History and Physical Assessment



History and Physical Assessment


Monika A. Buerger



The purpose of this chapter is to provide the doctor of chiropractic with the basic procedures necessary to evaluate the infant, toddler, pre-adolescent, and adolescent patient. The reader is referred to other sources for additional physical examination information not covered in this chapter (1,2). The focus of this chapter is on the case history and physical examination of the skin, head and neck, thoracic cavity, and abdomen. In this text, general orthopedics is presented in Chapter 13, the neurological examination in Chapters 6 and 11, and the spinal examination in Chapter 5.

The chiropractor should also be able to determine the extent of injury/illness, the type of treatment necessary, the amount/length of treatment necessary, and appropriate referral, if required.

The “chiropractic” portion of the pediatric evaluation may be performed before or after the general physical examination. In many instances, while performing the physical examination, portions of the spinal evaluation can also be incorporated. It is important for chiropractors to keep in mind their knowledge of the spine and nervous system and how it may or may not relate to any findings during the history or physical examination of a particular patient.

It is important for the physician to establish a relationship with various professionals in their community who specialize in the field of pediatrics. Such relationships can be crucial to encourage co-management of the pediatric patient. A network of professionals should include, but are not limited to, pediatricians, dentists, orthopedists, neurologists, ophthalmologists, optometrists, psychologists, nutritionists, physical therapists, speech therapists, audiologists, internists, dermatologists, and allergy specialists. A working relationship with a diagnostic imaging center and laboratory familiar with dealing with the pediatric patient is also important.


GENERAL CONSIDERATIONS

Physical assessment of the pediatric patient includes a complete and detailed history (primarily from a parent or caregiver), comprehensive physical examination, and complete chiropractic evaluation. Before beginning any procedures, an authorization to treat a minor must be signed by the parent or legal guardian of the child.

A systematic approach to the evaluation of a patient may be remembered by using the acronym HIPPIRONLT. The order of evaluation is history, inspection, palpation, percussion, instrumentation, range of motion, orthopedic evaluation, neurologic evaluation, laboratory testing (special tests), and treatment. The doctor of chiropractic must also include a complete spinal evaluation before determining the appropriate course of treatment.


History

The history is a way of collecting comprehensive data that will depict the child’s health and development from conception to the present time as well as help anticipate any future health concerns. History taking is an important step in establishing trust and confidence with any patient; it is especially important when dealing with the pediatric patient. The parents or caretakers need to know that their child is in competent and safe hands. A thorough history also will give the doctor information on how best to educate the parents or caretakers on a “wellness” or “dis-ease” lifestyle. Pediatrics is a unique area among the medical community because the emphasis of care is placed on disease prevention and parental guidance for a healthy lifestyle. This approach has always been a primary focus of the chiropractic profession and must be considered a part of the care received from the doctor of chiropractic. When discussing healthy lifestyle choices with the parents, regular
chiropractic check-ups should be considered as a part of disease prevention.

It is recommended that the entire history be taken before beginning the physical assessment portion of the evaluation. When obtaining the history of the adolescent patient, there may be portions of the history where the child may feel more comfortable answering the questions in the absence of their parents, for example, the psycho-social portion of the history dealing with recreational, sexual, and social issues.

The following is a history outline recommended for the chiropractic pediatric patient:



  • Identifying data (ID). Name, nickname, sex, date of birth, birthplace, first and last name of each parent, day and work phone number of each parent, home address of child and each parent


  • Source of history (SH). Record the source of given history information (e.g., patient, father, mother, other medical reports).


  • Chief complaint (CC). Depending on the child’s age, attempt to record the CC in their own words. It should be made clear in the records if the CC is a concern of the child, parent, or a third party (e.g., teacher, daycare provider, grandparent).

