Current Clinical
Strategies
Pediatrics
2004 Edition
Paul D. Chan, MD
Jane L. Gennrich, PharmD
Current Clinical Strategies
Publishing
www.ccspublishing.com/ccs
Digital Book and Updates
Purchasers of this book can download the digital
version and updates at the Current Clinical Strategies
Publishing web site:
www.ccspublishing.com/ccs/ped.htm
Copyright\u00a92004 by Current Clinical Strategies
Publishing. All rights reserved. This book, or any part
thereof, may not be reproduced or stored in an
information retrieval network without the permission of
the publisher. The reader is advised to consult the
package insert and other references before using any
therapeutic agent. The publisher disclaims any liability,
loss, injury, or damage incurred as a consequence,
directly or indirectly, of the use and application of any of
the contents of this text. Current Clinical Strategies is a
registered trademark of Current Clinical Strategies
Publishing inc.
Current Clinical Strategies
Publishing
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Laguna Hills, California 92653
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Printed in USA
ISBN 1-929622-41-4
General Pediatrics
Pediatric History and Physical
Examination
History
Identifying Data:Patient's name; age, sex. List the
patient\u2019s significant medical problems. Name and relationship to child of informant (eg, patient, parent, legal guardian).
Chief Complaint:Reason given for seeking medical care
and the duration of the symptom(s).
History of Present Illness (HPI):Describe the course of
the patient's illness, including when it began and the character of the symptom(s); aggravating or alleviating factors; pertinent positives and negatives. Past diagnostic testing.
Past Medical History (PMH):Past diseases, surgeries,
hospitalizations; medical problems; history of asthma.
Birth History:Gestational age at birth, whether preterm,
obstetrical problems.
Developmental History:Motor skills, language
development, self-care skills.
Medications:Include prescription and over-the-counter
drugs, vitamins, herbal products, homeopathic drugs,
natural remedies, nutritional supplements.
Feedings:Diet, volume of formula per day.
Immunizations:Up-to-date?
Drug Allergies:Penicillin, codeine?
Food Allergies:
Family History:Medical problems in family, including the
patient's disorder. Asthma, cancer, tuberculosis, HIV,
diabetes, allergies.
Social History:Family situation, living conditions,
alcohol, smoking, drugs. Level of education.
Review of Systems (ROS):
General: Weight loss or weight gain, fever, chills,
fatigue, night sweats.
Skin:Rashes, skin discolorations.
Head:Headaches, dizziness, seizures.
Eyes:Visual changes.
Ears:Tinnitus, vertigo, hearing loss.
Nose:Nose bleeds, nasal discharge.
Mouth and Throat:Dental disease, hoarseness,
throat pain.
Respiratory:Cough, shortness of breath, sputum
(color and consistency).
Cardiovascular:Dyspnea on exertion, edema,
valvular disease.
Gastrointestinal:Abdominal pain, vomiting, diarrhea,
constipation.
Genitourinary:Dysuria, frequency, hematuria.
Gynecological:Last menstrual period (frequency,
duration), age of menarche; dysmenorrhea,
contraception, vaginal bleeding, breast masses.
Endocrine:Polyuria, polydipsia.
Musculoskeletal:Joint pain or swelling, arthritis,
myalgias.
Skin
and
Lymphatics:
Easy
bruising,
lymphadenopathy.
Neuropsychiatric:Weakness, seizures.
Pain:Quality (sharp/stabbing, aching, pressure),
location, duration
Physical Examination
General appearance:Note whether the patient looks \u201cill,\u201d
well, or malnourished.
Physical Measurements:weight, height; head
circumference if less than 36 months, body mass index
(BMI). Plot on age-appropriate growth charts.
Vital Signs:Temperature, heart rate, respiratory rate,
blood pressure.
Skin:Rashes, scars, moles, skin turgor, capillary refill (in
seconds).
Lymph Nodes:Cervical, axillary, inguinal nodes: size,
tenderness.
Head:Bruising, masses, fontanels.
Eyes:Pupils: equal, round, and reactive to light and
accommodation (PERRLA); extra ocular movements intact (EOMI). Funduscopy (papilledema, hemorrhages, exudates).
Ears:Acuity, tympanic membranes (dull, shiny, intact,
infected, bulging).
Mouth and Throat:Mucous membrane color and
moisture; oral lesions, dentition, pharynx, tonsils.
Neck:Thyromegaly, lymphadenopathy, masses.
Chest:Equal expansion, rhonchi, crackles, rubs, breath
sounds.
Heart:Regular rate and rhythm (RRR), first and second
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Pediatrics
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