[01.12] Pediatric History-Taking and Physical Exam V2

Predictable pathway governed by the maturing brain

What is the first principle of child development regarding its progression?

Measure age-specific milestones to characterize a child’s development

According to the first principle, what should be measured to assess a child's development as normal or abnormal?

The range of normal development is wide

What is the second principle of child development concerning the rate of maturation?

No one value

According to the second principle, what should be avoided when determining if a child's development is abnormal?

Variety of physical, disease-related, social, and environmental factors

What strongly affects child development and health, according to the third principle?

Brain (and other organ) development

According to the third principle, what development is crucial in children and affects them later in life if disturbed?

Tailor the physical examination to the child’s developmental level

What must be done to the physical examination based on the child's developmental level, according to the third principle?

Child’s developmental level

What affects the nature of the medical history and physical examination, according to the fourth principle?

Fundamentally different

How does interviewing a 5-year-old compare to interviewing an adolescent, according to the fourth principle?

Similar

How does examining a 20-year-old and a 40-year-old compare to examining a 5-year-old and a 10-year-old, according to the fourth principle?

Parents and/or guardians

When taking a pediatric history and physical exam, who must you be mindful of dealing with?

Depending on the age of the patient, primary historian may be the patient and/or another person, usually the parent

What factor distinguishes pediatric from adult history regarding the primary historian?

Rapport with parents/guardians, and/or yayas

What needs to be established when talking with minor patients, as they might be involved?

Developmental factors

What factors are commonly considered in a pediatric medical interview?

The differential diagnosis of a condition

What may vary depending on the age of the patient in a pediatric interview?

Health care maintenance (e.g. immunizations and safety issues) and social issues

What plays a major role in emergent and routine pediatric care?

Prenatal, birth, maternal, neonatal, and feeding histories

Besides standard past medical history items, what else should be discussed in a pediatric history?

Age of the patient and the reason for the visit

What determines the relative importance of prenatal, birth, maternal, neonatal, and feeding histories?

Birth history is not significant

For an adolescent coming in for an acute minor trauma visit, what part of the history is generally not significant?

Patient history

What is considered the most important tool regardless of the type of doctor?

Poor patient history

What leads to poor differential diagnoses?

Good patient history

What is the physical exam hinged upon the context of getting?

Mother’s age at delivery, gravidity/parity and history of spontaneous abortions (miscarriages)

What specific information should be included in the prenatal history?

Diabetes or eclampsia/pre-eclampsia

What maternal past medical conditions should be inquired about in prenatal history?

Oligo- or polyhydramnios

What conditions related to amniotic fluid should be asked about in prenatal history?

Known fetal abnormalities and results of amniocentesis

What fetal-related information should be covered in prenatal history?

Maternal and paternal medications, occupational exposures at the time of conception and through the pregnancy

What exposures and substances for both parents should be asked about?

Maternal and paternal smoking, alcohol, homeopathic product, and illicit substance use

What specific substance use by parents should be inquired about in prenatal history?

Maternal uterine abnormalities, maternal pet exposure and meat ingestion

What other maternal factors are relevant to prenatal history?

Duration of labor and pregnancy

What details about labor and pregnancy duration should be obtained?

Duration of ruptured membranes

What information regarding membranes should be recorded?

Maternal treatment with medications and their timing (antibiotics and anesthetic agents)

What maternal treatments are important to note?

Presentation (vertex vs. breech) and method of delivery (including forceps or vacuum extraction)

What delivery characteristics should be included?

Gestational age at delivery and Birth weight

What two key measurements at birth are important?

APGAR scores

What scoring system is important to obtain from birth and neonatal history?

Interventions in the delivery room, length of stay in the hospital after birth, need for ICU care

What post-delivery care information is relevant?

Diagnosis of hypoglycemia, hypothermia, anemia, convulsions, respiratory distress, jaundice, birth injuries

What neonatal diagnoses should be included?

Initial feeding by breast or bottle (including frequency and duration/quantity), quality of latching and suck

What details about initial feeding methods are important?

Preparation of formula

If bottle-fed, what specific information about formula is relevant?

What they are eating, how much, if they are eating fruits and vegetables, caloric content/intake

For older patients, what should be asked about their current eating habits?

Introduction of solids (including quality and quantity of solids, any adverse reactions to foods)

What details about the introduction of solids are necessary?

Nutritional supplementation (incl. fluoride)

What type of supplementation should be inquired about?

Nutritional balance, meal frequency, fluid intake (including milk, juice, water, and sports drinks)

What aspects of overall diet and fluid intake should be covered?

Malnutrition/undernutrition

What nutritional issue is still common in the Philippines?

Allergies or adverse reactions to any medications or homeopathic preparations, herbal supplements or medicines

What types of substances should be inquired about for allergies?

Over the counter drugs

What type of medication do some patients not consider to be medication?

Type of reaction (e.g., hives, emesis, dystonia)

What specific detail about an allergic reaction should be noted?

Idiosyncratic reactions or side-effects

What are many symptoms perceived as "allergies" actually?

Probe the context of the patient taking the drug further (e.g. When, where, and how did the reaction happen?)

What is important to do beyond just knowing a patient's allergies?

