Pedia HX and PE - Reyes

Pediatric History
and
Physical Examination
Mark Nicholas B. Reyes

Pediatric History
FORMAT OF PEDIATRIC HISTORY
• Informant and reliability
• General data
• Chief complaint
•
• Mother’s or guardian’s words

• History of present illness
•
• Duration/ onset
• Intensity and frequency
• Factors that aggravate or relieve that symptoms
• General trend – improving or not
• Other symptoms
• Prenatal History
•
• What Para? Gravida?

• Mother’s age at the time of the birth of the child
• Wanted/unwanted pregnancy
• Prenatal History
•
• Maternal illness/es during pregnancy

• Drugs take during pregnancy
• Exposure to x-ray, injurious toxins including smoking and
alcoholism
• Natal/ Birth history
•
• Did the patient breathe spontaneously at birth

• APGAR score
• Birth weight
• Cord coil, meconium staining
• Manner of delivery
• Neonatal History
•
• Length of stay in the nursery

• Infection, convulsion, jaundice
• Were there bleeding problems?
• Nutritional/feeding records
•
• Type of feeding
•
• What type of milk is used?

• How was it prepared?
• Nutritional/feeding records
•
• Introduction to solid food

•
• Technique
• Types of foods
• Past medical history

•
• Details of any prior illness and hospitalization

•
• Signs and symptom if remembered

• Surgery
• Accidents
• Adolescent
•
• Sexual habits
• Contraceptives used
• Pregnancies
• Venereal diseases
• Immunization History
•
• Developmental milestone
•
• Age milestones were achieved

• Social/ Personal History

•
• Personality characteristics
• Personal habits
•
• Feeding
• Sleeping
• Toileting
• Games/play
• Social/ Personal History

•
• Sources of support
• School history
• Family History
•
• Illnesses
•
• Cardiac diseases
• Hypertension
• Allergy / Asthma
• Systems Review
•
• HEADSSFIRST
HEADSSFIRST
H- HOME
•
• Space
• Privacy
• Frequent geographic moves
• Neighborhood
HEADSSFIRST
E-Education/School
•
• Frequent school changes

• Repetition of a grade/in each subject
• Teachers’ reports
• Vocational goals
• After-school educational clubs (language, speech, math etc)
• Learning disabilities
HEADSSFIRST
• A- Abuse
•
• Physical
• Sexual
• Emotional
• Verbal
• Parental discipline
HEADSSFIRST
D- Drugs
•
• Tobacco, alcohol ,marijuana, inhalants, “club drugs”

•
• Age at initiation
• Frequency
• Alone or with peers
• Quit methods
• Number of attempts
HEADSSFIRST
S-Safety
•
• Seat belts
• Helmets
• Sports safety measures
• Hazardous activities
• Driving while intoxicated
HEADSSFIRST
S-Sexuality/Sexual identity
•
• Reproductive health (use of contraceptives, presence of STIs,

feelings, pregnancy)
HEADSSFIRST
F-Family and Friends

•
• FAMIILY
•
• Genogram
• single/married/separated/divorced/blended family
• Family occupations and shifts
HEADSSFIRST

•
• FAMIILY
•
st nd
• History of addiction in 1 and 2 degree relatives
• Parental attitude toward alcohol and drugs
• Parental rules
• Chronically ill, mentally or physically challenged parent
HEADSSFIRST

•
• FRIENDS
•
• Peer cliques and configuration

• Organizations, gangs, or cult affiliations
HEADSSFIRST
I-Image
•
• Height and weight perceptions

• Appearance
•
• Jewelry
• Tattoos
• Body piercing as fashion trends or other statement
HEADSSFIRST
R-Recreation
•
• Sleep
• Exercise
• Organized/unstructured sports
HEADSSFIRST
R-Recreation
•
• Recreational activities
•
• TV
• Video/computer games
• Internet
• Church/community youth group activities (Boy/Girl Scouts,
campus groups)
HEADSSFIRST
S-Spirituality and Connectedness

•
• Faith beliefs, importance and influence of faith, community

support
• Rituals
• Occult practices
• Community service or involvement
HEADSSFIRST
T-Threats and Violence

