1. History Taking and Physical Examination.pptx

medicine

1. History Taking and Physical Examination in 1

2. Learning Objectives Describe the components of history taking in pediatrics and child health Describe physical examination in pediatrics List relevant investigations for pediatrics 2

3. History Taking Medical history taking is a practice which collects information from the patient and/or patient care taker to make diagnosis and know the approach of management 3

4. The clinician will elucidate the problems posed by disease and apply his or her skill to council patients and families on how to manage these problems . Appropriate techniques and skills are needed to elicit the symptoms from the patient’s description and signs by observation and physical examination . 4

5. Components of a Good Paediatric History Demographic data Chief complains History of presenting illness Review of other systems Past medical history Immunization History Dietary history Developmental milestones Family and social history Summary 5

6. Components of good physical examination General Examination Systemic/Regional Examination Ear, Nose and Throat Head and Neck Chest (Thorax) Abdomen Extremities/Upper and Lower Limbs Neurological 6

7. Demographic data Child’s name Sex Age Place of residence Address and/or telephone number Date of taking the history/admission ƒReport who is the informant 7

8. Chief or main complaints Ask for the problem that has caused the child to be brought to the hospital Probe the caretaker to mention any other problems and let her/him explain, don’t interrupt (unless critical) Ask the duration of each symptom and arrange the problems (symptoms) in the chronological order 8

9. In chief complains ask for DOPARA Duration of onset of complains in days or hours M ode of onset of complains if acute or chromic Progress of complains whether increasing, decreasing or constant Aggravating factors Relieving factors Associated factors 9

10. If the complain is pain ask for SOCRATASA Site Mode of onset and duration Character of pain Radiation of pain Aggravating Timing of pain Alleviating factors Severity of pain Associated factors 10

11. Review of other systems Review the systems that have not been covered in the history of presenting illness, this should be done systematically to avoid omissions Cardiovascular system (CVS) Respiratory system (RS) Gastrointestinal system (GIT) Genital urinary system (GUS) Ear nose and throat (ENT) Musculo - skeletal system (MSS) 11

12. Past medical history Paediatric history Ask for previous admissions and their reasons , diagnosis and treatment given History of previous diseases that are associated with the current child’s problems or diagnosis that might be associated with current illness 12

13. Antenatal history Ask the mother for any illnesses and treatment during pregnancy, such as malaria, syphilis or severe anemia. Ask the mother if she received Tetanus toxoid vaccine as per EPI schedule Number of previous pregnancies and their results Serology for HIV, VDRL, blood grouping and Hb , their results and any medications given to the mother 13

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15. Natal history Was it a hospital or home delivery and if the pregnancy was full term Mode of delivery: spontaneous vertex delivery (SVD), assisted breech delivery(ASD ), caesarean section , vacuum or forceps delivery Rupture of Membranes and the liquor Did the baby cry immediately after birth or was any resuscitation done and what was the APGAR score 15

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18. Post natal history Any diseases suffered after delivery, how long did the child stay in hospital after delivery 18

19. Immunization History Ask for the RCH card 1, look to see if the child received all the vaccines and is up to date Look for of vaccines given and those not given and If the child is not fully immunized , then arrange for immunization before discharge 19

20. Dietary history Ask about how long did the child received exclusive breastfeeding Ask when did the child started complimentary feeding, what food, the amount the child receives and the frequency of feeding Use the normal feeding recommendations for the child’s age, and if you identify any abnormal practice, give feeding recommendations as per guidelines Ask if feeding pattern has changed during the illness 20

21. Developmental milestones Ask for the child’s developmental milestones: Gross motor (movement and posture) Hearing and speech Vision and manipulation Social behavior Ask specifically when the child started to do the above body functions and what the child is able to do now Compare the above with the child’s age and decide if milestones are normal, delayed or regressed 21

22. Family and social history Ask if the parents are alive, level of education, economic status, marital status, habits like smoking and drinking alcohol If the child is an orphan, who takes care of the child, the relationship to the child and then cover the above information about the guardian Gather information on the death of the parents and establish relationship with the child’s current illness 22

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24. If the child is in school, any similar symptoms with school mates Ask about siblings and their well-being Ask about family diseases Ask about important communicable conditions (like HIV and TB) 24

25. Summary Age, sex, how many days since admission , child’s status (e.g. orphan) Write the chief complaints, important findings from history that will lead to diagnosis, and also any complications developed Use few words, at most five lines 25

26. Physical Examination General Examination Older children usually cooperate and routine physical examination is no different from an adult examination A younger child should be examined sitting on his or her mother's lap and let the child be comfortable as possible 26

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28. Always talk to children do not be afraid of looking silly if the child is a cooperative Parts of the examination that are painful and/or unpleasant should be left until last. If the child is anyhow uncomfortable the immediate response will be crying 28

29. Look to see if the child is ill looking , dyspnea,, listen for grunting, wheeze or stridor Do quick assessment of level of consciousness ( AVPU ) A lert, V erbal response, responds to P ain or U nresponsive Look and palpate for anterior fontanelle Look for pallor, cyanosis, jaundice and Edema Examine the mucous membranes of the mouth for ulcers, white patches-oral thrush and dehydration 29

30. Touch the patient and feel for temperature also at the same time put an axillary thermometer and for the vital signs Look for lymph node enlargement , paleness, cyanosis, and edema Assess hydration status 30

