PAEDIATRICS Richard Shaw

Paediatric History
Formalities o Type of formula
Wash Hands Any other neonatal problems?
Introduction - name, age, birth date, (gender),
consent, confidentiality Developmental History
Establish relationship between child and other (e.g. For Infants: milestones, primitive reflexes, postural
parent, grandparent, nanny, caretaker etc) responses
Older children: milestones, educational (how are
History of Presenting Complaint they are school?), social difficulties.
Open Questioning ’SOCRATES and specific Milestones? (Can compare to siblings)
differential questioning. Gross Motor

Associated Symptoms Fine Motor

"Mini-systems Review" Social and Emotional
o Eating, drinking, peeing, pooing, playing, Speech and Language
sleeping? Cognitive
Fevers? Crying? Other changes? How well has the child grown? Bluebook?
Have there been any concerns about
Risk Factor Questioning developmental milestones, vision or hearing?
Specific risk factors to help differential/provisional
Travel or particular contact? (Infectious diseases) Immunizations
Is the child up to date with their immunizations?
Antenatal History If not, why not? Which ones were missed?
Gravida/Para of mother + pregnancy outcomes Are you planning to immunize?
o Any complications?
USS, Vaccinations, Screening and/or other tests? Past Medical/Surgical History
Length of pregnancy of this child, any Illnesses/infections? Surgeries?
complications? Asthma, diabetes, epilepsy?
Any medications/illnesses during pregnancy? Investigations/Test?
Pregnancy symptoms? Normal/abnormal?
Maternal medical problems? DM, H/T, Epilepsy Medications and Allergies
Natural or assisted conception? Complications? Drugs
Bloodgroup and rhesus status Prescribed drugs?
GBS Status, Hep B, Hep C, HIV and syphilis serology Over the counter drugs?
o Herbs/supplements?
Birth History Allergies/Drug Allergies
Gestation and weight/length/HC at birth Penicillin? Food? Latex?
How long was the labour? Intervention required? If yes,determine precise reaction and
causation
Any indications of fetal distress?
Method of delivery (VD, AVD, Assisted/ Planned CS)
Maternal fever or PROM? Family History
APGARS at 1, 5, 10 minutes? Ages of parents + any siblings? Their health?
Illnesses that run in the family?
Neonatal History Seizures, cancer, asthma.
Did the child have any neonatal problems o DM, H/T, Hypercholesterolaemia
o jaundice, cyanosis, respiratory distress? Contagious disease?
Was vitamin Kgiven? Consanguinity?
Was the child treated in NICU? Any deaths in infancy/childhood?
When did mother and child go home?
Breast fed/bottle fed? Weaning? Sleeping? Psychosocial History
Times a day? Duration/amount fed?
1
 PAEDIATRICS Richard Shaw

Remember HEADSSfOr adolescents --> get to know " joint pain, swelling
them e.g. starting with what school theygo to.
Home Environment Skin
Who is living at home at the moment? " rashes, hair, nails, mucosal symptoms
Is there anyone at home to support you?
Haematological
Where do you live? What type of "bone pain
accomodation is it?
Normal childcare arrangements? "weight loss
"infections
Parents and/or other carers
"malaria
Age, work, relationships
" mouth ulcer
Education/Employment/Financial -->
WHACS "repeated infections
Drugs: smoking (incl. 2nd hand), alcohol,
recreational drugs
ADLs and other activities

Systems Review
Respiratory
" breathing difficulties
" cough
" hoarseness
" noisy breathing
" possibility of foreign body inhalation

Cardiovascular
" blue or white episodes
" fainting
" shortness of breath
" palpitations
" feeding difficulties and sweating (infants)

Gastrointestinal
"appetite
" nausea and vomiting
" mouth ulcers
"weight loss
" diarrhoea and constipation
" stools- colour, blood, mucus

Genitourinary
" passing urine?
" number of wet nappies in 24hrs (infant)
" dysuria, nocturia, urine color

CNS
" headaches and/or migraines
" learning difficulties
" hearing and vision
" fits/seizures and clumsiness

