HISTORY

Obtaining a complete history on a pediatric patient not only is necessary, but also leads to the correct diagnosis in the vast majority of children. The history usually is learned from the parent, the older child, or the caretaker of a sick child. After learning the fundamentals of obtaining and recording historic data, the nuances associated with the giving of information must be interpreted.

For the acutely ill child, a short, rapidly obtained report of the events of the immediate past may suffice temporarily, but as soon as the crisis is controlled, a more complete history is necessary. A convenient method of learning to obtain a meaningful history is to ask systematically and directly all of the questions outlined below. After confidence is gained with experience, questions can be problem-directed and asked in an order designed to elicit more specific information about a suspected disease state or diagnosis. Some psychosocial implications will be obvious. More subtle details often are obtained by asking open-ended questions. Those with organic illness usually have short histories; those with psychosomatic illness have a longer list of symptoms and complaints.

During the interview, it is important to convey to the parent interest in the child as well as the illness. The parent is allowed to talk freely at first and to express concerns in his or her own words. The interviewer should look directly either at the parent or the child intermittently and not only at the writing instruments. A sympathetic listener who addresses the parent and child by name frequently obtains more accurate information than does a harried, distracted interviewer. Careful observation during the interview frequently uncovers stresses and concerns that otherwise are not apparent.

The written record is not only helpful in determining a diagnosis and making decisions, but also is necessary for observing the growth and development of the child. A well-organized record facilitates the retrieval of information and obviates problems if it is required for legal review.

The following guidelines indicate the information needed. If preferred, a number of printed forms are available, which contain similar material, or forms may be modified as long as consistency is maintained.

General Information

Identifying data include the date, name, age and birth date, sex, race, referral source if pertinent, relationship of the child and informant, and some indication of the mental state or reliability of the informant. It frequently is helpful to include the ethnic or racial background, address, and telephone numbers of the informants.

Chief Complaint

After the identifying data, the chief complaint should be recorded. Given in the informant's or patient's own words, the chief complaint is a brief statement of the reason why the patient was brought to be seen. It is not unusual that the stated complaint is not the true reason the child was brought for attention. Expanding the question of "Why did you bring him?" to "What concerns you?" allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying.

History of Present Illness

Next, the details of the present illness are recorded in chronologic order. For the sick child, it is helpful to begin: "The child was well until "X" number of days before this visit." This is followed by a daily documentation of events leading up to the present time, including signs, symptoms, and treatment, if any. Statements should be recorded in number of days before the visit or dates, but not in days of the week, because chronology will be difficult to retrieve even a short time later if days of the week are used. If the child is taking medicine, the amount being taken, the name of the medicine, the frequency of administration, and how well and how long it has been or is being taken are needed.

For the well child, a simple statement such as "No complaints" or "No illness" suffices. A question about school attendance may be pertinent. If the past medical history is significant to the current illness, a brief summary is included. If information is obtained from old records, it should be noted here or may be recorded in the past medical history.

Past Medical History

Obtaining the past medical history serves not only to provide a record of data that may be significant either now or later to the well-being of the child, but also to provide evidence of children who are at risk for health or psychosocial problems.

Prenatal History

If a prenatal interview has been held (see below), this information already may be available. Questions to be answered include those regarding the health of the mother during this pregnancy, especially in regard to any infections, other illnesses, vaginal bleeding, toxemia, or care of animals, such as cats, which may induce toxoplasmosis or other animal-borne diseases, all of which can have permanent effects on the embryo and child. The time and type of movements the fetus made in utero should be determined. The number of previous pregnancies and their results, radiographs or medications taken during the pregnancy, results of serology and blood typing of the mother and baby, and results of other tests such as amniocentesis should be recorded. If the mother's weight gain has been excessive or insufficient, this also should be noted.

Birth History

The duration of pregnancy, the ease or difficulty of labor, and the duration of labor may be important, especially if there is a question of developmental delay. The type of delivery (spontaneous, forceps-assisted, or cesarean section), type of anesthesia or analgesia used during delivery, attendance by other family members at delivery, and presenting part (if known) are recorded. Note this child's birth order (if there have been multiple births) and birth weight.

Neonatal History

Many informants are aware of Apgar scores at birth and at 5 minutes, any unusual appearance of the child such as cyanosis or respiratory distress, and any resuscitative efforts that took place and their duration. lf the mother was delayed in seeing the infant after birth, reasons should be sought. Jaundice, anemia, convulsions, dvsmorphic states, and congenital anomalies or infections in the mother or infant are some of the reasons that viewing or handling of the newborn by the mother may be delayed. The time of onset of any of these abnormal states may be significant.

Feeding History

Note whether the baby was breast- or bottle-fed and how well the baby took the first feeding. Poor sucking at the first feeding may be the result of sleepiness of the baby, but also is a warning sign of neurologic abnormality, which may not become manifest until much later in life. By the second or third feeding, even brain-damaged children usually nurse well.

If the infant has been bottle-fed, inquire about the type of formula used and the amount taken during a 24-hour period. At the same time, ask about the mother's initial reaction to her baby, the nature of bonding and eye-to-eye contact, and the patterns of crying, sleeping, urinating, and defecating. Requirements for supplemental feeding, vomiting, regurgitation, colic, diarrhea, or other gastrointestinal or feeding problems should be noted.

