Clinical Methods—A Key to Diagnosis in Paediatrics Dilip Mukherjee, Indraneel Banerjee
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History1

 
INTRODUCTION
Obtaining a good history is an art and gets better with practice. A sound history is vital to diagnosis as this is the structure on which to build upon. A problem history is most often from parents and not directly from the child. This entails a degree of bias which should not be ignored but rather weighed for its true worth. Communication is most essential in this process. The doctor-parent or doctor-patient relationship is not one way, rather it is a two-way process involving two people studying each other. The doctor must put the informant at ease and encourage him or her to talk freely.
History is not just limited to questions and answers. It helps to start a conversation by greeting the patient, addressing him or her by name, identifying a common town of origin or a mutual interest in pets. All this while, watch the parent's and patient's gestural language. The eyes and hands may tell you more than what is actually said.
Concentration is very important in a conversation. Your undivided attention must be devoted to hearing the complaint; otherwise the response from the patient's end will be incomplete. Gentleness is all-important, more so in a physical examination. The patient should be reassured and not frightened or put off.
Behavioural problems often make it more difficult for the interviewer. It helps to strike up a communication directly with the patient, be it verbal or non-verbal. Establishing a rapport with the distressed child relieves much anxiety relating to the disease.
The doctor, in an interview with the child and parents, must have a well balanced attitude. It would be unwise to allow your feelings to surface into confrontation. Barriers of language, culture or manners may tend to put you on the wrong track, and in such situations evaluation and re-evaluation of what has been said and what has been missed, is essential.
Let the informant unfold the story in his own words. Only when he or she has done so should he or she be asked to expand on what appears to be the more important aspects of the story. Specific leading questions should only be asked after you have reached the heart of the problem and have framed in your own mind a possible diagnosis and a differential diagnosis list.
It is important that you practice this art over and over again so as not to miss the salient points of interest. Time is important and often at a premium. In an unstructured setting, for example, in a busy emergency, you have to get all the details in a few minutes. This takes a lot of practice and practice builds on premonition. The following headings are relevant in history (Table 1.1):
Table 1.1   History taking
Name, age, sex and address
Presenting complaint
History of present illness
History of prior illnesses/past illness
Family history
Social history
Past medical/surgical treatment history
Antenatal and birth history
Postnatal history
Dietary history
Immunization history
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PRESENTING COMPLAINT
Try to define the main complaint and its duration. The presenting complaint is simply the problem that makes the patient seek medical help. This is usually confined to one or two key points. Multiple presenting complaints themselves represent the problem rather than the diagnosis. The timing and duration of symptomatic events is important since the chronology provides clues to the underlying pathology. Sometime the duration of actual presenting complaints is bypassed and the onset taken at the point of trivial complaints. This error has to be corrected as you go on taking the history.
 
THE HISTORY OF THE PRESENT ILLNESS
Ask the informant to give you a detailed account of the illness from the beginning. A history may not always start with a chief complaint, and may start with other relatively minor complaints. Ideally you should allow the narrator to continue without any interruption, but for people who are either quite reticent or too talkative and deviating from the symptoms, you will need to gently encourage them to stay on track.
 
 
Symptom Analysis
Each symptom has to be analysed thoroughly and qualified suitably. As an example, an illness starting with pain should be described as:
  • Timing and duration: When did the pain start? Does it come and go? How long does it last on average?
  • Character: What the pain feels like stabbing, burning, pricking, dull aching, colicky
  • Severity: Whether it interferes with daily activities or keeps the child awake at night
  • Radiation: Whether it stays at one place or spreads along the distribution of a nerve
  • Referral: Whether the pain at a site originates at a different site
  • Shifting: Whether the pain shifts from the original site to a new location
  • Aggravating factor: What brings it on and what worsens it?
  • Relieving factor: What makes it better?
Likewise, symptoms of fever can be described as:
  • Duration of illness
  • Height of temperature
  • Type of fever (remittent, intermittent, continued - Chap 2, )
  • Character (i.e., quotidian) — associated with chills or rigor
  • Associated convulsions
  • Associated malaise, headache
  • Descriptions of related symptoms.
Similar analysis of the other illness complaints will help us draw a pen picture of the child's problems. Relating one symptom to the other will then help you towards a differential diagnosis. The pattern of evolution of the complaints tells you of the natural history of a disease. Find out if the illness began insidously and gradually worsen or was it intermittent? Was the onset acute, then slowly getting better, but not fully disappeared? Is there a relation to a previously diagnosed illness? Of the symptoms presented, which ones are more relevant than others? Are there pieces of information that appear out of place? Do you need to revisit those issues and work out the connection, if at all? A good history is like an intricate network – it is your job to set this up so that you can make sense of it all.
An outline of the questions related to individual systems is given below:
 
General
 
Weight
  • Is it increasing, decreasing or stationary?
  • If the child has lost weight recently – has the child been unwell? Has he or she strenuously exercised to lose weight?
  • Is there a family history of obesity, type 2 diabetes mellitus or early cardiovascular morbidity?
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Sleep
  • Has the sleeping pattern changed?
  • Is there difficulty in getting to sleep or unsual early waking?
  • Does the child snare at night?
  • Is the patient sleepy and tired during the day?
  • Have the parents noticed any convulsions during sleep?
  • Any odd behaviour during sleep?
  • If the child is of an age of bladder continence, does he or she have nocturnal enuresis?
 