Musculoskeletal
2
Age Gross Motor Fine Motor Spoech and Language Adaptive and Social
Skills
6 wks Prone: lifts chin Social smie
intemittently
2 months Prone: ams extended Pulls at clothes Coos Recognizes parents
forward
4 months Prone: raises head + Reach and grasp, objects Responds to voice,
chest, rols over, no head to mouth laughs
lag
6months Prone: weight on hands, Unar grasp, transters Begins to babble Stranger andety beginning
tripod sit objects from hand to hand responds to name of object permanence
9 momths Pulls to stand, crawis Finger-thumb grasp "Mama, dada - Plays games, plays
appropriate, imitates peek-a-boo, separation
Iword stranger anxiety
12 months Walks with support Pincer grasp, throws 2words, folows 1-step Drnks with cup, waves
Command bye-bye
15 months Walks without support Draws a line Jargon Points to needs
18 months Cimbs up steps with help Tower of 3cubes, scribbing 10 words, follows Uses spoon, paints to body
simple commands parts
24 months Cimbs up 2feet/steps, Tower of 6 cubes, 2:3 word phrases, Paralel play, helps to dress
runs, kicks ball walks undresses uses"I, me, you",
up and dovwn steps 50% inteligble
3 yrs Tncycle, climbs up 1foot Copies a circle and a cross, Prepositions, plurals, Dress/undress fuly except
step, down 2fee/steps, puts on shoes Counts to 10, 75% buttons, knows sex, age
stands on one foot, jumps inteligible
4 yrs Hops on 1 foot. down Copies a square, uses Tells story, knows Cooperative play, tolet
1foot/step scissors 4colours, speech trained, buttons clothes,
inte ligible, uses past knows names of body
tense parts

5 yrs Skips, rides bicycle Copies a triangle, prints Fluent speech, future
name, ties shoelaces tense, alphabet

Podiatric Developmental Milestones

1yr.
single words
Developmental Red Flags 2 yrs:
-2 word sentences
Gross motor: Not walking at 18 months - understands 2 step cormmands
Fine motor: Handedness at <10 months 3yrs:
-3 word combos
Speech: <3 words at 18 months -repeats 3 numbers
-rides tricycle
Social: Not smiling at 3 months 4 yrs:
Cognitive: No peek-a-boo at 9 months -draws square
-cOunts 4 objects

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 PAEDIATRICS Richard Shaw

Examination (DJ,/Jarred)
Scope needs to be right up against
Neonatal Examination
your eye
GeneralAppearance Scleral haemorrhages may be
Looks well normal after labour
o Spontaneous movements Cloudy cornea
o Jaundice Normal to 28 weeks
Possibly pathological if in 1* 24 Excessive tearing
Movement
hours
Usually cephalo-rostral progression Rolling and cross eyed may be
Blanch the skin with a rubbing normal in aneonate, but not if they
motion on the abdomen, thighs and persist
legs to see ifyellow " Ears and Nose
o Erythema toxicum Inspect
Blotchy red spots with overlying o Size
white or yellow papules or pustules o Shape
Hands o Position
Inspect o Nasal patency
o Palmar creases Mouth, Palate and Throat
o Phalanges (extra) Inspect
Palpate Cleft lift/palate
o Grasping reflex Benign cysts
Stroke the inside of their palm and Epstein pearls in midpalatal
see if they grab it raphe
Head Gingival cysts
Inspect Retro- or micrognathia (jaw)
o Hair colour Tongue
o Pigment Defects o Protrudes beyond lips
o Hair line Macroglossia
Palpate o Frenulum under tongue
Check the following haven't fused: connecting it to floor of mouth
o Anterior fontanelle Palpate
o Sagittal suture o Rooting and Sucking reflex
o Posterior fontanelle With a gloved finger stroke the
Other sutures side of their mouth. The baby
should turn to that side and begin
Eyes sucking on your finger
Inspect
o Size
Neck
o Shape Inspect
o Position o Short/webbed neck
o Reaction to light Turner's
Consistent after 32 weeks Noonan's
o Red retinal reflex Clefts
Can do this from a distance Cysts
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 PAEDIATRICS Richard Shaw