Determine the ages at which solid foods were introduced and supplementation with vitamins or fluoride took place, as well as the age at which weaning occurred and the method used to wean. In addition, note the age at which baby foods, toddlers' foods, and table food were introduced, the response to these, and any evidence of food intolerance or vomiting. If feeding difficulties are present, determine the onset of the problem, methods of feeding, reasons for changes, interval between feedings, amount taken at each feeding, vomiting, crying, and weight changes. With any feeding problem, evaluate the effect on the family by asking, "How did you manage the problem?"

For an older child, ask the informant to supply some breakfast, lunch, and dinner (supper) menus, likes and dislikes, and response of the family to eating problems.

Developmental History

Estimation of physical growth rate is important. Attempt to ascertain the birth weight and the weights at 6 months, 1 year, 2 years, 5 years, and 10 years. Lengths at similar ages are desirable. These data are plotted on physical growth charts. Any sudden gain or loss in physical growth should be noted particularly, because its onset may correspond to the onset of organic or psychosocial illness. It may be helpful to compare the child's growth with the rate of growth of siblings or parents.

Ages at which major developmental milestones were met aid in indicating deviations from normal. Some such milestones include following a person with the eyes, holding the head erect, smiling responsively, reaching for objects, transferring objects, sitting alone, walking with support and alone, speaking the first words and sentences, and experiencing tooth eruption. Ages of dressing self, tying own shoes, hopping, skipping, and riding a tricycle and bicycle should be noted, as well as grade in school and school performance.

In addition, note should be made of the age at which bowel and bladder control were achieved. If problems exist, the ages at which toilet teaching began also may indicate reasons for problems.

Behavior History

Amount of sleep and sleep problems, and habits such as pica, smoking, and use of alcohol or drugs should be questioned. The informant should state whether the child is happy or difficult to manage, and should indicate the child's response to new situations, strangers, and school. Temper tantrums, excessive or unprovoked crying, nail biting, and nightmares and night terrors should be recorded. Question the child regarding masturbation, dating, dealing with the opposite sex, and parents' responses to menstruation and sexual development.

Immunization History

The types of immunizations received, with the number, dates, sites given, and reactions should be recorded as part of the history. In addition, it is helpful to record these immunizations on the front of the chart or in a conveniently obvious place with a lot number for future reference when completing school physical examinations or when determining need for booster immunizations or possible reactions.

History of Past Illnesses

A general statement should be made about the child's general health before the present encounter, such as weight change, fever, weakness, or mood alterations. Specific inquiry is helpful regarding the results of any screening tests and regarding any history of roseola, rubeola, rubella, pertussis, mumps, varicella, scarlet fever, tuberculosis, anemia, recurrent tonsillitis, otitis media, pneumonia, meningitis, encephalitis or other nervous system disease, gastrointestinal tract disease, or any other illness, as well as specific treatment, results, and residua. The history of each past illness should include dates of onset, course, and termination. If hospitalization or surgery was necessary, the diagnosis dates, and name of the hospital should he included. Questions concerning allergies include the occurrence and type of any drug reactions, food allergies, hay fever, and asthma. Accidents, injuries, and poisonings should be noted.

Review of Systems

The review of systems serves as a checklist for pertinent information that might have been omitted. If information has been obtained previously, simply state, "See history of present illness" or "See history of past illnesses." Questions concerning each system may be introduced with a question such as: "Are there any symptoms related to . . .?"

• Head (e.g., injuries, headache)
• Eyes (e.g., visual changes, crossed or tendency to cross, discharge, redness, puffiness, injuries, glasses)
• Ears (e.g., difficulty with hearing, pain, discharge, ear infections, myringotomy, ventilation tubes)
• Nose (e.g., discharge, watery or purulent, difficulty in breathing through nose, epistaxis)
• Mouth and throat (e.g., sore throat or tongue, difficulty in swallowing, dental defects)
• Neck (e.g., swollen glands, masses, stiffness, symmetry)
• Breasts (e.g., lumps, pain, symmetry, nipple discharge, embarrassment)
• Lungs (e.g., shortness of breath, ability to keep up with peers, cough with time of cough and character, hoarseness, wheezing, hemoptysis, pain in chest)
• Heart (e.g., cyanosis, edema, heart murmurs or "heart trouble," pain over heart)
• Gastrointestinal (e.g., appetite, nausea, vomiting with relation to feeding, amount, color, blood- or bile-stained, or projectile, bowel movements with number and character, abdominal pain or distention, jaundice)
• Genitourinary (e.g., dysuria, hematuria, frequency, oliguria, character of urinary stream, enuresis, urethral or vaginal discharge, menstrual history, attitude toward menses and opposite sex, sores, pain, intercourse, venereal disease, abortions, birth control method)
• Extremities (e.g.. weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps)
• Neurologic (e.g., headaches, fainting, dizziness, incoordination, seizures, numbness, tremors)
• Skin (e.g., rashes, hives, itching, color change, hair and nail growth, color and distribution, easy bruising or bleeding)
• Psychiatric (e.g., usual mood, nervousness, tension, drug use or abuse)

Family History

The family history provides evidence for considering familial diseases as well as infections or contagious illnesses.

A genetic type chart is easy to read and very helpful. It should include parents, siblings, and grandparents, with their ages, health, or cause of death. If problems with genetic implications exist, all known relatives should be inquired about. If a genetic type chart is used, pregnancies should be listed in a series and should include the health of the siblings (Fig 6-1).