History of Present Illness The current injury/illness should be recorded in a chronological fashion from the onset of signs/symptoms to the present. The nature and timing in which the injury/illness began, the location, the severity, in comparison to the current presentation, and any previous treatment should all be carefully recorded. Symptoms should be described in terms of onset, timing, location, quality, quantity, severity, duration, associated manifestations, and factors that influence the symptoms (e.g., what makes it better, what makes it worse). When taking the history, one must remember that children may not know the meaning of specific terms often used to obtain information. For example, the child may not know what pain or tenderness means, but they will understand “hurt.” They may not be able to describe where the “hurt” is, but they are able to point. They may not understand intensity, but will understand “not very much” or “a lot.” Therefore, it is helpful to have the child point to what “hurts”; then use words or examples that the child will understand to retrieve more detailed information.

With children, it is often wise to find out if there is a secondary gain to their injury/illness (e.g., not having to attend school or not having to do chores).


Medical History

Birth History The birth history is important for the doctor of chiropractic to determine the amount of trauma the spine or cranium may have sustained during the birth process. The parent or caregiver should be educated about the traumatic effects the birthing process may have on the child’s spine and nervous system. Birthing trauma can lead to vertebral subluxations in the newborn and go undetected, leading to putative neuropathophysiologic effects. The cause of trauma in most instances is caused by a forceful tractioning of the spine while in a hyperextended position. Longitudinal traction with rotation and flexion, or excessive lateral bending, also can cause injury (3).

Prenatal History Establish what the mother’s health status was before and during the pregnancy. What was the mother’s age? What was the mother’s gravida status and para status. Were there any prior miscarriages? If so, how many and how long ago? Were any drugs (prescription or otherwise) used before or during the pregnancy (including alcohol)? How much weight was gained during the pregnancy? Were there any complications with the pregnancy? Were there any parental concerns regarding the pregnancy, delivery, or care of that particular child? What was the term of the child (full term or premature)?

Natal History Ask about the duration and extent of difficulty of both labor and delivery. Was labor spontaneous or induced? Was the delivery “natural” or was it a cesarean section? If it was a cesarean section, what was the reason? Were forceps, vacuum extraction (suction cup), or other devices used? Did the mother require any type of analgesic drug? What was the position of the child at birth (e.g., vertex, transverse, breech). Was the child born in a hospital, home, or birthing center? Excessive tractional forces during vaginal delivery, breech births, cesarean births, and the use of forceps or vacuum extractors all can result in trauma to the cranium, cervical, and thoracic spine.

Neonatal History What was the child’s Apgar scores? Was there any need for resuscitation efforts? Were there any particular problems with feeding, respiration, cyanosis, jaundice, anemia, convulsions, congenital anomalies, or infections? What was the mother’s health status postpartum?


Feeding/Nutritional History

Infancy Was the child solely breastfed, breastfed along with supplemental feeding, or solely supplementally fed? If some type of supplemental feeding took place, what did it consist of? What was the frequency and duration of feedings? Were there any difficulties associated with the feedings (e.g., spitting-up, not latching onto the breast, not wanting to eat from the right or left breast, colic, or diarrhea)? Sometimes, because of irritation caused by an upper cervical vertebral subluxation, one will find that
the child will not want to latch-on or feed when his head is turned toward one particular side. There is also the possibility that the infant is unable to turn his or her head to one particular side because of joint restriction caused by a vertebral subluxation (e.g., with an ASRP atlas, the child may not be able to turn their head far enough to the left to comfortably nurse at the right breast).

Early Childhood At what age did the child begin to eat solid foods? How were foods introduced: one at a time or many at one time? Did there seem to be any allergic reactions to certain foods? If so, which foods were they and what type or reaction occurred?

Childhood, Pre-adolescent, and Adolescent What are the child’s current and past eating habits? Is he or she eating large quantities of fast foods (see Chapter 18)? Is he or she eating foods with good nutritional content? Is there evidence of any eating disorders such as anorexia nervosa or bulimia? If an overeating or undereating disorder is suspected, a 14-day food intake diary may be helpful to make a proper assessment.


