PEDIATRIC CLINICAL HISTORY iv.

Medications (generic and

brand names) in
History taking in Pediatrics is unique and distinctive mg/kg/day or mkd
because… v. Associated symptoms:
1. Content Variations onset, course, chronology
 Prenatal and birth history and intensity
 Developmental history  Begin with statement that includes
 Feeding history age, sex, color and duration of
 immunization history illness,
 social history ex.: This is the first UMC
 environmental history admission for this 8 year
2. Indirect source of clinical information old white male who has
 parent’s interpretation of clinical complained of headache
features may affect accuracy of for 12 hours TPA.
data V. REVIEW OF SYSTEMS
 reliability of parent’s observation  Purpose:
varies i. It will often bring out
 parental behaviors/emotions symptoms or signs missed
in collection of data
ii. It might direct the
I. GENERAL DATA
interviewer into
 basic information about the
questioning about other
patient
systems that have some
 name of informant and reliability indirect bearing on the
II. CHIEF COMPLAINT present illness
 Why was the patient brought to iii. it serves as a screening
the hospital? device for uncovering
 Should not be diagnostic terms or symptoms, past or
names of diseases present, which were
 Use exact words of the informant omitted in the earlier part
whenever possible of the interview
III. SOURCE OF THE HISTORY AND  Ask only symptoms applicable to the
RELIABILITY age of the patient
IV. HISTORY OF PRESENT ILLNESS i. in prepubertal females:
 Presented in chronological order discharge and itching
 maternal and birth history may be ii. pubertal and adolescent
incorporated here female: history of
 Readmissions, if related to HPI may menstrual period (onset,
be included frequency, regularity and
 WHEN- was the patient last pain), date of last period
entirely well?  same format with PD
 HOW and WHEN did the VI. PAST MEDICAL HISTORY
disturbance start? 1. Infections: Age, types, number,
 Elaborate on the: severity.
i. Onset (acute or chronic?) 2. Contagious Diseases: Age,
ii. Intensity of symptoms complications following measles,
iii. Aggravating/relieving rubella, chickenpox, mumps, pertussis,
factors diphtheria, scarlet fever.
3. Past Hospitalizations: including
operations, age.
 4. Allergies, with specific attention to C. Neonatal:
drug allergies - detail type of reaction.  APGAR score; color, cyanosis, pallor,
5. Medications patient is currently jaundice, cry, twitchings, excessive
taking. mucus, paralysis, convulsions, fever,
hemorrhage, congenital abnormalities,
VII. FAMILY HISTORY (GENOGRAM FORM) birth injury.
Know the symbols and how to write  Difficulty in sucking, rashes, excessive
 A. Father and mother (age and condition of weight loss, feeding difficulties.
health). What sort of people do the parents  You might discover a problem area by
characterize themselves as being? asking if baby went home from hospital
 B. Marital relationships. Little information with his mother.
should be sought at first interview; most IX. DEVELOPMENTAL HISTORY
information will be obtained indirectly.  Note the red flags in development if
 C. Siblings. Age, condition of health, there are any
significant previous illnesses and problems.  Young children (1-5 years)
 D. Stillbirths, miscarriages, abortions; age at  Middle Childhood (6-11 years)
death and cause of death of immediate i. School performance
members of family. ii. Tanner’s Maturiy Rating
 Adolescence (10-20 years)
 E. Tuberculosis, allergy, blood dyscrasias,
mental or nervous diseases, diabetes,
X. NUTRITIONAL HISTORY
cardiovascular diseases, kidney disease,  Breast or Formula: Type, duration,
rheumatic fever, neoplastic diseases, major formula changes, time of
congenital abnormalities, cancer, convulsive weaning, difficulties. Be specific about
disorders, others. how much milk or formula the baby
 F. Health of contacts. receives.
 2. Vitamin Supplements: Type, when
VIII. BIRTH AND MATERNAL HISTORY started, amount, duration.
A. Antenatal:
 3. "Solid" Foods: When introduced,
 Health of mother during pregnancy.
how taken, types.
 Medical supervision, drugs, diet,
 4. Appetite: Food likes and dislikes,
infections such as rubella, etc., other
idiosyncrasies or allergies, reaction of
illnesses, vomiting, toxemia, other
child to eating. An idea of child's usual
complications;
daily intake is important.
 Rh typing and serology, pelvimetry,
 Usual food intake and amount per day
medications, x-ray procedure,
 Assess 5 basic food groups
maternal bleeding, mother's previous
 ACI vs RENI
pregnancy history.  Food likes or dislikes/ feeding
B. Natal: difficulties
 Duration of pregnancy, birth weight,
kind and duration of labor, type of XI. PERSONAL AND SOCIAL HISTORY
delivery, presentation, sedation and
anesthesia (if known), state of infant at
birth, resuscitation required, onset of
respiration, first cry.
 XII. IMMUNIZATION HISTORY Immediate assessments at birth
XIII. ENVIRONMENTAL HISTORY 1. APGAR Scoring