Energy
  • Is it loss of energy or boredom?
  • Is it part of a general malaise?
  • Is there unusual fatiguability?
  • What time of the day is there lethargy?
  • Can the child play with his/her friends?
  • Is the child so tired that he/she does not want to be with his/her friends?
 
The Gastrointestinal System (Table 1.2)
Gastrointestinal symptoms can be of upper or lower tracts. The following questions should help you get to the bottom of the problem.
Table 1.2   GI system
  • Pain
  • Appetite
  • Vomiting
  • Water brash
  • Heart burn
  • Dysphagia
  • Diarrhoea
  • Constipation
 
Pain
  • What site is the pain?
  • Judge the severity
  • Is it localized or diffuse? Is it persistent or intermittent?
  • Does it radiate in any particular direction?
  • For how long has the patient had it?
  • Are there intervals of freedom? If so, for how long?
  • What is its relation to meals (if any)?
  • Does it wake the patient at night? Does the child wake up in the night screaming with pain?
  • What things aggravate it? What affords relief (food, anatacid, vomiting)?
  • Does any particular posture relieve the pain?
  • Is it relieved by defaecation or by the passage of flatus?
  • Is there underlying anxiety or tension suggesting a functional non-organic aetiology?
  • What medication does the child have for the pain?
 
Appetite
  • Is it increased or reduced?
  • Does the child dislike certain foods?
  • Does the child eat good size portions at mealtimes?
 
Vomiting
  • How serious a problem is this?
  • Does the child throw up after milk feeds (gastro-oesophageal reflux)?
  • Is abdominal pain relieved by vomiting (gastritis)?
  • Is there vomiting in the morning (raised intracranial pressure)?
  • What does the child throw up?
  • Check if the vomitus is bilious (intestinal obstruction)
  • Does it ever contain fresh blood (mucosal tear)?
  • Does it ever look like coffee grounds (gastric mucosal haemorrhage)?
  • Is the child having regular intermittent vomiting episodes as in intermittent malrotation?
  • Is the child passing urine? Large fluid loss may result in dehydration
  • Is the child on any medication that is emetogenic, for example opioids?
  • Is this is gastroenteritis, or is there a more serious underlying illness like diabetic ketoacidosis, pyelonephritis or metabolic disorder?
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Water Brash
  • Does the patient ever experience excessive secretion of saliva into the mouth, with regurgitation of mouthfuls of clear, tasteless fluid?
 
Heartburn
  • Does the patient suffer from pain behind the sternum?
  • Does it come on especially when lying down?
 
Dysphagia
  • Record the child's words—what does he/she mean by difficulty of swallowing?
  • Where does the food appear to stick?
  • Is it worse with liquids or with solids?
  • Is swallowing painful?
  • Is there underlying anxiety that itself could be responsible for difficulty of swallowing?
 
Diarrhoea
  • What is the duration of diarrhoea?
  • How frequent and at what times are the motions during the day?
  • What is their relation to meals?
  • Does the child have loose motions after eating certain types of food?
  • Has the child eaten unusual food in the recent past?
  • Is there a possibility of food poisoning?
  • What colour are the motions?
  • Has the patient ever passed any blood or mucus with stool (dysentery, inflammatory bowel disease)?
  • Are they unformed, porridge-like, frothy, or watery (chronic diarrhoea, malabsorption)?
  • Do they float in the lavatory pan or are they difficult to flush away (malabsorption)?
  • Is the diarrhoea painless?
  • Is there colicky abdominal pain, suggestive of colitis?
  • Does the patient use laxatives?
  • How is the child's appetite?
  • Is the child gaining weight appropriately?
 
Constipation
  • How often does the child “go” to the toilet?
  • Get the parents or child to describe the motions—small, dry, hard and pellety, elongated but hard or tubular and formed
  • Is this a long standing problem (habit constipation, megacolon)?
  • Does the child avoid the toilet because it is painful to defaecate?
  • Does the child consume reasonable amounts of fruit, vegetables and greens?
  • Can this be explained by change in circumstances, medicines, etc.?
  • Is the child constantly wearing nappies and will not pass motions if taken off (habit)?
  • Is there soiling of clothes suggestive of overflow incontinence of stools secondary to constipation?
  • Did the child open his or her bowels in the first day of life (Hirschprung disease)
  • Is the child taking medication to relieve constipation? If so, what dose?
  • Is there any colicky pain? Is the pain aggravated when using laxatives like senna?
  • Is there blood in the stools (anal fissure)?
 
