Pedia Integ

History taking

Intro Introduce yourself

Source of information & reliability

General data ● Full name

● Age -
● Sex -
● Date & place of birth -
● Occupation sang nanay
● Handedness (preference kung baby pa)
● Religion -
● Address -
● Nationality -

Chief complaint Most important symptom which prompted the admission

History of present ● Onset -

illness ● Duration -
● Character -
● Severity -
● Aggravating/relieving factors
● Remedies to relieve symptom
● If meds were given, note the type, dose, frequency, & response -
● Info about consultations done

ROS General
● Weight gain or loss -
● Fatigue
● Weakness -
● Fever

HEENT
● Headache, dizziness, tingling
● wearing of glasses, Eye strain, vision loss, blurring, discharge, any foreign body or infection, red eyes
● Hearing loss, discharge, infection
● Frequent colds, sneezing, stuffy nose, discharge, post-nasal drip
● Sore throat, mouth breathing, snoring

Skin
● Rashes
● Bruising
● Pigmentation changes
● Hair problems
● Lumps under arms, neck

Cardiorespi
● Dyspnea
● Cyanosis
● Chest pain
● Palpitations
● Cough
● Sputum
● Wheeze
● Hemoptysis
 GI
● Vomiting -
● Diarrhea
● Constipation
● Stool color and character -
● Abdominal pain/discomfort
● Jaundice
● Hematemesis
● Appetite -

GU
● Enuresis - loss of bladder control - dont ask if <3yrsold
● Dysuria - painful urination
● Frequency
● Polyuria - excessive urination
● Character of stream
● Discharge
● Previous infection

Neuromuscular / Musculoskeletal
● Convulsions
● Habit spasms
● Ataxia - abnormal, uncoordinated movements
● Gait
● Postural deformities
● Injuries
● Muscle or joint pains
● Stiffness
● Swelling
● Variation in joint pain during the day

Endocrine
● Excessive fluid intake
● Polyphagia - eats excessive amount of food

Hematologic
● Bruise easily
● Difficulty stopping bleeds

Neurologic:
● Changes in mood, attention, or speech -
● changes in orientation,
● memory, insight, or judgment
● Headache
● Dizziness
● Vertigo
● Fainting
● Blackouts
● Weakness -
● Paralysis
● numbness or loss of sensation
● tingling or “pins and needles
● tremors or other involuntary movements
● Seizures or spasms -

Past medical ● Childhood illnesses -

history ● Accidents and injuries
● Head trauma
 ● CNS infections
● Hospitalizations - what age, where, duration
● Operations - where, by whom, for what diagnosis
● Allergies (food and meds) - what type of reaction -

Family history ● Age and health of family members (parents, grandparents, siblings)
● Illnesses present in the immediate family members and household members (covid, tb, etc.)
● Known genetic diseases (allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular
diseases, kidney disease, rheumatic fever, neoplastic diseases, congenital abnormalities, cancer,
convulsive disorders, etc.)

Maternal history ● Parity - given birth >20 weeks AOG, >400g -

● Gravidity - # pregnancy -
● Age during pregnancy -
● Drug intake -
● Stress during pregnancy

Birth history ● AOG -

● Difficult or prolonged labor
● Manner of delivery -
● Who and where delivered
● APGAR score
● Birth weight -
● Head circumference
● Complications -

Growth and ● Physical growth: weight and height at birth and at 1, 2, 5, 10 yo

developmental ● History of slow or rapid gains or losses
history ● Tooth eruption and loss pattern
● Developmental milestones
● Comparison of development to siblings
● Unusual behavior (thumb sucking, excessive masturbation, severe & frequent temper tantrums,
negativism, etc.)
● Sleep disturbances
● Phobia
● Pica - ingestion of substances other than food
● Bed wetting

Nutritional ● Breastfeeding/Formula: duration, how much formula -

(feeding) history ● Preparation of milk
● Micronutrient supplements (vitamins: type, when started, amount, duration)
● Complementary feeding (solids: when introduced, how taken, types)
● Childhood eating habits
● Food intake/appetite
● Feeding problems (regurgitation, excessive colic)
●
 Personal and ● Child’s ability to associate with others
social history ● Living conditions (age of habitat, # of people at home)
● Influences of school/community
● Type of dwelling and neighborhood
● Marital status of parents and involvement with child
● Parental work schedules

HEADSSS ● Home: inquire about all individuals living with the adolescent and their relationship
(adolescent) ● Education/employment: name of school, year level, whether the recently transferred, grades,
favorite/least fav subject, relationship with teachers and classmates, bullying; if working, ask about
nature of work, employers
● Activities: hobbies, recreational activities, sports or exercise, activities they do with friends, hours per day
using gadgets
● Drugs: inquire first whether their friends drink alcohol, smoke, or have used illicit drugs, before inquiring
whether the adolescent has tried or is currently
● Sexuality: dating history or relationships with same/opposite sex, sexual activity, contraceptive use,
pregnancy, sex education from parents, secondary sexual characteristics, STDs; for females: menarche,
LMP, problems with menses
● Suicidality: depression, suicidal ideation, attempts to hurt self
● Safety: if they feel safe at home/neighborhood, presence of guns at home, previous or current abuse

