Write-Up Guide

This was designed to serve as a reference source in the writing of the formal history and physical examination on the Pediatric Clerkship. What follows is comprehensive and extremely thorough, such that all aspects of a complete H&P may be considered. It may be appropriate to defer some parts of the history or physical in certain situations. The extent of the appropriate history and physical should be discussed with your attending.

History taking, as one means by which we collect data about our patients, will be dealt with first. Subsequently, suggestions will be made relative to the pediatric examination. These added to any laboratory data make up the data base which logically lead to formation of an assessment statement and problem list. The next step is to design a diagnostic and therapeutic approach to solution of the problems on the list - a plan. Finally, a discussion should follow showing evidence of outside reading with application to your patient.

Remember that the order or recording of the historical and physical examination is often not the same as it was elicited. This is especially true where the pediatric age group is concerned. Allow the informant the "free wheel" with gentle guidance as is consistent with good interviewing techniques. Keep in mind also that taking the history and not pointing out parental deficiencies is your goal. That first contact is critical as it is the foundation on which the often talked about doctor-patient relationship is built.

The write up should include the following information at the top of the first page:

1. Name of Patient
2. Hospital Number (Unit Number)
3. Service of
4. Primary Care Physician
5. Data Recorded by
6. Data obtained from:
* Name of informant and relation to patient
* Other sources (chart, social worker, etc.)
7. Date of Admission

 

CHIEF COMPLAINT (CC)

Indicate the reason of admission to the hospital in the words of the informant.

HISTORY OF PRESENT ILLNESS (HPI)

Begin with a statement which includes identifying information, pertinent chronic conditions, and an idea about duration of illness, i.e. "This is the first admission for this seven year old previously well boy who has complained of abdominal pain since approximately noon today."

The presenting illness should be described in chronologic order and in a problem oriented fashion. Significant epidemiologic and negative historical information should be included. A brief example of a possible present illness would be as follows:

This is the first admission for this 13-month-old white boy who was felt to be well until approximately 3 weeks ago when his stools became loose and frequent.

This problem persisted with three to four stools daily until three days ago when he developed a fever (documented only by his mother's feeling that he was warm). The stools became green and "slimy" although the frequency remained unchanged. His intake of fluids consisted of three 3-oz. bottles of whole milk. No solids were tolerated.

Two days prior to admission all feeding were refused and the infant seemed much less active. He was lethargic. The stools were now blood streaked as well as green.

On the day prior to admission his mother took him to another hospital (state the name) and was advised to give only clear liquids. His stool pattern remained unchanged on this regimen. Wet diapers between bowel movements were not noted by his mother.

On the day of admission the baby did not take any feedings. He vomited twice en route to the hospital. No fever was noted. His responsiveness had decreased to the point of unresponsiveness. On arrival in the emergency room he was immediately given an intravenous bolus of normal saline and admitted to the ward.

There are no family members who have been ill with gastrointestinal complaints and none of the neighbors reported having sick children. His weight was 10.1 kilograms at his one-year checkup but nothing is known about weight gain since that time. His diet has consisted primarily of boiled milk, "grits" and the clear liquid prescribed by the other hospital.

PAST MEDICAL HISTORY (PMH)

Certain data from the past takes on special relevance in pediatrics. We are considerably more interested in the mother's pregnancy, the perinatal period and several aspects of the time between birth and preschool than are those who care for adults. The pertinence of each of the following depends on the child's age and concern.

Prenatal, Labor, and Delivery

Important questions are concerned with mother's previous pregnancy history, diet and health during her present pregnancy including bleeding or drugs and other possible pertinent influences on the fetus or its environment. The time of onset of movement as well as quality and quantity of fetal movement should be explored. Mother's serology, blood type and Rh factor, especially in the newborn period are essential data.

Describe the labor. Was it easy or difficult? How long did it last? Was induction necessary?

Regarding delivery, questions should be asked about the following: anesthetic used - local, general or none, presentation (breach or head first), use of forceps or vacuum, baby's behavior immediately at delivery, did baby cry immediately? What kind of resuscitation was needed if not? Also ask if the baby went to the normal Newborn Nursery or NICU, what happened there, and whether or not the baby went home with its mother.

