PEDIATRIC MEDICAL HISTORY AND PHYSICAL EXAMINATION 2011-2012

General Approach Method Normal Range

1. Gather as much data as possible by rectal temp. 36.6 – 38oC (97.9 – 100.4oF)
observation first
2. Position of child: parent’s lap vs. exam table ear temp. 35.8 – 38oC (96.4 – 100.4oF)
3. Stay at the child’s level as much as possible.
Do not tower. oral temp. 35.5 – 37.5oC (95.9 – 99.5oF)
- Order of exam: least distressing to most
axillary temp. 34.7 – 37.3oC (94.5 – 99.1oF)
distressing
4. Rapport with child
- include child – explain to the child’s level
- distraction is a valuable tool Age Recommended Technique
5. Examine painful area last – get general
Rectal (definitive)
impression of overall attitude 0 – 2 years
Axillary (screening)
6. Be honest. If something is going to hurt, tell it
to them in a calm fashion. Do not lie.
7. Understand developmental stages’ impact on Rectal (definitive)
> 2 – 5 years
a child’s response. Example, stranger anxiety Axillary/Tymapnic (screening)
is a normal stage of development which tends
to make examining a previously cooperative Oral (definitive)
> 5 years
child more difficult Axillary/Tympanic (screening)

I. GENERAL SURVEY
A. Statement about striking and/or Heart Blood
important features Respiratory
Age Rate Pressure
B. Nutritional Status Rate
(bpm) (mmHg)
C. Level of consciousness 55-75/35-
D. Mental state premature 120 – 170 40 – 70
45
E. Toxic or distressed 65-85/45-
F. Cyanosis 0 – 3 mos 100 – 150 35 – 55
55
G. Cooperation
70-90/50-
H. Hydration 3 – 6 mos 90 – 120 30 – 45
65
I. Dysmorphology
80-100/55-
6 – 1 yr 80 – 120 25 – 40
65
II. VITAL SIGNS
90-105/55-
A. Normal differ from adults and varies 1 – 3 yrs 70 – 110 20 – 30
70
according to age (36.4 to 37.1oC)
B. Temperature 95-110/60-
3 – 6 yrs 65 – 110 20 – 25
C. Heart Rate 75
o auscultate or palpate apical pulse 100-
6 – 12 yrs 60 – 95 14 – 22
or palpate femoral pulse in infants 120/60-75
o palpate antecubital or radial pulse 110-
> 12 yrs 55 – 85 12 – 18
in older children 135/65-85
D. Respiratory Rate
o observe for a minute III. SKIN AND LYMPHATICS
o infants normally have periodic A. Birthmarks – nevi, hemangiomas,
breathing so that observing for Mongolian spots, etc.
only 15 seconds will result in a B. Rashes, petechiae, desquamation,
skewed number pigmentation, jaundice, texture, turgor
E. Blood Pressure C. Lymph node enlargement, location,
o appropriate cuff size: 2/3 of upper mobility, consistency
arm D. Scars or injuries, especially in patterns
F. Growth Parameters suggestive of abuse
o must plot an appropriate growth
curve IV. HEAD
1. weight A. Size and shape
2. height/length o caput succedaneum /
3. occipital frontal cephalhematoma
circumference (OFC): across B. Fontanelle(s) – open/closed
frontal occipital prominence 1. size
so greatest diameter 2. tension – calm and in sitting up
position
C. Sutures – overriding / prominence
(premature syanostosis)
D. Scalp and hair

V. EYES
A. General

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1. Strabismus 1. Quality in upper and lower