Liver and Gallbladder
 
Jaundice
  • Has the child noticed any yellow discolouration of conjunctivae or skin, or high coloured urine?
  • Are the motions pale or dark?
  • Does the skin itch?
  • Any bruises or unusual skin marks?
  • Have there been any other cases of jaundice among family or friends?
  • Any foreign travel?
  • Was any injection given in the last 3 or 4 months?
 
Pain
  • Where is it?
  • Has the patient ever had attacks of very severe pain, coming on suddenly and lasting for a few hours?
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  • If so, did the pain radiate and in what direction?
  • Was there any jaundice after the pain subsided?
  • Did the pain radiate to the tip of the shoulder or the middle of the back?
 
The Cardiovascular System
If the symptoms point to disease of the circulatory system, enquire about the following:
 
Dyspnoea
  • When does this come on? Is it present at rest or only on exertion?
  • What degree of exertion is necessary to produce it?
  • Judge the severity of dyspnoea. Does it impede routine daily activity?
  • Are there attacks of breathlessness at night (paroxysmal nocturnal dyspnoea)?
  • Does the patient have to sleep sitting up (orthopnoea)?
  • Does the child have palpitations and how long do they last?
  • Does the heart give an occasional thump now and then?
  • Is the pulse rate increased on occasion and is it regular or irregular?
 
Cough
  • Enquire about cough, sputum and haemoptysis, as detailed in the section on the respiratory system
 
Oedema
  • Do the heels or ankles swell?
  • Does the face also swell up?
 
Other Symptoms
  • Are there cramp-like pains in the calves when walking relieved by rest? Or
  • Is there undue coldness, redness or blueness of the extremities?
  • Is there a past history of rheumatic fever or chorea?
 
Haemopoietic System
If the clinical features suggest a blood disorder, enquire about the following:
  • Tiredness, lethargy, feeling miserable (anaemia)
  • Infections involving the mouth, skin, lungs, urinary tract and perianal area (bone marrow aplasia)
  • Blood loss from gums, nose, bruising, rectum as well as malaena (black stools) and menstrual irregularity (bleeding disorder)
  • Is bleeding or bruising out of proportion to degree of trauma (bleeding or clotting diathesis)?
  • Does the child appear to be pale?
  • Are there red skin spots (purpura, petechiae) and changes in skin colour?
  • Is bleeding or skin rash associated with pallor?
  • What about diet–ask for consumption of meat and green vegetables
  • If the child is drinking far too much milk there may be iron deficiency anaemia
  • Does the child go about barefoot–hook-worms can cause enough blood loss to cause significant anaemia
  • Any excessive bleeding after dental extraction or tonsillectomy
  • Has the child ingested drugs known to cause bone marrow aplasia or haemolytic anaemia?
  • Is there a family history of blood disorders (haemolytic disease)?
  • Has the child noticed any glandular enlargements (lymphoma, leukaemia)?
 
The Respiratory System
Parents will often tell you that their child has been coughing for some time or been rather wheezy. Asthma is a common problem, so explore atopy and allergy. Do think about tuberculosis as a possible diagnosis, even though 6this may not be very obvious. You should also ask for possible exposure to animal, mineral or vegetable dusts to search for an explanation for chronic cough.
 
Cough
  • What is the duration of the cough?
  • Did the cough start recently or is it present for weeks or even months?
  • Is it chronic persistent (tuberculosis, bronchiectasis) or chronic episodic (asthma)?
  • Is it dry or productive?
  • In the child less than a year, is the cough “fruity” (bronchiolitis)?
  • If this a baby, does the cough sound like a “whoop” (pertussis)?
  • Enquire if the child had surgery (tetralogy of Fallot repair) – viral upper respiratory tract infections can trigger a “TOF” cough
  • At what time of the day or night is it worst?
  • Has the child used inhalers (relievers like salbutamol) and do they help?
  • Are there family members who smoke around the child?
  • Does the child have eczema or family history of atopy, suggesting a predisposition to asthma?
  • Is it worsened by any particular conditions, such as cold or dust?
  • Is it painful or not?
  • Is the child taking medication (like captopril) that may aggravate the cough?
  • Are there associated symptoms to worry about pulmonary tuberculosis?
  • Are there family members with a chronic coughing illness suggesting tuberculosis?
  • Is there a functional element in the history (habit cough)?
 
Sputum
  • How much? (in children more than 6 years of age).
  • When is expectoration maximal?
  • What is the consistency, colour, and odour?
  • Is it purulent (bacterial infection)?
  • Is it ever blood-stained, and if so whether with streaks or clots (tuberculosis, bronchiectasis, trauma, pulmonary sequestration, haemosiderosis)?
  • Does the child do chest physiotherapy to help produce sputum (bronchiectasis)?
 
