SAINT LOUIS UNIVERSITY – HOSPITAL OF THE SACRED HEART

ASSUMPTION ROAD, BAGUIO CITY, 2600, PHILIPPINES DEPARTMENT [DATE]

OF PEDIATRICS

PEDIATRIC HISTORY
GENERAL DATA
Name: Birth date:
Age: Birth place:
Sex: Present Address:
Classification: Number and Date of Hospital
Admission:
Race Name of informant and
(ethnicity): relation to the patient:
Religion: Reliability of the informant Factors affecting % Reliability:
(%): - Relationship of the informant to
the patient
- # of hours the informant stays
with the patient
- Educational attainment of the
informant
- Involvement of the informant in
the care of the patient
CHIEF COMPLAINT
- Why was the patient brought to the hospital
- Single symptom or a group of related symptoms
- Not diagnostic terms or names of diseases
- For OPD patients: follow-up, CP clearance, well-baby care, immunization
- Give the exact words of the informant whenever possible*
HISTORY OF PRESENT ILLNESS
A. Signs and symptoms should be described in chronological order, from the start of the illness
- Use specific number of hours or days or weeks or months prior to admission
- Not “last Monday” or “a few weeks ago”
- Chronic illnesses: state also the date and age at onset
B. Elaborate on the symptoms as to:
1. Onset (acute or chronic)
2. Intensity of symptoms: interference with activity, quality, location, duration, extent, severity and frequency
3. Factors that aggravate or relieve the main symptoms
4. Medications (generic and brand names):* actual dose (mg/kg/day or mg/kg/dose), duration of treatment; brand
names should be written in parenthesis
5. Associated symptoms described as to: onset, course, chronology, intensity
o If the history suggests a particular disease, inquire about signs and symptoms characteristic of the
disease. Pertinent negatives are of value in the differential diagnosis
o Other symptoms*
- Re-admissions: if previously admitted to this hospital or had Out Patient Department consultations, obtain these
records from the hospital and summarize
- Records of any admission to other hospitals should also be obtained and summarized
- Previous admissions not related to the HPI are placed under Past illnesses
- If the previous admissions are related to the present illness, these should be written in the first paragraph of the HPI
- Based on the HPI, the physician should already have an initial impression and differential diagnosis
PERSONAL HISTORY
GESTATIONAL HISTORY (PRENATAL HISTORY)
(<2y/o; if related to the illness >2y/o)
Age of mother during pregnancy, her parity, health, nutrition, infections, intake of drugs, roentgen exposures, etc;
duration of gestation
BIRTH (NATAL HISTORY)
(<2y/o; if related to the illness >2y/o)
AOG: term/ premature/ postmature, hours of labor, manner of delivery: NSD, LCCS (indication), bag of waters, persons

GOMEZ, JOSEPHINE B. 1
SAINT LOUIS UNIVERSITY – HOSPITAL OF THE SACRED HEART
ASSUMPTION ROAD, BAGUIO CITY, 2600, PHILIPPINES DEPARTMENT [DATE]
OF PEDIATRICS