Figure 6-1. Genetic type chart.

(Circle, female, square, male.) 1, maternal grandmother, 67 years old, living and well; paternal grandmother, 66 living and well. 2, Maternal grandfather, died at 62 of heart disease. 3, Paternal grandfather, 71, living and well. 4, Single horizontal line, married. 5, Double horizontal line, consanguineous marriage. 6, Mother, 39 years old, living, diabetic. 7, Father, 41 years old, living, hypertensive. 8, Stillbirth. 1968 (x, died). 9, Male sibling, 14 years old, living, hay fever. 10, Patient, 12 years old (note light circle). 11, Brother, 10 years old, living and well. 12, Female, died at 2 days old of respiratory distress (year can be included).

Family diseases, such as allergy; blood, heart, lung, venereal, or kidney disease; tuberculosis; diabetes; rheumatic fever; convulsions; skin, gastrointestinal, behavioral, or mental disorders; cancer; or other disease the informant mentions should be included. These diseases may have a heritable or contagious effect. Pertinent negatives should be included also.

Social History

Details of the family unit include the number of people in the habitat and its size, the presence of grandparents, the marital status of the parents, the significant caretaker, the total family income and its source, and whether the mother and father work outside the home. If it is pertinent to the current problems of the child, inquire about the family's attitude toward the child and toward each other, the type of discipline used, and the major disciplinarian. If the problem is psychosocial and only one parent is the informant, it may be necessary to interview the other parent and to outline a typical day in the life of the child.

Prenatal History

It is desirable, if feasible, to interview the mother and father before the child is born. Not only can some necessary data be obtained, but also the parents can become acquainted with the doctor who will be seeing them shortly after the arrival of their newborn. The health of the mother, whether she will nurse or bottle-feed the baby and whether the husband supports her choice, the preparation for the baby on arrival home, and whether help will be available can be ascertained. Because the father may feel bypassed by the pregnancy except for the initial event, it is important to direct some questions to him, such as, "Do you want your son circumcised?," and to get the family history of diseases first from him.

History From the Child

Even young children should be asked about their symptoms and their understanding of their problem. This also provides an opportunity to determine the interaction of the child with the parent. For most adolescents, it is important to take part of the history from the adolescent alone after asking for his or her approval. Regardless of your own opinion, obtain the history objectively without any moral implications, starting with open-ended questions related to the initial complaint and then directing the questions.

PHYSICAL EXAMINATION

Examination of the infant and young child begins with observing him or her and establishing rapport. The order of the examination should fit the child and the circumstances. It is wise to make no sudden movements and to complete first those parts of the examination that require the child's cooperation. Painful or disagreeable procedures should be deferred to the end of the examination, and these should be explained to the child before proceeding. For the older child and adolescent, examination can begin with the head and conclude with the extremities. The approach is gentle, but expeditious and complete. For the young, apprehensive child, chatter, reassurance, or other communication frequently permits an orderly examination. Some children are best held by the parent during the examination. For others, part of the examination may require restraint by the parent or assistant.

When the complaint includes a report of pain in a certain area, this area should be examined last. If the child has obvious deformities, that area should be examined in a routine fashion without undue emphasis, because extra attention may increase embarrassment or guilt.

Because the entire child is to be examined, at some time all of the clothing must be removed. This does not necessarily mean that it must be removed at the same time. Only the part that is being examined needs to be uncovered and then it can be re-clothed. Except during infancy, modesty should be respected and the child should be kept as comfortable as possible.

With practice, the examination of the child can be completed quickly even in most critical emergency states. Only in those with apnea, shock, absence of pulse, or, occasionally, seizures is the complete examination delayed. Although the method of procedure may vary, the record of examination should be in the same format for all children. This provides easy access to needed information later. The description that follows is the usual way of recording the examination and not necessarily its required order. When diseases are given with a sign, these are examples and not a complete differential for that sign. The significance of a previous examination cannot be overstressed. A murmur that was not heard a year ago but now is easily audible has far different significance than does a similar murmur heard many years before.

Completion of the history can be accomplished during the physical examination. Talking to the parent frequently reassures the child. Praising the young child, explaining the parts of the examination to the older child, and reassuring the adolescent of normal findings facilitates the examination. Usually, if the examiner enjoys the spontaneity and responsiveness of children, the examination will be easier and more thorough.

Measurements (Vital Signs)

Temperature is taken in the axilla or rectum in the young child and by mouth after 5 or 6 years of age, when the child can understand how to hold the thermometer. Electronic thermometer probes inserted as usual or in the ear canal give rapid, accurate determinations. Elevated temperature occurs with infection, excitement, anxiety, exercise, hyperthyroidism, collagen-vascular disease, or tumor. Decreased temperature occurs with chilling, shock, hypothyroidism, or inactivity. Temperature may be decreased after taking certain drugs, with hypocortisolism, or with overwhelming infection.

