Identifying data include the examination date; the patient’s name, age, and birth date, gender, and race; the referral source if pertinent; the relationship of the child and informant, and some indication of the mental state or reliability of the informant. It frequently is helpful to include the ethnic or racial background, address, and telephone numbers of the informants.

After the identifying data, the chief complaint should be recorded. Given in the informant’s or patient’s own words, the chief complaint is a brief statement of the reason why the patient is being seen. The stated complaint often is not the true reason the child was brought for attention. Expanding the question, “Why did you bring the child in?” to “What concerns you?” allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying.

Next, the details of the present illness are recorded in chronologic order. For the sick child, it is helpful to begin, “The child was well until days before this visit.” This is followed by a daily documentation of events leading up to the present time, including signs, symptoms, and treatment, if any. Statements should be recorded in number of days before the visit or specific dates, but not by days of the week, because chronology will be difficult to retrieve even a short time later. If the child is taking medicine, the record should indicate type and brand, the amount being taken, the frequency of administration, how well it has worked, and how long it has been taken.

For the well child, a simple statement such as “No complaints” or “No illness” suffices. A question about school attendance may be pertinent. If the past medical history is significant to the current illness, a brief summary is included. If information is obtained from old records, it should be noted.

Depending on the age of the patient, some aspects of the past history that follow may not be pertinent. Obtaining the past medical history serves not only to provide a record of data that may be significant to the well-being of the child either now or later, but also to provide evidence of children who are at risk for health or psychosocial problems.

If a prenatal interview has been held (see following discussion), this information already may be available. Questions to be answered include those regarding the health of the mother during the pregnancy, especially in regard to any infections, other illnesses, vaginal bleeding, toxemia, or exposure to
animals (e.g., maternal exposure to cats may raise the possibility of toxoplasmosis), any of which can have permanent effects on the embryo and child. The time and type of fetal movements should be determined. The record should include the number of previous pregnancies and their results, whether radiography was performed, what medications were taken, and whether the mother smoked or abused drugs or alcohol during the pregnancy, results of serology and blood typing of the mother and baby, and results of other tests such as amniocentesis. If the mother’s weight gain was excessive or insufficient, this should be noted.

The duration of pregnancy, the ease or difficulty of labor, and the duration of labor may be important, especially if there is a question of developmental delay. The type of delivery (spontaneous, forceps-assisted, or cesarean section), type of anesthesia or analgesia used during delivery, attendance by other family members at delivery, and presenting part (if known) are recorded. Note the child’s birth order (if there have been multiple births) and birth weight.

Many informants are aware of Apgar scores at birth and at 5 minutes, any unusual appearance of the child such as cyanosis or respiratory distress, and any resuscitative efforts that took place and their duration. If the mother was delayed in seeing the infant after birth, reasons should be sought. Jaundice, anemia, convulsions, dysmorphic states, and congenital anomalies or infections in the mother or infant are some of the reasons why viewing or handling of the newborn by the mother may be delayed. The time of onset of any of these abnormal states may be significant.

Note whether the baby was breast- or bottle-fed and how well the baby took the first feeding. Poor sucking at the first feeding may be the result of sleepiness, but also is a warning sign of neurologic abnormality, which may not become manifest until much later in life. By the second or third feeding, even brain-damaged children usually nurse well.

If the infant has been bottle-fed, inquire about the type of formula used and the amount taken during a 24-hour period. Ask about the mother’s initial reaction to her baby, the nature of bonding and eye-to-eye contact, and the baby’s patterns of crying, sleeping, urinating, and defecating. Supplemental feeding, vomiting, regurgitation, colic, diarrhea, or other gastrointestinal or feeding problems should be noted.

Determine the ages at which solid foods were introduced and supplementation with vitamins or fluoride took place, as well as the age at which weaning occurred and the method used to wean. In addition, note the age at which baby foods, toddlers’ foods, and table food were introduced, the response to these, and any evidence of food intolerance or vomiting. If feeding difficulties are present, determine the onset of the problem, methods of feeding, reasons for changes, interval between feedings, amount taken at each feeding, vomiting, crying, and weight changes. With any feeding problem, evaluate the effect on the family by asking, “How did you manage the problem?”