PHYSICAL EXAMINATION
Approaching the Child
 Adequate time should be spent in becoming
acquainted with the child and allowing
him/her to become acquainted with the
examiner.
 The child should be treated as an individual
whose feelings and sensibilities are well
developed 1min Apgar Score
 The examiner's conduct should be  8-10 -Normal
appropriate to the age of the child. A  5-7 -Some Nervous System depression
 0-4- severe depression, requiring
friendly manner, quiet voice, and a slow and
immediate resuscitation
easy approach will help to facilitate the
5min Apgar Score
examination.  8-10- normal
 The total evaluation of the child should  0-7 - high risk for subsequent CNS
include and other organ system
 Impressions obtained from the time the dysfunction
child first enters until s/he leaves; it should
2. Birth weight and GA
not be based solely on the period during
 which the patient is on the examining table.
Sequence of Examination
 NO routine one can use and each
examination should be individualized
 Get down to the child's level and try to gain
his trust
 For example,
o infants under 6 months -examining
table
o 8 months to 3 years -mother's lap.
o After 4 years, exam on the table 3. Ballard Scoring System
again
 Wash your hands with warm water before
the examination begins.
 With the younger child, get to the heart,
lungs and abdomen before crying starts. (H-
L-A first)
 Save looking at the throat and ears for last.
(T-E last)
 Looking for animals in their ears or
listening to birdies in their chests is often
another useful approach to the younger
child.
 3. Jaundice: Jaundice is common after the
second day of life. The presence of jaundice
within the first 24 hours of life suggests a
hemolytic process.

II. VITAL SIGNS

 Temperature
 pulse rate
 respiratory rate
 blood pressure (the cuff should cover
2/3 of the upper arm)
 weight
 height
 head circumference.
 The weight should be recorded at each
Assessment several hours after birth
 Note the newborn’s color, size, body visit; the height should be determined
proportions, nutritional status, and posture at
 Respirations and movement of the head a. monthly intervals during the first
and extremities year
 Spontaneous motor activity, with flexion b. 3-month intervals in the second
and extension alternating between the
year
arms and legs
c. twice a year thereafter.
 Observe brief tremors of the body and
extremities during vigorous crying, and even  The height, weight, and circumference
at rest of the child should be compared with
standard charts and the approximate
I. GENERAL SURVEY percentiles recorded.
Examine painful areas last, and forewarn Length
children about areas you are going to examine.
 <2 y/o (Infantometer)
If a child resists part of the examination, you can
 Height: >2y/o (Stadiometer)
return to it at the end.
 Place the child supine on a measuring board
or in a measuring tray
1. Posture: The normal healthy newborn
 Tape measure can be use but inaccurate
demonstrates flexion of the legs and arms
when supine.
a. Lack of this posture might indicate
hypotonic conditions such as Down
Syndrome or neurologic or muscle
disease.
2. Cyanosis: Mild cyanosis is normal at birth
but after the first few minutes of life, the
Weight
child's tongue and mucous membranes
should be pink. Peripheral cyanosis might  Weigh infants directly with an infant scale.
persist for one to two days.  Infants should be weighed naked or be
a. Persistent central cyanosis clothed only in a diaper.
suggests an obstructed airway, Head Circumference
respiratory disease, cardiac
anomalies, neurologic depression,  first 2 years of life, but measurement can be
useful at any age to assess growth of the
and rarely methemoglobinemia.
head.
 The head circumference in infants reflects  99.0°F (37.2°C) until after age 3 years;
the rate of growth of the cranium and the 101°F (38.3°C) in normal children,
brain. particularly in late afternoon and after
vigorous activity.