The pulse rate can be obtained at any peripheral pulse (femoral, radial, or carotid) or by palpation over the heart. The normal rate varies from 70 to 170 beats per minute at birth to 120 to 140 shortly after birth, and ranges from 80 to 140 at 1 to 2 years, from 80 to 120 at 3 years, and from 70 to 115 after 3 years. The sleeping pulse after the age of 2 years normally is about 20 beats per minute less than the awake pulse, but does not decrease with rheumatic fever or thyrotoxicosis. For each degree of temperature rise, the pulse rate increases about 10 beats per minute. The pulse rate is elevated with excitement, exercise, or hypermetabolic states, and is decreased with hypometabolic states, hypertension, or increased intracranial pressure. Irregularity may be caused by sinus arrhythmia, but can indicate underlying heart disease. Absence of the femoral pulse is a cardinal sign of postductal coarctation of the aorta.

Respiratory Rate

The respiratory rate should be determined by observing the movement of the chest or abdomen or by auscultating the chest. The normal newborn rate is 30 to 80 breaths per minute; the rate decreases to 20 to 40 in early infancy and childhood and then to 15 to 25 in late childhood and adolescence. Exercise, anxiety, infection, and hypermetabolic states increase the rate; central nervous system lesions, metabolic abnormalities, alkalosis, depressants, and other poisons decrease the rate.

Blood Pressure

The blood pressure should be measured with a cuff, with the bladder completely encircling the extremity and the width covering one half to two thirds of the length of the upper arm or upper leg. The pressure should be recorded and compared with normal readings (Figs 6-2 through 6-7). High systolic pressure occurs with excitement, anxiety, and hypermetabolic states. High systolic and diastolic pressures occur with renal diseases, pheochromocytoma, adrenal disease, arteritis, or coarctation of the aorta.

Figure 6-2. Age-specific percentiles of blood pressure (BP) measurements in boys--birth to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP.

(American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)

Figure 6-3. Age-specific percentiles of blood pressure (BP) measurements in boys--1 to 13 years of age; Korotkoff phase IV (K4) used for diastolic BP

(American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)

Figure 6-4. Age-specific percentiles of blood pressure (BP) measurements in boys--13 to 18 years of age; Korotkoff phase V (K5) used for diastolic BP

(American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)

Figure 6-5. Age-specific percentiles of blood pressure (BP) measurements in girls--birth to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP

(American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)

Figure 6-6. Age-specific percentiles of blood pressure (BP) measurements in girls--1 to 13 years of age; Korotkoff phase IV (K4) used for diastolic BP

(American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)

 Figure 6-7. Age-specific percentiles of blood pressure (BP) measurements in girls--13 to 18 years of age; Korotkoff phase V (K5) used for diastolic BP

(American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)

Height, Weight, Head Circumference

To obtain height and weight recordings, measure the infant supine up to the age of 2 years, and standing thereafter. Measure head circumference in all infants less than 2 years of age and in those with misshapen heads. Record height, weight, and head circumference measurements with percentiles on a chart (Figs 6-8 through 6-15).

Figures 6-8 through 6-15 are in PDF format and were downloaded from the National Center for Health Statistics (NCHS) Web site (http://www.cdc.gov/nchs/). Additional figures, information, and statistics are freely available from this site.

• Figure 6-8. NCHS percentiles of physical growth in girls--birth to 36 months.

• Figure 6-9. NCHS percentiles of physical growth in girls--2 to 20 years of age.

• Figure 6-10. NCHS Girls Weight-for-Stature percentiles.

• Figure 6-11. NCHS percentiles of physical growth in boys--birth to 36 months.

• Figure 6-12. NCHS percentiles of physical growth in boys--2 to 20 years of age.

• Figure 6-13. NCHS Boys Weight-for-Stature percentiles.

• Figure 6-14. Head circumference, boys.

• Figure 6-15. Head circumference, girls.

Shortness may be caused by malabsorption, chronic illness, or syndromes with dwarfism. Gigantism may be the result of pituitary abnormalities. Compare sitting height and total height in dwarfs to standard measurements to determine the type of syndrome present.

Decreased weight can be caused by conditions similar to those that cause decreased height. In states of malnutrition, weight percentile is less than height percentile; head circumference remains normal unluess the condition is severe and persists. Overweight usually is exogenous and associated with increased height until epiphyseal closure. Overweight resulting from endocrine disorders is associated with decreased linear growth.

Skin Fold Measurements

Skin fold measurements are useful in determining obesity and in identifying and following malnutrition. Skin fold calipers are applied over the mid-triceps.

General Appearance

A statement should be recorded about the alertness, distress, general development, and nutrition of the child. Mental status, activity, unusual positions, or apprehension or cooperativeness may direct one to consider an acute or chronic illness or no illness at all. The child who lies quietly, staring into space, may be gravely ill. The child who lies quietly but becomes irritable when held by his mother (paradoxic irritability) may have meningitis or pain in motion. Note any unusual odor, which may suggest the presence of a foreign body in one of the orifices or certain metabolic diseases or toxins.

Skin

In examining the skin, record its color and turgor, the type of any lesions, and the condition of body and scalp hair and nails.

Normal color of the skin is the result of the presence of melanin; depigmented areas are vitiligo: absence of pigment occurs in albinism. Cyanosis is caused by unsaturation of or abnormal forms of hemoglobin; jaundice is caused by excessive bilirubin deposited in the adipose tissue. Note the size and borders of nevi, which usually are darkly pigmented areas, and caf-au-lait spots, which are brownish areas that may signal neurofibromatosis. White spots shaped like a leaf suggest tuberous sclerosis. Ecchymoses or petechiae and scars may indicate abuse.