For an older child, ask the informant to supply some breakfast, lunch, and dinner menus; likes and dislikes; and response of the family to eating problems.

An estimation of physical growth rate is important. Attempt to ascertain the birth weight and the weights at 6 months, 1 year, 2 years, 5 years, and 10 years. Lengths at similar ages are desirable. These data are plotted on physical growth charts. Any sudden gain or loss in physical growth should be noted, because its onset may correspond to the onset of organic or psychosocial illness. It may be helpful to compare the child’s growth with the rate of growth of siblings or parents. Ages at which major developmental milestones were met aid in indicating deviations from normal. Such milestones include following a person with the eyes, holding the head erect, smiling responsively, reaching for objects, transferring objects, sitting alone, walking with support and alone, speaking the first words and sentences, and experiencing tooth eruption. Ages of dressing self, tying own shoes, hopping, skipping, and riding a tricycle and bicycle should be noted, as well as grade in school and school performance.

In addition, note should be made of the age at which bowel and bladder control was achieved. If problems exist, the ages at which toilet teaching began also may indicate reasons for problems.

The amount of sleep and sleep problems and habits such as pica, smoking, and use of alcohol or drugs should be questioned. The informant should state whether the child is happy or difficult to manage and should indicate the child’s response to new situations, strangers, and school. Temper tantrums, excessive or unprovoked crying, nail biting, and nightmares and night terrors should be recorded. Question the child regarding masturbation, dating, dealing with the opposite sex, and parents’ responses to menstruation and sexual development. Questions should be free of heterosexual assumption, direction of romantic interests, and gender of partners.

The types of immunizations received, with the number, dates, sites given, and reactions should be recorded as part of the history. In addition, it is helpful to record these immunizations with lot numbers on the front of the chart or in a convenient, obvious place.

A general statement should be made about the child’s general health before the present encounter, such as weight change, fever, weakness, or mood alterations. Specific inquiry is helpful regarding the results of any screening tests and any history of infectious or contagious diseases, or any other illness, as well as specific treatment, results, and residua. The history of each past illness should include dates of onset, course, and termination. If hospitalization or surgery was necessary, the diagnoses, dates, and name of the hospital should be included. Questions concerning allergies include the
occurrence and type of any drug reactions, food allergies, hay fever, and asthma. Accidents, injuries, and poisonings should be noted.

The review of systems serves as a checklist for pertinent information that might have been omitted. If information has been obtained previously, simply state, “See history of present illness” or “See history of past illnesses.” Questions concerning each system may be introduced with a question such as, “Are there any symptoms related to …?”

The family history provides evidence for considering familial diseases as well as infections or contagious illnesses. A genetic type chart is easy to read and very helpful. It should include parents, siblings, and grandparents, with their ages, health, or cause of death. If problems with genetic implications exist, all known relatives should be inquired about. If a genetic type chart is used, pregnancies should be listed in a series and should include the health of the siblings (Fig. 5.1).

Family diseases include allergy; blood, heart, lung, venereal, or kidney disease; tuberculosis; diabetes; rheumatic fever; convulsions; skin, gastrointestinal, behavioral, or mental disorders; cancer; or other disease the informant mentions. These diseases may have a heritable or contagious effect. Pertinent negative answers should be included.

Details of the family unit include the number of people in the habitat and its size, the presence of grandparents, the marital status of the parents, the significant caretaker, the total family income and its source, and whether the mother and father work outside the home. If it is pertinent to the current problems of the child, inquire about the family’s attitude toward the child and toward each other, the type of discipline used, and the major disciplinarian. If the problem is psychosocial and only one parent is the informant, it may be necessary to interview the other parent and to outline a typical day in the life of the child.