Blood Pressure

 routinely performed after age 3 years. III. HEAD AND NECK

 Caput succedaneum
 need your skills in distraction or play
 Cephalohematoma
 Doppler method, which detects arterial
 Anterior and posterior fontanelle
blood flow vibrations, converts them to
should be soft to palpation
systolic blood pressure levels, and transmits
 Head circumference should be between
them to a digital read-out device.
33 and 35cm for a full-term infant
Pulse
 Eyes: Slant and size of the eyes should
 Palpate the femoral arteries in the inguinal be examined. Pupillary light reflex and
area or the brachial arteries in the a red reflex
antecubital fossa, or auscultate the heart.  Ears: Low-set ear suggests
chromosomal anomaly and malformed
ears are associated with renal
abnormalities.

IV. CHEST AND LUNGS

 Respiration might be periodic with
short periods of apnea.
Respiratory Rate  There should be no nasal flaring or
intercostal of subcostal retractions.
 Newborn: 30-60 breaths/min
 Commonly accepted cutoffs for defining V. HEART
tachypnea are birth to 2 months, >60/min; 2  A persistent heart rate of less than 100 or
to 12 months, >50/min. more than 160 beats/minute is a cause for
concern.
Temperature  Absence of peripheral pulses, especially the
femorals, suggests coarctation of the aorta.
 Axillary and thermal-tape skin temperature
 Normal blood pressure is about 60/30 mm
recordings in infants and children are
of Hg at term.
inaccurate. Auditory canal temperatures are
 Transient murmurs are often heard after
accurate.
birth, but the presence of a loud murmur,
 Rectal temp = most accurate
heart sounds that are difficult to hear or are
o Place the infant prone, separate
heard louder on the right side of the chest,
the buttocks with the thumb and
or central cyanosis suggest a significant
forefinger on one hand, and with
cardiac abnormality
the other hand gently insert a well-
 *same examination to adults but can be
lubricated rectal thermometer, to
fearful and inability to cooperate can be a
a depth of 2 to 3 cm. Keep the
difficulty
thermometer in place for at least 2
 Position: stand, sit on mother's lap, facing
minutes.
her shoulder or being held
  Give something to hold - no free hand to Auscultation:
push you away  Evaluate heart rhythm - sinus dysrhythmia
 Chat with patient is common among infants and children --
 You can let older children hold the identify if repetitive and correlate with
stethoscope, go back to listen properly respiration
 Heart sounds
 (+ from Bates)
neonates - detect split S2 when infant is
 General abnormalities - can be congenital
completely quiet of asleep -- eliminates
cardiac disease (Down/Turner syndrome)
serious congenital cardiac defects
Inspection:  Listen A2 and P2 intensity - A2 louder
 Check for  S3 (@lower left sternal border/apex) - rapid
 cyanosis - if present evaluate distribution ventricular filling : normal
*confirm via oximetry reading  S4 - apparent gallop: normal
 Observe for:  Heart murmurs
 general signs of health - tachynea, Characterize by noting their location,
tachycardia, hepatomegaly -- suggests heart timing, intensity, and quality
failure  Benign murmurs:
Often preschoolers and school-aged
 Respiratory rate and pattern - diffuse bulge
children - also you may detect venous hum
leftside outward – cardiomegaly
 *check for
Palpation:  Still's murmur-most common
 Check for  Carotid bruits - carotid area / above
 peripheral pulses clavicles
brachial - neonates and infants
easier to feel *Practical notes:
radial A. Many children normally have sinus arrhythmia.
 temporal The child should be asked to take a deep breath to
 femoral - absent/diminished can determine its effect on the rhythm.
be indicative of coarctation of aorta B. Extrasystoles are not uncommon in childhood.
o Lower extremities pulses felt using C. The heart should be examined with the child
middle/index finger recumbent.
 dorsalis pedis
 posterior tibial VI. ABDOMEN
INSPECTION:
 Blood pressure - measure bp both arms, 1 Size and contour, visible peristalsis, respiratory
leg (pts 3-4y/o) to check coarctation of the movements, veins (distension, direction of flow),
aorta - thereafter, right arm bp umbilicus, hernia
measurement needed. AUSCULTATION:
Abdominal Bruits, Bowel sounds
 PMI (Point of Maximal Impulse) - not always PALPATION: tenderness, rebound tenderness,
palpable pulsation, palpable organs or masses (size, shape,
 usually an interspace higher than in adults - position, mobility), femoral pulsations, bowel
heart lies more horizontal in the chest sounds. If the liver is palpable below the right costal
 Chest wall palpation - assess volume margin, its total span must be recorded. A deep
abdomen palpation must be done on every child.
changes within heart
PERCUSSION:
 Thrills - turbulence (heart/vessel)
Tympany, shifting dullness, fluid wave
transmitted to surface, has rough vibrating
quality; use your palm or base of fingers *Practical notes:
 A. The abdomen may be examined while
the child is lying prone in the mother's lap
 or held over her shoulder, or seated on the  umbilical cord should have two arteries
examining table with his back to the doctor. and one vein
These positions may be particularly helpful  The liver normally extends 2 cm below
where tenderness, rigidity, or a mass must the costal margin, and the tip of the
be palpated. In the infant the examination spleen can sometimes be felt. Both
may be aided by having the child suck at a kidneys can be palpated
"sugar tip" or nurse at a bottle.  Abnormal masses such as Wilm's
 B. Light palpation, especially for the spleen, tumor, neuroblastoma, hydronephrosis
often will give more information than deep. or a multicystic-dysplastic kidney or
 C. Umbilical hernias are common during the renal vein thrombosis can be easily
first 2 years of life. They usually disappear palpated. A tight abdomen or
spontaneously. persistent abdominal distention
suggests intestinal obstruction or
ascites.