2. Slant of palpebral fissures extremities
3. Hypertelorism or telecanthus
B. EOM (Doll’s Eye Test)
C. Pupils
D. Conjunctivia, sclera, cornea XII. ABDOMEN
E. Plugging of nasolacrimal ducts A. Inspection
F. Red reflex 1. Shape
G. Visual fields – gross exam a. Infants usually have protuberant
abdomens
VI. EARS b. Becomes more scaphoid as child
A. Position of ears matures
1. observe from front and draw line 2. Umbilicus (infection, hernias)
from inner canthi to occiput 3. Muscular integrity (diasthesis recti)
B. Tympanic membranes B. Auscultation
C. Hearing – gross assessment only usually C. Palpation
1. Tenderness – avoid tender area until
VII. NOSE end of exam
A. Nasal septum 2. Liver, spleen, kidneys
B. Mucosa (color, polyps) a. May be palpable in normal
C. Sinus tenderness newborn
D. Discharge 3. Rebound guarding
a. Have child blow up belly to touch
VIII. MOUTH AND THROAT your hand
A. Lips (color, fissures)
B. Buccal mucosa (color, vesicles, XIII. MUSCULOSKELETAL
moist/dry)
C. Tongue (color, papillae, position, A. Back
tremors) 1. Sacral dimple
D. Teeth and gums (number, condition) 2. Kyphosis, lordosis, scoliosis
E. Palate (intact, arch) B. Joints (motion, stability, swelling,
F. Tonsils (size, color, exudates) tenderness)
G. Posterior pharyngeal wall (color, lymph, C. Muscles
hyperplasia, bulging) D. Extremities
H. Gag reflex 1. Deformity
2. Symmetry
IX. NECK 3. Edema
A. Thyroid 4. Clubbing
B. Trachea (position) E. GAIT
C. Masses (cyst, nodes) 1. In-toeing, out-toeing
D. Presence or absence of nuchal rigidity 2. Bow legs, knock knee
a. “Physiologic” bowing is frequently
X. LUNGS/THORAX seen under 2 years of age and will
A. Inspection spontaneously resolve
1. Patter of breathing 3. Limp
a. Abdominal breathing is normal in F. Hips
infants 1. Ortolani’s and Barlow’s signs
b. Period breathing is normal in
infants (pause < 15 seconds) XIV. GENITO-URINARY
2. Respiratory Rate A. External genitalia
3. Use of accessory muscles: retraction B. Hernias and hydrocoeles
location, degree/flaring 1. Almost all hernias are indirect
4. Chest wall configuration 2. Can gently palpate; do not poke finger
B. Auscultation into the inguinal canal
1. Equality of breath sounds C. Cryptorchidism
2. Rales, wheezes, ronchi 1. Distinguish from hyper-retractile
3. Upper airway noise testis
C. Percussion and palpation often not 2. Most will spontaneously descend by
possible and rarely helpful several months of life
D. Tanner staging in adolescents
E. Rectal and pelvic exam not done routinely
XI. CARDIOVASCULAR – special indication may exist
A. Auscultation
1. Rhythm XV. NEUROLOGIC (most accomplished through
2. Murmurs observation alone)
3. Quality of heart sounds A. Cranial nerves
B. Pulses B. Sensation
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C. Cerebellum
D. Muscle and strength
E. Reflexes
1. DTR
2. Superficial (abdominal and
cremasteric)
3. Neonatal primitive

Reflex Normal Response Age of

Reflex and Age of
Deep tendon Disappearanc
Muscle Tone Emergence
reflexes e
a. Biceps brisk response without spread Tonic neck 35 wks,
4 mos
reflex peak at 44 wks
Crossed adductor response to
b. Knee
knee jerk 28 wks
Moro reflex incomplete, 5 mos
c. Ankle Ankle clonus up to 10 beats
37 wks complete
Palmar hand grasp closure over finger
Head turn in
Plantar grasp flexion of toe and forefoot 37 wks variable
prone
toe extension, with or without Palmar grasp 28 wks 2 mos
Babinski reflex
initial flexion
Trunk
28 wks 4 – 5 mos
extension and abduction of the incurvation
arms followed by flexion and
Moro reflex Placing,
adduction; cry may or may not 37 wks 2 – 4 mos
be present stepping

