OnExam

Pediatric Considerations

  • Begin by first acknowledging the child directly and then introducing yourself to the caregiver
  • Approach gradually, use a toy to attract attention/curiosity
  • Be flexible on where you examine the child (e.g., floor, parent's arms)
  • If the child is hesitant it can be helpful to perform aspects of the physical examination, such as auscultation or using the otoscope, on the caregiver first to put them at ease
  • Be playful about the examination and use a friendly, reassuring voice throughout
  • Do the least distressing examinations first, leave more distressing manoeuvres (looking at the throat and ears) for last
  • In the impatient child, examine crucial, high-yield areas first
  • Since much of the history will come from a parent or caregiver, clarify their relationship to the patient

Identifying Information

Gather the patient's general identifying data.

History of Presenting Illness (HPI)

  • Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.
  • Onset
  • Location
  • Duration
  • Characteristic
  • Aggravating/Alleviating factors
  • Radiating
  • Timing
  • Severity

Past Medical History (PMHx)

Specifically ask about:

  • Past medical history
  • Past surgical history

Birth History

  • Routine prenatal care
  • Maternal illnesses or drug use during pregnancy:
    • Infections
    • Gestational Diabetes
    • Pre-eclampsia
    • Smoking
    • Alcohol
    • Other substances (IV drugs, etc.)
  • Length of gestation
  • Mode of delivery (vaginal or Cesarean section)
  • Birth weight
  • Complications of delivery
  • Apgar score at birth (many parents will not remember this)(Special test: APGAR score)
  • Any irregularities/malformations, respiratory distress, jaundice, cyanosis, or seizure activity during the neonatal period
  • Maternal age and parity information using the GTPAL method (link to Obstetrical History GTPAL)
  • Length of stay in hospital, any time in NICU

Nutritional History

  • Child's current diet: breast, formula (ask if iron fortified) what solids
  • How baby was initially fed immediately after birth
  • How long baby was breast-fed
  • Number of feeds/day and quantity/duration per feed
  • Ounces of cow's milk/day
  • Juice, non-homogenized milk, or honey intake

Growth and Development

  • Developmental milestones for appropriate age
  • Number of words, sentences
  • Social development, including joint attention and imaginative play
  • Reviews gross motor and fine motor milestones
  • Ask about any regression or loss of milestones already obtained
  • Ask about any delay in milestones the child may have experienced
  • Family History (FmHx)

    Specifically ask about:

    • Health of parents, siblings, and other relatives
    • Hereditary diseases, malformations, developmental delays
    • Parental height, weight, and head cirucumference, helpful for children with short stature or suspected macro/microcephaly

    Social History (SocHx)

    Specifically ask about:

    • Parents: age, gender, occupation, ethnicity
    • hysical living situation: house/apartment, age of the house/apartment, chipped paint, renovations, others sharing same space (siblings, etc.)
    • Exposures in home: smoking, pets
    • Recent travel or immigration
    • Safety precautions around the home: carbon monoxide detectors, smoke detectors, protection of outlets, car seats
    • Educational history
      • When they started attending school
      • Where/what grade currently enrolled
      • Any special needs and how these are being met
      • Concerns from teachers

    Psychosocial History

    Should ideally be obtained from the patient alone, without the presence of parents or guardians if the child is at an age or development level where this is deemed appropriate. Discuss this with the patient and politely ask the caregiver to step out.

    HEEADSSS mnemonic

    • Home environment
      • Living arrangements
      • Relationships at home
      • Supports in the home
      • Changes in living arrangements (e.g., divorced parents)
      • Custody arrangements
      • Any time spent living away from the home
    • Education and Employement
      • Favourite/least favourite classes
      • Grades and changes in grades
      • Bullying
      • Future educational/employment goals
      • Is patient working, and if so where and how many hours
    • Eating
      • Body image
      • Weight change
      • Dieting or other weight management attempts
      • Exercise
      • Current diet/interpretation of a healthy diet
    • Activities
      • What the patient and their friends do for fun
        • With whom, where, when?
      • What their family does for fun
      • Extracurricular activities
      • Sports
      • Groups, clubs, or other organized social activities
    • Drugs
      • Whether friends use alcohol/drugs/tobacco
      • Whether family members/people at home use
      • Whether the patient does
      • Family history of alcohol or drug problems
    • Sexuality
      • Has patient been in a romantic relationship
      • Sexual activity and partners
      • Whether their sexual activities are enjoyable
      • Use of contraceptives and protection from STIs
    • Suicide/depression
      • The patient’s mood
      • Sleeping patterns
      • Level of interest in hobbies or activities
      • Have they ever considered or attempted harming themselves or someone else
      • If so, do they have a plan to carry out suicide
      • What supports do they have to help cope with this
    • Safety
      • Prior injuries
      • Seatbelt use
      • Drinking and driving or accepting rides from people who were drinking
      • Safety equipment (sports or other activities)
      • Violence in the home
      • Violence in the neighbourhood/school/among friends
      • Any history of physical or sexual abuse

    Substance Use

    Medications and Immunizations

    Gather complete list, but specifically ask about:

    • Oral contraceptive pills
    • Childhood immunizations

    Allergies

    Note allergies and ensure they concord with those listed in the EMR

    Immunizations

    Note that it is especially important to note immunization history as described in the immunization history section.

    Review of Systems

    Conduct a review of systems, keeping other etiologies from your differential in mind.

    References

    1. Swartz MH. Textbook of Physical Diagnosis: History and Examination. 6th ed. Philadelphia: W.B. Saunders Company; 2010.
    2. Bickley LS, Szilagyi PG. Bates' guide to physical examination and history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009.
    3. Rourke L, Leduc D, Rourke J. Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance. Canadian Pediatric Society Website. http://www.cps.ca/english/statements/CP/Rourke/RBRNational.pdf. Last updated July, 2011. Accessed on December 20, 2011.
    4. Behrman RE, Kliegman, RM, Jenson HB. Textbook of Pediatrics. 17th edition. Saunders; 2003.
    5. Rosen DS, Goldenring JM (January, 2004). Getting into adolescent heads: An essential update. Contemporary Pediatrics, 21(1), 64-90.
    6. Zitelli, B J., McIntire, S.C., Nowalk, A.J. Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis, 6th ed.. Saunders, 2012
    7. Rourke, L., Leduc, D., Rourke, J. Rourke Baby Record: Evidence Based Infant/Child Health Maintenance,Colleges of Family Physicians of Canada and Canadian Pediatric Society, Retrieved November 2013 from http://www.rourkebabyrecord.ca/pdf/RBR2011Nat_Eng.pdf
    8. Kleigman, R., Stanton, B., Schor, N., Behrman, R. Nelson Textbook of Pediatrics, Saunders, 2011