Childhood Illnesses and Exposures

Childhood Illnesses Does the child have a history of chickenpox, mumps, measles, rubella, rubeola, rheumatic fever, or whooping cough? At what age did they experience the illness? Were there any complications caused by the illness? What was the extent of the illness and what type of treatment was rendered? Other illnesses that should be inquired about in the history include chronic ear aches/infections, asthma, chronic colds/flu, or headaches. These may be indicative of a compromised immune system caused by vertebral subluxation or other factors.

Recent Exposures Has there been any recent exposure to contagious childhood illnesses that should be noted? What was the nature of the exposure and have there been any signs or symptoms of the disease?

Travel/Pets Has there been any recent or past travel to other countries or other locations? Has there been any exposure to animals?

Operations/Injuries/Hospitalizations Record the dates/ages of each incident. If there is a history of past injuries, what were the circumstances surrounding them? What medical procedures were performed and by whom were they performed? Was a blood transfusion necessary? Was therapy or chiropractic care necessary? Are there any current repercussions arising from the incident? Are the medical records available for your review if necessary?

Allergies Does the child have a history of allergies to any medications or foods or other environmental substances? Have they shown any signs of eczema, urticaria, or hypersensitivity to insect bites or pollens? As with any patient suffering from allergies, children should be checked for vertebral subluxations. Specific areas that should be examined are C6-T3 for thyroid involvement and T7-T12 for adrenal involvement (4). The lower lumbar spine (L4-L5) and the second sacral segment should also be examined for subluxation. Nutritional support with antioxidant vitamin supplements is also recommended.

Special Testing or Screening Procedures Record the date/age and results of any special tests or screening procedures performed on that specific child; for example, blood tests for hematocrit levels, blood lead levels, or sickle cell anemia. Were any vision, hearing, urinalysis, or tuberculin tests performed? Was there any testing for genetic or high-risk disorders?

Vaccinations Record the ages/dates of any vaccinations. Were there any reactions? If so, to what extent? If vaccines have not yet been administered, is the intention that they will be in the future? The doctor of chiropractic should have knowledge regarding the potential risks/benefits in relation to immunizations (see Chapter 10 and 19). The chiropractor should be able to offer the parents literature about various vaccines and the risks associated with them, as well as educate parents about why vaccines may or may not be necessary for their children. Rather than advising the parent(s) to vaccinate or not to vaccinate, the chiropractic doctor should focus on educating the parent(s) on the subject and allowing the parent(s) to make the decision they feel is most appropriate for their child.

Growth and Development The developmental history is especially important for the infant and toddler for detecting and/or treating any abnormalities of physical growth, psychomotor development, intellectual retardation, or behavioral disorders.

Physical Growth What is the child’s current weight and height? Has there been any period of rapid weight gain or weight loss? Has there been a progressive growth and maturity pattern, and has the child shown normal tooth eruption and loss patterns? If the child is being treated regularly in your office, it is advisable to obtain an updated physical growth history at various ages. The recommended ages are 1, 2, 5, 10, and 16 months (see chapter 13).


Developmental Milestones These are specific tasks and/or accomplishments achieved by the majority of normal children by a certain predictable age. Examples include lifting the chin at 6 to 8 weeks, rolling over at 3 to 5 months, and sitting without support at 6 to 8 months (Table 15.1). Record ages/dates when major milestones were attained.

Psycho-social Development This area deals with information regarding the child’s lifestyle, behavior, environment, emotional, and cognitive functioning. Questions should be reflective of the patient’s age. The adolescent patient may be more comfortable in the absence of their parents and may be more likely to answer your questions truthfully. The following are some areas to touch on in relation to psycho-social development:



  • Sleep patterns: amount, frequency of naps, nightmares, sleep walking.


  • Toileting: age toilet training was introduced, age that bowel and bladder control were attained, and occurrence of accidents or enuresis. If enuresis is reported, evaluation of the fifth lumbar, second and third sacral segments, and the T11-L2 spinal segments should be checked for vertebral subluxations. The most common vertebral levels associated with enuresis are the second and third sacral segments. The upper cervical spine also should be evaluated for vertebral subluxations in a child with enuresis (3).


