Interviewing the parent
Interviewing the child
Bio-graphic Demographic Information
Name, age, health care provider
Parents name age /siblings age
Ethnicity / cultural practices
Religion / religious practices
Child occupation: If an adolescent
Past Medical History
Trauma / hospitalizations
Did baby go home with mom / special care nursery
Genetics: anything in the family
Current Health Status
Any underlying illness / genetic condition
What concerns do you have today?
Review of systems
Ask questions about each system
Measuring data: growth chart, head circumference, BMI
Nutrition: breast fed, formula, eating habits
Growth and development: How does parent think child is doing?
General appearance & behavior
Posture / movement
Development: grossly fits guidelines for age
Temperature: rectal only when absolutely necessary
Pulse: apical on all children under 1 year
Respirations: infant uses abdominal muscles
Blood pressure: admission base line
Height and weight and head circumference for 2 years and younger
Skin, hair nails
Head, neck, lymph nodes: fontanelles
Eyes, nose, throat…look at palate and teeth
Chest: auscultate for breath sounds and adventitious sounds
Breasts: tanner scale
Heart: PMI, murmurs
Glasgow coma scale
Observe their natural state: Play games with them, especially children under 5 year
CNS grossly intact: II – XII
Rooting: disappears at 3-4 months
Sucking: disappears at 10 to 12 months
Palmar grasp: disappears at 3 to 4 months
Plantar grasp: disappears at 8 to 10 months
Tonic neck: disappears by 4 to 6 months
Moro (startle): disappears by 3 months
Babinski: disappears by 2 years
Stepping reflex: disappears by 2 months
Examine on parent lap
Leave diaper on
Comfort measures such as pacifier or bottle.
Start with heart and lung sounds
Ear and throat exam last
Examine on parent lap if uncooperative
Use play therapy
Distract with stories
Let toddler play with equipment / BP
Call by name
Quickly do exam
Allow parent to be within eye contact
Explain what you are doing
Let them feel the equipment
Allow the older child the choice of whether to have a parent present
Teaching about nutrition and safety
Ask if the child has any concerns or questions
How are they doing in school?
Do they have a group of friends they hang out with?
What do they like to do in their free time?
Allow choice of having parent present
Privacy and modesty.
Explain procedures and equipment.
Interact with child during exam.
Be matter of fact about examining genital area.
Ask about parent in the room
Should have some private interview time: time to ask the difficult questions
HEADSS: home life, education, alcohol, drugs, sexual activity / suicide
Privacy issues: HIPPA
Choose your words carefully when explaining vital sign measurements to a young child. Avoid saying, for example, "I’m going to take your pulse now." The child may think that are going to actually remove something from his or her body. A better phrase would be "I’m going to count how fast your heart beats."
Use of tympanic membrane is controversial.
Oral temperature for children over 5 to 6 years.
Rectal temperatures are contraindicated if the child has had anal surgery, diarrhea, or rectal irritation.
Check with hospital policy.
Apical pulse for infants and toddlers under 2 years
Count for 1 full minute
Will be increased with: crying, anxiety, fever, and pain
Neonate: 70 – 190
1-year: 80 – 160
4-year: 80 – 120
14-year: 65 – 105 / males 60 – 100
18-year: 55-95 / males 50 - 90
Auscultate Heart Sounds at aortic, pulmonic, erbs, tricuspid and mitral points.
Count for one full minute
May want to do before you wake the infant up
Rate will be elevated with crying / fever
Pre-term: 40 – 60
Newborn: 30 – 40
Panic levels: <> 60
To accurately assess respirations in an infant or small child wait until the baby is sleeping or resting quietly.
You might need to do this before you do more invasive exam.
Count the number of breaths for an entire minute.
The width of the rubber bladder should cover two thirds of the circumference of the arm, and the length should encircle 100% of the arm without overlap.
Crying can cause inaccurate blood pressure reading.
Consider norms for age.
Blood Pressure Cuff
Needs to be recorded on a growth chart
Gain about an inch per month
Deviation of height on either extreme may be indication for further investigation: endocrine problems
Needs to be recorded on a growth chart
Newborn may lose up to 10% of birth weight in 3-4 days.
Gains about ½ to1 oz per day after that
Too much or too little weight gain needs to be further investigated.
Double birth weigh by 5-6 months
Triple birth weight by 1 year
How much formula?
How often being breast fed?
Solid foods: 4 to 6 months of age
What are they eating?
Over 1 year: How much milk vs solid foods. They can have whole milk.
School age: typical diet
I always ask the child if I were to ask their mom what do they need to eat more of what would she say?
Most common nutritional problems:
Iron deficiency anemia
Head Needs to be measured until age 2 years
Plot on growth curve
Anterior: closes by 12 to 18 months
Posterior: closes by 2-5 months
Shape: flat headed babies due to back-to-back sleep position
Condition of teeth
Number of teeth
No teeth eruption by 12 months think endocrine disorder
Brushing / visit to dentist
Check for red-reflex: lack of this may mean retinoblastoma
Can the infant see: by parent report
Alignment of eye important due to correlation with brain development
May need to corrected surgically
5-year-old and up can have vision screening
Refer to ophthalmologist if there are concerns
Common eye infections:
A red-flag in the newborn may be STD from travel down the birth canal
Pre-school: number one reason they are sent home: wash with warm water / topical eye gtts
Inflammation of eye: history of juvenile arthritis
Most common reason children come to the pediatrician or emergency room
Fever or tugging at ear
Often increases at night when they are sleeping
History of cold or congestion
ROM: right otitis media
LOM: left otitis media
BOM: bilateral otitis media
OME: Otitis media with effusion
(effusion means fluid collection)
Pleural effusion, effusion of knee
Why a problem?
Infection can lead to rupture of ear drum
Chronic effusion can lead to hearing loss
OM is often a contributing factor in more serious infections: mastoiditis, cellulitis, meningitis, bacteremia
Chronic ear effusion in the early years may lead to decreased hearing and speech problems
Oral antibiotics: re-check in 10 days
Tylenol for comfort
PET: pressure equalizing tubes
Need to keep water out of ears
Head, chest, and abdominal circumference.
A high percentage of admissions to hospital are respiratory: croup, bronchitis, pneumonia, and asthma
In the infant it is hard to separate upper air-way noises from lower air-way noises.
How does the child look? Color, effort used to breathe
Possible Sites of Retractions
Red flags: grunting / nasal flaring
Wheeze or Stridor
Wheezes occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure.
Wheezes is lower airway
Asthma = expiratory wheezes
A stridor is upper airway
Inflammation of upper airway or FB
Inspection and auscultation are performed before palpation and percussion because touching the abdomen may change the characteristics of the bowel sounds.
Normally occur every 10 to 30 seconds.
Listen in each quadrant long enough to hear at least one bowel sound.
Absence of bowel sounds may indicate peritonitis or a paralytic ileus.
Hyperactive bowel sounds may indicate gastroenteritis or a bowel obstruction.