O Masses Urine stream

Testes
" Thorax o Hernia
Inspect Females
o Observe the work of breathing. o Cliteromegaly
Respiratory distress indicated by: o Meatus
RR Labia
Grunting o Vaginal opening
Nasal Flaring o Hernia
Intercostal/subcostal tug Patency of anus
Accessory muscle use Check for passing of meconium in
Palpate first 48 hours (99% of neonates
o Palpate clavicles
do this)
Auscultate
o HR Spine
Age Respiratory Heart BE Inspect
Rate Rate o Cutaneous manifestations of
0-6months 30-50 120-140 80/55
6 20-40 95-120 90/60
pathologies
12months Sacral dimple
1-5years 20-30 90-110 100/65 May be normal if within 2cm of
6-10years 18-25 80-100 110/70 anus and has no other
>10years 12-25 60-100 120/75
pathological manifestation
(tuft of hair etc)
o Additional sounds
If not, may be indicative of
o Murmurs
meningomyelocele/spinda
" Abdomen bifida
Inspect Dermal sinus tract (remnants of
o Look for distension incomplete NT closure)
Check umbilicus for:
Legs
Still present (falls off after 7-10 Inspect
days) o See if the skin folds on the thigh are
3 vessels and skin
symmetrical - sign of asymmetric
Dried out (it should be) thigh folds
Signs of infection (erythema etc)
Palpate
Palpate o Palpate femoral pulses
o Liver - tip below costal margin Coarctation of the aorta may
o Spleen - tip just below costal margin present >week (due to patent DA)
o Palpate kidneys with inferior cyanosis on legs
Auscultate
o Auscultate bowel sounds Feet
Inspect
Genitourinary/Anus o Kicking?
Inspect
o Phalanges
Check for micturition in first 48
Internally rotate feet and see if they
hours (97% of neonates will do this) return to normal position
Males
Talipes
o Site of meatus
" Internally rotated feet

5
 PAEDIATRICS Richard Shaw

May be postural (movable) or Leave uncomfortable things until

last
fixed
Positioning
Hips Babies
Examination couch with
Palpate parents next to them
REs are breech birth, and 1s degree Toddlers
Fx In mother's lap/over
o DO ONE HIP AT A TIME parents shoulder
Preschool
o First abduct the hip to check to see if
Whilst playing
it is already dislocated Exposure
Barlow manoeuvre - adduction of Ask the parent if the child would
the hip, and then pressure on the mind exposing the area
knee forcing femur backward to see Examine in stages, redressing the
child after each stage
if it dislocates
o Ortolani manoeuvre - flexion of the Inspection
You must watch the child play
hips and anterior pressure applied to
greater trochanters with the thumbs
abducting the hip. This is positive if Paediatric
there is a click of the head back into
the acetabulum Examination
" Tone and Reflexes " General Appearance
Pull to sit Good tips for examining a child
o Pull them up by their arms and see if Get to the child's level
their head lags Go slowly
Alittle lag is normal, but there Engage parents and carers
should not be completely toneless Demonstrate on teddy/doll/yourself
in the neck Clear and simple explanations
Morrow reflex Be fun but firm
o Hold head and neck in hand above Leave uncomfortable things until
cot. Move downwards towards cot last
rapidly and check if arms and hands . Its good to have someone the same
spread out as if to grasp something gender as the child with you when
to stop from falling. you do the examination/Hx
Head tone Position
o Hold the baby prone an see if they o Babies
hold their head up, and if so, check if Examination couch with parents
it is midline. next to them
o Toddlers
Paediatric Examination In mother's lap/over parents
shoulder
Examination Tips
General
Preschool
Get down to the child's level Whilst playing
Go slowly Older children
Engage parents and carers
Often concerned about privacy, so
Demonstrate on
teddy/doll/yourself have an appropriate chaperone
Clear and simple instructions present