  • Speech: record any stuttering, lisping, or hesitation of speech patterns. Verbally interact with the child to obtain some sense of their vocabulary (e.g., number of words in their vocabulary, clarity of words, understanding of words).


  • Discipline: What is the child’s temperament (behavioral style) and how does the parent/caretaker respond to it? Does the discipline style used seem to be successful? Does the child demonstrate negativity, withdrawal from others, temper tantrums, or aggressive behavior? Children suffering from attention deficit hyperactivity disorder may tend to demonstrate aggressive behavior. They show little thought about or regret for any of their actions, even if they involve injury to others. These children are easily distractible and impulsive and are often unpopular with their peers. Any child with hyperactive tendencies should be checked for vertebral subluxations. Special attention should be paid to the upper cervical region (i.e., occiput to C3) (3).


  • Schooling: Does/did the child attend day care or preschool? At what age did the child begin kindergarten? What is the current satisfaction of the child and parent with the schooling? Are there any specific academic achievements or concerns regarding schooling? Is there a history of an attendance problem?


  • Recreational: Is the child involved in any recreational activities? If so, was it the child’s choice to participate or the parents’ decision? If the child participates in sports do they participate in team sports or individual sports?


  • Sexuality: Is the child comfortable with his/her sexual orientation? What is their relationship with members of the opposite sex? Do they have any questions regarding conception, pregnancy, contraception, or sexually transmitted diseases? Is their relationship with their parent(s) one that permits discussion of sexual concerns?


  • Personality: What is the child’s degree of independence/autonomy? What is their relationship with parents, siblings, peers, and teachers? What is their self-image? What do they feel their major assets are?


FAMILY HISTORY

Obtain a family history of parents, siblings, and grandparents. Is there a family history of any medical conditions such as heart disease, high blood pressure, diabetes, stroke, kidney disease, tuberculosis, cancer, AIDS, arthritis, anemia, headaches, mental illness, alcohol, or drug abuse? If so, what type of treatment was given? Is there a history of any infant or childhood deaths or congenital anomalies? Are the parents living or deceased? If living, what are their ages? If deceased, was there a known cause of death? If the child is adopted, ask the adoptive parents if there is any known family medical history.


REVIEW OF SYSTEMS

The review of systems is designed as a “safety net” to assess any problems/concerns that may not have surfaced during the other portion of the patient history. Ask a few general questions about each system. If there is a system (area) of concern, more detailed questions should be asked in order to rule-in or rule-out any possible dysfunction/disorder:



  • General: weight changes, energy level, sleep patterns, growth patterns, fever, fatigue


  • Skin: birthmarks, rashes, pallor, sweating, itching, bleeding, swelling, dryness, color changes, lumps, changes in hair or nails


  • Head: headaches, head injuries, dizziness


  • Eyes: vision disorders, pain, redness, excessive tearing, glasses


  • Ears: hearing disorders, infections, dizziness, ringing in ears, discharge



  • Nose and sinuses: frequent colds, nasal stuffiness, hay fever, nosebleeds, drainage, discharge, sinus troubles


  • Mouth and throat: dental or gum problems, sore throats, speech problems, hoarseness, sore/enlarged tongue, last dental examination


  • Lymphatics: enlarged and/or painful lymph nodes


  • Neck: pain, lumps/masses, thyroid problems, wryneck (torticollis), “swollen glands”


  • Breasts: pain, discharge, masses, asymmetry, selfexaminations


  • Respiratory: cough, sputum (color and quantity), difficulty breathing, wheeze, frequent colds, exercise intolerance, hemoptysis, tuberculin test, bronchitis, asthma, history of chest x-rays


  • Cardiovascular: heart murmur, heart abnormalities, high blood pressure, rheumatic fever, dyspnea, chest pain, palpitations, edema, cyanosis