Breathing
  • Is there increased work of breathing?
  • Is the child unusually tachpnoeic?
  • Does dyspnoea occur at rest, or after varying degrees of exertion?
  • Describe the level of activity that brings out dyspnoea
  • Does the child snare at night?
  • Does he or she fall asleep easily during the day, suggesting obstructive sleep apnoea?
 
Wheeze
  • Is it wheeze or stridor?
  • Is it constant or intermittent?
  • Is the child a “happy wheezer” (viral wheeze)?
  • Does anything provoke it?
  • Does the child become wheezy with viral upper respiratory infections?
  • Is it worse at any particular time of day or night?
  • What relieves it?
  • Is there a history suggestive of foreign body inhalation?
  • What is the dose of inhaled reliever medication?
  • What about the technique of inhaler use?
  • Is the child growing well (severe asthma)?
  • Is the child missing a lot of school days? (severity of asthma)?
  • Can the child play a full game (assess functional ability)?
 
Chest Pain
  • Where is it – all over the chest or central and retrosternal?
  • Is the pain unilateral (pleural effusion)?
    7
  • Is it aggravated by deep breathing or coughing?
  • Describe the pain character – sharp, stabbing (pleuritic) or dull, aching (haematoma, trauma, neuralgia).
  • Is it associated with an increase in cough, sputum or dyspnoea (pneumonia)?
  • Is the onset sudden and sharp and accompanied by significant dyspnoea (spontaneous pneumothorax)?
 
The Urinary System
Pain on micturition, haematuria, oliguria and oedema are pointers in the direction of a renal or urology problem. Probe further if you feel that the waterworks are at fault.
  • Is there less urine (oliguria)?
  • Is the child passing urine too frequently (polyuria—diabetes mellitus, insipidus)?
  • Is the child drinking large amounts of fluids (polydipsia)?
  • Will the child drink water instead of juice (compulsive juice drinking)?
  • Does the child wake up often through the night for a wee (polyuria)?
  • Is the child at an age of continence?
  • Is there nocturnal enuresis? If so, how many nights a week?
  • Is there day time incontinence and accidents when the child is awake (bladder detrusor weakness)?
  • What methods have the parents tried to make the child continent?
  • Explore the child's social circumstances
  • What is the colour of the urine?
  • Is there blood in urine?
  • If there blood in urine, at what stage of the micturition is it (upper renal tract – constant, lower tract—end of micturition)?
  • Is micturition painful? Does the child have a burning or stinging sensation (cystitis)?
  • Any pain shooting down to the groin or genitalia (calculi)?
  • Is the child passing less urine (oliguria)?
  • Is there a record of fluid intake-output? Have the nappies been weighed to estimate urine output?
  • Is the child losing fluid elsewhere (e.g. diarrhoea, vomiting)?
  • Is urine output disproportionate to the oral intake?
  • Is there a history of diarrhoea preceding oliguria (haemolytic uraemic syndrome)?
  • Does the face or ankles swell (nephrotic syndrome, renal failure)?
  • What medications is the child on?
  • Is the child on long term steroids?
  • Are the side effects from medication (Cushingoid appearance, infections from steroid use)?
  • Is the child on dialysis? If so, what type?
  • Has the child had a renal transplant?
  • What immunosuppressives is the child using?
  • Is the child on antihypertensives?
  • If so is hypertension well controlled?
  • Has the child been admitted to intensive care with headaches, blurring of vision, drowsiness or fits (hypertensive encephalopathy)?
  • Is the child gaining weight and growing well (poor growth and inadequate weight gain in renal failure)?
 
Skin Diseases
 
Itch
  • Has the child got an itchy skin problem (eczema, contact dermatitis, scabies)?
  • Whereabouts is the itch (between fingers in scabies, flexures in eczema)?
  • Does the child have jaundice (obstructive jaundice)?
  • Enquire carefully into the patient's hygiene – clothing, cleanliness etc (scabies)
  • Is there any exposure to chemical substances or other irritants? Ask about recent drug therapy.
    8
  • Is there a history of asthma, hay fever or any other allergic disorder (atopic dermatitis)?
  • Is there contact with animals, insects, or plants (contact dermatitis)?
  • Does the child have dry skin (eczema)?
  • What topical medications have been used?
  • Is there a family history of skin disease, asthma, hay fever, urticaria (atopy)?
 
Rash
  • Where is the rash?
  • What colour is the rash (red—measles, enterovirus, meningococcal infections)?
  • Is the rash vesicular (chicken pox, folliculitis, burns)?
  • Is the rash associated with joint swelling (Henoch-Schonlein purpura, juvenile idiopathic arthritis, vasculitis, inflammatory bowel disease)?
  • Is the rash brought on by specific food ingestion (cow's milk protein intolerance)?
 