Swelling may be caused by edema. Lack of turgor occurs with dehydration or recent weight loss. Describe any rashes, many of which are characteristic of viral or bacterial infection.

Head and Face

Record the shape, symmetry, and any defects of the head; the distribution of hair; and the size and tension of fontanelles. A large head may be an early sign of hydrocephalus or an intracranial mass. A small head may be a result of early closure of sutures or lack of brain development. For any deviation from normal head size, frequent measurements are necessary. The fontanelles normally are flat. The posterior fontanelle closes by 2 months of age, and the anterior fontanelle closes by 12 to 18 months of age. Unusual hair whorls are associated with severe intracranial abnormalities.

The face may appear distinctive for a number of syndromes. For example, unilateral facial paralysis may be associated with congenital heart disease. Coarse facies occur with storage diseases. Epicanthal folds occur in a number of syndromes, including Down (5trisomy 21.)

Eyes

Test vision grossly in the young child with brightly colored objects. In the older child, test with Snellen's E chart. Evaluate for strabismus by noting the position of the reflection of light on the cornea from a distant source. Evaluate the range of eye movements and the presence of nystagmus. Both eyelids should open equally. Failure to open is ptosis and may be caused by neurologic or systemic diseases. Upward slanting of the palpebral fissures with covering of the inner canthus (epicanthal folds) is a sign of Down syndrome. The conjunctivae should be pink, but not inflamed; the sclerae should be white. Examine the cornea for haziness (a sign of glaucoma) or opacities. Record the size and shape of the pupils, the color of the iris, and the response of the iris to light and accommodation. In the fundoscopic examination, use a zero lens and note the presence of a red reflex, or hemorrhages or pigmented areas, and the size of the veins compared to the arteries. Any obstruction, such as corneal or lenticular cataract will obliterate part or all of the red reflex. The disc borders should be sharp. They are blurred with increased intracranial pressure. The macula may not be clear, which is a sign of degenerative diseases. Obtain the corneal reflex by lightly touching the cornea with a piece of cotton. Failure to blink indicates trigeminal or facial nerve injury.

Ears

Note the position of the ears and abnormalities of the external ear, the pinna. Low-set ears may suggest the presence of renal agenesis. Tags and deformities frequently are associated with other minor or major anomalies. Grossly evaluate hearing, then proceed with examination of the inner ear. Pull the earlobe up and anteriorly. Grasp an otoscope equipped with a bright light so that the holding hand rests on the child's head and moves with any movement of the head, and use the largest speculum that will fit into the canal. The canal should be clear, and the drum should be pearly gray in color and concave. A cone of light, the malleus, and sometimes the incus will be identified. If the bones are not visualized, the drum is not gray in color or is infected, or the drum is not concave, fluid may be in the inner ear, which is diagnostic of otitis media.

Nose

Raise the tip of the nose and look up the nose with a bright light. Deformities of the septum, bleeding, or discharges should be recorded. The normal nasal mucosa is light pink in color. Tap on the maxillary and frontal sinuses for tenderness. Feel for air egress from both nares.

Mouth and Throat

Examination of the mouth and throat usually is the most resistant part of the examination and should be performed near the end of the examination. The child should be sitting so that the tongue is less likely to obstruct the pharynx. Deformities or infections around the lips are recorded. Count the number and note the condition of the teeth. Similarly, note the condition and color of the tongue, buccal mucosa, palate. tonsils, and posterior pharynx. Normally, these are pink in color. Exudate indicates infection by bacteria, viruses, or fungi, but etiology usually cannot be determined by physical examination alone. Note also the presence of the gag reflex and the voice or cry. If the child seems hoarse, question the parent concerning the normal voice. Laryngitis can lead to airway obstruction. After the age of 2 years, children should not drool. Chronic drooling may suggest mental deficiency, but acute onset of drooling is a grave sign of epiglottitis or poison ingestion.

Neck

Feel in the neck for lymph nodes, which normally are nontender and up to 1 cm in diameter in both the anterior and posterior cervical triangles. Larger or tender nodes occur with local or systemic infection or malignancies. Feel the trachea in the midline. The thyroid may not be palpable. Other masses may be present and are always abnormal. Flex the neck. Resistance to flexion is a cardinal sign of meningitis, except in infancy, but this also occurs with severe infections around the neck or dislocation of the cervical vertebrae.

Lymph Nodes

In addition to the lymph nodes in the neck, palpate inguinal, epitrochlear, supraclavicular, axillary, and posterior occipital nodes. Normally, inguinal nodes may be up to 1 cm in diameter: the others are nonpalpable or less than 5 mm. Larger or tender nodes hold significance similar to that described for abnormal cervical glands.

Chest

Observe the chest for shape and symmetry. The chest wall is almost round in infancy and in children with obstructive lung disease. Respirations are predominantly abdominal until about 6 years of age, when they become thoracic. Note suprasternal, intercostal, and subcostal retractions, which are signs of increased respiratory work. Swelling at the costochondral junctions is an indication of rickets. Edema of the chest wall occurs in children with superior vena cava obstruction. Asymmetry of expansion occurs with diaphragmatic paralysis, pneumothorax, or other intrathoracic abnormalities.

Breasts

Breasts normally are hypertrophied at birth; they regress within 6 months and develop with the onset of puberty. Development during adolescence is staged. Breast development in both boys and girls usually begins asymmetrically. Palpate for nodules, which may be cysts or tumors. Redness, heat, and tenderness usually indicate infection.

