APPROACH TO

DIAGNOSIS
Ari Hidayat
Department of Pediatrics
Ospital ng Maynila Medical Center

OBJECTIVES
Obtain an adequate and reliable history
appropriate for the developmental age
of the patient
Perform an accurate physical
examination of newborns, infants, older
children, and adolescents.
Assess growth and development and
nutritional status.
Discuss techniques to arrive at a
diagnosis.

Source
Fundamental of Pediatrics Volume 1
Competency Based.

 History taking is
an art acquired
through experience
and patience

What is the
difference?

Prenatal and birth history

Developmental history
Feeding history
Immunization history
Social history
Environmental history

History taking
1.
2.
3.
4.
5.
6.
7.
8.
9.

General data
Chief complaint
History of present illness
Review of systems
Past personal History
Immunization History
Family History
Sosioeconomic History
Environmental History

1. General Data
Name
Age
Date and place
of birth
Sex
Race
Religion
Present address

Number annd
daate of hospital
admission
Informants
name and
relation to the
patient
reliability in %.
relationship,
time, degree of
involvement,
educational
attainment.

2. Chief Complaint
Why was the
patient brought to
the hospital

3. History of the Present

Illness
Signs and symptoms :
- Onset
- Intensity
- Aggravating or relieving factors
- Medications
- Associated symptoms
- Pertinent negative

4. Review of systems

General
Cutaneous
Head
Cardiovascular
Gastrointestinal
Genitourinary
Endocrine
Nervous/Behavioral
Musculoskeletal
Hematopoietic

5. Past Personal History

Gestational history
Birth history
Neonatal history
Feeding history
Developmental/ Behavioral history
Past Illnesses

Gestational History

Mothers age during pregnancy

Health
Nutrition
Intake of drugs
Roentgen exposure
Duration of gestation

Birth History

Term,posterm, preterm
Manner of ddelivery
Persons attended the delivery
Birthweight

Neonatal History
Apgar score
Spontaneous respiration or required
resuscitation
Cyanosis,pallor, cry, jaudice,
convulsions, respiratory distress,
congenital abnormalities, birth injury

Feeding History
< 2years :
- Type of feeding
- Complementary foods
Childhood and Adolescence
- Early feeding not included unless
pertinent
- Appetite

Developmental/Behavioral
History
1.
-

Young children (1-5 years)

Developmental milestones
Dental eruption
Urinary continence
Toilet training
Temper tantrums
etc

Developmental/Behavioral
History
2. Middle Childhood (6-11 years)
Dental eruption
- School performance
- Sexual development using Tanners
sexual maturity rating

Developmental/Behavioral
History
3. Adolescence (10-20 years)
HEEADSSS
Home
Education
Eating behavior
Activities
Drugs
Sexual
Suicidal
Sexual development

Past Illnesses

Contagiouss diseases
Hospitalization
Operations
Allergy, asthma
injuries

6. Immunization History
Type of vaccines
Date and place
Adverse Reactions

7. Family History
Parents
Siblings
Familial illness or aanomalies

8. Sosioeconomic History
Living circumstances
Economic circumstances

9. Environmental History

Cigarette smoke
Pollutants and duration
Garbage disposal
Sewage disposal
Water source

PHYSICAL EXAMINATION
A. General survey
B. Vital signs
C. Anthropometric data
D. Organ of the body

A. General survey
Mental state / sensorium, level of activity
Cardiopulmonary distress, color, chest
retractions
Gait if ambulatory, position if bedridden
Nutritional statee ( well, under, or
overnourished)
State of hydration
Well,mildly ill, or severely ill-looking

B. Vital signs

Temperature
Cardiac Rate (rate,rhytm, volume)
Respiratory Rate
Blood Presssure

C. Anthropometric Data

Weight (Wt) in kg
Length (Lt)*
Height (Ht)*
Head circumference (HC)*
Chest circumference (CC) *
Abdominal circumference (AC)*
Arm span
Lower segment & Upper segment (U/L
ratio)

Nutritional status
Z score ( weight for age,
length/height for age)
BMI

Skin

Color
Turgor
Rash
Edema
Jaundice
Etc

Head

Shape
Sutures
Hair
SCALP
Fontanels

Face
Asymmetry
Unusual facies
Deformities

Eyes

Lids
Conjunctivae
Sclerae
Pupils
Extraocular movements
Vision
Strabismus
Opacities
Discharge
ROR

Ears

Size
Shape
Location
Position

Nose

Patency of nares
Alar flaring
Discharge
Position of septum
Sinus tenderness

Mouth and throat

Lips
Gums
Tongue
Mucous membrane
Dentition
Palate
Posterior pharyngeal wall
Tonsils

Tonsils

Presence or absence
Size
Surface
Color
Exudates
Membranes

Neck

Masses
Venous engorgement
Flexibility
Rigidity
Lymph nodes
Cysts
Enlarged thyroid

Chest and Lungs

Chest expansion
Retractions
Vocal fremitus
Breath sounds

Heart and blood vessels

Precordium
Visible pulsations
Apex beat (PMI)
Thrills
Heart sounds
Rhytm
Pulses
Heart sounds and murmur

 Grading of murmur intensity :

I. Barely audible
II.Medium intensity
III.Loud but no thrill
IV.Louder with thrill
V.Loud and audible with stethoscope barely
on the chest
VI.Audible with the stethoscope off the chest

Abdomen

Inspect
Auscultation
Percussion
Palpation

Inguinal region
Hydrocele
Undescended testes
Lymph nodes

Genitalia
Anus and rectum
Extremities
Spine
Lymph nodes

STEPS IN DIAGNOSIS

Patient with
salient features

Step 1: Choose
presenting
manifestation

Step 2:
Construct
clinical
diagnosis
Confirmatory test

Step
3:Establish
working
diagnosis
Search for new
data

Step
4:Ascertain
final diagnosis

THANK YOU FOR

LISTENING