Pigmentation
  • Are there patches of skin depigmentation (vitiligo, psoriasis, pityriasis)?
  • Is there generalised pigmentation of the skin with associated mucosal pigmentation (Addison disease)?
  • Are there leathery, dark patches over the neck and axillae (acanthosis nigricans)?
 
Hair
  • Is there loss of hair (alopecia)?
  • Is the child on cytotoxic chemotherapy (alopecia)?
  • Is the child on sodium valproate (hypertrichosis)?
  • Is there excess hair in a girl (hypertrichosis or hirutism)? What is the distribution (forearm, arm, legs—hypertrichosis; moustache, sideburns, chest—androgenic)
  • Is there irregularity of periods associated with excess hair (polycystic ovarian syndrome)?
 
Neurology
Headaches, convulsions, limb weakness, altered consciousness should alert you to investigate the child's neurology.
 
Headache
  • How often does the child have headaches?
  • How long do they last?
  • Is it one side only (migraine)?
  • Are the headaches relieved by sleep (migraine)?
  • Do the headaches occur in the evening after coming back from school (tiredness)?
  • What exactly does the child mean by the term “headache” (headache an attention seeking device in preschool children)?
  • Do headaches occur early in the morning and improve by the end of the day (space occupying lesions)?
  • Any associated visual perceptions (acute — migraine, chronic—craniopharyngioma, optic nerve glioma)?
  • Any family history of headaches with or without visual disturbances (migraine)?
  • Is there loss of balance (cerebellar astrocytoma)?
  • Does the child have an intracranial shunt? If so when it was last revised?
  • Was there weakness of the limbs at any stage (migraine, stroke, vasculitis, tumours)?
  • What medication does the child take to relieve the headaches?
 
Convulsion
  • Is it a convulsion—get a first hand account (jerking of limbs, incontinence, biting of tongue, eyes rolling back—suggest tonic clonic seizures)
  • Any post ictal symptoms (headaches, paralysis)?
  • Was the child standing when it happened (syncope)?
  • Was the episode brought about by exercise (hypertrophic cardiomyopathy)?
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  • Is there a family history of sudden death (hypertrophic cardiomyopathy)?
  • Does the child have episodes where he or she appears vacant and inattentive (behavioural, absence seizures)?
  • Does the child show abnormal behaviour (complex partial seizures)?
  • Is it a morning seizure with numbness of the face, drooling and garbled vocalization (Rolandic seizure)?
  • Was the convulsion triggered off by flashing lights (photosensitive epilepsy) or accompanied by lauging bouts (gelastic seizure)?
  • Is there warning or aura (focal seizures)?
  • Was there loss of consciousness (generalized epilepsy) or not (partial epilepsy)?
  • What is the treatment history?
  • Assess the compliance with anticonvulsants.
 
Dizziness
  • Is dizziness induced by moving the head in a particular way or assuming a particular posture (positional vertigo)?
  • Did it follow an injury or a presumed viral infection (inner ear abnormality)?
  • Is there a history of long standing aminoglycoside use (inner ear toxicity)?
  • Does the child appear unusually anxious (panic attack)?
  • Was the episode following intake of medication (hypotension following antihypertensive ingestion)?
  • Did dizziness precede headaches (migraine)?
 
Weakness
  • Is the weakness transient? (atypical hemiplegic migraine)
  • Is the weakness present from birth (spinal muscular atrophy, cerebral palsy, congenital myopathies)?
  • Was the onset of weakness acute (vasculitis, injury, infections) or chronic (tumours, degenerative disease)?
  • Is the weakness generalized (malnutrition, chronic illness) or localized (nerve or muscle lesions)?
  • Is there weakness in the lower limbs with sphincter incontinence (transverse myelitis)?
  • Any paraesthesia (Guillain-Barre syndrome)?
  • Any history of trauma to back or surgical intervention (spinal injury)?
  • Was the child treated for tuberculosis (spinal tuberculosis)?
  • Is weakness associated with headaches or dizziness (brain tumour, vasculitis)?
  • Any associated mouth ulcers and skin rash? (Behcet syndrome).
 
Locomotor System
Symptoms related to this system are covered elsewhere. However, you may find to it important to ask a few pertinent questions.
  • How far can the child walk (functional ability)?
  • Can the child run without hindrance (excludes major abnormalities)?
  • Is there swelling of one or more joints (juvenile idiopathic arthritis, vasculitis)?
  • Is joint swelling accompanied by high temperatures (osteomyelitis, vasculitis, juvenile idiopathic arthritis)?
  • Was joint swelling preceded by gastroenteritis (reactive arthritis)?
  • Is the child's walking distance getting progressively short (Duchenne dystrophy)?
  • Does the child receive physiotherapy?
  • Is there use of pain relieving medication?
  • Does the child use orthopaedic devices (ankle foot orthoses for Charcot Marie Tooth disease, special boots for talipes equinovarus)?
  • Was there any surgery to limit the child's movement?
 
