• Clinical science

Pediatrics: history and physical examination

Summary

Taking a history and performing a physical examination with children differs from adults and comes with a set of unique challenges. Symptoms are typically reported by a parent or guardian, who may not be able to accurately transmit the information from the child to the examiner and characterize the child's concerns. To fill in the gaps, a pediatrician must have good communication skills and the ability to develop a rapport with children as well as their families. Pediatricians must also pay special attention to growth and developmental issues unique to the pediatric population and be aware that certain diseases manifest differently in children than in adults. This article specifically covers nuances involved in history and physical examination for pediatric patients to supplement general information found in the “Medical history” and ”Physical examination” articles.

Medical history

In addition to the details of a general medical history, there are some notable differences to be aware of when taking a pediatric medical history, including certain patient details, the source of information, and modes of communication.

  • Additional patient details
  • Source of information
    • The presence of a parent/guardian generally facilitates taking a child's history.
    • Children aged > 4 years may be encouraged by the parent/guardian or clinician to report their own concerns. However, the clinician should still rely primarily on the parent's/guardian's report.
    • In pubescent patients, it may be appropriate to offer a private interview to discuss sensitive health care issues (e.g., sexual health, recreational drug use, mental health) in a more open as well as private setting.
    • One of the challenges in pediatrics is that parents/guardians may not have sufficient (subjective and objective) understanding of the child's concerns to report these accurately and reliably.
  • Communication
    • Always open the interview with casual conversation to establish rapport between you and the child or parents/guardian.
    • Begin the medical portion of the interview by taking the social history before addressing the current health concern.
    • Observe parent-child interaction, and always be vigilant regarding signs of potential child neglect or maltreatment.
  • Pediatric settings: The focus of a pediatric history varies depending on the setting.
    • Inpatient vs. outpatient
    • Sick-child vs. well-child
    • Subspecialist vs. general
  • Example: For a sample pediatric case, refer to case 7: Toddler with a cough and fever.

Chief concern and history of present illness

General information

  • Age: Pediatric patients generally have their age reported in days until 2 weeks old, in weeks until 2 months old, and in months until 2 years old. However, this may vary from institution to institution.
  • Sex
  • Other relevant identifying information
  • Informant: the person accompanying the patient and assisting in providing history and their relationship with the patient (e.g., parents, legal guardians, siblings, caretakers)

Chief concern

  • The main concern for which the patient or parent/guardian is seeking health care.
  • It is reported in the patient's or parent's/guardian's own words.

History of present illness (HPI)

  • The details of the present illness are recorded in chronological order.
  • Depending on the condition of the child, mention the following:
    • Sick child
      • Duration and a brief description of current signs, symptoms, and treatment, if any.
      • If the child is receiving medication, record the name of the drug, dose, frequency of administration, and response to medication.
    • Well child: It suffices to mention that there are “no concerns.”
  • If the past medical history is significant to the present illness, it is briefly mentioned here.

Past history

  • Prior conditions/trauma
    • Start with any conditions that still affect the patient.
    • Previous hospital admissions with dates and diagnoses
    • List of prior procedures and dates
    • Any prior trauma: fractures, lacerations
    • For more information, see “Past medical history” in medical history.
  • Medications: In children, medications are typically dosed by weight, and it is important to document medications with dosage and weight.
  • Allergies: In addition to noting an allergy, it is necessary to describe the type of allergic reaction and its severity. For more information, see “Past medical history” in medical history.
  • Immunization history
    • Ideally, this should be checked on the child's vaccination record. If the record is unavailable, ask the parent/guardian about the vaccinations received as well as the dates, sites of injection, and reactions (if any).
    • If the immunization of the child is incomplete, identify the reason for missed immunizations. Include specifics regarding:
      • Name of the missed vaccine
      • Originally scheduled date/dose of the missed vaccine
    • For more information, see the immunization schedule article.

Prenatal and birth history

This information is especially most important for young children and is often irrelevant for adolescent patients. It is usually best to get a history of these details from the patient's mother herself, but if the mother is unavailable, do your best to find out what you can to gain a fuller picture.