long latency; not fully Ankle clonus 33 – 35 wks (?) 1 month

developed; increased tone, leg Pupillary
extension on side of head 32 wks never
response
direction, flexion on
Tonic neck reflex contralateral arm and leg; this Flexor tone,
response is the basis for lower 32 wks > 1 year
asymmetries in tone and extremity
reflexes when the head is not Flexor tone,
in the midline upper 36 wks > 1 year (?)
extremity
extension of the leg without
Placing 8 – 12 months
dorsal stimulation Babinski reflex
upto 2 years
Stepping and range from minimal weight-
walking bearing to several brisk steps

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PEDIATRIC MEDICAL HISTORY o “What’s been bothering you or

your child?”
The medical history tells the physician which - initially broad, neutral, and open-ended
specific signs to check for, and what other forms of as possible
diagnosis are needed to obtain the information he - allow the patient or informant unlimited
seeks. latitude in describing the chief complaint
as they see it
Two distinct features and attributes that are
essential and not found in other diagnostic methods:
HISTORY OF PRESENT ILLNESS
1. Covers the past tense - concise chronological account of the
- the genesis and development of the illness, including any previous treatment
patient’s various illnesses and complaints with full description of the symptoms
(pertinent positives) and pertinent
2. Main vehicle for eliciting information about negatives
the patient’s / parent’s subjective symptoms - severity, frequency, etc.
- how the patient / parent reacts to, - including precipitating and relieving
experiences, or feels about the illness may factors
be just as important as, or more - other accompanying symptoms
important than, the illness itself, and - recent exposure to any infectious disease
provide valuable keys to treatment (when, where, how)

The Heart of the Doctor-Patient Relationship PAST MEDICAL HISTORY

- The physician establishes a rapport with A. Major medical illnesses
the patient and communicates to him / B. Major surgical illnesses
her his sincere caring and commitment to - list of operations and dates
their recovery and improvement of health C. Trauma (fractures, lacerations)
and well-being D. Previous hospital admissions
- This caring in itself can have a great - list of diagnoses and dates
therapeutic value E. Current medications
F. Known allergies
Sadly, this personal rapport between doctor G. Immunization status (specific and updated)
and patient is what is most lacking in modern - BCG
medicine. On the average, it is said that the modern - DPT
doctor spends only about ten minutes or so talking to - Polio
his patient. This cold impersonality of modern - Measles (rubeola)
medicine can be anti-therapeutic, and exacerbate the - Mumps
problem. - Rubella
- Varicella
Competencies (Expectations): - Hepatitis A/B
To obtain an accurate and complete history of - others
a pediatric patient in different age groups
a. 1 year PRENATAL AND BIRTH HISTORY
b. 1 to 5 years A. Prenatal
c. more than 5 years - maternal health during pregnancy
d. adolescent - bleeding, trauma, hypertension, fevers,
infectious illnesses, medications, drugs,
GENERAL DATA alcohol, smoking, rupture of membranes
- includes the name, age, sex, residence, B. Birth History
number of times admitted, and date of - gestational age at delivery, birth weight,
present admission delivery (home or hospital), length of
labor, fetal distress, type of delivery
CHIEF COMPLAINT (vaginal / Cesarean section), use of
- brief statement of primary problem forceps, anesthesia, breech delivery
(including duration) that caused the C. Neonatal Period
family to seek medical attention - APGAR scores, breathing problems, use of
o “What can I do for you?” oxygen, need for intensive care,
hyperbilirubinemia, birth injuries, feeding

