adult, and begin to observe the child. Establish who the adult
is – a parent, grandparent or foster carer, for example – and
consider to what extent the child will be able to contribute to
the history. Let the child become accustomed to you before
Start with open-ended questions. Most often a parent will
wish to explain their perspective on their child’s problem and it is
important to enable them to do so. Some teenagers may welcome
this but most often they do not. Once the presenting symptoms
have been outlined, the history should focus on questions that
aim to elucidate the differential diagnosis; children are often good
at helping with these more specific questions. Respect age ability
to recall events and adopt a balanced perspective on whether
Diagnosis is built on patterns of symptoms; rarely will any one
symptom or sign lead to a ‘spot diagnosis’. The initial history
suggests a differential diagnosis and prompts additional questions
to assess the probability of particular diagnoses. As with adults,
presenting symptoms should be described in terms of onset,
frequency, severity, duration, aggravating and relieving factors,
associated features and impact on function. Pain and the need
for analgesia can be particularly difficult to assess in young
children; objective scoring systems may help (Box 15.6).
The most common presenting problems in the child affect
the respiratory, gastrointestinal and nervous systems (covered
in Boxes 15.7–15.9), and the skin.
answers from parents are more likely to be accurate than those
from the child. Children under 6 years often provide little history,
those aged 6–11 years can do so if they are sufficiently confident,
and those aged 12 years and above should be able to provide
a valuable history in the correct environment and with the use
of questions that are framed in appropriate terminology. As you
would for adult history taking, include reflective summing up: for
example, ‘So what you are saying is that …’.
A paediatric history includes elements that are not part of the
adult history (obstetric, developmental, immunisation histories),
systematic enquiry has different components from those in
adults (see later), and the differential diagnosis may include
conditions seen only in children such as abdominal migraine,
toddler diarrhoea, croup, viral wheeze and febrile convulsion.
Most other diagnoses also occur in adults.
15.6 Pain assessment tool: FLACC scale
Face No particular expression or
Occasional grimace or frown, withdrawn,
Frequently or constantly quivering chin, clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position,
Squirming, shifting back and forth, tense Arched, rigid or jerking
Consolability Content, relaxed Reassured by occasional touching,
hugging or being talked to, distractible
Difficult to console or comfort
if associated with Differential diagnosis
LRTI, asthma, acute episodic wheeze, inhaled foreign
body. Rarely, supraventricular tachycardia, congenital
heart disease, heart failure or muscular weakness
Cough *** Low SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Wheeze *** Moderate SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Musculoskeletal pain, empyema, reflux oesophagitis,
Stridor *** High URTI, high fever, choking Croup, foreign body, epiglottitis (if not immunised)
** Low Cough, wheeze, failure to
Lack of fitness, respiratory pathology, cardiac pathology,
Cough *** Low Wheeze, SOBoe, failure
Isolated cough with sputum suggests infection,
commonly bronchitis, rarely bronchiectasis, cystic
fibrosis, inhaled foreign body. If also wheezy, consider
asthma or viral-induced wheeze
Wheeze *** Moderate SOBoe, failure to thrive Isolated, persistent ‘wheeze’ usually arises from the
nose (stertor, e.g. adenoidal hypertrophy) or the largest
airways (stridor, e.g. laryngomalacia). Episodic wheeze
with cough suggests asthma or viral-induced wheeze
Chest pain * High Exercise Non-specific chest pain, musculoskeletal chest pain,
the next room, is not genuine wheeze. b
Coexistent failure to thrive or weight loss always increases the significance of any symptom.
LRTI/URTI, lower/upper respiratory tract infection.
not blanch with pressure are of most concern. These may be viral
in origin but importantly can be an early sign of meningococcal
disease (particularly if the child is febrile). A differential diagnosis
of a purpuric rash is idiopathic thrombocytopenic purpura.
Chronic skin excoriation, most commonly in the flexures,
suggests eczema, while plaques on the elbows/knees may
Hair loss is distressing to a child. If associated with itch, it
is often due to tinea capitis; with a history of preceding illness,
Skin symptoms can be acute or chronic. Acute-onset rash
is common in children and can be described using the same
terminology as for adults (p. 286). Most rashes are viral and
Rash with blisters is often itchy. It may be urticaria (with an
environmental, viral, food or medicine trigger) or an insect bite.
Blisters with associated yellow crusting may be infected bullous
impetigo (most commonly caused by Staphylococcus aureus).
Red, circular lesions with a pink centre are most often erythema
multiforme (target lesions). Petechial or purpuric rashes that do
associated with Differential diagnosis
Vomiting *** Low: a very non-specific
Acute gastritis/gastroenteritis, any infection (otitis media,
pneumonia, urinary tract infection, meningitis), head injury,
Diarrhoea *** Moderate Fever, dehydrationa Acute gastroenteritis/colitis, appendicitis
** Moderate Fever, bloody stools Acute gastroenteritis/colitis, acute surgical causes, e.g.
Vomiting *** Moderate Failure to thrivec
Gastro-oesophageal reflux (rare in older children compared
with infants), raised intracranial pressure, food allergy
Diarrhoea *** Moderate Failure to thrivec Commonly toddler’s diarrhoea, also lactose intolerance. If
failure to thrive, consider coeliac disease, inflammatory
*** Low Pain that is not periumbilical
If isolated and periumbilical, non-specific abdominal pain
is common and other diagnoses include abdominal
migraine, renal colic. If associated with other symptoms
and/or failure to thrive, consider coeliac disease,
inflammatory bowel disease, constipation
Symptoms of dehydration include dry mouth, foul-smelling breath, anuria and lethargy. b
Abdominal pain can be difficult to identify in young children who are not able to
Coexisting failure to thrive or weight loss always increases the significance of any symptom.