Growth and Development

Physical growth
Gather any available data regarding sequential weights, lengths, and head circumference (this might also be available from old records). PLOT THE GROWTH DATA ON A GROWTH CURVE.

 

Motor development
Several major areas should be considered and questions about achieving certain developmental milestones explored. When was the child able to hold his head erect, sit alone, stand, walk alone, etc.? When was the child toilet trained? What are the fine motor skills the child has mastered? (also see physical exam on neurologic examination)

 

Mental development
Inquire about social skills. Inquire about expressive and receptive speech development (first words, simple sentences). It may helpful for mother to compare him to siblings. If the child is in school, then grade, special difficulties and teacher's comments are important.

 

Senses
Elicit any concerns the family has about the child's hearing or vision.

 

Previous Illnesses
A comment relative to the child's previous general health should be made. Then explore the various areas listed below.

 

Hospitalizations

 

Accidents and injuries

 

Surgical procedures

 

Specific illnesses
Note any unusual manifestations or complications of these.

MEDICATIONS, ALLERGIES, IMMUNIZATIONS

List any medications the child takes, including over-the-counter medications. Ask about home remedies, vitamins, and supplements as well.

Note all allergies and specify the response with each.

Be familiar with current accepted recommendations of the American Academy of Pediatrics. Note any untoward reaction or complications.

PRIMARY CARE PROVIDER

Essential to note. That person should be made aware of admission and should be called at time of discharge.

SOCIAL HISTORY

This is a critically important part of the history as it invariably yields important information in understanding the child's present problem and the family's reaction to it. This history should include delineation of present family structure including the child's relationship with parents. The patient's cultural setting should be noted and considered including its impact on the patient’s care. A delineation of who lives in the home and their relationship to the patient is important. The occupation and employment of adult family members in the home should be noted. Financial problems and marital stability are important factors. In the pre-school age child, the primary daytime caretaker should be identified. For the school-age child, academic performance, relationship to peers, and hobbies should be described. Any history of alcohol or drug abuse in the family should also be noted as should major life events (death of beloved grandparent, recent move to the city, parental loss of job, etc.) The home setting (rural, city), sanitation and exposure to environmental hazards should be discovered. Exposure to tobacco smoke should always be asked about and recorded. Explore the possibilities of domestic violence and child abuse. For older children, ask (with the child alone) about sexual activity and substance use. The social history in a teenage patient can be explored using the mnemonic BHEADSS (body image, home, education, activities, drugs, sexuality, suicide risk).

FAMILY HISTORY

The family history should include the current family structure with the age and health status of first line relatives (parents, siblings). This might be most effectively diagramed in family tree. Inquire about a family history of identified disease or symptom complex similar to that of the patient. A family history of hereditary disease, or tendency toward any disease or condition would also be elicited, even if unrelated to the patient's present problem (condition such as diabetes, hypertension, migraine, seizures, asthma, etc.). Any childhood deaths or developmental delay in the family should be noted. Consanguinity of the parents should be identified if present.

REVIEW OF SYSTEMS (ROS)

The ROS will often bring out symptoms or signs missed in the collection of data about the present illness. Generally, if the complaint relates to the chief complaint it should be recorded in the HPI. Current issues not directly related to the CC should be recorded in the ROS. There is no need to repeat previously recorded information again in the ROS. Examples of topics in the ROS are included below.

Constitutional: fever, weight loss, night sweats

Skin: Rashes, hives, problems with hair, skin texture or color?

Head : Head injury, headache, dizziness?

Eyes : Have the child's eyes ever crossed? Any foreign body or infection? Glasses? Conjunctivits?

Nose : Nose bleeds, snoring discharge, mouth breathing?

Ears : Hearing difficulty, earaches?

Mouth and Throat : Frequent sore throats or "tonsil trouble," difficulty swallowing, teeth problems or hay fever, hoarseness?

Neck : "Swollen glands," pain?