Lungs

Examination of the lungs includes observation, palpation, percussion, auscultation, and, if indicated, transillumination.

Observation

Note the type and rate of the child's breathing. The rate of respiration varies, as described previously. Rapid rates, known as tachypnea, are associated with infection, fever, excitement, exercise, heart failure, or intoxicants. Slower rates are characteristic of intracranial lesions, depression caused by sedative drugs, heart block, or alkalosis. Cheyne-Stokes breathing, which is characterized by periods of deep, rapid respirations followed by slow, shallow respirations, is common in premature and newborn infants, and in those with intracranial or metabolic abnormalities. Dyspnea, or distress during breathing, is associated with flaring of the intercostal spaces and nares. Inspiratory dyspnea is more common with obstruction high in the respiratory system and expiratory dyspnea is more common with lower respiratory diseases.

Palpation

Feel the entire chest with the palms and fingertips. Note masses or areas of tenderness. Tactile fremitus, a vibratory sensation during crying or speaking, normally is felt over the entire chest. Fremitus is absent if the airway is obstructed.

Percussion

Either direct percussion (tapping the chest wall directly with either the index or middle fingers) or indirect percussion (placing a finger of one hand firmly on the chest wall and tapping that finger with the index or middle finger of the opposite hand) may be used in children. The entire chest wall is percussed anteriorly, posteriorly, and along the midaxillary line. A resonant sound will be obtained over most of the chest except over the scapulae, diaphragm, liver, and heart, where dullness is elicited. Dullness detects consolidation in the lungs, as well as the size and position of the liver and heart. Scratch percussion, which involves tapping the chest wall with a finger while listening with a bell stethoscope over the heart and liver, is especially useful in determining heart and liver size. Increased resonance is found with increased trapped air, emphysema, or air in the pleural space (pneumothorax).

Auscultation

To auscultate the lungs in children, listen with a small bell in small children and with the diaphragm in older children. Normal breath sounds are bronchovesicular and inspiration is twice as long as expiration in young children; breath sounds are vesicular and inspiration is three times as long as expiration in older children. Breath sounds are decreased with consolidation or pleural fluid in the young child and increased with pneumonia in the older child. Fine crackles either in inspiration or expiration (rales) indicate foreign substances, usually fluid, in the alveoli or smaller bronchi, as occurs in bronchitis, pneumonia, or heart failure. Coarse extraneous sounds (rhonchi) are the result of foreign substances in the larger airways, as in crying or upper respiratory infection. Musical extraneous sounds (wheezes) are caused by airflow through compromised larger airways, as in asthma.

Transillumination

If pneumothorax is present, the chest will transilluminate. This is especially useful in the newborn.

Heart

In addition to the heart's rate (pulse) and rhythm, and the blood pressure, note the size, shape, sound quality, and presence of murmurs when examining the heart.

Precordial bulging is a sign of right-sided enlargement. A cardiac impulse may not be noted in a young child, but in a thin, active child, it may suggest the size and position of the heart. An apex beat outside the midclavicular line in the fifth interspace indicates cardiomegaly, which is a significant sign of heart disease or heart failure. Palpation and percussion are described above. Auscultate both in the sitting and the supine position. Determine the heart rate and rhythm if this was not done previously. Auscultate initially over the apex (mitral area), then over the lower right sternal border (tricuspid area), the second left intercostal space at the sternal edge (pulmonary area), and the second right intercostal space at the sternal edge (aortic area). Next, proceed to the remainder of the precordium, the axillae, back, and neck. Note heart sounds and any arrhythmia. A loud first sound at the apex occurs with mitral stenosis, a loud second sound at the pulmonary area occurs with pulmonary hypertension, and a fixed split-second sound in the pulmonary area occurs with an atrial septal defect. Innocent murmurs are systolic, musical, or vibratory and of low intensity, and usually are heard at the second left Interspace, just inside the apex, or beneath either clavicle. The latter is a venous hum that may be continuous and that disappears when the patient is supine. Diastolic murmurs are almost always significant. Significant systolic murmurs may be stenotic and are loudest in mid-systole over the aortic or pulmonary areas. Regurgitant murmurs begin immediately after the first sound. Over the mitral or tricuspid area, they indicate valvular insufficiency. A continuous or uneven systolic murmur along the upper left sternal border indicates patent ductus arteriosus.

Abdomen

Observe the shape of the abdomen. A flat abdomen may indicate diaphragmatic hernia; a distended abdomen may indicate intestinal obstruction or ascites. Auscultate before percussing or palpating. Normally, peristaltic sounds are heard every 10 to 30 seconds. High-pitched frequent sounds occur with obstruction or peritonitis; absent sounds indicate ileus. Next, palpate gently, beginning in the left lower quadrant and proceeding to the left upper, right upper, right lower, and midline areas. Then palpate more deeply in the same areas and follow with palpation in the same areas with the unused hand, pushing toward the front hand from the child's back. Feel especially for the liver in the right upper quadrant and the spleen in the left upper quadrant, and estimate their size. Any other masses are abnormal. Determine tenderness and attempt to locate the maximum point of any tenderness, which may indicate intra-abdominal infection such as peritonitis, cystitis, or appendicitis, or rapid enlargement of organs, as occurs with enlargement of the liver in heart failure. Percuss to verify findings. Feel in the costovertebral angles to determine kidney size. Tenderness usually indicates pyelonephritis.