6
 PAEDIATRICS Richard Shaw

Be aware of cultural sensitivities Crown of the head

Exposure touching the head
o The area to be examined must be board
inspected fully 4. Move the footboard up so
Be sure to ask the parent if the child they are touching the
would mind exposing the area heels
Examine in stages, redressing the 5. Read the measurement
child after each stage " Height
e ALWAYS: 1. Take shoes off
o Use alcohol rub/wash your hands, 2. Ensure:
both BEFORE and AFTER a. Heels are right
o WARM your against the wall
Hands b. Back of head,
Stethoscope shoulder blades and
Inspection buttocks are against
o THIS IS THE MOST IMPORTANT wall
PART OF A
PAEDIATRIC c. Child is looking
EXAMINATION straight ahead
o Watch the child play. It will allow you 3. Use a flat object to place
to assess: on top of the top of the
Severity of illness child's head, and read
Growth and nutrition what their height is
Behaviour and social c. Plot their height on the appropriate
responsiveness growth chart (CDC in NSW) for
Level of hygiene and care their:

Growth " Age

" Gender
1. Height/Length
a. Determine method of measurement " Adjust for prematurity if below
36 months
" <24 months is length " Note that these are for Caucasian
" 24-36 months either
children, and therefore some
>36 months height
ethnicities might fall outside
" Note that supine length is usually normal values, but still be
slightly longer than height
healthy
(about +2cm according to new
d. Ifyou have weight measurements
CDC graphs) over a period of time, plot the
b. Measure the child
child's weight on the growth
" Length
velocity graph as well
1. Take the nappy off
The following are categories for
2. Needs 2 people, with carer height:
holding the child's head
3. Ensure that:
" <3rd percentile in height for age
is short stature
Back, legs and head
" <25th percentile in height
are straight
velocity is growth failure
Shoulders are
touching the board
 PAEDIATRICS Richard Shaw

" Constitutional delay is short, but b. Crossing 2 major

with no growth failure OR centile lines over time
delayed bone maturity c. If chronic, weight may
o Height is an indication of long term be affected, but HC
nutrition usually preserved if
2. Weight not severe

a. Ensure the weighing machine is e. Expected weight growth in children

properly calibrated are as follows:
b. Weigh the child " Average birth weight: 3.5kgs
" Child should have bare " Some weight loss in first 5-7
weight/minimum clothing on, days, regained by 10-14 days
depending on the age of the child " Weight triples in first 12 months
" In an uncooperative child, weight " Gain of 2.5kg in 2nd year
the parent and the child together, Weight is an indication of short
and then the parent, subtracting term nutrition
the second value from the first 3. Head Circumference
C Plot the child's weight on the a Find 0 on a non-stretch measuring
appropriate growth chart (CDC in tape
NSW) for their: b. Take a length
" Gender c. Put it around their head and find
" Age the occiput
" Adjust for prematurity if below d. Wrap it around so that the tape
21 months goes over the supraorbital ridges
" Note that these are for Caucasian (thus taking the largest head
children, and therefore some circumference)
ethnicities might falloutside e. Pull it tight
normal values, but still be f. Do this three times until a
healthy consistent measurement is
achieved
Determine what percentile the
child is in g. Plot the child's weight on the
d. Determine the child's BMI appropriate growth chart (CDC in
(assuming you previously did NSW) for their:
height) " Gender
" BMI =Weight (kgs) /(Height in " Age
m)^2 " Adjust for prematurity if below
" Plot this on the correct graph 18 months
according to age Note that these are for Caucasian
" These have the following children, and therefore some
abnormal categories: ethnicities might fall outside
>95% is considered obese normal values, but still be
85-95% is considered healthy
overweight o This is useful in infants >2 years;
<5% isconsidered over 2 it slows and is not as useful
underweight o Other methods of measuring growth
o Failure to Thrive is: may include:
a. Weight <3%
 PAEDIATRICS Richard Shaw

