THE PEDIATRIC HISTORY:

patient interviews occur in a variety of clinical settings, including: initial history for
a hospital admission or first ambulatory visit, health maintenance visit, acute care
visit, interim visit for a child with an acute or chronic health condition. The
student should develop an awareness that in conducting a medical interview in a
variety of settings, it is sometimes appropriate to obtain a complete medical
history, while at other times a more limited, focused or interval history is
appropriate. Initially, the emphasis should be on obtaining complete medical
histories. Opportunities to do more focused work-ups should be available as the
student builds competence.
the pediatric history and physical examination have the same goals as in the case of
any patient. However, there are several differences between the conduct of
evaluations in children and adults.
the youngest patient cannot communicate with you verbally, and even the older
child is likely to be reluctant to speak freely. The physician must gain the trust and
confidence of every patient he or she works with, but the need for this is even
greater with pediatric patients.
the physical examination must be structured carefully to provide the maximum
information, since if the patient cries or otherwise becomes agitated, it may be
difficult to hear murmurs or subtle changes in lung sounds, for example.
you must use the parent or caretaker as a source of much of the information, and so
must gain their confidence and trust as well. Conversely, there will be situations
when you will wish to speak with the pediatric patient privately, and this must be
accomplished diplomatically, without offending the parent or other accompanying
person.
your history and physical must always be evaluated with reference to the expected
sequence of developmental changes, both physical and emotional, through which
we all pass.
pediatricians should engage in anticipatory guidance for a wide variety of problems
that may face children and their parents. That is, we try to anticipate
developmental events and problems, and help parents and children to plan for them
in advance.
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CHIEF COMPLAINT: Establish the reason for the current clinic visit or
hospitalization. It is usually a symptom-oriented description(eg, coughing,
headache, vaginal bleeding, sadness, etc). In the case of certain patients, usually
those with chronic or recurrent illnesses, the chief complaint may involve the

actual diagnosis (eg, recurrence of asthma, breakthrough of seizures while on

medication, etc).
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PRESENT ILLNESS: When investigating the present illness, use some or all of the
following descriptors, to produce a more complete picture of each symptom:
When the symptom first occurred
Type of onset (eg, sudden, gradual, cyclic, etc)
Frequency of occurrence (daily, hourly, weekly, etc)
Time of day or night when symptom is worst, or when it abates
if painful, describe location, duration, severity, quality, etc.
Factors which precipitate or alleviate the symptom (stress, fatigue, eating a
meal, exercise, etc)
Associated symptoms (eg, is it nausea alone or nausea and vomiting)
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PAST HISTORY (Including Pregnancy, Labor, & Delivery): Especially with

younger children, a review of the prenatal and natal history are important. This
should include:
Gestational age at birth
Gravidity and parity of mother
Complications or problems of pregnancy
Complications or problems of delivery (eg, significant bleeding, was meconium
present?)
Type of delivery (Vaginal vs. C-section; if C-section - indication)
Immediate postnatal status of baby (eg, were there respiratory difficulties?)
Baby's birth weight
Length of stay in hospital for baby at birth
Perinatal medical conditions--neonatal jaundice, feeding intolerance problems,
etc.
Ask if the child has ever been hospitalized? Are there any recurrent or chronic
medical problems (diaper rash, feeding intolerances, skin rashes, colic, etc)? Have
there been any surgical procedures? Has the child suffered any accidents?
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IMMUNIZATIONS, MEDICATIONS AND ALLERGIES: A knowledge of the

child's immunization status is very important, because it will expand or shrink the
list of possible diagnoses you will ultimately consider.
what immunizations has the child received? Were they well tolerated?
is the child currently taking any medications (including OTC)?