Toxicity, overdosage, non-immunologically related allergies

What different drug effects should be considered when assessing allergies?

Enumerate immunizations and any adverse reactions

What two pieces of information are essential for immunization history?

Enumerate different vaccines with the patient

What action helps determine if a patient's vaccination record is truly "complete" from a physician's perspective?

Major adverse effects (e.g., seizure not long after vaccination)

What should be asked about regarding a patient's tolerance to immunization?

Immunodeficiency issues

What might be present if a patient gets a live vaccine while they had a disease?

Family tree (genogram) that includes the last two generations

What visual tool should be constructed for family history, and how many generations should it include?

Genogram symbols are fixed

What is important to remember about genogram symbols?

Childhood diseases and adult diseases with childhood onset

What specific types of diseases should be asked about in family history?

Consanguinity

What specific family relationship should be inquired about, especially for neurodeficiencies and genetic diseases?

Neurodeficiencies and genetic types of diseases

Consanguinity is important for what conditions?

Related to the patient’s chief complaint

What type of specific questions should be asked about family history?

Current developmental progress

What should be inquired about in developmental history?

Gross motor, Visual-motor / problem solving, Language, Social / adaptive

What are the four major streams of development for which milestones should be attained?

Correlate the patient’s age to the milestones they should be doing/have accomplished

What should be done when assessing milestones based on the patient's age?

Work backwards starting from the patient’s current age

What strategy should be employed if any delayed milestones are noted?

General disposition of the child

What general characteristic of the child should be inquired about?

Colic, toilet training, temper tantrums, biting, head-banging, phobias, pica, and night terrors

What specific behaviors should be inquired about?

Red flags

What should be looked for in developmental/behavioral history?

An eight-year old with bad temper tantrums

Which age displaying bad temper tantrums may be considered a red flag, as opposed to a two-year-old?

Developmental delays, autism spectrum diseases, other mental or psychiatric issues

What conditions are important to consider when reviewing behaviors like temper tantrums?

Present grade, specific problems, interaction with peers

What school information should be gathered?

Methods of parental discipline

What aspect of parenting should be inquired about?

Scenario, where you are, circumstances, and your rapport with the patient

What factors should be considered when asking about methods of parental discipline?

Outpatient setting or well-baby visit

In what settings is it generally more appropriate to ask about discipline methods?

ER setting, first time seeing them

In what settings might it be difficult or inappropriate to ask about discipline methods immediately?

Later on, when admitted and stabilized, or during follow-up as the child’s pediatrician

When can questions about parental discipline be asked if not immediately appropriate?

Who lives at home with the patient, including extended family members and family friends

What specific details about household members should be asked?

Occupation of the patient or parents’ job, and educational attainment

What two pieces of socioeconomic information are relevant?

Smoking and alcohol consumption, sexual history, illicit drug use

What personal habits and sensitive topics should be inquired about in social history?

Unintentional injuries, including motor vehicle accidents

What is the major cause of morbidity and mortality in adolescents?

Drug or alcohol use

What contributes to more than half of adolescent motor vehicle accidents?

Unwanted pregnancy, Sexually transmitted disease (STD), Eating disorders, Mood disorders

What are the next most important causes of morbidity in adolescents?

Good rapport

What is important to have when interviewing adolescent patients?

Interview the adolescent patient without the parent

What is sometimes important to do when interviewing an adolescent patient, especially for sensitive topics?

Talk to them together first, then ask if it would be okay to speak with the patient on their own.

What approach is advised when attempting to speak with an adolescent alone?

Smoking, drugs, sex and sex partners

What are some intense and personal matters that adolescents may not feel comfortable talking about initially?

Have somebody present (an assistant, a nurse, or a co-doctor)

What tip is given for physical exams regardless of the patient's age or sex of physician/patient?

Home, Education / Employment, Eating, Peer group Activities, Drugs, Sex / Sexuality, Suicide / depression, Safety

What does the acronym HEEADSSS stand for?

Dr. Harvey Berman

Who developed the HEEADSSS system in 1972?

Dr. Cohen

Who later refined the HEEADSSS system?

Facilitate communication and to create a sympathetic, confidential, respectful environment

How does the HEEADSSS method structure questions?

Make you more organized and ensure you do not miss and forget anything

How does HEEADSSS help a physician?

If they are having sexual relations with men or women

Beyond simply asking if they are sexually active, what specific question is important for Sex/Sexuality?

Being a male homosexual

What is the number one risk factor for HIV in the Philippines?

Where you are, the context, the circumstances, and what’s comfortable

What factors are important to consider when deciding whether to ask HEEADSSS questions?

ER setting or when the chief complaint is fracture

In what specific scenarios might it be difficult or inappropriate to do HEEADSSS immediately?

To get the information to help your patient

What is the point of asking HEEADSSS questions?

1 in 4 children

How many children in the pediatric population will get diseases from environmental exposure and hazards?

Lead and arsenic exposure, smoking and other pollutants in the air

What preventable environmental exposures significantly affect the pediatric population?

Smoke from uling (charcoal) and burning

What environmental hazard is more common in rural areas?

Car exhausts

What environmental hazard is more common in urban populations?