HISTORY OF PRIOR ILLNESS/PAST ILLNESS
Search for any past illness and whether it bears a relation to the present illness. A history of fever 10and sore throat is relevant in the context of acute glomerulonephritis. Children with immune deficiency often have recurrent hospital admissions. Children with inadequate weight gain may have had chronic illnesses in the past. Diseases like juvenile idiopathic arthritis or chronic renal failure can lead to growth failure. Prior steroid use may be the cause of later problems of obesity. Always consider the child's current problems in the context of previous episodes of illness and treatment. Do not, however, assume that the present and past problems are associated all the time. The child may have different pathologies at different points in time.
 
SOCIAL HISTORY
No history will be complete without a thorough evaluation of the child's social and economic background. Many diseases are borne out of the child's circumstances. Malnutrition occurs in children of families of meagre income. Obesity occurs relatively commonly where the family income has received a boost. Diseases may be spread by poor quality of housing and sanitation. Hookworm infestation, giardiasis, scabies are typical examples.
It is important to estimate the living condition of the family. Ask about the number of family members, the number of rooms, water supply and waste disposal facilities. It helps to understand the family's economic structure. This is often a delicate matter and not all families will be keen to discuss their financial status. If you manage to extricate this information you may compare this against a socio-economic scale such as that given in Table 1.3. You should remember this table holds little relevance in real life as burgeoning costs and inflation have rendered it obsolete. You could devise a scale along similar lines depending upon the economic prosperity and average income of people of your region.
Table 1.3   Socio-economic class as per BJ Prasad
Class
Per capita income in Rs per month
I
1536 and above
II
770-1535
III
360-769
IV
150-359
V
Less than 150
 
FAMILY HISTORY
Note the patient's position in the family and the ages of siblings if any. Also record the state of health, important illnesses and cause of death of immediate relatives. Draw a family tree going back three generations. Ask about consanguinity as this is important for autosomal recessive conditions. Document diseases in each family member—a detailed description will help you understand if the child is likely to be a carrier or case of an autosomal recessive condition. Often the child is the index case and diagnosis in other family members may be made after the diagnosis in the child. In a child with Langer mesomelia, check the heights of the parents, uncles and aunts as they may have undiagnosed Leri-Weill dyschondrosteosis (haploinsufficiency of SHOX). Very often a child will have died in the family from an unknown disease. It may be relevant to know the circumstances leading to death. For example, a child may have died of thalassaemia major and secondary infections prior to actual diagnosis. This indicates that the parents are carriers and hence exclusion of thalassaemia in the other children is important.
Enquire about associated diseases in other family members – coeliac disease in a child with type 1 diabetes mellitus, tumours in multiple endocrine neoplasia and stillbirths in congenital adrenal hyperplasia. Further, enquire about close relations with persons outside the family. It may be important to know of a next door neighbour with tuberculosis who may have infected the child.
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Treatment History
Document medical or surgical treatment, if any. Record details of medicines—their dose, duration, complications and efficacy. Previous surgical intervention is important to know in the context of a child with possible intestinal obstruction. Chemotherapy and craniospinal radiation can damage the hypothalamus and pituitary gland resulting in hypopituitarism. Sodium valproate for epilepsy can lead to weight gain in puberty. Carbamazepine can give rise to Stevens-Johnson syndrome acutely. Long term steroids in nephrotic syndrome lead to obesity and stunting of height. Previous treatment for urinary tract infection is important in the child with chronic renal failure.
 
ANTENATAL, BIRTH AND POSTNATAL HISTORY
Data on any untoward event in pregnancy (rubella) may be important as a causation of disease in the infant (congenital rubella). Equally important is the history of drugs taken which may adversely affect the fetus (fetal hydantoin, fetal alchol syndromes). Record if the antenatal scan was normal. What was the growth of the fetus in utero? Was the baby born premature? Was there any perinatal asphyxia? Document the treatment if the child was in the neonatal unit. Intraventricular haemorrhage may have a bearing in a child with dystonic cerebral palsy. Extrahepatic portal vein thrombosis may be due to umbilical venous catheterization in the newborn period. A child with metabolic syndrome may have been born small for gestational age.
 
IMMUNIZATION HISTORY
Note whether the child received oral polio, BCG, triple antigen and measles as per the immunisation programme. Ask the mother whether a BCG left a scar or not. A BCG vaccine without a scar is best taken as having had no conversion. Also enquire about the other vaccines namely hepatitis B, rabies, MMR. Ask for any serious side effects after the first triple antigen dose.
 