Immunization ● Specific dates of administration of each vaccine -

Environmental ● Environmental tobacco smoke -

history ● Water source to home - .
● Pets -
● Smoke & CO detectors
● Firearms

Differentials:
Questions for PE: Neck:
Cervical lymphadenopathy present?
APGAR score: Any palpable thyroid mass?
Neck mass present?
General survey Midline trachea?
Normal or ill-appearing:
Looks pale or flushed: Thorax and Lungs
Facial configuration: Any mass or lesion?
Unusual body odor: Any deformity or defect on the chest wall?
Is there lagging respiratory movement?
Vital signs Chest expansion (regular or irregular, symmetrical or
Blood pressure: asymmetrical):
Temperature: Retractions present?
Respiratory rate: Tenderness?
Breathing pattern: Equal tactile fremitus?
Cardiac rate: Resonance on percussion?
O2 saturation: Equal lung sounds on both fields?
Crackles present?
Anthropometric Measurements: Wheezing present?
Weight:
Height: Cardiovascular
Head circumference: Precordial bulging or lesions on the chest?
Chest circumference: Heaves?
Abdominal girth: Thrills?
Arm span: PMI:
Arm circumference: Precordium (dynamic or adynamic):
Rate and rhythm of heart sounds:
HEENT Quality of heart sounds:
Head: Murmurs? Bruits?
Symmetrical facial features?
Palpable mass? Abdomen
Hair texture and distribution? Flat?
Eyes: Non-distended?
Sunken? Any scar or lesion?
Conjunctiva: Discoloration?
Icteric or anicteric sclera: Any visible veins?
Ears: Visible peristalsis?
Mobile pinna? With or without masses or Abnormal bowel sounds?
tenderness? Soft on palpation?
Discharge? Rebound tenderness?
Nose: palpable mass/es present?
Symmetrical? Abdominal reflex
Midline nasal septum?
Equal size and shape of nares? Extremities
Discharge? Masses or atrophy noted?
Oral cavity: Symmetrical muscles on extremities?
Moist? Joint tenderness?
Lesions? Normal range of motion?
Masses? Quality of pulses in both upper and lower extremities:
Tonsillo-pharyngeal congestion? Capillary refill time
Bounding pulses
Dryness of skin ○ Does the patient pull forward with both
Edema? Pitting or non pitting? arms and the abdominals able to assist?
Cyanosis? Location? ● Bulk
Redness or tenderness in the joints? ○ Is there any asymmetry in muscle bulk?
● Abnormal movements
Genitourinary ○ Tremors?
Normal external genitalia? ○ Fasciculations?
Lesions? ○ Myoclonus?
Vaginal discharge? ○ Tics?
Intact rectal vault? ○ Dystonia?
Blood in the urine? ○ Chorea?
○ Athetosis?
Skin ● Tone
Warm or cool to touch? ○ What is the normal resting tone of the
Lesion? patient?
Masses? ○ Traction response:
Cyanosis? ○ Vertical suspension:
Cafe au lait spots? ○ Horizontal suspension:
Petechiae? ○ Spasticity:
Hypo/hyperpigmentation? ○ Rigidity:
Melanosis? ○ Are the legs extended at rest?
Neurofibromas? ○ Is there presence of frog-leg position of
lower extremities?
Neurologic ● Strength
MSE ○ Grade of muscle strength
● Is there spontaneous eye opening?
● Are there spontaneous movements in the face and REFLEXES
extremities? ● Moro reflex (present or absent):
CN ● Palmar grasp (present or absent):
● I - check for alerting response or withdrawal using ● Plantar grasp (present or absent):
coffee or peppermint ● Rooting and sucking reflex (present or absent):
● II - response to bright light; pupillary reflex; check ● Tonic neck reflex (present or absent):
optic disk for edema ● Deep tendon reflex
● III, IV, VI - check if patient can follow moving objects ● Babinski reflex (present or absent):
with eyes; doll’s eye maneuver ● Chaddock sign (present or absent):
● V - corneal reflex; sucking reflex ● Oppenheim reflex (present or absent):
● VII - during crying, check facial movement for
fullness or asymmetry DERMATOMES
● VIII - test hearing with a ringing bell ● Test sensation on all dermatome levels
● IX - gag reflex
● XI - extend the head on the side of the bed with the CEREBELLAR TESTS
infant in a supine position then palpate the ● Cannot elicit
sternocleidomastoid
● V, VII, IX, X, XII - test for sucking and swallowing MENINGEAL TESTS
● Check for nuchal rigidity, Brudzinski, and Kernig sign
MOTOR EXAM
● Proximal and distal strength of the upper extremities Laboratories
○ Can the patient reach for a toy overhead? ● Lumbar tap
○ Can the patient manipulate small objects? ● EEG
● Pull to sit maneuver ● CBC, Serum electrolytes