who attended the delivery, birth weight, APGAR score

NEONATAL HISTORY
(<2y/o; if related to the illness >2y/o)
Jaundice (age of onset); convulsions; hemorrhage; respiratory or feeding difficulties; congenital abnormalities; birth
injury; blood type
FEEDING HISTORY
Infancy (<2y/o)
1. Type of feeding: breastfeeding, exclusive or mixed; how many times per day; how long each breast; if not
breastfeeding, give reason; formula used, dilution and amount given per day, bottle feeding or cup feeding
2. Complementary foods: age introduced*; consistency of food (pureed, soft, lumpy, table foods); frequency of
feeding per day
3. Sample diet*breakfast, lunch, dinner, snacks
- Assess if the 5 basic food groups (cereals/ rice, fruits, vegetables, meat/ fish/ chicken, beans/egg, milk,
oil/sugar) are eaten daily
4. Compute for acute caloric intake (ACI) compare with Recommended Energy & Nutrient Intake (RENI) or
compare both the amount and quality of food intake with the food guide pyramid
5. Food intolerance
6. Multivitamins and iron supplements: Dosage, frequency
7. Caregiver: mother, household help, grandparents, siblings
Childhood and Adolescents (2-18 yrs)
- omit early feeding history unless pertinent to the present illness
- Assess:
1. appetite: good, picky eater
2. sample diet: breakfast, lunch, dinner, snacks (am, pm)
3. Assess if 5 basic food groups are eaten daily
4. Compute for ACI and compare with RENI or compare both the amount and quality of food intake with the food
guide pyramid
5. Food likes or dislikes; feeding difficulties
6. Multivitamins & iron supplements: dosage & frequency
GROWTH AND DEVELOPMENT
Young Children (1-5 yrs)
1. Development using the Modified Developmental Checklist: motor; adaptive/personal; language; social
2. Dental eruption
3. Other behavioral problems: urinary continence, during day and night; toilet training, started and completed;
temper tantrums; head banging; phobias; pica; night terrors; sleep disturbances
Middle Childhood (6-11 yrs)
- Inquire about school performance and sexual development using Tanner’s Maturity Rating
Adolescence (12-20 yrs)
- Inquire about: HEADSSS: home, education, eating behavior or habits, activities, drugs, sexual, suicidal ideations
- Sexual development using TMR; females: include menstrual history
PAST ILLNESS

GOMEZ, JOSEPHINE B. 2
SAINT LOUIS UNIVERSITY – HOSPITAL OF THE SACRED HEART
ASSUMPTION ROAD, BAGUIO CITY, 2600, PHILIPPINES DEPARTMENT [DATE]
OF PEDIATRICS

Age when contracted; severity; complications

1. Contagious diseases: measles, varicella, mumps, pertussis, etc.
*Describe the clinical course of illness
2. Other medical illnesses: Hospitalized?: where and for how long
3. Operations: surgical condition, type and place of operation
4. Allergy, eczema, asthma, food or drug sensitivities, etc.
5. Injuries: include effects if any ( verify accuracy of diagnosis by inquiring into signs, symptoms, course of illness)
IMMUNIZATION HISTORY
Type of Immunization Age Given Place given Untoward reactions

Types of immunizations given, including ages when given, place (heath center, doctors’ clinic) where given and
untoward reactions
FAMILY HISTORY
- Parents: state of physical and mental health; if not living - age of death, cause and nature of symptoms, history of
consanguinity
- Siblings: number, ages, state of health; if not living - age of death and cause
- Familial illness or anomalies: TB (state contact with patient); DM, syphilis, Ca, epilepsy, RF, allergy, hematologic
disorders, MR, congenital defects, etc
- Presence of illness similar to patient's illness in other members of the family or household
- Family pedigree - if a genetic anomaly is suspected
SOCIOECONOMIC AND ENVIRONMENTAL HISTORY
Parents: age, occupation, educational attainment
Living circumstances: place and nature of dwelling, number of persons living in the house
Economic circumstances: members of the family who work , source of funds
Environmental circumstances: exposure to cigarette smoke and other environmental pollutants (include what pollutants
and the duration of exposure)
Garbage disposal (segregation, recycling)
Sewage disposal
Water source: drinking, washing
REVIEW OF SYSTEMS
Only symptoms applicable to the age of the patient
General: weight loss/gain; activity level, delay in growth
Cutaneous: rash; pigmentation; hair loss; acne; pruritus
Head: (include eyes, ears, nose, mouth, throat); headache; dizziness, visual difficulties, lacrimation;
hearing; aural discharge; otalgia; nasal discharge; epistaxis; tooth ache; salivation; sore throat
Cardiovascular: Orthopnea, cyanosis, easy fatigability; fainting spells
Respiratory: Chest pain; cough; difficulty of breathing
Gastrointestinal: Vi=omitting, bowel movements – diarrhea, constipation; encopresis; passage of worms;
abdominal pain; jaundice; food intolerance; pica
Genitourinary: Color of urine; burning sensation; frequency; discharge; enuresis; swelling of hands and feet; in
prepubertal female: discharge and itching; in pubertal and adolescent female – history of
menstrual periods (onset, frequency, regularity, pain), date of last period
Endocrine:: Breast asymmetry, pain or discharge; palpitations; cold/heat intolerance; polyuria, polydipsia,
polyphagia
Nervous/ Behavioral: Tremors, sleep problems; convulsions; weakness or paralysis; mental deteriorations;
personality or behavioral changes; memory loss; eating problems, school failures; mood
changes; temper outbursts; hallucinations
Musculoskeletal: Pain in bone, joint or muscle; swelling in bone, joint, or muscle; limitation of motion; stiffness,
limping
Hematopoietic: Pallor; bleeding manifestations; easy bruisability

