History and examination

The introduction

There will be a variable amount of information available prior to seeing each patient. There may be a detailed previous history from a colleague and whenever possible it should be read before seeing the family. Depending upon the age of the child, it is usually helpful to establish how the child likes to be addressed and who any accompanying adults are. For older children and young people, it may be appropriate to conduct the consultation without a parent present.

There are no ‘hard and fast’ rules about when a young person becomes an adult in terms of responsibility for their health. However, there are some useful data from research. In general, the proportion of responsibility for healthcare issues increases as the child gets older. By 13 years of age, the responsibility for taking treatment and disease management in asthma is shared equally ( Fig. 3.1 ). This provides a useful rule of thumb for how to share the consultation in clinical settings. In early childhood, it is necessary to use the parents for much of the consultation, but as the child gets older and increases in confidence, they can come to share and then own the consultation.

The presenting problem

Often this information is available, either as part of the triage information or as a referral letter. However, it is vital to ensure that all parties are in agreement about what the problems actually are. Once all the problems have been identified, it should be possible to start formulating a differential diagnosis and to hone down on the important details of the history.

General enquiry and systems review

These are highly age-dependent questions and should be driven whenever possible by a differential diagnosis. It is only possible to determine a sensitivity and specificity for these questions when they are placed in context and asked at the appropriate time.

For instance, nearly all vomiting is described as ‘projectile’ by parents. However, this is only a really useful historical clue when the diagnosis of pyloric stenosis is being sought. A 15-month-old child with projectile vomiting does not have pyloric stenosis so eliciting this history and the distance travelled by vomitus from the child is not helpful outside of this context.

Other symptoms and signs are widely misreported either by parents or healthcare professionals. Whilst there are many possible examples, two of the best described in paediatric practice relate to the lack of specificity seen in the usage of highly informative medical terms. The first is the use of the word ‘wheeze’ by parents. In a landmark study published in 2000, exactly what parents meant by the term ‘wheeze’ was unpicked in detail. They found that parents used the term differently from doctors and frequently used it to describe difficulty breathing. When children were directly observed, parents and doctors agreed less than half the time about the presence of wheeze. This study has highlighted the dangers of assuming that families are using specific medical terminology correctly.

However, this phenomenon is not restricted to parents. For example, parents, GPs, SCBU nurses and postnatal midwives were asked to choose the colour of bile from the colour chart shown ( Fig. 3.2 , Table 3.2 ). The majority of parents and almost half of the GPs chose a yellow colour (shades 1–4). A quarter of the SCBU nurses and almost a third of the postnatal midwives also selected a yellow colour, whereas the correct answer was a green colour (any shade 5–8).

Past medical history

The past medical history is an important diagnostic clue. However, the relevance of early details, such as birth history, may become less relevant with time. Nonetheless, it is nearly always important to ask about major events such as birth details, immunizations and past illnesses or hospital admissions. The drug and allergy history often acts as a prompt for ‘forgotten’ details of previous illnesses. List the child's current medications accurately, including dosage and frequency, and (if possible) when they were commenced.

This is also a useful point at which to ask about developmental status. This is covered in more detail in Chapters 4 and 5 . Parents may have brought along the parent-held child record to the interview. This contains details and plots of previous weights and lengths/heights that will allow assessment of the child's physical growth and details of the immunization status. For older children and teenagers, it is important to ask about the onset of puberty (see also Chapter 12, Growth and puberty ).

Previous medical history is not always a reliable guide. Whilst previous behaviour is widely purported to be a reasonable guide to future behaviour, this does not always stand up to scrutiny. For instance, in examining paediatric asthma deaths in the eastern region of the UK between 2001 and 2006, only 1 out of 20 children who died had previously been admitted to the paediatric intensive care unit and 40% had never been admitted to hospital previously.

Family and social history

Families will share genetic factors, environmental factors and inevitably many infections. It is therefore vital to take a family history and have an appreciation of some of the recurrence risks of commoner diseases like asthma, diabetes and coeliac disease.

It is usually helpful to record family structure and draw a genetic family tree, including parents, siblings and sometimes grandparents. It is vital to sensitively elicit whether parents are related as this will increase the risk of certain conditions (for more details and some examples of pedigrees, see Chapter 9, Genetics ).

Ask about who makes up the household. Details about the size and type of accommodation may be helpful. Occupation of the parents and whether they smoke are covered in this section. Major or psychiatric illness affecting parents can be clarified at this stage. It is worth asking whether there are any financial problems and what benefits the family are currently receiving. It may be relevant to know if the family has any pets. Further details about the child's school, school work and school friends, as well as any problems at school such as bullying or teasing, can also be checked out at this stage.

‘The first step forward is a step backwards’

It is advisable not to rush into the physical examination of children. Taking a breath, and a step backwards can help remind oneself that a significant amount of information is gained simply by careful observation. Although having a clear technique is useful so that no part of the examination is inadvertently omitted, the order in which it is performed needs to be flexible. Many of the important examination findings can be determined from careful observation whilst the child is playing or sat on the parent's lap whilst one is taking the history. However, with suitable distraction techniques and rapid use of brief opportunities, it is almost always possible to examine infants and young children even if the situation is not ideal.

Based on the history, the relevant aspects of the examination can be targeted and performed rapidly rather than trying to do a complete and thorough physical examination, which will often be thwarted by young children. There are some elements of the clinical examination that are known to be more and others less reliable, e.g. in determining whether a child has congenital heart disease, it has been shown that even amongst experienced examiners, most agree on the presence or absence of digital clubbing but other signs are less reliably determined.

For many observable characteristics, there is a range of normality which exists. This includes simple physiological variables like heart rate and respiratory rate (see below) and more complex characteristics including development. A detailed description of the techniques used to assess development is included in Chapters 4 and 5 and will not be discussed further here.

Rather than discouraging us from undertaking clinical examination, we need to acknowledge its limitations, even in experienced hands. Where technology can assist, especially if non-invasive such as oxygen saturation measurements or ultrasound, we should embrace its use but need to understand the underlying physiology and its limitations. Oxygen saturation monitoring is a particularly good example of how technology can enhance the sensitivity of the clinical exam. By combining pulse oximetry with clinical examination, the sensitivity of screening for congenital heart disease in newborns has been shown to increase from 31% for oximetry alone and 46% for clinical examination alone to 77% using both.