Developmental History
Gather information from the parents on the child's play, speech and social interactions. You should be able to assess the age at which the child functions in gross motor, fine motor, personal-social and speech-language areas. You can calculate the Development Quotient (DQ) as ratio of developmental age for chronological age. A DQ of less than 70 is taken as developmental delay. You can quantify the child's developmental age with the aid of an inventory (a screening test like the Denver Development Screening Test or a comprehensive Griffith Development Assessment) but in the bedside situation it helps to be aware of the common milestones as given below.
You should remember that there is considerable variation in individuals and that you should allow for social and cultural situations. A child with limb weakness will perform below par in gross motor skills. A child with recurrent otitis media may lag behind in speech and language areas. Children with chronic illnesses may falsely appear to have global developmental delay.
 
MILESTONES OF DEVELOPMENT
 
Neonatal Period (1st 4 weeks)
Prone
:
Lies in flexed attitude, turns head from side to side, head sags on ventral suspension.
Supine
:
Generally flexed and a little stiff.
Visual
:
May fixate face or light in line of vision, ‘Doll's eye’ movement of eyes on turning head.
Reflex
:
Moro response active, stepping and placing reflexes, grasp reflex active
Social
:
Visual preference for human face.
 
4 Weeks
Prone
:
Legs more extended, holds chin up momentary, lifts head from plane of body on ventral suspension.
Supine
:
Tonic neck posture predominates, head lags on pull to sit position.
12
Visual
:
Watches person, follows moving object.
Social
:
Body movements in cadence with voice of other in social contact, beginning to smile.
 
8 Weeks
Prone
:
Raises head slightly further, head sustained in line of body on ventral suspension.
Supine
:
Tonic neck posture predominates, head lags on pull to sit.
Visual
:
Follows moving objects.
Social
:
Smiles on social contact, listens to voice and coos.
 
12 Weeks
Prone
:
Lifts head and chest arms extended, head above plane of body on ventral suspension.
Supine
:
Tonic neck posture predominates, reaches towards and misses objects, waves at toy, shows hand regard.
Sitting
:
Head lag partially compensated on pull to sit, early head control with bobbing motions, back rounded, leans forward.
Reflex
:
Moro disappears, makes defensive movements or selective withdrawal reactions.
Social
:
Sustained social contact, listens to music, says “aah, ngah.” (hatching socially).
 
16 Weeks
Prone
:
Lifts head and chest, head in approximately vertical axis, legs extended.
Supine
:
Symmetric posture predominates, hands in midline, reaches and grasps objects and brings them to mouth.
Sitting
:
No head lag on pull to sit, head steady, enjoys sitting with full trunk support.
Standing
:
When held erect, pushes with feet
Adaptive
:
Sees pellet, but makes no move to it
Social
:
Laughs aloud, may show displeasure if social contact is broken, excited at sight of food.
 
28 Weeks
Prone
:
Rolls over, pivots.
Supine
:
Rolls over (Back to stomach – 6 mon), squirming movements.
Sitting
:
Sits briefly with support of pelvis, leans forward on hands, back rounded.
Standing
:
May support most of weight, bounces actively.
Adaptive
:
Reaches out for and grasps large object (voluntary grasp at 20 wk), grasps using radial palm, rakes at pellet, transfers object from hand to hand, bangs cubes on table.
Language
:
Polysyllabic vowel sounds formed (Da, Ma, Ba, Ka).
Social
:
Prefers mother, babbly, enjoys mirror, responds to changes in emotional content of social contact.
 
40 Weeks
Sitting
:
Sits up alone and indefinitely without support, back straight.
Standing
:
Pulls to standing position, ‘cruises’ or walks holding to furniture.
Motor
:
Crawls (creeps—44 wk)
Adaptive
:
Grasps objects with thumb and forefinger, pokes at things with forefinger, picks up pellet with assisted pincer movement, uncovers hidden toy, atttempts to retrieve dropped object (object constancy), releases object grasped by other person, clicks 2 cubes in imitation.
Language
:
Repetitive consonant sounds (mama, dada).
Social
:
Responds to sound of name, plays peek-a-boo (‘tuki’) or pat-a-cake (‘tai-tai’), waves bye - bye (‘ta-ta’).
13
 
52 Weeks (1 year)
Motor
:
Walks with one hand held (48 wk), rises independently, takes seveal steps.
Adaptive
:
Picks up pellet with unassisted pincer movement of forefinger and thumb, releases object to other person on request or gesture, may kiss on request, rings a bell.
Language
:
A few words besides ‘mama, dada.’
Social
:
Plays simple ball game, makes postural adjustment to dressing.
 
15 months
Motor
:
Walks alone, crawls up stairs.
Adaptive
:
Makes tower of 3 cubes, makes a line with crayon, inserts pellet in bottle.
Language
:
Jargon, follows simple commands, may name a familiar object (ball), looks with interest at coloured pictures.
Social
:
Indicates some desires or needs by pointing, hugs parents.
 