Mid upper arm circumference Mobility

(MUAC) Trauma
" Useful in patients with Tumour
oedema/liver Osteomyelitis/septic arthritis
disease/abdominal tumours Reactive arthritis
Knee height Alertness
" Useful in CP patients with Interactiveness wit h environment
contractures where height is Children usually hypervigilant in
hard to measure new environment
o Skinfold thickness Consolability
o Bone density and age If parents cannot settle child,
you should be worried
Growth Charts
Vocalisation
Plotting on growth charts Strength of cry
o Ensure you have the right: Speech
Gender
Both quantity and quality
Age
Palpate
o Determine if they were premature
o Vital signs
(<37 weeks) so measurements can
Temperature
be adjusted
Hypo- or Hyperthermic/Febrile
For every week premature they are,
one month must be taken off their Importance on not how high the
age on the growth chart (even if fever is, but what is causing it
B
this means this makes them a fetus
Late to change
on the chart) RR
This is done until:
HR
18 months for HC
Late to change
21 months for weight Alertness
36 months for length
One off measurements do not give a Breathing
complete picture of the child growth, Inspect
with serial measurements being o Airway noises
required to see changes in growth over Stridor
time This sounds like an inspiratory
gasp
The Acutely Ill Child Can be very soft
" General Appearance and Indicates URT obstruction
Grunting
Airway Caused bya closed glottis
Inspection
providing positive pressure to
o Do they look generally unwell/do prevent atelectasis of alveoli
parents think they look wrong? Can be a sign of pain which may
Well/Unwell not always be respiratory
Toxic/Non-toxic
related (gut etc).
o Do they have spontaneous
May be a squeaking noise in
movement, or are they limp and neonates
lethargic Wheezing
9
 PAEDIATRICS Richard Shaw

These are musical expiratory How many times do you need to

noises change the child each day
Snoring normally and how wet are the
Position diapers
Sniffing position How many times have you
" Head held up and slightly needed to change the child
extended to hold airway open recently and how wet are the
Tripod position diapers
" Leaning forward to stabilise Should admit if urine output is
accessory muscles to improve <50% of normal
their action Weight change over the day
o Increased work of breathing " Palpation
Accessory muscles o Perfusion
Abdominal movements Press on sternal skin, capillary refill
Stomach usually goes out during should return in 2-3 seconds
inspiration Dextrose
Paradoxical breathing may occur
Investigate
in respiratory distress due to o BSL
huge negative pressure
generation DO IT ALL AGAIN
Speech (Regular reassessment)
Only able to say single words
indicates respiratory distress
o Cyanosis
Circulation
Inspect
Cyanosis
Mottled appearance
Fluid in/out
Urine