is the child allergic to anything, including food products, environmental

substances, or
medications?
have there been any adverse reactions to particular medications?
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FAMILY HISTORY: This should begin with notation of the mother's, fathers and
sibling's ages. The general health status of the parents and siblings should be
noted. Special attention is given to any serious illness in the parents and siblings,
especially those which might resemble the chief complaint of the patient currently
being seen. Serious childhood illnesses or deaths in any relatives should be noted.
Family history of illnesses that affect children, including seizures, recurrent
infections, diabetes, bleeding problems, SIDS, etc.
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GROWTH AND DEVELOPMENT: is the child gaining weight and length normally?
Has the child achieved a normal sequence of developmental milestones [motor
skills, language skills, toilet training, etc]? How does the child compare to his or
her siblings with respect to development?
consult an age- and gender-specific growth chart, and compare the child's weight,
height, and head circumference to published norms(see attached). Obtain previous
data points to allow following of trends.
perform a Denver Developmental Assessment, and compare the child's performance
to published norms (see attached). Using the published norms as a guideline,
discuss the milestones with the family. Make careful note of any sign that
development is reaching a plateau, or even regressing. See the Denver
Developmental Charts in the Week One material in this Syllabus (by Dr. Bachrach)
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SOCIAL HISTORY: Information in this area must be a combination of factual

information about which you can ask and inferences you draw without the
opportunity for factual confirmation. The question of whether to act upon one's
suspicions or fears is a constant source of anguish for the pediatric health care
provider.
in what sort of dwelling does the patient reside? Who are his or her caretakers (during
the day and during the night) [parent, babysitter, grandparent sibling, neighbor, etc].
Is the child kept warm and clean, and protected from extreme temperature changes?
Is the home kept clean, and are clean clothes provided?
especially for the infant, what does the child eat, how often, and what difficulties are
there with eating? Does the child have a good appetite, or is he a picky eater?
Bottle fed vs. breast fed? Type of formula? Variety of foods?
what are the child's bowel and bladder habits, and is control in these areas
appropriate for age?
how well does the child sleep, and how regular is his pattern of sleeping? Are there
any disturbances to sleep [eg, recurring nightmares, sleepwalking, night terrors]?

if appropriate, ask how well the child has adjusted to school. What is his academic
status, and how is he adjusting to the social demands of school? Appropriate grade
level for age? What language is spoken in the home?
does the family's financial situation have an adverse effect on the child?
what seems to be the stability of the family unit? Is the child's safe and protected?
history of recent travel and type of pets
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REVIEW OF SYSTEMS: note whether the review of systems comes from the
patient, from the parent, or both. Relevant items are limited in the infant, but
expand as the patient's age increases.
ENT--are there frequent sore throats or ear infections? nosebleeds? facial or neck
pain?
CARDIORESPIRATORY--is there shortness of breath? does the child refrain from
exertion, at home or in school? does the child ever turn blue? for the baby, can the
baby feed without having to pause to catch his breath? is there any sign of syncope?
GASTROINTESTINAL--are there problems with diarrhea or vomiting? is there
blood in the stool, or staining the diaper? are there intolerances to particular foods?
does the child eat regularly, or is feeding a source of conflict between parent and
child? is the child gaining/maintaining weight appropriately?
GENITOURINARY--frequency of urination? if a male, does he make a strong
urinary stream? if a female, are there signs of inflammation in the vaginal area? for
both sexes, is urination painful? for females of appropriate age, has menstruation
begun, and is it occurring regularly? is there prolonged pain or anxiety about
menstruation? has adequate information about menses been made available to the
young girl?
HEMATOLOGIC/SKIN--does the child appear pale, or ruddy? is there jaundice, in
the skin and/or in the sclerae? are there any rashes or itching? are there any moles
or other skin markings which are concerning? unusual masses? easy bruising?
MUSCULOSKELETAL--have there ever been broken bones? is there joint pain, or a
limp? is there any pain or limitation of motion in the joints?
NEUROLOGIC-SENSORY--is there any complaint about vision [blurriness, double
vision, etc]? in the infant, are the parents concerned that the child does not see
normally/ are there problems with balance, gait, or muscular coordination/ are
there any dizzy spells, headaches, or fainting spells? have there been any seizures?