Chest : Cough, difficulty breathing or wheezing?

Heart : Palpitations, sweating, exercise intolerance?

Gastrointestinal : Appetite, vomiting, abdominal pain, character and frequency of stool, bloody stools, encopresis?

Genitourinary : Enuresis, frequency urgency, pain on voiding, vaginal discharge, hernia, urinary stream?

Allergy : Any intolerance to foods, pollen, animals, chemicals, drugs?

Endocrine: Problems with pubescence, menarche, menstruation, breast, thyroid gland?

Neuromuscular: Convulsion, coordination problem, weakness, spasticity, or movement disorder?

Behavioral History : Does the child manifest any unusual behavior?

Nutritional History : An idea of the child's usual daily intake will be of importance. Be specific about how much the baby takes. Does/did the baby breast feed?

 

THE PHYSICAL EXAMINATION

Skill, tack and above all patience are required to gather an optimal amount of information when examining a child. Each examination should be individualized and should conform to the age and temperament of the child.

Wash your hands before examination begins.

Learn all you can from inspection, before approaching the child too closely. Expose as much of the child as possible so you can note things like work of breathing from a safe distance. With the younger child, get to the heart, lungs and abdomen before the crying starts. Save looking at the throat and ears for last. If part of the examination is uncomfortable or painful, tell the child in a warm, honest but determined tone that this is necessary. Restrain and move quickly when necessary.

Remember that you must respect modesty in your patients, especially as they approach pubescence. Some time during the examination, however, every part of the child must have been undressed. It usually works out best to start with those areas which would least likely make your patients anxious.

Vital signs and measurements:

Usual measurements should include pulse, respirations, temperature and blood pressure. The cuff should cover 2/3 of the upper arm. Pulse ox measurements are often included in vital signs.

Height, weight and head circumference should be measured and plotted on a growth chart and listed as percentiles in children less than 3. If heights, weights, or head circumference measurements are available from history or old records, plot those on the graph. Growth curves can be found on the clerkship webpage.

In older children note the weight, length, BMI and percentiles.

General Appearance:

Describe whether the child appears ill or well. If ill, does he appear acutely or chronically ill? Note any distress. Is he active or inactive? Consider facial expressions, development, speech, posture and reaction to parents.

Skin, Hair, and Nails : Color, cyanosis, petechiae, ecchymosis, turgor, amount of subcutaneous tissue, edema, inflammation, etc.

Head : Remark about the size, shape and symmetry. Are the fontanels, if open, unusually tense or depressed? (The posterior fontanel is usually closed by 6-8 weeks - anterior is usually closed by 18 months.) Palpate the sutures. Is there an unusual facies? Listen for bruits if indicated.

Lymph Nodes : Report size, location, the presence or absence of tenderness and consistency.

Eyes : Gross visual acuity should be assessed. Look for strabismus by performing the cover/uncover test. Describe the conjunctiva and note the appearance of the iris and cornea. Is there excessive tearing? Are the pupils equal and reactive directly and consensually to light? Can the child accommodate for near vision? In the older child, grow visual fields can be determined. An attempt to see the fundi must be made in all children. The presence of a red reflex should be recorded. (At 2-4 weeks an infant will follow light. Four months is the age at which coordinated eye movements should be seen.)

Ears : Indicate any anomaly or abnormal position. Look for discharge or tenderness in canals. Describe the tympanic membranes.

Nose : Is the septum straight? Is there flaring of the alae nasi? Look at the mucosa and turbinates. Look also for evidence of sinus disease. (At birth the maxillary antrum and anterior and posterior ethmoid cells are present. At 2-4 years pneumatization of the frontal sinus takes place but is rarely a site of infection until the 5 th -10 th year. At birth the mastoid consists of a single cell, the so-called antrum. By 4-5 years pneumatization extends to the tip of the mastoid process.)