Developmental history

  • Significance: A detailed record of developmental milestones is important in younger children (especially those aged < 3 years), but less so in adolescents. Ask questions about age-specific milestones and tailor these according to context and patient concerns.
  • General: Ask about the ages at which milestones were achieved and current developmental abilities. For further information on the topic, see the child development and milestones article.
  • Specific questions regarding:

Feeding or nutrition history

  • Significance: It is generally important to include a discussion of a pediatric patient's associated lifestyle factors that influence this aspect of their care.
  • Infants (0–1 years)
    • Breast fed or bottle-fed?
    • Formula or breast milk (include types of formula, frequency and amount in a day, reasons for any changes in the formula)?
    • Medical issues related to feeding (e.g., vomiting, regurgitation, baby colic, diarrhea, and other gastrointestinal or feeding problems) should be noted.
  • Children (2–12 years)
    • Age at weaning and introduction of solid foods
    • Supplementation with vitamins or fluoride
    • If feeding/eating concerns are present ask about:
      • Onset of the problem
      • Methods of feeding
      • Frequency of feedings
      • Amount taken at each feeding
      • Medical concerns such as vomiting, crying, and weight changes
      • Initial management of the problem by the parents/guardians
    • Ask the parent/guardian to describe what the child typically eats for breakfast, lunch, snacks, and dinner to assess whether the child is receiving adequate nutrition.
  • Adolescents (13–17 years)
    • Ask the patient to describe what they traditionally eat for breakfast, lunch, snacks, and dinner to assess whether the child is receiving adequate nutrition.
    • Screen for eating disorders

Family history

  • Significance: Information about the development and behavior of the parents and siblings may be relevant in the diagnosis of pediatric conditions, including genetic disorders.
  • Medical conditions
    • Age of onset
    • Progression
  • Sick contacts
    • Important in patients with a suspected contagious disease.
    • Ask if anyone at home is sick (e.g., parents, siblings, household members), the nature of the illness, and if the child attends daycare.

Social history

The social environment of the child is a key determinant of the child’s present and future health. The medically relevant social factors vary depending on age.

Infants (0–1 years)

  • Food security
  • Socioeconomic status
  • Household members
  • Sleeping arrangements
  • Childcare arrangements
  • Although physicians should always be observant of the relationship between parents and their children, during this age, they should especially be vigilant of mothers potentially affected by new-onset postpartum psychiatric conditions, such as postpartum depression or postpartum psychosis, which may in turn negatively affect the infant.

Toddlers (2–3 years)

  • Food security
  • Socioeconomic status
  • Household members
  • Childcare arrangements
  • Home safety (e.g., childproofing electrical outlets, making sure chemicals and medications are out of reach of children. etc.)

Young children (4–6 years)

  • Socioeconomic status
  • School performance
  • Social life (e.g., friends, extracurricular activities, sports, conduct, being bullied)
  • Childcare arrangements

Older children (7–12 years)

  • Socioeconomic status
  • School performance
  • Social life (e.g., friends, extracurricular activities, sports, conduct, being bullied)
  • Technology use and screen time
  • Childcare arrangements

Adolescents (13–17 years)

  • Although unable to legally provide consent for most things, keep in mind that they will soon become adults who are wholly responsible for their own medical care.
  • During these years, there is often a strong attraction to high-risk behavior, which can be influenced by:
    • A strong desire for peer approval
    • Less thought about consequences of actions
    • A curiosity of certain experiences and pushing limits (e.g., driving recklessly, drinking alcohol, drugs)
    • Feelings of invincibility
  • Social history should be taken privately, without the presence of a parent/guardian.
  • This method of interviewing is a way to prepare the patient for entering the world of adult healthcare and will help ensure the building of a doctor-patient relationship without being potentially influenced by parents.
  • Clarify to the patient that what is discussed will be held in strict confidence unless you have reason to believe that the patient or someone else is directly in harm’s way.
  • Know the state's laws regarding when parental consent is required and what are the exceptions. See “Informed consent in minors” in the “Principles of medical law and ethics” article for more information.

Adolescent psychosocial screening: HEADSS assessment

The mnemonic HEADSS helps to remember the components of a comprehensive social history in this age group.

Start the interview with general topics before progressing to more sensitive issues like recreational drug use and sexuality. It is important to be direct and open when addressing these issues and not to hesitate to explore them further with the patient. Be prepared to counsel and educate patients about any sensitive issues!