Genitalia

Average adolescent development in girls proceeds as follows:

1. breast development at  10.5 years of age,
2. pubic hair at 11 years of age,
3. increase in height velocity at 12 years of age,
4. menarche at 12.5 years of age
5. axillary hair at 13 years of age.

Average development in boys proceeds as follows:

1. testicular enlargement at 11.5 years of age,
2. pubic hair at 12.5 years of age,
3. increase in height velocity at 14 years of age,
4. facial and axillary hair at 14.5 years of age.

Variations in order of development suggest hormonal abnormalities. Modesty of the child should be respected during the examination, especially of the genitalia.

Inspect the genitalia for urethral discharges, which are always pathologic and indicate infection anywhere in the genitourinary systems.

In a girl, vaginal bleeding after the newborn period and before puberty may be the result of injury or foreign body. Fused labia minora usually part with hygiene. Imperforate hymen causes hydrocolpos before puberty and hematocolpos after menarche. Vaginal discharge may be the result of injury or foreign body in a young girl, usually is normal at the start of puberty, and suggests infection in an older girl. Adolescents with vaginal discharge, dysuria, lower abdominal pain, irregular bleeding, or sexual activity require a complete vaginal examination. The uterus in a younger child is palpated for size, shape, and tenderness with one hand over the lower abdomen and a finger of the other hand in the rectum. For an older child, the cervix is visualized with a vaginoscope or small speculum, and cultures are obtained.

In boys, testes should be in the scrotum after birth, although active cremasteric reflexes may empty the scrotum temporarily. The meatal opening should be slit-like and the urinary stream should be strong. Hydroceles, which do not reduce and do transilluminate, and hernias, which reduce but do not transilluminate, enlarge the scrotum. Testicular tenderness suggests torsion of the testis or epididymitis.

Rectal

Inspect the anus for fissures, inflammation, or lack of tone. The latter may indicate child abuse. The rectum is not examined routinely, but is examined in all children with abdominal or gastrointestinal complaints, including diarrhea, constipation, or bleeding from the rectum.

Extremities and Back

Asymmetry, anomalies, unusual size, pain, tenderness, heat, and swelling deformities of the extremities and back must be distinguished from congenital malformations, osteomyelitis, cellulitis, myositis, or, rarely, rickets and scurvy. Joint heat, tenderness, swelling, effusion, redness, and limitation or pain on motion may indicate arthritis, arthralgia, synovitis or injury, or septic arthritis (which is a medical emergency). Observe as the child walks for the presence of a limp. Clubbing of the fingers is a sign of chronic hypoxemia, as in congenital heart or chronic pulmonary diseases.

The spine should be straight with mild lumbar lordosis. Kyphosis, scoliosis, masses, tenderness, limitation of motion, spina bifida, pilonidal dimples, or cysts may be caused by injury, malformation, infections, or tumors.

Weakness, tenderness, or paresis of the muscles suggests inflammatory muscle disease, congenital or metabolic neuromuscular diseases, or central nervous system abnormalities.

Neurologic Examination

Mental status and orientation help determine the acuteness of a child's illness, depending on the environmental conditions. Position at rest and abnormal movements such as tremors, twitchings, choreiform movements, and athetosis are characteristic of hyperirritability of the central nervous system. Incoordination of gait usually indicates cerebellar dysfunction. Kernig's sign (inability to extend the leg with the hip flexed) and Brudzinski's sign (flexing the neck with resultant flexion of the hip or knee) are indications of meningeal irritation.

Cranial nerves can be tested. Dysfunction of olfactory nerve 1 results in anosmia. Nerves II, III, IV, and VI are described briefly under "Eyes" in Chapter 34, and nerve VIII is discussed under "Ears" in Chapters 36.6 and 36.7. Dysfunction of the trigeminal nerve V results in lack of sensation of the face and tongue. With peripheral facial nerve VII paralysis, neither the forehead nor the face moves. With nuclear VII paralysis, the forehead moves. Difficulty in swallowing and loss of pharyngeal reflexes are caused by dysfunction of the glossopharyngeal nerve IX or the vagus nerve X. Patients cannot contract the sternocleidomastoid or trapezius muscles with involvement of the spinal accessory nerve XI. The tongue protrudes to the involved side with hypoglossal nerve XII lesions.

Examination of tendon reflexes (biceps, triceps, patellar, and Achilles) is less important than is observation of general activity. Hyperactive reflexes indicate an upper motor neuron lesion or hypocalcemia. Decreased reflexes are seen in lower motor neuron lesions or the muscular dystrophies.

NEWBORN EXAMINATION

In the delivery room, a minimal examination is needed. The general appearance is noted and, at 1 and 5 minutes of age, an Apgar score is assigned (Table 6-1). A score of 7 or less indicates that an infant is at risk.

The infant is placed in a warmer. A small catheter is passed through both nares. Secretions are aspirated, and the tube is continued into the stomach and the stomach contents are aspirated. Easy passage of the catheter indicates patency of both nares. Passage into the stomach obviates blind pouch types of tracheoesophageal fistula. The infant may urinate or defecate, indicating patency of these orifices. The mouth is inspected for cleft palate. Gestational age is assessed based on neurodevelopmental signs. Newborn care then is given and further examination is deferred to the nursery.