•
• Self harm or harm to others

• Cruelty to animals
• Guns, fights, arrests, stealing
• Fights in school
Physical Examination
General Approach
• Gather as much data as possible by observation first

• Stay at the child’s level as much as possible
• Order of exam:
•
• Least distressing to most distressing

Vital Signs
• Temperature
•
• Tympanic
• Axillary
• Oral
Vital Signs
• Heart Rate
•
• Apical or femoral pulse in infants

• Radial or antecubital pulse in older children
Vital Signs
• Respiratory Rate
•
• Observe for 1 full minute

• Blood pressure
•
• Appropriate size of cuff

•
• 2/3 width of upper arm

Growth Parameters
• Plot on appropriate growth curves

•
• Weight
• Height/length
• Head circumference
General Appearance
• Level of consciousness
• If in distress
• Presence of cyanosis
• Mental state
• Any dysmorphology
Skin and Lymphatics
• Birthmarks
• Rashes, petechiae, pigmentations
• Scars or injuries
• Lymph node enlargements, locations, and consistency
Head
• Size and shape

• Fontanelles
• Sutures
• Scalp and hair
Eyes
• General appearance
• EOM
• Pupils
• Conjunctiva, sclera, cornea
• Visual acuity and visual fields
• Red orange reflex
Ears
• Position of ears
• Tympanic membranes
• Gross assessment of hearing
Nose
• Nasal septum
• Mucosa (color, presence of polyps)
• Sinus tenderness
• Discharge
Neck
• Thyroid
• Trachea position
• Neck masses
• Nuchal rigidity
Lungs and Thorax
• Inspection
•
• Pattern of breathing
• Use of accessory muscles
• Chest wall configuration
Lungs and Thorax
• Auscultation
•
• Equality of breath sounds

• Presence of adventitious breath sounds
Cardiovascular
• Auscultation
•
• Rhythm
• Presence of murmurs
• Pulses
•
• Quality in upper and lower extremities

Abdomen
• Inspection
•
• Shape
• Umbilicus
• Muscular rigidity
• Auscultation
Abdomen
• Palpation
•
• Tenderness
• Guarding
Musculoskeletal
• Back
•
• Kyphosis, lordosis, or scoliosis

• Joints
•
• Motion and stability

• Swelling or any tenderness
Musculoskeletal
• Extremities
•
• Deformities
• Symmetry
• Edema
Musculoskeletal
• Gait
•
• Bow legs or knock knees

• Hips
•
• Ortolani’s or Barlow’s signs

Neurologic
• Cranial nerves
• Sensation
• Muscle tone and strength
• Reflexes
Genitourinary
• External genitalia
• Hernias and hydroceles
• Cryptorchidism
• Rectal and pelvic exam not routinely done

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Pediatric History

Mark Nicholas B. Reyes

• Mother’s or guardian’s words

• What Para? Gravida?

• Maternal illness/es during pregnancy

• Did the patient breathe spontaneously at birth

• Length of stay in the nursery

• What type of milk is used?

• Introduction to solid food

• Past medical history

• Details of any prior illness and hospitalization

• Signs and symptom if remembered

• Age milestones were achieved

• Social/ Personal History

• Social/ Personal History

• Frequent school changes

• Tobacco, alcohol ,marijuana, inhalants, “club drugs”

• Reproductive health (use of contraceptives, presence of STIs,

F-Family and Friends

F-Family and Friends

F-Family and Friends

• Peer cliques and configuration

• Height and weight perceptions

S-Spirituality and Connectedness

• Faith beliefs, importance and influence of faith, community

T-Threats and Violence

• Self harm or harm to others

• Gather as much data as possible by observation first

• Least distressing to most distressing

• Apical or femoral pulse in infants

• Observe for 1 full minute

• Appropriate size of cuff

• 2/3 width of upper arm

• Plot on appropriate growth curves

• Size and shape

• Equality of breath sounds

• Quality in upper and lower extremities

• Kyphosis, lordosis, or scoliosis

• Motion and stability

• Bow legs or knock knees

• Ortolani’s or Barlow’s signs

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