  • Home
    • Household members
    • Stressors
    • Room: Does the patient have their own room?
  • Education and employment
    • Grades
    • Favorite subject
    • Relationship with teachers
    • Disciplinary issues at school
    • Current job
    • Future plans
    • Employment of parent/guardian
  • Activities
    • Hobbies
    • Activities with their peer group
    • Extracurricular activities and volunteer work (e.g., school clubs, art classes, sports teams, religious groups)
  • Drugs
    • Start by asking if any peers engage in recreational drug use (e.g., nicotine, alcohol, inhalants, marijuana, ecstasy)
    • If yes, try to clarify if peers drive while under the influence of drugs.
    • Follow up by asking the patient if they engage in recreational drug use
    • While asking these questions, be specific by naming the drugs, and be aware of their street names. For more information, see the article on substance-related and addictive disorders.
    • Be ready to handle these issues in a sensitive manner and counsel on substance abuse.
  • Sexuality
    • Menstrual history
      • Teenage girls should be asked about their menstrual cycles.
      • Refer to the article “OB/GYN: history and physical examination article” for more information.
    • Open the discussion on sexuality by asking about peers: Do any friends/peers date or want to date?
    • Progress to the patient: Is the patient interested in anyone, boys and/or girls? Is the patient currently in a relationship?
      • If yes, ask about the relationship and screen for emotional/physical abuse and sexual activity.
      • Try to be as specific as possible, ask about: kissing, touching, oral sex, penetrative sex, etc.
    • Conclude by asking about the use of contraception/protection and encourage engaging in safe sexual practices.
    • Previous sexual contact: Are there any concerns about sexually transmitted infections? Does the patient have a past history of pregnancies/abortions?
    • Does the patient have any concerns regarding their sexuality or gender?
  • Suicidal ideation and depression screening
    • Start by asking about the patient’s general mood.
    • If necessary, probe further to find out about thoughts of harming self or others, including specifically asking if they have had suicidal thoughts or actions.

To remember the components of social history in adolescents, use the word “HEADSS”: Home, Education/employment, Activities, Drugs, Sexuality, Suicidal ideation/Screening for depression.

Leading causes of death [1][2]

  • The leading causes of death in children and adolescents (in order of prevalence):
  • It is important to counsel pediatric patients and parents regarding safety and preventable death in children and adolescents.

The social history of adolescents in brief, with a special focus on the leading causes of death in this age group, is covered by the mnemonic SAFE TEENS: Sexuality, Accidents, Firearms/homicide, Emotions (suicide, depression), Toxins (e.g., alcohol, tobacco, recreational drug use), Environment (home, friends, school), Exercise, Nutrition (e.g., eating disorders), Shots/immunizations.

Review of systems

Physical examination

General principles

  • Newborns: See assessment of the newborn.
  • Infants and young children (1–6 years)
    • Remember that in early childhood, most children have stranger anxiety.
    • Set a light mood during the physical exam to maximize cooperation.
    • Explain your next steps (e.g., “Now I'm going to check your ears...”) rather than ask the child for permission (e.g., “Is it ok if I check your ears?”), as the child may say no.
    • Having toys in the office is useful for distracting children, and small, inexpensive gifts can be handed out after the visit to build rapport.
    • Perform examinations that the patient is likely to find uncomfortable and may decrease cooperation (e.g., ear exam) towards the end of the physical exam.
  • Older children and adolescents (7–17 years): The physical examination is similar to that in an adult. Refer to the physical examination article for further information.

It is important to remain flexible and consider patient preferences in the order with which the systems are examined. It is generally recommendable to perform examinations that the patient is likely to find uncomfortable and may decrease cooperation towards the end of the physical exam.

In young children, it is often helpful to perform maneuvers on the guardian first to show that they will not hurt and so encourage the child's cooperation.

Vital signs

  • Ensure that the child is quiet and relaxed while assessing the vital signs.
  • Use the correct blood pressure cuff size for the child's age.
  • Remember that pediatric vital signs have appropriate ranges based on age.

Growth measurements

  • Weight
    • Measure the weight at every visit.
    • Ask the parent/guardian about weight at birth (especially for infants and young children).
    • Ask the parent/guardian if they have noticed any recent changes in weight.
  • Height/length: Measure children < 2 years in the supine position. Older children are measured standing.
  • Head circumference: Measure head circumference in all infants aged < 2 years.
  • Puberty: Take note of Tanner stages.

Always record height, weight, and head circumference with percentiles on a growth chart to track the progression of these values.

General physical exam

Skin and lymphatics

  • Birthmarks: Include details regarding the number, site, size, and color, and document any changes mentioned by the parents/guardians.
  • Other skin findings
    • Rashes, petechiae, desquamation
    • Scars and injuries (may be signs of abuse)
  • Lymph nodes: If enlarged, note the location, mobility, and consistency.