VII. SKIN AND EXTREMITIES

A. General: Deformity, hemiatrophy,
bowlegs (common in infancy), knock-
knees (common after age 2), paralysis,
edema, coldness, posture, gait, stance,
asymmetry.
B. Joints: Swelling, redness, pain, limitation,
tenderness, motion, rheumatic nodules, carrying
angle of elbows, tibial torsion.
C. Hands and feet: Extra digits, clubbing, simian
lines, curvature of little finger, deformity of
nails, splinter hemorrhages, flat feet (feet
commonly appear flat during first 2 years),
abnormalities of feet, dermatoglyphics, width of
thumbs and big toes, syndactyly, length of
various segments, dimpling of dorsa,
temperature.
D. Peripheral Vessels: Presence, absence or
diminution of arterial pulses.
Note for presence of:
Syndactyly
Polydactyly
Oligodactyly
Congenital Talipes Equinovarus (CTEV)
Metarsus Varus
The vernix caseosa, a cheesy white covering, is
normally present at birth as our fine hair
(lanugo) on the shoulders and back and pinpoint
white papules caused by blocked sebaceous
glands (milia) on the nose and cheeks.

Large blue patches of pigment over the lumbar

area, buttocks, or extremities are known as
Mongolian spots and are a common
 phenomenon in the dark-skinned races. These ○ Scrotal edema (effect of estrogen).
tend to fade over time. ● Palpate:
○ Testes - make sure in scrotal sacs
Capillary hemangiomas, common on the upper
NOT inguinal canal.
eyelids, forehead, and the nape of the neck are
known as stork bite nevi and also tend to fade ■ 10 mm width x 15 mm
with time. length.
○ 3% cryptorchidism
Erythema toxicum consists of yellow papules on ● Examine testes for swelling in scrotal sac.
a red base and may appear between the second (hydroceles and inguinal hernias)
and fourth days of life. These papules contain ○ Note if size changes when infant
eosinophils and are seen mostly on the trunk.
cries.
○ See if you can trap mass between
The Ortolani test or Ortolani maneuver is part of the fingers.
physical examination for developmental dysplasia of ○ Note tenderness
the hip, along with the Barlow maneuver. ○ Note if it transilluminates.
Female Genitalia