18 months
Motor
:
Runs stiffly, sits on small chair, walks up stairs with one hand held, explores drawers and waste baskets, manages spoon without rotating near mouth, turns 2-3 pages of book at a time.
Adaptive
:
Makes a tower of 4 cubes, imitates scribbling, imitates vertical stroke, dumps pellet from bottle.
Language
:
Ten words (average), names pictures (4), identifies one or more parts of body, identifies 3 parts on doll.
Social
:
Feeds self, a seeks help when in trouble, may complain when wet, or soiled, kisses parents with pucker, alternates between clinging and resistance.
 
24 months
Motor
:
Runs well (walks backward – 21 mon), walks up and down stairs, one step at a time, opens door, climbs on furniture, jumps.
Adaptive
:
Tower of 7 cubes, circular scribbling, imitates horizontal stroke, folds paper once imitatively, parallel play but not playing with other children.
Language
:
Puts 3 words together (subject, verb object), vocabulary of 100 words or more.
Social
:
Helps undress, listens to story with pictures, dry at night if lifted out late in the evening.
 
30 months
Motor
:
Goes upstairs alternating feet, jumps on both feet.
Adaptive
:
Tower of 9 cubes, makes vertical and horizontal strokes, but generally will not join them to make a cross, imitates circular stroke, forming closed figure.
Language
:
Refers to self by pronoun “I,” knows name.
Social
:
Helps put things away, pretends in play.
 
36 months
Motor
:
Rides tricycle, stands momentarily on one foot.
Adaptive
:
Tower of 10 cubes, imitates construction of “bridge” of 3 cubes, copies circle, imitates cross.
Language
:
Knows age, sex, counts 3 objects correctly, repeats 3 numbers or a sentence of 6 syllables.
Social
:
Parallel play with other children, unbuttons clothing, puts on shoes, washes, handedness established.
14
 
48 months
Motor
:
Hops on one foot, throws ball overhand, uses scissors to cut out pictures, climbs well.
Adaptive
:
Copies bridge from model, imitates construction of “gate” of 5 cubes, copies cross and square, draws a man with 2-4 parts besides head, names longer of 2 lines.
Language
:
Counts 4 coins, tells story.
Social
:
Goes to toilet alone plays with several children.
 
60 months
Motor
:
Walks easily on narrow line, runs lightly on toes, skips on alternate feet.
Adaptive
:
Draws triangle form copy, names heavier of 2 weights.
Language
:
Names 4 colours, repeats sentence of 10 syllables, counts 10 coins correctly, fully, nine-letter vision chart at 6 meters and near-vision testing card (Stycar), delights at reciting, gives full birthday, home address.
Social
:
Dresses and underesses, asks questions about meaning of words, domestic role play, chooses own friends, enjoys jokes and riddles.
 
SCHOOL PERFORMANCE
School is often the window to judge a child's overall health. Check if he or she finds it difficult with numbers and concepts (Turner syndrome). Is there a problem with inattention, hyperactivity or impulsiveness (attention deficit disorder)? Has there been a recent steady decline in school work (autoimmune hypothyroidism)? Is the child missing school frequently (chronic illness)? Is the child isolated and avoiding contact with other children (autism spectrum)?
 
Dietary History
A proper dietary history is important to assess the nutritional state. Record the child's average daily intake of food in terms of calories and grammes of protein. A rigorous dietary assessment is crucial to evaluating the extent of malnutrition. In infants, note the the duration of breast feeding, weaning foods and weight gain.
A list of commonly used food items and their calories and proteins are given in Table 1.4.
Table 1.4   Calorie and protein value of commonly used foods
Kcal
Protein
1 Medium chapati (25g)
85
3
1 Medium katori Rice (25g)
86
2
1 Slice bread (25g)
60
2
1 Medium katora bread (25g)
86
6
1 Medium sized egg
60
6
1 Piece fish
60
9
2 Pieces Meat
60
10
Cow's milk (250 ml)
165
8
Curd (100 gm)
60
3
Leafy vegetable (100 gm)
1/3 cup (cooked)
28
3
1/2 cup cooked potato (100 gm)
100
2
1 Medium sized apple (100 gm)
60
-
1 Medium sized orange (100 gm)
48
-
1 Medium sized Banana (100 gm)
120
-
Oil and ghee 2 tsp
90
-
Sugar (25 gm) 5 tsp
100
-
Jaggery (15 gm) 1 small cup
96
-
 
Plan of Diagnosis (Table 1.5)
A careful history will help you piece together a credible story. There will be positive pointers as well as important negative attributes that will you build a multi-layered pen picture. A good history will be multidimensional and allow you to choose the thread to follow further with your examination.
Table 1.5   Plan of diagnosis
History
-
Suggest something
General survey
-
Suggest specific system for clinical diagnosis
Specific system
-
Points toward clinical diagnosis
Investigation
-
Probable diagnosis
Successful specific treatment/Surgery/Autopsy
-
Final diagnosis