Current Clinical Strategies
Pediatrics
2004 Edition
Paul D. Chan, MD
Jane L. Gennrich, PharmD
Current Clinical StrategiesPublishing
www.ccspublishing.com/ccs
Digital Book and Updates
Purchasers of this book can download the digitalversion and updates at the Current Clinical StrategiesPublishing web site:www.ccspublishing.com/ccs/ped.htmCopyright
©
2004 by Current Clinical StrategiesPublishing. All rights reserved. This book, or any partthereof, may not be reproduced or stored in aninformation retrieval network without the permission of the publisher. The reader is advised to consult thepackage insert and other references before using anytherapeutic 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 aregistered trademark of Current Clinical StrategiesPublishing inc.
Current Clinical StrategiesPublishing
27071 Cabot RoadLaguna Hills, California 92653
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info@ccspublishing.comPrinted in USA ISBN 1-929622-41-4
General Pediatrics
Pediatric History and PhysicalExamination
HistoryIdentifying Data:
Patient's name; age, sex. List the
patient’s 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 ExaminationGeneral appearance:
Note whether the patient looks “ill,”
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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Gastrointestinal Disorders for Pediatrics
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