Head and neck

  • Size and shape
  • Scalp and hair
  • Fontanelles (in infants): describe the size and tension (if any)
  • Sutures
  • Neck: The neck is often very short and difficult to examine in infants. However, it is nonetheless important to evaluate for masses (e.g., cysts, nodes) and examine the thyroid gland.

Ear exam

  • General examination: position of ears
  • Otoscopic examination
    • Examination of the tympanic membranes is particularly important in children with suspected acute suppurative otitis media.
    • Have the parent hold the child in his/her lap, using one hand to turn and restrain the head and the other to restrain the arms.
    • In young children, it is recommendable to place a finger against the side of the child's head as you insert the otoscope. This will help prevent a restless child from turning their head towards you and potentially incurring injury to the ear canal from the otoscope.
  • Hearing examination
    • In young children, the child's response to the parent/guardian's speech is usually sufficient to assess hearing in the setting of a well-child visit.
    • If there are concerns regarding the child's hearing or delayed speech, a complete hearing and speech evaluation may become necessary.

Eyes

Nose

Oropharyngeal exam

  • This is usually done last in children aged < 7 years, after examination of all other systems, the assumption being that by the end of the physical exam, the patient may be crying, giving you an opportunity to look into their mouth.
  • Lips: Assess lip color (e.g., blue lips in cyanosis).
  • Buccal mucosa: observe the color, look for vesicles, assess hydration
  • Tongue
  • Teeth and gums
  • Palate: Assess the arch and look for clefts.
  • Tonsils: Record the size, color, and presence of exudates.

Cardiovascular exam

  • Requires the child to be quiet
  • Warm the stethoscope by rubbing it between your palms to avoid discomfort and crying in young children.

Lung exam

  • If the child is crying, it is sufficient to include this in documentation as crying demonstrates airway integrity.

Abdominal exam

  • Be particularly cautious when palpating the abdomen of patients with abdominal pain. Children with abdominal pain may not allow the examiner to repeatedly examine the painful area, so an attempt should be made to gather all of the required information on the first attempt.
  • The spleen and liver are palpable in all infants and newborns.

Musculoskeletal exam

  • The active movement of all four extremities is a reliable indicator of neuromuscular function.
  • If the child is old enough, instruct it to stand up and touch its toes. While the patient is bent over, examine the spine for signs of scoliosis.

Neurological exam

  • Cranial nerves
    • It may not be possible to test all the cranial nerves in young children and infants, as they are unable to follow commands.
    • In young children, toys are very useful for this portion of the exam. For example, the child can be asked to follow the motion of a toy, such as a brightly colored ball, to assess eye movement (test the function of the oculomotor, trochlear, and abducens nerves).
    • Any concerns regarding speech and hearing should be followed up with a formal evaluation by speech and hearing sub-specialists.
  • Strength
    • It is helpful to turn the strength exam into a game to encourage proper effort in small children. (e.g., “Now it's time to show me how strong you are! Can you push my hand away from you really hard?”)
    • In children who cannot follow instructions, you will have to depend on clinical observation to determine strength (e.g., observing limb movements against gravity)
  • Reflexes
  • Sensation: It may be easier to test sensation in young children by turning the examination into a “tickle game.”
  • Gait and balance
    • If the child can follow instructions you may certainly ask them to demonstrate gait and balance by asking them to walk across the room, as one would with an adult.
    • If the child cannot or will not follow instructions, clinical observation of the child's gait on entering the room or climbing on the examination table may represent the only source of diagnostic information.

It is often challenging to have children under the age of 7 years perform all the tasks involved in a complete neurological examination. You may have to improvise or do it in different parts.

Genitourinary exam

  • Infants: Be sure to stand slightly to either side of the patient as you examine the infant, to avoid any urine in case the infant urinates.
  • Toddlers and young children: Prior to examining the external genitalia, it is important to say, “Next, I will be taking a look at your private parts to make sure everything is fine. This is okay because I am a doctor and your mother/father is here with us.” This illustrates to the child the special and exclusive nature of the setting, in which it is appropriate to undress before an adult and allow an adult to touch one's genitals.
  • Older children and adolescents
    • Approach
      • Prior to the exam, the patient should always be given the option of having the parents/guardians leave the room.
      • If you are concerned asking the patient in front of the parents will result in the patient agreeing despite not wanting to, you should just ask the parents to leave and explain it is standard procedure for this age group. They can always come back in if the patient would prefer the parents are present.
    • Take note of Tanner stages
    • See “OB/GYN: history and physical examination” for more information about examining girls

last updated 06/30/2020
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