Pediatric Consultation: History & Physical Examination

Forfar & Arneil 7th Edition · Age-appropriate communication · Cultural considerations · Confidentiality · History taking · Physical exam · Growth · Temperature
📌 Key principles: Build rapport with child and parents; respect cultural and religious needs; maintain confidentiality; take systematic history (presenting complaint, past medical, feeding, development, social); perform age-appropriate examination; plot growth parameters; measure temperature accurately.

📖 Pediatric History & Examination: Core Principles

🗣️ Age-appropriate communication
Neonates: observe. Toddlers: use play, demonstrate on toy. School-age: explain, offer choices. Adolescents: confidential interview, HEADSS assessment (Home, Education, Activities, Drugs, Sexuality, Suicide).
🌍 Cultural & religious considerations
Respect modesty, hand-shaking customs, dietary practices, interpreter use. Be aware of consanguinity, traditional remedies, and disease prevalence in different ethnic groups.
🤝 Confidentiality & consent
Gillick competence: child <16 can consent if understands. Parental responsibility. Breach confidentiality only if serious risk of harm. Document chaperone if needed.
📋 Clinical history components
Presenting complaint (onset, duration, severity, associated symptoms), past medical (birth, neonatal, hospital admissions), feeding & growth, developmental milestones, social/family history, immunizations, drug allergies.
🩺 Physical examination basics
Inspect first, warm hands, use distraction. General assessment (well/unwell, hydration, alertness). Growth: weight, length/height, OFC (centile charts). Temperature: tympanic/axilla/rectal (avoid mercury).
📊 Growth: Weight doubles by 5 months, triples by 1 year. Length increases ~25cm in first year. OFC increases 12cm in first year. Use WHO growth charts (or national references). BMI >97th centile = obesity.

🔍 Structured approach to pediatric consultation

1
Prepare the environment – Quiet, private, toys available, child-friendly. Ensure parent/carer comfortable. Wash hands.
2
Introduce yourself to child and parent – Address child by name. Explain your role. Gain trust. Use eye contact.
3
Elicit presenting complaint – Open-ended question: “What brought you here today?” Let parent speak uninterrupted. Then clarify: onset, progression, associated symptoms, treatments tried.
4
Take systematic history – Past medical (birth history, neonatal problems, previous illnesses, hospitalizations). Feeding (breast/formula, solids, appetite). Development (milestones, parental concerns). Social (family structure, housing, school).
5
Review systems & risk factors – Immunizations, allergies, medications, foreign travel. Family history (genetic conditions, atopy).
6
Address child directly (age-appropriate) – Ask school-age child about symptoms, feelings, fears. For adolescents: offer private interview (confidentiality limits explained).
7
Summarize and check understanding – “Let me make sure I understand…” Ask parents and child if any additional concerns.
📌 Communication tip: For young children, get down to their eye level. Demonstrate examination on a toy first. Use praise and distraction. Avoid asking “will you let me…” – instead say “I’m going to listen to your heart now.”

📋 Stepwise history taking & physical examination

1
History – Presenting complaint (PQRST) – Provoking/Palliating factors, Quality (description), Region/Radiation, Severity (score 0-10 for older child, parent observation), Timing (onset, duration, frequency).
2
Past medical history – Perinatal: gestation, birth weight, delivery mode, APGAR, neonatal complications (jaundice, sepsis, ventilation). Childhood: previous admissions, operations, chronic illness.
3
Feeding & growth history – Infants: breast or formula, volumes, frequency, difficulties (choking, reflux). Older children: diet variety, food fads, weight/growth trajectory. Plot on centile chart.
4
Developmental history – Gross motor (sitting, walking), fine motor (grasp, drawing), language (first words, sentences), personal-social (smile, pointing, play). Ask about regression (loss of skills).
5
Social, school & family history – Parental occupations, smoking, housing, pets. School performance, friendships, bullying. Family history of genetic/atopic illness. Genogram useful.
6
Physical examination – General assessment – Observe: well/unwell? Level of alertness, interaction, hydration (mucous membranes, skin turgor, fontanelle), colour (cyanosis, pallor, jaundice), respiratory distress (tachypnoea, recession, grunting).
7
Growth assessment – Weight (kg, electronic scales, undressed). Length/height (recumbent <2y, standing >2y). OFC (disposable tape, largest measurement). Plot on appropriate centile chart. Calculate weight-for-length/BMI.
8
Temperature measurement – Tympanic (infants >3mo), axillary (screening, add 1°C), rectal (gold standard but invasive). Forehead strips inaccurate. Normal core 36.5-37.5°C.
⚠️ Red flags in history: Unexplained persistent fever, poor weight gain (crossing centiles), regression of milestones, recurrent infections, parental concern for “something wrong”. Always listen to parental intuition.

🧠 Reflex prompts: communication, history & exam

👶 A 2-year-old is very distressed and refuses examination. Best approach?
Observe from parent's lap, perform examination opportunistically (listen to heart while child distracted by toy), leave painful parts to end. Use play specialist if available.
🗣️ An adolescent asks for confidentiality. What do you say?
Explain limits: “I will keep what you say private unless I am worried you or someone else is at serious risk of harm.” Then offer private interview.
🌍 A child presents with fever and rash. Family recently arrived from sub-Saharan Africa. Which diseases have higher prevalence?
Malaria, tuberculosis, HIV, sickle cell disease, typhoid, measles. Take travel and immunization history.
🩺 A 3-month-old with poor weight gain. Plotting shows weight dropped from 25th to 2nd centile. First step?
Take detailed feeding history (breastfeeding latch, milk intake, vomiting), examine for dysmorphism/organomegaly, check urine for infection. Faltering growth workup.
🤝 What is Gillick competence?
Child under 16 can consent to medical treatment if they have sufficient intelligence and maturity to understand nature and implications of treatment. Parental consent not required.
📏 How is length measured in an infant?
Recumbent length on a measuring board (infantometer). Two people: one holds head against fixed plate, other straightens legs and moves foot plate. Accurate to nearest 0.1cm.
🌡️ Which temperature method is most accurate for fever detection in a 6-month-old?
Rectal (core temperature) is gold standard. Tympanic is acceptable alternative >3 months. Axillary is less sensitive but practical for screening (add 1°C).
📝 What information must be included in medical documentation?
Date/time, history (presenting complaint, past medical, etc.), examination findings, differential diagnosis, investigation plan, treatment, follow-up plan. Signed and printed name. Legible.
👩‍⚕️ When is a chaperone required during pediatric exam?
If patient or parent requests, or for intimate examination (genital, breast, rectal) especially if doctor is male examining female adolescent. Document chaperone presence.
📊 A 4-year-old boy has weight on 10th centile, height on 50th centile. What does this suggest?
Low weight for height (wasting). Possible undernutrition, chronic disease, or constitutional thinness. Plot BMI. Requires dietary and medical assessment.