associated with Differential diagnosis
Vomiting, fever, neck stiffness,
Acute (simple) headache, migraine, meningitis/
Unsteady gait * High Varicella encephalomeningitis, vestibular neuronitis
Seizurea * High Febrile seizure, meningitis/encephalitis
* High Encephalitis, intoxication/drug ingestion
Brain tumour, migraine, chronic non-specific
* Moderate Widening gap between age and
* High Muscular dystrophy, inborn error of metabolism,
Seizure * High Epilepsy; rarely, long QT syndrome or inborn error
headache can also arise from the mouth (e.g. dental abscess) or face.
Has the child regularly seen a healthcare professional (current or
past) or are they currently taking any regular medication? Have
they been in hospital before, and if so, why?
The impact of preterm birth goes beyond early childhood and
• Was the child born at term or preterm (if so, at what
• Was the neonatal period normal? For example, did the
child need to go to a special care baby unit?
• If the child is under 3 years of age: what was the
birthweight and were there any complications during
Are the child’s immunisations up to date according to
country-specific schedules? If not, explore why and consider
how best to encourage catch-up.
This is particularly important for children under 3 years of age
or those with possible neurodevelopmental delay (see p. 307
Prescribing errors often arise from poor reconciliation of medication
lists between different healthcare professionals. It is a doctor’s
duty to ensure that medicines are accurately reconciled within
documentation. Transcribe the medication, dose and frequency
direct from the medication package or referral letter if possible.
Enquire about any difficulties in taking medication to establish
adherence. Clarify any adverse or allergic reactions to medications.
• Who lives in the family home and who cares for the child?
• Are there any pets? Are any symptoms associated with
• Are there any similar symptoms in the child’s first- or
Sketch a family tree, noting any step-parents, step-siblings
or shared care arrangements Consider parental consanguinity,
which is not uncommon in some ethnic groups. Children at risk
of neglect may have complex domestic arrangements such as
Occasionally, chronic symptoms are associated with anxiety
or potential ‘secondary’ gain for the child; these include
chronic cough, abdominal pain and headache in a well-looking
8–12-year-old in whom examination is normal. Look carefully
at the child’s facial expression, eye contact and body language
when asking questions. Ask specifically about school (avoidance
and bullying), social interactions (does the child have many
friends?) and out-of-school activities. School avoidance should
be addressed if it is related to anxiety or if the pretext of medical
This screens for illnesses or symptoms that may be not recognised
as important or relevant by the child or parents. For children aged
over 12 years, the questions used for adults are appropriate. In
younger children, ask age-related questions. Specific areas include:
• Ear, nose and throat: ask the parents about their
perception of a child’s hearing ability (reduced in chronic
otitis media) or the presence of regular snoring with
periods of struggling to breathe (symptomatic obstructive
• Gastrointestinal system: ask whether growth is as
expected and whether there is pain or difficulty in opening
• Respiratory system: ask whether the child has regularly
coughed when otherwise well or had wheeze on a
recurrent basis (consider asthma).
• Urinary system: 15% of children at 5 years of age will
continue to have primary nocturnal enuresis.
An understanding of child development is vital to identifying
whether symptoms and signs are consistent with age.
Infants born prematurely should have their age adjusted to
their expected date of delivery instead of their date of birth
for the first 2 years of life when growth and development are
assessed. Failure to make this correction would otherwise create
a false impression of poor growth and developmental delay.
Prematurely born infants are at increased risk of impaired growth
and development, and merit increased surveillance; most develop
Growth after infancy is extremely variable. Use gender- and
ethnic-specific growth charts (such as those shown in Fig. 15.17).
These compare the individual with the general population and
with their own previous measurements. Each child should grow
along a centile line for height and weight throughout childhood.
Failure to thrive is failure to attain the expected growth trajectory.
A child on the 0.4th centile for height may be thriving if this has
always been their growth trajectory, while a child on the 50th
centile for height may be failing to thrive if previously they were
A child’s height is related to the average of their parents’
height centile ± 2 standard deviations. Parents whose average
height lies on the 50th centile will have children whose height will
normally lie between the 2nd and 98th centiles (approximately
10 cm above and below the 50th centile).
Normal development is heterogeneous within the population, which
makes identifying abnormalities difficult. Important determinants
are the child’s environment and genetic potential. Developmental
The physical examination • 311
The school-age child (5+ years)
By this age, developmental problems are usually known to parents
and relevant agencies, such as educational ones, may already be
engaged. However, more subtle developmental problems such as
dyslexia (learning disability affecting fluency and comprehension
in reading) may be unrecognised and can be a major handicap.
Ask general questions such as, ‘How is your child getting on at
school?’ and follow up by enquiring specifically about academic
assessment requires patience, familiarity with children and an
understanding of the range of normality for a given age.
The preschool child (1–5 years)
At the younger end of this range, questions relating to gross
motor skills are most sensitive; as the child becomes older,
questions relating to fine motor and personal social skills are
more meaningful. Delayed speech with normal attainment of
motor milestones is not uncommon, particularly in boys, but
should prompt hearing assessment (see Box 15.5).
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