● Examine supine.
● Labia majora and minora dull pink (light
skinned infants), hyperpigmented (dark-
skinned infants).
● First few weeks normal milky white
discharge
● Examine:
○ Size of clitoris
○ Color and size of labia majora
○ Rashes, bruises, external lesions
● Separate majora with thumbs examine:
○ Urethral orifice
○ Labia minora
○ Asses hymen (normally thick w/
The Barlow maneuver is a physical examination
central orifice)
performed on infants to screen for developmental
○ Note discharge
dysplasia of the hip.
Rectal Examination

VIII. GENITALIA AND RECTAL ● Not performed unless there is patency of

● Inspect male genitalia with infant supine. anus or an abdominal mass.
Note appearance of penis, testes, and ● Flex infants hips fold legs to head. Use
scrotum. lubricated gloved pinky
● Foreskin completely covers glans penis. NEUROLOGIC EXAMINATION
○ Retract to visualize urethral MENTAL STATUS
meatus. I. Appearance, Attitude, Behavior, and Social
● Inspect shaft of penis. No abn, and is Interactions
straight. • Dress (age appropriate?)
• Ease in Separation from Parent
● Inspect scrotum.
• Manner In Relating (regressed?)
○ Note rugae (present at 40 wks • Attention Span
aog). • Speech and Language
I Appearance VII Thought Content
• Does the child appear to be wellnourished and • Do they: ~have overvalued ideas?
well-developed; is he overweight or too thin? ~express firmly held, fixed false beliefs that cannot
• Is the child well-groomed, well-dressed and be explained by the patient’s culture or religion?
attentive to personal hygiene? ~have any unusual sensory experiences or
• Who accompanies the child? perceptions; if so, in which sensory modality?
• Are they sitting, standing, lying down? hallucinations?
• Eye contact and relatedness? ~ have active suicidal or homicidal ideation, intent
and plan; e latter must be thorough and tailed
II. Motor Activity • Hallucinations
• Hyperactive • – Auditory Hallucinations
• Still • – Visual hallucinations
• Fidgets • –Obsessions and Compulsions
• Gross (large muscle groups) or • – Imaginary Companions
• Fine (small muscle groups) Motor Coordination
VIII Intellectual Functioning
III Mood • Orientation to Time, Place, Person and Situational
• “How do you feel;” this is patient’s subjective self- Context Cognition: Assess domains of cognition.
report and is best presented as direct quotes in the • Attention and working memory-
patient’s own words (eg, “I feel angry.”). ~have child spell short words forwards and
• Fantasies, Feelings, and Inferred Conflicts • backwards
Nonverbal Clues to Feelings ~days of week and then backward
• Clues to Depression ~months of year and then backward
• Anxiety Registration and short-term memory -> ask child to
repeat a list of three items presented earlier in the
IV Affect interview-always keep same 3
Does the patient display the normally expected • long-term memory ask where they went to school
range of facial expressiveness previously and currently, calculations (serial
-a narrowing or constriction of affect subtraction of 3’s or 7’s), and visuospatial ability (ask
-a “flattening” of affect? the patient to draw a geometric figure from a sample
Does the facial expressivity show lability (rapidly and later from memory).
changing mood, tearful, difficult to control); Abstraction Evaluate with similarities/differences of
is the lability marked? Is facial expressivity and apple and orange and proverbs – “what does ‘you
affectual displays appropriate with respect to: can lead a horse to water but you can’t make him
prevailing mood, ideational content? drink’ or ‘ even monkeys fall out of trees’ mean?”
V Speech Estimated Intelligence “average”, “above”, “below”,
• Think about music and describe the musical “unable to determine”
qualities of speech
• ~ rate, rhythm, loudness and tonality. XI. Judgment and Insight
~note unusual pauses or latencies, articulation
problems, and stuttering and stammering ~prosody

VI Thought Processes
• Listen!
• Flow and production – Paucity – Overproductive –
Rapid – Coherent/Incoherent – Understandable?

Do they: ~respond to questions in a logical, relevant

coherent and goal-directed manner? ~give too
much, unimportant detail (ie, circumstantial)?
~skip from topic to topic not elaborating fully on any
one of them (ie, tangential)?
• Judgment regarding day to day behaviors a. Cochlear portion - Hearing, lateralization,
• Insight into why they are here, having behavior

problems, anxiety, depression, anger air and bone conduction, tinnitus.