Mouth: Discuss any abnormality of the lips, gums, or tongue. Examine the buccal mucosa and salivary gland orifices. The number and condition of the teeth should be recorded. (A child should have 20 teeth by age 2 1/2 years. When the teeth begin to erupt is quite variable but most infants have their two lower central incisors by 8-10 months.) Look at the palate and uvula. Observe any abnormality of the posterior pharynx. Pay attention to the cry or voice. Is hoarseness or stridor evident?

Neck: Be sure the neck is supple (flex and extend the neck fully). Palpate for nodes, salivary glands, thyroid and trachea. Is the trachea midline? Look for tilting or masses in the sternocleidomastoids.

Chest: The examination of the chest should be done in an orderly manner beginning with inspection and palpation which can be done simultaneously. Then proceed with percussion and auscultation.

Inspection: describe shape, any asymmetry, flaring or retractions. Note the work of breathing. Is abdominal breathing present?

Palpation: note any discomfort as bony structures are palpated. Feel for crepitation. Feel the scapulae with special attention to their position.

Percussion: the chest wall is thinner and the bronchi relatively larger in children than adults. Therefore, the chest sounds more resonant. Dullness will be found over the scapulae, diaphragm, liver and heart.

Auscultation: listen for breath sounds and describe what is heard. Record any abnormal sounds, absence of sounds, etc. In infants, breath sounds will be somewhat louder and harsher normally.

Breasts: Breast development, or its absence in older adolescent females, should be commented upon. Do a systematic examination of the developed adolescent female to include the axilla.

Heart : Certain basic information should be part of every cardiac examination. There should be rate, rhythm, the presence or absence of thrills and description of heart sounds, and extra cardiac sounds (e.g., click). Murmurs, if present are described in detail. Femoral pulses must be palpated and any delay while simultaneously palpating the brachiales should be recorded.

The same approach as was used to examine the chest should be followed:
Inspection - report any bulging of the precordium. The apex beat or cardiac impulse can often be seen in the thin child. Distended veins are described.

Palpation - record the location and intensity of the apex. Are there thrills or palpable sounds? Palpate the suprasternal notch and carotid for thrill and pulse character.

Auscultation - Listen first with your diaphragm and concentrate on S1. Listen at the apex, lower left sternal border, upper left sternal border and upper right sternal border. Then listen hard for S2 (usually heard best with diaphragm at the base). Listen in inspiration and expiration, denote intensity and splitting. Go on to any other sounds or clicks. The next step is to carefully listen to the systole. Describe in detail any murmur heard considering the duration, quality, character, constancy, variation with position. Finally listen to diastole. (Consider drawing heart sounds and murmurs).

Abdomen : Auscultate for bowel sounds. Is the shape unusual or protuberance present? Describe any tenderness or rigidity. Palpate for organs or masses. Is there a hernia?

Genitalia : Note developmental status using Tanner staging. In the male note the descent of the testes, location of the meatus and whether or not is inflamed. In the female an intravaginal examination is not routinely necessary.

Anus and Rectum : Inspect for fissures, fistulae, hemorrhoids, prolapse and other protrusions. Rectal examination should be considered in any child with abdominal pains or symptoms referable to the lower gastrointestinal tract. Record sphincter tone and any masses.

Extremities : The shape, symmetry, abnormalities in size, muscle development, weakness, or the failure to use one or more for whatever reasons are of importance. Any cyanosis of nail beds or clubbing of fingers or toes requires notation. Move all joints through their range of motion. Observe the gait.

Back and Spine : Mobility and posture need to be observed. Any dimples or sinuses are noted. Unusual hair tufts may be present. As myelinization proceeds from cephalad to caudad, cervical, thoracic and lumbar curves develop in that order. The infant has a relative lordosis and more flexible spine generally.

Neurologic Examination

Only a brief outline will be presented here as a guide.

To assess the child's developmental age, appraise the following:

Motor performance
gross and fine motor achievement
adaptive and integrative skills


Language development

responses to external stimuli (hearing)
spontaneous and elicited language


Social development and adaptation

responses to the examiner
play activity as observed and historically
acquisition of certain skills such as dressing oneself or undressing


The formal examination itself will be adapted to the specific age group but should in all children include:

cranial nerves and special senses
motor system
coordination and cerebellar function
sensation
reflexes

LABS and STUDIES

List routine and specific diagnostic test and their results. Include other diagnostic tests such as x-rays and other studies.