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problems, length of stay, other F. GIT – abdominal or colic pain, changes in

complications appetite, vomiting, diarrhea, stool color and
character, constipation, hematemesis,
FEEDING HISTORY jaundice/hepatitis
A. Breast or bottle fed, types of formula, G. GUT – urinary frequency, nocturia, polyuria,
frequency and amount, reasons for any dysuria, bladder control, hematuria,
changes in formula discharge, quality of urinary stream, previous
B. Solids – when introduced, problems created infections, facial edema, change in urinary
by specific types pattern such as enuresis in previously toilet-
C. Vitamins used and amount trained child
D. For older children – weight gain and actual H. Musculoskeletal – joint pains or swelling,
dietary pattern scoliosis, myalgia or weakness, injuries, gait
changes
DEVELOPMENTAL HISTORY I. Reproductive (adolescents) – secondary
A. Ages at which milestones were achieved and sexual characteristics, menses and menstrual
current developmental abilities – smiling, problems, pregnancies, sexual activity, genital
rolling, sitting alone, crawling, walking, discharges
running, first word, toilet training, riding a
tricycle, etc. (see developmental charts) INTERVAL HISTORY
B. School – present grade, specific problems, - previous hospitalizations (summary of
interaction with peers each)
C. Behavior – enuresis, temper, tantrums, - inquire about the condition of the child
thumb-sucking, pica, nightmares, etc. from the time of discharge to the time of
readmission
FAMILY HISTORY HEADS/S F/FIRST
A. Illnesses – cardiac disease, hypertension,
stroke, diabetes, cancer, abnormal bleeding, Home: space, privacy, frequent geographic moves,
allergy, asthma, epilepsy neighbourhood
B. Mental retardation, congenital abnormalities,
chromosomal problems, growth problems, Education/School: frequent school changes,
consanguinity, ethnic background repetition of a grade or in each subject, reports,
vocational goals, after-school educational clubs,
SOCIAL CONDITIONS learning disabilities
A. Living situation and conditions – daycare,
safety issues, etc. Abuse: Physical, sexual, emotional, verbal abuse;
B. Composition of family parental discipline
C. Occupation of parents
D. Educational attainment of parents Drugs: tobacco, alcohol, marijuana, inhalants, “club
drugs”, “rave” parties, others; drug of choice, age at
REVIEW OF SYSTEMS initiation, frequency, mode of intake, rituals, alone or
(usually very abbreviated for infants and younger with peers, quit methods and number of attempts
children)
A. Weight – recent changes, weight at birth Safety: seat belts, helmets, sports safety measures,
B. Skin and Lymph – rashes, adenopathy, hazardous activities, driving while intoxicated
lumps, bruising and bleeding, pigmentation
changes Sexuality/Sexual Identity: reproductive health (use
C. HEENT – headaches, concussions, unusual of contraceptions), presence of STD, feelings,
head shape, strabismus, conjunctivitis, visual pregnancy
problems, hearing, ear infections, draining
ears, cold and sore throats, tonsillitis, mouth Family: family constellation, genogram,
breathing, snoring, apnea, oral thrush, single/married/separated/divorced/blended family,
epistaxis, caries family occupations and shifts; history of addiction in
D. CVS – cyanosis, dyspnea, heart murmurs, first and second degree relatives, parental attitude
exercise tolerance, squatting, chest pain, toward alcohol and drugs, parental rules, chronically
palpitations ill physically or mentally challenged parent
E. Respiratory – pneumonia, bronchitis,
wheezing, chronic cough, sputum,
hemoptysis, TB

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Friends: peer cliques and configuration (“preppies”,

“jocks”, “nerds”, “computer geeks”, “cheerleaders”),
gang or cult affiliation

Image: height and weight perceptions, body

musculature and physique, appearance (including
dress, jewelry, tattoos, body piercing as fashion
trends or other statement)

Recreation: sleep, exercise, organized or structured

sports, recreational activities (television, video
games, computer games, internet, chat rooms, church
or community youth group activities), how many
hours per day or days per week involved?

Spirituality and Connectedness: use HOPE (*) or

FICA (ϯ) acronym; adherence, rituals, occult
practices, community service or involvement

Threats and Violence: self-harm or harm to others,

running away, cruelty to animals, guns, fights, arrests,
stealing, fire-setting, fights in school