (clinical) examination:

General examination Systemic examination

General examination: inspection
(look!) and palpation (touch)
1) General appearance:
• Severity of illness (toxic looking?, acutely ill-looking?, chronically ill-
looking?). If acutely ill, perform a rapid assessment for Airway and
Breathing (respiratory rate/effort, stridor or wheeze and cyanosis),
Circulation (heart rate, pulse volume, capillary refill time) and Disability
(level of consciousness)
• Lethargy (poor or absent eye contact and refusal to interact with
environment)
• Nutritional and growth status (well nourished? poorly nourished? small-for-
age)
• Dysmorphic features (e.g. chromosomal disorders)
General examination: inspection
(look!) and palpation (touch)
2) General signs: pallor, pyrexia (axillary temperature >37.7⁰C),
cyanosis, jaundice, lymphadenopathy, peripheral oedema, finger
clubbing
3) Vital signs and anthropometry: Temperature, pulse rate/heart rate,
respiratory rate, blood pressure, height, weight, and head
circumference (generally measured until age 3 years). Measurements
should be compared to normals for age (BP nomogram, growth charts)
4) Face, head and neck, and hands: stigmata of syndromes/diseases,
fontanelle and sutures
Systemic examination:
important reminders
• It is better to first examine the system(s) implicated by the presenting
complaint(s)
• For each system, follow the IPPA pattern
• Textbooks on clinical methods are recommended to guide you on the
examination of systems
• You will be exposed to hands-on experience on systemic examination
during the Paediatric postings (P1 & P2)
• Try and acquire competences or skills in each systemic examination
during the postings