PHYSICAL EXAMINATION

GOMEZ, JOSEPHINE B. 3
SAINT LOUIS UNIVERSITY – HOSPITAL OF THE SACRED HEART
ASSUMPTION ROAD, BAGUIO CITY, 2600, PHILIPPINES DEPARTMENT [DATE]
OF PEDIATRICS

GENERAL SUVERY
Mental state of sensorium, level of activity; presence of cardiopulmonary distress, ambulatory of bedridden; nutritional
state (well, under or over nourished); state of hydration; ill looking
VITAL SIGNS
Temperature (C): Respiratory Rate (RR)
Cardiac Rate (CR)/ Pulse Blood Pressure (BP) if >3
Rate (PR) y/o

ANTHROPOMETRIC MEASUREMENTS
Weight (wt) Kg: Chest Circumference (CC)
cm:
Length (Lt)/ Height (Ht): Abdominal Circumference
(AC) cm:
Head Circumference (HC): Arm spam and U/L ration
BMI (wt in Kg):
SKIN
Color, tissue turgor (wrinkling or loss of elasticity), subcutaneous tissue, rash or eruptions, hemorrhages, scars, edema,
jaundice
HEENT
HEAD: hair, shape or contour , scalp, fontanels, sutures, auscultate the skill for bruits, face
EYES: lids, conjunctive, sclera, opacities, discharge, red orange reflex, periorbital edema, eyeballs, tears
EARS AND MASTOIDS: size, shape, location, and position of ear in relation to the rest of the head, ear discharge,
tympanitic membrane, ear canal
NOSE AND PARANASAL: patency of nares, alar flaring, presence and character of discharge, position of septum,
sinus tenderness
MOUTH AND THROAT: lips, gums, tongue, mucous membranes, dentition, palate, pharyngeal wall
LIPS: color, moisture or dryness, excoriations cleft
GUMS: color, continuity, bleeding
TONGUE: size, moisture, color, milky white coatings, geographic tongue, ankyloglossia. Ulcers
DENTITION: milk teeth, color, molting, pitting of enamel, dental carries
OROPHARYNGEAL MUCOSA: thrush, vesicles, ulcers, enanthems
PALATE AND UVULA AREA: symmetry, cleft, high arched
NECK : venous engorgement, flexibility, rigidity, masses, LN
CHEST AND LUNGS
INSPECTION: size, shape, movements with respiration, retractions, chest expansion
PALPATION: vocal fremitus
PERCUSSION: direct, indirect
AUSCULTATION: bronchial, vesicular, bronchovesicular, lobar pneumonia (bronchophony, egophony, whispered

GOMEZ, JOSEPHINE B. 4
SAINT LOUIS UNIVERSITY – HOSPITAL OF THE SACRED HEART
ASSUMPTION ROAD, BAGUIO CITY, 2600, PHILIPPINES DEPARTMENT [DATE]
OF PEDIATRICS

pectoriloquy)
HEART
INSPECTION: precordium, visible pulsations
PALPATION: thrills, substernal thrust, character of pulses
AUSCULTATION: s1, s2, s3, murmur,