31. Do the anthropometric measurements Weight Height/length: then Determine W/L Mid upper arm circumference (MUAC) for age Head circumference (occipital frontal circumference) 31

32. Systemic/Regional Examination In the pediatrics population it is advised to do regional approach instead of systemic approach in doing physical examination The examination may have to be opportunistic , as each child will dictate the order of the examination by their reactions to various procedures S tart with the least threatening maneuvers and use the following steps: Inspection, Palpation, Percussion and auscultation 32

33. Ear, Nose and Throat Inspection : Discharge and lesion, ulcers, obvious deformty , if uvulectomy has been done Palpation, Percussion and auscultation 33

34. Head and Neck Inspection : Shape and size of the head (bossed, obvious swelling, hair pattern and texture, marks, cephalohematoma and caput succedaneum) Palpation: Fontanel, if bulging or normal, sutures if are closed well or abnormal 34

35. Lymph node enlargement, and if enlarged you should describe them by shape ,size, texture, mobility Gentle percussion For patients with hydrocephalus for a cracked pot sound on percussion of the skull Auscultation may be needed for some swellings/mass 35

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40. Chest (Thorax ) Let the mother undress the child , to expose the chest both anteriorly and posterioly sitting on mother’s lap Avoid unnecessary exposure in newborn babies and in children with severe malnutrition, as they are at risk of hyporthermia 40

41. Inspection Look for nasal flaring Look at the chest for any asymmetry Look at the breasts and nipples, deformity, lesions , marks, scars or new growths, and also look for visible pulsations Remember you had already counted breathing per minute, now see if chest moves symmetric with each respiration , any chest in drawing 41

42. Palpation on axilla region for lymphnodes Locate the apex beat and estimate tactile vocal fremitus Asses for Precordial bulging and heave Percussion Lung zones following the anatomical land marks , anteriorly, axillary and posteriorly Normal percussion note is resonance 42

43. Auscultation Auscultate for breath sounds in each zone, anterior and posterior, taking note that you compare the two sides simultaneously ƒ Are they vesicular, or bronchial? Auscultate for any added sounds such as rhonchi , crepitations /crackles, murmurs, transmitted sounds Auscultate for vocal resonance (older child) 43

44. Count heart rate, use reference range for normal values Auscultate for heart sounds, and report if 1 st and 2 nd heart sounds are heard and normal or you hear a 3 rd heart sound (Gallop rhythm) Auscultate the bases of the lungs for crepitations , (suggestive of congestive heart failure) Auscultate for added sounds, murmurs 44

45. Abdomen Inspection Contour , distension, symmetry, umbilicus, any obvious lesion, movement with respiration , dilated vessels, visible peristalsis or pulsations Palpation Tenderness, succession splash , masses, liver, spleen , kidneys (bimanual palpation), bladder (describe the texture, size, location) 45

46. Percussion (normal percussion note is tympanic) Masses, fluid, and abdominal tenderness Auscultation: Bowel sounds Inspect the Genitalia, groins and anus Rectal examination when relevant (new born gently pass rectal thermometer to verify patency of rectum) 46

47. Extremities/Upper and Lower Limbs Inspection General examination of arms and hands, legs and feet Palpation; Finger nails ( clubbing or koilonychias) Oedema of feet Pulse rate, rhythm, volume and character synchronize with other peripheral pulses Muscles (wasting, tone) Joint movement, tenderness or swelling 47

48. Summary 2 Which includes not more than five lines explaining from history through physical exam incorporating important positives and important negatives 48

49. Diagnosis and Investigations Specimens Specific to Paediatrics Sickling test Gastric aspirate: Appearance For Acid Fast Bacili (AFB) For Gram staining Culture and sensitivity 49

50. Bedside investigations Serology/HIV test/Status : reactive or non reactive Random blood glucose test (RBG) Blood coagulation Test MRDT Syphilis test (VDRL) Urine for Glucose/ Ketone 50

51. Laboratory investigations Blood slide for Malaria Urine analysis Stool analysis Full blood picture (complete blood count) Blood grouping and cross match Gram stain of different body fluid and discharges 51

52. ZN stain of different body fluid and discharges Renal function test: Creatinine level Liver function test Culture and sensitivity of body fluids and discharge Tissue biopsy 52

53. Image investigations X ray of different body regions and parts Ultrasound Electrocardiogram ECG ECHO Endoscopic studies: esophagioscopy , colonoscopy, Computer tomography CT-Scan Magnetic resonance image MRI Posistron emission tomography scan. PET scan 53

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58. Diagnosis After thorough history taking and appropriate examination, in 80 % of cases a diagnosis should be reached Diagnosis should be reached after matching the specific signs and symptoms of the patient with specific signs and symptoms of diseases Patient can have several diagnoses at the same time but usually two or three outstands the others 58

59. Provisional diagnosis This is the most likely diagnosis found on the patient The diagnosis should be supported by clinical symptoms and signs elicited by the patients, and if available should also be supported by results of tests and investigations 59

60. Differential diagnosis These are the alternative diagnoses apart from the provisional diagnosis The differential diagnosis reflects some of the signs and symptoms of the patient that could almost reflect a certain disease but are not adequate enough to match the disease Instead some symptoms and signs are like one disease but some of the symptoms and signs are not like it 60

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62. Treatment Patient stabilization and initial treatment Definite treatment of the diagnosis Supportive treatment Palliative therapy Rehabilitation 62

63. Questions… 63