It is desirable, if feasible, to interview the mother and father before the child is born. Not only can some necessary data be obtained, but also the parents can become acquainted with the doctor who will be seeing them shortly after the arrival of their newborn. The health of the mother, whether she will nurse or bottle-feed the baby and whether the husband supports her choice, the preparation for the baby on arrival home, and whether help will be available can be ascertained. Because the father may feel left out of the pregnancy experience, it is important to direct some questions to him (e.g., “Do you want your son circumcised?”) and to get the family history of diseases from him first.

Even young children should be asked about their symptoms and their understanding of their problem. This also provides
an opportunity to observe the child interact with the parent. For most adolescents, it is important to take part of the history from the adolescent alone after asking for his or her approval. (see Chapter 89 for a more complete discussion of appropriate components of the history in the adolescent patient.) Regardless of your own opinion, obtain the history objectively without any moral implications, starting with open-ended questions related to the initial complaint and then directing the questions.

Temperature is taken in the axilla or rectum in the young child and by mouth after 5 or 6 years of age, when the child can understand how to hold the thermometer. Electronic thermometer probes inserted into the mouth or rectum give rapid, accurate determinations. In general, the rectal temperature will be approximately 0.5 degrees higher than the oral temperature. Sometimes body temperature is determined by placing the thermometer under the child’s arm, with the upper arm held firmly by the side. Somewhat less accuracy is possible with this method, and in general, the reading that results will be about 1 degree lower than the rectal temperature. There is some controversy about the accuracy of electronic assessment through use of probes in the external ear canal. It is important to correlate the temperature determined by this method with the clinical condition of the child. Elevated temperature occurs with infection, excitement, anxiety, exercise, hyperthyroidism, collagen-vascular disease, or tumor. Decreased temperature occurs with chilling, shock, hypothyroidism, or inactivity. Temperature may be decreased after taking certain drugs, with hypocortisolism, or with overwhelming infection.

The pulse rate can be obtained at any peripheral pulse (femoral, radial, or carotid) or by palpation over the heart. The normal rate varies from 70 to 170 beats per minute at birth to 120 to 140 shortly after birth, and ranges from 80 to 140 at 1 to 2 years, from 80 to 120 at 3 years, and from 70 to 115 after 3 years. The sleeping pulse after the age of 2 years normally is approximately 20 beats per minute less than the awake pulse, but does not decrease with rheumatic fever or thyrotoxicosis. For each centigrade degree of temperature increase, the pulse rate increases approximately 10 beats per minute. The pulse rate is elevated with excitement, exercise, or hypermetabolic states and is decreased with hypometabolic states, hypertension, or increased intracranial pressure. Irregularity may be caused by sinus arrhythmia, but can indicate underlying heart disease. Absence of the femoral pulse is a cardinal sign of postductal coarctation of the aorta.

The respiratory rate should be determined by observing the movement of the chest or abdomen or by auscultating the chest. The normal newborn rate is 30 to 80 breaths per minute; the rate decreases to 20 to 40 in early infancy and childhood, and then to 15 to 25 in late childhood and adolescence. Exercise, anxiety, infection, and hypermetabolic states increase the rate; central nervous system lesions, metabolic abnormalities, alkalosis, depressants, and other poisons decrease the rate.

The blood pressure should be measured with a cuff, with the bladder completely encircling the extremity and the width covering one-half to two-thirds of the length of the upper arm or upper leg. The pressure should be recorded and compared with normal readings (Tables 5.1 and 5.2). High systolic pressure occurs with excitement, anxiety, and hypermetabolic states. High systolic and diastolic pressures occur with renal diseases, pheochromocytoma, adrenal disease, arteritis, or coarctation of the aorta. Press and release the child’s nail. Normally, color returns in less than 1 second, the capillary refill time. Color returns in 2 to 3 seconds with 50 to 90 mL/kg fluid depletion, and in more than 3 seconds with greater than 90 mL/kg fluid depletion. At more than 90 mL/kg fluid depletion, medical shock ensues.

To obtain height and weight recordings, the infant should be measured supine up to the age of 2 years and standing



thereafter. Head circumference should be measured in all infants younger than 2 years and in those with misshapen heads, and measurements should be recorded with percentiles on a chart (Figs. 5.2, 5.3, 5.4, 5.5, 5.6 5.7).