  • Gastrointestinal: abdominal pain, nausea, vomiting, diarrhea, constipation, colic, food intolerance, vomiting of blood, excessive belching or passing of gas, jaundice, bloody or tarry stools, hepatitis, liver or gall bladder problems


  • Urinary: pain, frequency, infections, enuresis, blood in urine


  • Genito-reproductive: male: age of onset of puberty, hernias, undescended testicle, testicular pain or swelling, discharge from or sores on penis, sexually transmitted diseases, sexual activity, sexual concerns; female: age at menarche; regularity, frequency, and duration of periods; dysmenorrhea; last menstrual period; excessive abdominal and/or back pain or bleeding associated with menstrual cycles; sexually transmitted diseases; sexual activity; pregnancies; sexual concerns; vaginal abnormalities; ovarian cysts; discharge; itching


  • Musculoskeletal: pain or swelling in joints, joint stiffness, arthritis, pain in muscles or bones, congenital abnormalities, sports injuries, scoliosis, gait abnormalities, back or neck pain. Inconsistencies in the history of this area are especially important for detecting suspected child abuse or maltreatment (see Chapter 16)


  • Neurological: fainting, blackouts, seizures, paralysis, local weakness, numbness, tingling, memory, personality changes, abnormal movements or vocalizations, difficulties with handwriting, balance/coordination, central nervous system (CNS) infections, delayed development, functioning at school


  • Psychiatric: nervousness, tension, mood, memory, behavior, depression, hallucinations


  • Endocrine: thyroid problems, heat/cold intolerance, excessive sweating, diabetes, excessive hunger, thirst, urination


  • Hematologic: anemia, bruising, bleeding, past transfusions










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Related posts:

  1. Selected Neurologic and Visceral Disorders
  2. Pediatric Nutrition
  3. Adolescent Patients with Acute Spinal Fractures and Subluxations
  4. Sacro-Occipital Technique for the Pediatric Patient

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May 24, 2016 | Posted by in PEDIATRICS | Comments Off on History and Physical Assessment

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Development Milestones


1-2 months


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Observational activities


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Holds head up


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Raises head prone 45 degrees


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Turns head and eyes to sound


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Acknowledges faces


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Follows objects through visual fields


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Drops objects (toys)


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Is alert in response to voices


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Activities reported by parents


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Smiles responsively and spontaneously


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Recognizes parents


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Language capabilities


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Engages in vocalization (coos)


3-5 months


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Observational activities


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Smiles, laughs, gurgles


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Holds head high and raises body with hands while in prone position


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Reaches for and brings objects to mouth


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Makes “raspberry” sound


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Sits with support (head steady)


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Holds rattle briefly


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Follows objects 180 degrees


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Activities reported by parents


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Anticipates food on sight


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Rolls from front to back


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Turns from back to side


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Excited upon recognizing familiar people


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Language capabilities


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Squeals


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Babbles, initial vowels


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Guttural sounds (“ah,” “go”)


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Consonants: m, p, b


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Vowels: o, u


6-8 months


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Observational activities


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Imitates “bye-bye”


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Reaches


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Sits alone for a short period of time


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Some weight bearing


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Passes object from hand to hand in midline


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First scoops up a pellet then grasps it using thumb opposition


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Activities reported by parents


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Rolls front to back and back to front


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Is indifferent to the word “no”


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Language capabilities


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Babbles/Imitates speech sounds


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Syllables: da, ba, ka


9-11 months


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Observational activities


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Sits alone


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Pulls to stand


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Stands alone


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Creeps


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Imitates pat-a-cake and peek-a-boo


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Uses thumb and index finger to pick up pellet


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Activities reported by parents


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Feeds self finger foods


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Walks supported by furniture


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Follows one-step verbal commands (e.g., “Come here”, “Give it to me”)


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Language capabilities


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MaMa/DaDa nonspecifically


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Approximates names: baba/bottle


12 months


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Observational activities


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Walks with support or independently