Table 6-1. Apgar Score

Preferably within the first few hours of birth, an admission newborn examination is performed in the presence of the parents. The examiner should develop a routine for the newborn examination so that critical areas are never omitted. In the first few hours of life, the newborn usually is awake, but after 4 hours, he or she may be sleepy. The pressing question to be answered in the first examination is: "Is my child normal?" Although the order of the examination may vary, as with the history, a stereotyped order of recording should be initiated for easy retrieval of information if it is needed later.

Vital Signs

Vital signs include temperature, heart rate, respiratory rate, blood pressure (using an apparatus for newborns) in an upper and a lower extremity, weight, length, and head, chest, and abdominal circumferences. In addition to recording these, it is essential that they also be plotted on a chart (see Figs 6-8, 6-11).

General Appearance

Within a few moments, observe the movement of the four extremities, the appearance of the head and neck, body symmetry, and any gross abnormalities.

Skin

The skin may be covered by a white, greasy, easily removable material called vernix caseosa. Note skin color, consistency, and hydration. Cyanosis, jaundice, eruptions, edema, bruises, petechiae, and pallor are significant abnormalities. Note also hemangiomas and nevi, their size and location. Mongolian (brown) spots over the back are not suggestive of disease, but caf-au-lait spots, if they are numerous, may be a cardinal sign of neurofibromatosis. Papules and pustules must be identified as either normal eruptions or infections.

Head and Neck

The fontanelle size and head circumference are variable on the first day because of molding. Scalp edema (caput succedaneum) crosses the midline and may be present; this is distinguished from cephalhematoma, which does not cross the midline and is caused by subperiosteal bleeding.

Unusual facies suggests dysmorphic syndromes. Peripheral facial nerve palsies are common. Edema of the eyelids is a result of birth processes or reaction to silver nitrate prophylaxis. Sub-conjunctival and retinal hemorrhages are found frequently. Red reflex from the fundus, if not visible, indicates some obstruction in the preretinal chambers. Malformation of the pinnae of the ears often is accompanied by severe congenital malformations. If the nose was not found to be patent in the first examination, it should be examined at this time by passing a catheter through both nares. The mouth should be reexamined for cleft palate. The neck should be examined for shortening (as in Klippel-Feil syndrome), redundant skin folds (as in gonadal dysgenesis), vertebral anomalies, cysts, sinuses, and limitation of motion (torticollis).

Chest

The chest normally is barrel-shaped and smooth at birth, and expands symmetrically with no retractions. Unequal expansion or asymmetry suggests intrathoracic pathology such as cardiac enlargement, pneumothorax, or diaphragmatic hernia. The respiratory rate normally is less than 60 breaths per minute. Occasional irregularities with apnea up to 10 seconds can be normal. Auscultation may reveal adventitious sounds for the first 4 to 6 hours. Percussion is resonant throughout. Maximal cardiac impulse is felt in the fourth interspace close to the sternum. Thrills, if they are present, usually indicate cardiac abnormalities. Murmurs are present in 60% of normal newborns, but the lack of a murmur does not eliminate a diagnosis of congenital heart disease. Brachial and femoral pulses, if they are not of equal intensity, suggest vascular anomalies such as coarctation of the aorta. If chest expansion is unequal, transilluminate the chest. Transillumination occurs with pneumothorax and occasionally with diaphragmatic hernia.

Abdomen

Distention of the abdomen occurs with sepsis, intestinal or urinary system obstruction, ascites, tumors, or pneumoperitoneum. Scaphoid abdomen suggests a diaphragmatic hernia. Palpate gently. The liver's edge usually is felt 1 to 2 cm below the costal margin and the spleen tip is barely palpable. The bladder, if it is palpable, should be reexamined after voiding. Palpation of the costovertebral angle with ballottement helps to determine the size of the kidneys. The umbilical cord contains two arteries, which are small and thick-walled, and one vein, which is larger and thin-walled. A single umbilical artery is associated with an increased incidence of congenital anomalies. Erythema at the base of the cord suggests omphalitis. Note the patency of the urethral meatus by observing voiding and the patency of the anus either by observing the passage of meconium or by inserting a small rubber catheter.

Extremities

Asymmetric posturing requires careful palpation of the clavicles, shoulders, and extremities for fractures or brachial plexus injuries. Anomalies of the hands and feet such as webbing, polydactyly, and clubfoot are noted. Abduct both legs to determine any limitation of movement or instability of the hips, which is characteristic of dislocated hips. Read Barlow and Ortolani tests.

Genitalia

Testes normally are in the scrotum of term infants. Determine the position and size of the urethral meatus. The newborn's penis is greater than 2cm in length. An enlarged clitoris can be confused with a small penis and requires evaluation for chromosomal sex and other abnormalities of the genitourinary system. The vaginal opening is inspected, and mucosal tags, imperforate hymen, and ambiguous genitalia are sought.

Neurologic Examination

Assess muscle tone and strength. Extremities normally recoil spontaneously when they are extended from a flexed position and thrash about when irritated. Moro's reflex, which is obtained by loud noise or sudden motion, involves abduction of the upper arms and legs, and extension at the elbows and knees, followed by flexion. Absence of this reflex indicates central nervous system depression. Asymmetry suggests extremity fracture or peripheral nerve injury.