10
 PEDIATRIC HISTORY
1-50URCE OF HISTORY
2-PERSONAL DATA: -Name -Age -Sex -Nationality -Date of admission (OPD - ER)
-Any known illness (Duration +Medication)
3-MAIN COMPLAINT + DURATION
4-HISTORY OF PRESENTING ILLNESS (HPI): (check the note)
-Complaint analysis -Associated symptoms
-Previous episodes -Review of related system
-Risk factors
-Special questions related to the differential diagnosis / Important negatives
-History of any chronic disease (check the note)
5-HoSPITAL COURSE:
-What happened since admission: Improving - Worsening
-Investigations done +Findings -Medications given
-New diagnosis -New complaints
-Plan (or reason for hospital stay)
6-5YSTEMIC REVIEW: (Symptoms in light blue are for older children)
-General: Weak crying - Wight loss - Poor feeding - Irritability - Fever - Pallor -Lethargy
-CVS: Dyspnoea (Breathless &sweaty on feeding - Slow to feed)
Blue episodes - Dizzy spells - Fainting - Palpitation - Chest pain
-Respiratory: Sore throat - Ear ache - Cough (dry or Productive) - Heamoptysis - Wheeze
Dyspnoea - Frequent chest infections - Stridor (Noisy breathing)
-GIT:
An Appetite - Weight loss - Nausea - Vomiting - Heamatemesis - Abdominal pain
Dysphagia - Jaundice- Diarrhea - Constipation - Blood/Mucus in stool - Pruritis ani
Travel aboard - Animals contact - change in stool color - Recent fast food intake
-Genitourinary: Enuresis (dry during daytime?) - Nocturia - Dysuria (Crying during micturation)
Heamaturia - Abnormal genitalia - Urine color change- Age of menarche (female)
-CNS: Dizziness -Nervousness - Fits (Convulsion), Faints or Funny turns
Drowsiness - Weakness, Clumsiness or Frequent falls - Abnormal movements
Vision, Hearing, Taste &Smell problems - Incontinence - Tingling
Numbness or Unpleasant sensation - Headache
-Rheumatology: Limping - Bone pain - Joint (pain - Swelling - Redness) - Muscle pain
-Hematology: Epistaxis -Easy bruising - Circumcision bleeding - Petichae or Echemosis
Gum bleeding
-Dermatology: Rash - Itching - Pigmentation - Lump - Hair or Nail changes
-Endocrine: Polyuria - Polydepsia - Polyphagia
7-PAST HISTORY: -Medical -Surgical
-Hospital Admissions -Blood transfusion
8-ALLERGIES
9-PERINATAL HISTORY: -Antenatal: Pregnancy (Complications - Drugs - Radiation) - Gestation
-Natal: Mode of delivery - Birth weight
-Post natal: Diseases (e.g. Jaundice) - Admission to special care
Ventilation - Discharged (With mom / Stayed. .Why?)
10-NUTRITIONAL HISTORY:
-Bottle or breast fed...for how long?
-Timing of introduction of solids or cereals
-Current Dietary intake (Any dietary restriction?)
-Bottle fed (Type - Preparation - Volume - Duration - Frequency - Total daily intake)
 11-IMMUNIZATION HISTORY: -Immunization card (Up to date?) -Last vaccine taken
-If not received... Why? -Extra Immunization
-Allergies or side effects from any vaccine
12-DEVELOPMENTAL HISTORY: (Compared to siblings) (Check the note)
-Gross motor -Fine motor & Visual -Social -Speech &Hearing
13-MEDICATION HISTORY: -Name -Duration -Dose -Side effects
14-50CIAL HISTORY:
-Family social status -Financial support
-Home environment -Travel history -Pets at home
-Patient social status:
-Schooling (Which school - What sort -Level -Grades)
-Does the patient miss school? How frequent?
-How does he get on with other children?
amarch517 -Effect of his chronic illness on his school performance
15-FAMILY HISTORY:
-Similar illness in family -Living where?
-Siblings (Number - Age - Sex- order - Healthy or..)
-Parents (Age - Education - Occupation - Income - Diseases - Consanguinity - Smoking)
16-5UMNMARY: -Name -Age -Sex -Main complaint + Duration -Known illnesses
-Associated symptoms -Important findings (depend on the case)
Note: (HPI)
-If the problem of the patient was present since birth, then it is better to start
your HPI from birth (start with the perinatal history) untilthe day of admission.
(How to ask about developmental history?)
-Start asking about the skills that should be performed at his age, if acquired then no need to
ask the rest of the skills, however, if not acquired then ask about the skills that should be
performed at younger age till you find out the latest skills the patient acquired.
-Ask if the patient lost previously acquired skills.
-If the patient goes to school, don't ask about these skills. However, you should ask about school
performance, getting along with children, problems in walking, handling things or daily activity.
(History of any chronic disease)
-Since when?
-Diagnosed in which hospital?
-What were the presenting symptoms?
-What investigations were done to confirm the diagnosis?
-Medications being used / Surgeries were done.
-Improving / Worsening with the medications.
-Medications compliance? Home monitoring of the disease? By what? What are the usual readings?
-Following up in which hospital? Who is the treating doctor?
-Chronic or persisting symptoms.
-Exacerbations of the disease (Acute attacks - Acute complications)? Precipitating factors?
-Hospital admissions / ICU admissions.
-Complications? Follow up in other clinics to treat the complications.
DONE By:
Amar Raut Chhetri
MBBS, KMCTH
For ary queries,contact via:
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