THE PEDIATRIC PHYSICAL EXAMINATION

A child is naturally fearful of physical examination. Hopefully, you will have
established some rapport and trust during the history-taking. Save potentially
unpleasant parts of the exam till last(ear exam, rectal). By all means, listen to the heart
and lungs, examine the fontanelle, and try to do the abdominal examination when the
child is at his most quiet. Make use of the parent or care-giver, who may be able to
hold the child on his or her lap to provide reassurance. Sit down beside the child
whenever possible, keeping yourself at eye level. Do not expect to complete the entire
exam with the child lying cooperatively on his back on the examination table. Be
flexible with the order of your examination. Take advantage of what the child does and
wants to do. Use a toy to help comfort (and distract) the child; examine a stuffed
animal (or parent or sibling) whenever possible to reduce anxiety.
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TO BEGIN WITH:
1. Wash your hands in front of the patient and family----Never appear rushed
doing the exam or the history-taking!
2. Establish rapport with children of various ages in order to perform the physical
examination--treat all patients and families with respect.
2. Recognize that the age of the child influences the areas included in the exam, as
well as the order of the examination, and the approach to the patient. For
example, use play with the smaller child to observe behaviors.
3. Recognize the important role of observation as a method of obtaining data in
the assessment of the child.
4. Perform complete physical examinations on an infant, child and adolescent,
including the observation and documentation of normal physical findings.
5. Be respectful of the childs potential modesty---no need to have the child
completely disrobe throughout all of the exam, for example.
6. Demonstrate the appropriate use of the limited or focused examination,
particularly in the ambulatory setting.
7. Use developmental assessment as part of the physical examination for all ages-play with the smaller child as a means to evaluate behaviors and skills.
8. Observe how normal behaviors, such as stranger anxiety, affect the ability of the
examiner to perform the examination, and develop strategies for improving
rapport.
9. Perform the Denver Developmental Screening Test, for those patients at the
appropriate age, and know how it is used to assess motor, language and
social development.
10. Identify the physical changes of puberty and be able to conduct Tanner
staging.
11. Observe and demonstrate physical exam findings unique to the pediatric age
group, and understand how findings have different clinical significance
depending on the age of the child. Some examples are:
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APPEARANCE:
Recognize signs of acute illness in an infant, toddler and child by evaluating skin
color, respiration, hydration, mental status, cry and social interaction
Recognize the importance of observing the psychosocial condition of the child,
including behavior, development, body habitus (height, weight, body fat),
relationship to parent and examiner, and general condition.

VITAL SIGNS
Measure heart rate, respiratory rate, blood pressure and temperature in an infant
and child, demonstrating knowledge of the appropriate sized blood pressure
cuff, interval to count respirations, and normal variation in temperature
depending on the route of measurement (oral, rectal, axillary or tympanic)
Understand that normal values of heart rate, respiratory rate and blood pressure
change with age
Recognize the importance of assessing vital signs in the evaluation of acute
illness.

MEASUREMENTS
Accurately measure height, weight and head circumference
Plot the data on an appropriate growth chart, with previous points if possible
Understand the normal relationships between height, weight and head
circumference
Recognize the usefulness of longitudinal data

SKIN
note the skin color, texture, and absence or presence of jaundice. Are there any
noteworthy lesions?
Recognize petechiae, purpura, common birth marks (such as nevus flammeus and
Mongolian spots), vesicles, urticaria and common rashes, such as erythema
toxicum, impetigo, eczema, diaper dermatitis and viral exanthems
Recognize common skin findings associated with child abuse
Assess skin turgor. Make note of any hair present as part of secondary sexual
maturation. Are there any lymph nodes palpable?

HEENT
Identify the anterior and posterior fontanels and assess them for fullness or turgor
Recognize the need for careful observation of the head size and shape, symmetry,
facial features, ear size and hair whorls as part of the examination for
dysmorphic features
Recognize the red reflex and strabismus
Assess hydration of the mucous membranes; examine the oropharynx
Examine the tympanic membranes using pneumatic otoscopy

EYES
are the sclerae clear or inflammed? is there ptosis? do the eyes move fully and
symmetrically?

do the pupils react? Perform ophthalmoscopic exam in older children. In all ages,
is there a red reflex?
check extraocular movements and visual fields

NECK
Palpate lymph nodes; know what anatomic areas they drain
Know that lymph nodes are more prominent during childhood, especially small
nodes in the anterior cervical region
Recognize and demonstrate maneuvers that test for nuchal rigidity, or l;imitations
to neck motion

CHEST
Recognize how the rate and pattern of respirations change with age, and that
abdominal respirations are normal in infants
Observe the rate and effort of breathing as a measure of respiratory distress
Recognize stridor, wheezing and rales and be able to distinguish between
inspiratory and expiratory obstruction
Interpret less serious respiratory sounds such as transmitted upper airway sounds

CARDIOVASCULAR
Palpate pulses in the upper and lower extremities
Auscultate the heart for rhythm, rate, quality of the heart sounds and murmurs

HEART AND PULSES--check heart rate and compare to pulse in extremity or

neck. With stethoscope, check for bruits over neck vessels. Note unusual PMI on
observation of chest. Ascertain S1 & S2, and any extra sounds. Note murmurs, and
localize along sternal border or in other locations.