ABDOMEN
(9 or 4 quadrants)
INSPECTION: size and shape, prominent vessels, striae, peristaltic movements, umbilical hernia, movements in
relation to respiration
AUSCULATATION: bowel sounds, borborygmi
PERCUSSION: fluid wave, shifting dullness
PALPATION: direct tenderness, rebound tenderness, proas sign, obturator sign, costovertebral angle tenderness
INGUINAL REGIONS
Hydrocele, undescended testes, LN, indirect inguinal hernia
GENITALIS
MALE: Phimosis, hypospadias, epispadias, cryptorchidism, hydrocele, hernia
FEMALE: Gynecological exam, sexual maturity testing
ANUS AND RECTUM
Rectal exam
EXTEMITIES
Color of nail beds, peripheral pulses, cyanosis, edema, mobility of joints, deformities, tests for congenital hip dislocation
(neonates), clubbing, LN
SPINE
Inspect for deformities, sacrococcygeal dimple, pilodendal sinus and local tenderness, screen for scoliosis
LYMPH NODE
Size, number, location, consistency, tenderness, mobility, discrete, matted
NEUROLOGICAL EXAMINATION
CEREBRUM
Mental State; Sensorium
States of decreased consciousness- lethargy obtundation, stupor, coma
Speech- dysphonia, dysarthria , dysphasia
CEREBELLAR
Finger to nose test; clumsiness and incoordination; rapidly alternating movement
CRANIAL NERVES
OLFACTORY NERVE (CN I): Anosmia
OPTIC NERVE (CN II): Visual acuity (Snellen, jaeger, E - >3y/o; blink reflex); Visual fields (confrontation testing);
Fundoscopy; Papilledema
OCULOMOTOR, TROCHLEAR, ABDUCENS NERVES (CN III, IV, VI): EOM movements (Abnormalities – strabismus,
ptosis, limitations, nystagmus)
TRIGEMINAL NERVE (CN V): Sensory (light touch, temperature, pain, corneal reflex); Motor (muscles of mastication)
FACIAL NERVE (CN VII): muscle of facial expression (Central facial palsy, Peripheral facial palsy), taste sensation
anterior 2/3 of the tongue
VESTIBULOCOCHLEAR NERVE (CN VIII): Hearing (weber test, rinnes’s test), Vestibular function (caloric testing)

GOMEZ, JOSEPHINE B. 5
SAINT LOUIS UNIVERSITY – HOSPITAL OF THE SACRED HEART
ASSUMPTION ROAD, BAGUIO CITY, 2600, PHILIPPINES DEPARTMENT [DATE]
OF PEDIATRICS

GLOSSOPHARYNGEAL AND VAGUS NERVE (CN IX, X): palatal movement, uvular position and movement, gag
reflex, phonation, suckling and swallowing
SPINAL ACCESSORY NERVE (CN XI): trapezius and sternocleidomastoid muscle function
HYPOGLOSSAL NERVE (CN XII): tongue muscle test
MOTOR
Gait and posture, Muscle bulk, tone, strength; Coordination (Gower’s sign)

SENSORY
Sensation of touch, pain, temperature; Position sense; Vibration sense; Romberg sign (Dorsal column dysfunction);
Finger sensation (stereognosis, two-point discrimination, Graphastesia)
DEEP TENDON REFLEX
Biceps jerk C5, C6 roots, musculocutaneous nerve; Triceps jerk C6, C7, C8 roots; Supinator jerk C6, C7 roots, radial
nerve; Knee jerk L2, L3, L4 roots; Ankle jerk S1, S2 roots; Superficial reflexes (abdominal, cremasteric)
PATHOLOGIC REFLEXES
Babinski; Oppenhein; Gordon; Bing; Gonda; Kernig’s sign; Brudinski’s sign

GOMEZ, JOSEPHINE B. 6