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Pincer grasp


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Gives toys upon request


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Brings two blocks together; tries to build tower


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Releases objects into cup after demonstration


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Activities reported by parents


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Points to desired objects


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Looks for hidden objects


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Language capabilities


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MaMa/DaDa specific


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Jargon begins (own language)


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2-3 words understandable


18 months


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Observational activities


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Throws ball


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Climbs/descends stairs with aid


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Turns pages


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Uses a spoon


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Identifies body parts


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Seats self in chairs


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Scribbles spontaneously


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Builds tower of 3-4 blocks


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Activities reported by parents


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Feeds self


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Carries and hugs doll


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Understand a two-step command


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Language capabilities


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Says 4-20 words


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Consonants: t, d, w, h, n


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2-word phrases understandable


24 months


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Observational activities


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Kicks ball


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Holds cup securely


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Points to named objects or pictures


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Jumps off floor with both feet


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Stands on one foot alone


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Builds tower of 6-7 blocks


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Climbs/descends stairs unaided


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Turns pages of a book singly


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Activities reported by parents


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Verbalizes toilet needs


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Mimics domestic activities


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Pulls on simple garments


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Language capabilities


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Three-word phrases understandable


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Use of pronouns: mine, me, you, I


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Vowels uttered correctly


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Approximately 270 words


30 months


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Observational activities


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Refers to self as I


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Copies a crude circle


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Walks backward


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Begins to hop on one leg


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Holds crayon in fist


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Activities reported by parents


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Helps put things away


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Language capabilities


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Carries on a conversation


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Uses prepositions


36 months


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Observational activities


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Shares playthings


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Copies a circle


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Holds crayon with fingers


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Imitates a vertical line


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Builds a tower using 9-10 blocks


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Gives first and last name


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Activities reported by parents


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Dress with supervision


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Rides tricycle using pedals


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While looking at a picture book able to answer “what is … doing?”


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Language capabilities


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Some degree of hesitancy and uncertainty in common


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Intelligible four-word phrases


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Approximately 900 words


3-4 years


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Observational activities


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Walks on heels


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Climbs/descends stairs with alternating feet


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Responds to command to place objects in, on, or under table


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Draws a circle when asked to draw a person (man, boy or girl)


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Knows own sex


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Finger opposition


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Begins to button and unbutton


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General knowledge: full name, age, address (two out of three)


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Activities reported by parents


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Takes of shoes and jacket


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Feeds self at mealtime


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Language capabilities


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Intelligible five-word phrases


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Approximately 1,540 words


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Answers questions using plurals, personal pronoun, and verbs: “What do you want to do that is fun?”


4-5 years


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Observational activities


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May stand on one leg for at least 10 seconds


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Runs and turns without losing balance


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Tiptoes


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Tells simple story


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Knows days of the week (“What day comes after Monday?”)


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Draws a person (head, two appendages, and possibly two eyes. No torso)


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Counts to 4 by rote


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Begins understanding rules (right and wrong)


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Cuts and pastes


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Gives appropriate answers to: “What must you do if you are sleepy? Hungry? Cold?” etc.


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Activities reported by parents


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Dressing and undressing without supervision


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Buttons clothes and laces shoes but does not tie


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Self-care with toilet needs (may need help wiping)


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Plays outside for at least 30 minutes


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Language capabilities


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Intelligible four-word phrases


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Approximately 1,540 words


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Uses plurals, personal pronouns, and verbs


5-6 years


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Observational activities


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Skips


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Catches a ball


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Copies a + that is already drawn


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Tells own age


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Knows right and left


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Draws a recognizable person with at least 8 details


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Understands the concept of 10 (is able to count out 10 objects)


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Describes favorite television program or video in some detail


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Activities reported by parents


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Goes to school unattended or meets the school bus


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Helps with simple chores at home (taking out the garbage)


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Good motor capability but little aware of dangers


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Language capabilities


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Intelligible six- seven-word sentences


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Approximately 2,560 words


6-7 years


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Observational activities


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