ABDOMEN
inspect for symmetry, presence of hernias. While palpating abdomen attempt to
distract child's attention so as to make child's responses more reliable. It
often helps to gently flex the child's hips, which produces relaxation of the
abdominal wall muscles.
In infant, can palpate for kidneys, abdominal aorta. Listen with stethoscope for
bowel sounds, note frequency and quality.
Understand that the liver edge, spleen tip and kidneys may be palpable in the
normal newborn and young child. Record precise size of any organs/masses.
Examine the umbilical cord for signs of infection
Examine the abdomen for distention, tenderness, rebound and mass lesions in an
infant or young child with lethargy, irritability or signs of acute illness,
noting the inability of the patient to communicate symptoms of abdominal
complaints
Be able to do a rectal examination, and recognize when it is indicated

GENITALIA
Recognize the appearance of normal male and female genitalia in the newborn
Recognize abnormalities, including cryptorchidism, hypospadias, testicular mass
in the male. Inspect and gently palpate testes to assess for testicular descent,

and for the presence of hydrocoele. Inspect penis and retract foreskin to
inspect for inflammation. Inquire about urinary stream in male.
Be able to examine the external genitalia of a female patient. Look for normal
appearance of genitalia by gently separating labia. DO NOT perform vaginal
digital exam as a routine.
Recognize the need for privacy at all ages

EXTREMITIES
Note symmetry. Development of musculature. Determine full range of motion.
Ask child to walk and view gait from side and in front. Examine for any
joint tenderness or limitations in joint mobility.
Examine the hips of a newborn for dysplasia
Recognize arthritis
Evaluate gait and limp

BACK
In newborn, palpate along the vertebral column. Noting position of vertebral
spines and any discontinuities in vertebral column.
Palpate to determine straightness of spine in all ages. In older child, ask patient to
"touch "toes" while you inspect the arched back(good way to screen for
scoliosis). Note any tenderness.

NEUROLOGIC EXAMINATION
Elicit primitive reflexes
Note alertness and test orientation and awareness by age-specific tests.
Assess tone, gait, strength and reflexes, recognizing the importance of symmetry
Test deep tendon reflexes in ankles, knees, elbows, forearms. Test for gait if child
is old enough.
Test cranial nerves sequentially, with modifications appropriate for age.
Perform gross sensory exam throughout body.
Give mental status exam appropriate for age--short-term memory, general tests of
intellectual growth, speech, etc.
Assess developmental milestones
Recognize that much of the neurologic examination of infants and children is
accomplished through observation alone

Those working with children, of all ages, need to recognize which vital signs are in the
normal range and which are not. Below are some tables to show the normal values at
specific ages:
NORMAL HEART RATES & BLOOD PRESSURE
NORMAL HEART RATE RANGE
SYSTOLIC
DIASTOLIC
90--180 bpm(85-100 OK for term
55-75 +/-10
30-45 +/-10
newborns at sleep)
1 month-->1 year
75*--150 [low figure with sleep]
80-95 +/-15
45-60 +/-14
1 year.-->3 years
60--130
94-106 +/-22
52-67 +/-21
3 years-->8 years.
60--100
95-105 +/-23
54-68 +/-22
8 years-->16 years
50**--90
104-112 +/-25 58-70 +/-23
16 years-->adult
50--80
115-127 +/-25 59-75 +/-18
AGE
Newborn

NORMAL RATES OF RESPIRATION

AGE
RESPIRATORY RATE
NEWBORN
40-55 bpm
1 month--->1 year
30-35 bpm
1 year--->3 years
25-35 bpm
3 years--->8 years
20-30 bpm
8 years--->16 years
14-24 bpm
16 years--->ADULT
12-24 bpm

MAP
35-42
52-68
58-78
60-75
70-82
72-84