THE ASSESSMENT

The patient's situation should be summarized in one or two sentences. Examples include, "This is a previously well 3yo who presents with acute abdominal pain for 2 days" or "This is a 8 month old ex-26 week premature infant with multiple problems including chronic lung disease with tracheostomy, Tetrology of Fallot status post repair, developmental delay secondary to intraventricular hemorrhage, and poor growth who is admitted for dehydration associated with an upper respiratory infection".

THE PROBLEM LIST

The problems can be definite diagnoses, symptoms, abnormal findings, or other concerns. Probable or possible diagnosis ("rule out") should not be listed as problems. If your problem list contains a number of symptoms or signs that initially do not fit together each should be listed separately. They may on subsequent days be seen s manifestations of the specific disease. They may then be combined into one problem.

Health Maintenance should be included on the problem list for all children. We list it as a problem to remind us that our major goal is to not let the immediate disease obscure our view of the whole patient. Include here the follow up plan, even from the start. That will help remind the inpatient care team to communicate with the primary care provider.

An example of a problem list follows for a child who is hospitalized with fever, vomiting and pyuria. You find in the past history that he had an allergic reaction to penicillin 6 months ago. In this case the problem list might be put in the chart as:
Fever
Vomiting
History of penicillin allergy
Health Maintenance
Any new problems can be added as the database expands.

THE PLAN

Each problem should have its own identified plan. Begin with a statement about your assessment for each problem. What do you think is going on and why? Remember that these are only initial plans, and more can be added later if necessary. Specific plans for each problem can usually be thought of as one of three categories: to collect more data, to outline specific treatment, or to educate the patient or parents.

To continue the example of the patient listed above, the problem list on your written history and physical might read:

Fever . I believe that urinary tract infection, specifically pyelonephritis, is a likely diagnosis. I am concerned about the possibility of blood stream invasion in this patient. Plan: obtain a urine culture, a CBC with differential and a blood culture on this patient. We will begin therapy with intravenous gentamicin at 2.5 mg/kg per dose every 8 hours. For his fever >101.5 we will give him acetaminophen 15 mg/kg every 4 to 6 hours.

Vomiting . I believe this is probable related to the urinary tract infection. There is no sign of abdominal obstruction or dehydration. Plan: keep the patient NPO overnight, while giving IV fluids at a maintenance rate. I plan to try the patient on clear liquids in the morning and advance the diet as tolerated.

History of allergic reaction to penicillin. The patient has a strong history of a serious reaction to penicillin and beta-lactam drugs will be avoided, if possible, during this hospitalization. If they become necessary we can consider an allergy evaluation for penicillin skin testing and possible desensitization.

Health Maintenance. This child is current with his well child care in the continuity clinic of Dr. Jones.

DISCUSSION

A concise (3-4 paragraphs) discussion of one or more aspects of our patient's medical problem should follow.

The topic should be pertinent to your patient. The goal is not to exhaust the medical literature on a given topic, but to stimulate patient-oriented reading and to encourage you to synthesize your thoughts.

For example, on a patient admitted with sickle cell disease and fever, you might choose to discuss the immune problems of children with sickle cell and their clinical importance. You would not be expected to discuss the molecular biology of sickling and all the various problems this creates.

After you have demonstrated outside reading on a topic, the most important step in the discussion is to apply that reading to the care of your patient. Write at least a concluding paragraph in your discussion that directly relates what you have read to the care of your patient. For example, when writing about immune problems in sickle cell disease, you might conclude with a paragraph of your patient's probable immune problems given his sickle cell disease. This will show interpretation of your reading and application to your patient's care based on his age, past medical history, and current presenting symptoms.

If you are unsure about a topic, or need help with sources, discuss this with your attending.

Include a list of references used at the end of your discussion. At least one basic text and in addition one recent article from the peer reviewed literature should be included as references.