• Rate or Specify: Excellent, good, impaired, poo b. Vestibular - Caloric tests.
I. CRANIAL NERVES 7. IX (glossopharyngeal), X (vagus) -
1. I (olfactory) - Identify odors; disorders of
Pharyngeal gag reflex, ability to swallow and
smell
speak clearly; sensation of mucosa of
2. II (optic) - Visual acuity, visual fields,
pharynx, soft palate, and tonsils; movement
ophthalmoscopic examination, retina.
of pharynx, larynx, and soft palate;
3. III (oculomotor), IV (trochlear), and VI
autonomic functions.
(abducens) - Ocular movements, ptosis,
8. XI (accessory) - Strength of trapezius and
dilatation of pupil, nystagmus, pupillary
sternocleidomastoid muscles.
accommodation, and pupillary light
9. XII (hypoglossal) - Protrusion of tongue,
reflexes.
tremor, strength of tongue.
4. V (trigeminal) - Sensation of face, corneal
II. MOTOR TONE AND STRENGTH
reflex, masseter and temporal muscles, Muscle size, consistency, and tone; muscle
maxillary reflex (jaw jerk). contours and outlines; muscle strength;
5. VII (facial) - Wrinkle forehead, frown, myotonic contraction; slow relaxation;
smile, raise eyebrows, asymmetry of face, symmetry or posture; fasciculations; tremor;
strength of eyelid muscles, taste on anterior resistance to passive movement; involuntary
portio of tongue. movement.
6. VIII (acoustic) -
 III. SENSORY abnormalities of muscle tone or
Hearing, vision, light touch, pain, position, speech.
vibration. VI. MENINGEALS
VII. Ask patient to flex and extend neck.
IV. DTR VIII. B. Passively flex and extend patient’s
 DTRs are variable in newborns and neck
infants - corticospinal tracts not fully IX. C. Observe for palpable stiffness on
developed
either active or passive movement.
*same exam technique as adults - you
X. Meningeal Signs.
can substitute neurohammer with
index/middle finger XI. Neck stiffness often accompanies the
meningeal irritation of meningitis or
1. Deep reflexes - Biceps, brachioradialis, triceps, subarachnoid hemorrhage. This can be
patellar, Achilles; rapidity and strength of assessed by observing for palpable
contraction and relaxation. stiffness on either active or passive
2. Superficial reflexes - Abdominals, cremasteric, flexion and extension at the neck.
plantar, gluteal. There are a couple of other meningeal
3. Pathologic reflexes - Babinski ( can be + up to signs (Brudzinski’s and Kernig’s) do not
2yrs), Chaddock, Oppenheim, Gordon triceps, provide any additional information
brachioradialis and abdominal reflexes - hard to elicit beyond simple testing for neck
before 6mos stiffness, hence testing for meningeal
-anal reflex - present at signs is not necessary in a screening
birth, important if spinal exam
cord lesion is suspected

*primitive reflexes :
 Palmar grasp
reflex
 Plantar grasp
reflex
 Rooting reflex
 Moro/Startle
reflex
 Assymetric
tonic neck reflex
 Trunk incurvation/Galant's reflex XII. FUNDOSCOPY
 Landau reflex ● Examine the red retinal reflex
 Parachute reflex ○ Scope at 0 diopters.
 Positive support reflex ○ View pupil from 10 inches.
 Placing and stepping reflex ● Focal lengths:
○ Cornea: +20 diopters
V. CEREBELLARS ○ Lens: +15 diopters
 Finger to nose, finger to examiner's
○ Fundus: 0 diopters
finger
● Examine optic disc (same as adult)
 rapidly alternating pronation and
supination of hands; ability to run heel ○ Optic disc lighter, less macular
down other shin and to make a pigmentation.
requested motion with foot; ability to ○ Foveal light reflection may not be
stand with eyes closed; walk; heel to visible.
toe walk; tremor; ataxia; posture; arm ● Check for:
swing when walking; nystagmus; ○ Retinal hemorrhage
papilledema (rare)