Respiratory system.
KEY QUESTIONS FROM THE
HISTORY
Breathlessness
•
Breathless at rest or with activity?
•
Poor weight gain in infancy (a sign of
respiratory distress)
Cough
•
Chronology any link to time of
day/activity/environment
•
Nature of cough: dry (viral), loose
(productive), barking (croup), paradoxical (forced repetitive cough with
difficult inspiration, seen in whooping cough)
Feeding in infancy
•
Choking (gastro-oesophageal reflux)
•
Symptoms with introduction of formula milk
(cow’s milk protein allergy)
Fever
N.oisy breathing
•
Noise in expiration (wheeze = lower airway
obstruction)
•
Noise in inspiration (stridor = upper airway
obstruction)
Cough, wheeze or stridor in a young child
•
If sudden onset, is there a history of inhaled
foreign body or choking?
Ear, nose and throat
•
Child pulling at their ears (middle ear
infection)
•
Difficulty in swallowing (tonsillitis or
epiglottitis)
•
Offensive odour breath (bacterial infection)
•
Nasal secretions, bleeding
Family history
•
Family history of respiratory problems (asthma,
cystic fibrosis)
•
Asthma, eczema, hay fever in close relative
(atopy)
•
Any smokers or pet animals in household?
•
Travel to area of high tuberculosis prevalence,
or contact with infected relative?
Cardiovascular system
KEY QUESTIONS FROM THE HISTORY
Breathlessness
•
Breathing difficulties without signs of acute
infection (consider cardiac disease)
Exercise
•
Exercise limited by shortness of breath,
palpitations or chest pain
•
Competitive sports rarely these may need to be
limited with some cardiac defects
Colour change
•
Cyanosis central (tongue) or peripheral (hands
and feet)
•
Pale and sweaty, poor perfusion (sign of cardiac
failure or an arrhythmia)
Growth
•
Feeding problems in babies (breathlessness
impairs feeding)
•
Poor weight gain on growth chart
Syncope
•
Unexplained collapse or fainting
•
Collapse linked with exercise
•
Palpitations
•
Ask the parents to demonstrate rate/rhythm by
tapping with their hand
Murmurs
•
Previously noted heart murmur (physiological
flow murmurs sometimes audible only at times of illness or after exercise)
Family history
•
Family history of congenital heart disease
•
Sudden death in early adulthood (congenital cardiomyopathy)
Medical condition associated with cardiovascular problems
•
Genetic syndromes involving structural heart
defects (e.g. Down’s, Turner’s or Marfan’s syndromes)
•
Renal problems (hypertension)
•
Chemotherapy (some drugs cardiotoxic)
Abdominal system and nutritional status
Nutrition
•
Infant feeding pattern duration of breastfeeding
•
Note any breastfeeding problems
•
Is therea key professional to give support to
breastfeeding?
•
If formula milk fed, review type and volume (note:
1 fluid ounce = 28 mL)
•
Review intake typical infant intake is 100 –150
mL/kg in 24 hours
•
Age at weaning on to semi-solids, any choking
problems, foods taken
•
Detail what the child eats in a typical day
•
Review calorie intake and nutritional balance
•
Level of appetite, any difficult feeding
behaviours
•
Pattern of weight gain
•
Review the parent-held health record (UK Red
Book) growth pattern
Vomiting
•
Vomiting frequency, colour
•
Green vomit in infancy suggests bile
(gastrointestinal obstruction)
•
Posseting (small vomits of milk in mouth) in
infancy suggests gastro-oesophageal reflux
•
Blood in vomit in infancy suggests maternal
blood swallowed with breastfeeding
•
Blood in vomit in older children suggests
oesophageal bleeding due to vomiting
Bowel habit
•
Faeces—frequency, consistency, colour, any
mucus, blood, greasy faeces
•
Diarrhoea—frequency, consistency, urgency,
blood, link with diet
•
In newborn, meconium should be passed in first
24 hours after birth
•
Age of potty training (child develops awareness
and can con- trol bowel movement to use potty)
•
Constipation straining, pain, reduced frequency,
hard faeces
•
Soiling of faeces in underwear (seen with
overflow in constipation)
•
Encopresis (behavioural problem of passing
faeces in inappropriate place)
Pain
•
Abdominal pain site, radiation, chronology,
nature, exacerbating and relieving factors
Family history
•
Family history of liver, kidney, bowel disease
Genito-urinary symptoms
•
Urinary frequency, dysuria, haematuria
•
Enuresis (childhood urinary incontinence) by day
and night
•
Age at menarche, cycle frequency, regularity
•
Menstrual bleeding flow, duration, pain symptoms
Neurological assessment
•
Problems during pregnancy or neonatal period
•
Review development:
• loss
of developmental milestone skills (regression, a sign of serious problems)
• pattern
of delay—global or limited (e.g. isolated speech and language delay)
•
Headache symptoms
•
Early morning vomiting (raised intracranial
pressure)
•
Involuntary movement, convulsion, unexplained
collapse, altered consciousness level
•
Sensory symptoms
•
Urinary and faecal continence
•
Hearing or vision problems, squint
•
School performance
•
Behaviour, mood, empathy, concentration
•
Coordination, clumsiness, gait problems
•
Function how is the child limited by any
neurological impairment?
•
Home environment any adaptations to assist care?
•
Extra support received:
• who
assists with care of the child?
• respite
to parents
• financial
support to assist with care and mobility
•
Family history of neurological problems:
• epilepsy,
blindness, deafness, learning difficulty, genetic disorder
The visual system
Musculoskeletal system
Newborn
•
Risk factors for congenital hip dysplasia female
gender, breech, family history
Older children
•
Inflammation—joint pain, swelling, heat,
restricted move- ment
•
Limitation to activities (sports, walking
distance)
•
Gait problems:
• limp
with pain, hemiplegia
• waddling
gait with diplegia, muscle weakness, congenital dislocation of the hip
• tip-toe
walking—often behavioural but may also be a sign of diplegic cerebral palsy
•
Fever or skin rash (autoimmune disorders, septic
arthritis)
