 Intensity

PEANUT BUTTER AND JELLY LEGS

PEDIATRICS  Pertinent negatives
6. Previous admissions related to
symptoms
I. CLINICAL HISTORY
GENERAL DATA
1.Name PERSONAL HISTORY
2.Age and sex 1. GESTATIONAL HISTORY (PRENATAL)
3.Neonate? Adolescent? Age of mother during pregnancy
4.Date of birth and birthplace Duration of gestation
5.Nationality Parity
6.Race (ethnicity) – if relevant
Maternal illnesses or trauma
7.Religion
8.Present address - Toxoplasma, HIV, Rubella, CMV,
9.Informant: Chickenpox, Hepatitis
 Name Intake of drugs
 Relation to patient Prenatal check ups
 Educational attainment - Done regular or irregular?
 % Reliability - Work ups? CBC, urinalysis, OGTT,
10. Date and number of times of ultrasound, radiation exposures
admission in facility
Stillbirths? Miscarriages? Premature
delivery?
CHIEF COMPLAINT
2. BIRTH (NATAL)
Term? Premature? Postmature?
HISTORY OF PRESENT ILLNESS Hours of labor
1. Onset of symptom Manner of delivery (NSD? LCCS?)
(acute or gradual or chronic)  Indicate reason why LCCS
2. Location site (Elective or Emergency?)
 Anesthesia or sedation?
3.Duration of symptom  Duration of labor and delivery
(Minutes, hours, days)  Any difficulties/complications
4. PQRST encountered?
 Attended/Performed the delivery
 Palliative/Provocative Birth weight
(Alleviating or aggravating factors)
 Remedies done
3. NEONATAL HISTORY
Birth weight
 Medications (Date started, Blood type
Generic/Brand name, dosage,
Length of hospital stay
frequency, outcome)
Meconium? Within 48 hours?
 Quality/Character (Describe)
Any jaundice? Onset and duration?
NBS and hearing test
 Radiation
Breathing problems? Use of oxygen
(Local or does it spread)
support?
 Severity
Convulsions?
(Scale out of 10, interfere with
Hemorrhage?
daily activity?)
Feeding difficulties
 Course
Congenital abnormalities
(Intermittent or constant,
worsening or improving, fluctuate) Birth injury
 Timing Umbilical stump fall when?
(How did it start? Occur during the
day/night? During/after activities? 4. FEEDING HISTORY -- MyPlate food guide. (From US Department of Agriculture:

\
http://www.choosemyplate.gov/.)
For how long?)
Type of feeding:
5. Associated symptoms
 Breast fed? Exclusive or mixed?
 Onset
 Course o If not breastfed, reason why?
 o If artificial feeding, formula  Dental eruptions
name and amount per day  Sleeping habit?
 Others: Urinary continence? Toilet
o Bottle or cup?
training? Tantrums? Head banging?
 How many times in a day? Any phobia? Night terrors?
 How long each feed?
Middle childhood (6-11 y/o)
Complementary food
 School performance
 Age started  Sexual development: Tanners
 Consistency (Soft, lumpy, table  Social activity: Friends? Games?
Sports? .

food, purred)
 Frequency in a day
Adolescent (12-20 y/o)
Sample diet  HEADS refer to psychosocial
 Appetite? Good or picky? assessment
 Sexual development: TMR?
 What’s for breakfast? Lunch?
 FEMALES:
Dinner? Snacks?  Menstrual History
 Eating habit? Food likes and - Menarche
- Subsequent menses
dislikes?
- Interval
 Assess if taken daily: Cereal/Rice?
- Duration
Fruits? Veggies? Beans? Eggs? - Amount
Milk? Sugar? - Associated signs and
symptoms
 Any food intolerance?
 LMP and PMP
Multivamins: Onset, Brand, dosage,  Past Gynecologic History
frequency (illnesses, surgeries,
immunizations, screening tests)
 Compute for acute caloric
 Family Planning or
intake (ACI) – Compare with
Contraceptive use
RENI or with food guide pyramid  Sexual History
 Weaned? When?
6. PAST ILLNESSES
 CHILDHOOD AND ADOLESCENT (2
 Childhood contagious diseases:
to 18 Y/O): OMIT early feeding (Describe the course of illness)
unless pertinent  Measles
 Varicella
Allergies to food? S/S during attacl?
 Mumps
 Pertussis
5. GROWTH AND DEVELOPMENTAL  TB
Young children (1-5 y/o)  Other medical illnesses? (Major
 Physical growth and surgical illnesses)
 Birth weight (BW)  Hospitalization? For how
 Birth length (BL): long?
 Head circumference (HC):  Checkups done?
 Chest circumference (CC):  Operations:
 Modified Developmental Checklist  Surgical condition/ Diagnosis
** Appendix A **  Type of surgery
 Gross Motor:  Date and place
 Fine Motor:  Medications
 Language:  Allergies to food and drugs?
 Accidents and injuries?
 Personal/Social:
 Social development: Shy? Active? At
par with age?
 IMMUNIZATION HISTORY  Working members of the family
Vaccines 1st Dose 2nd Dose 3rd Dose Booster Place  Source of income
 Support from relatives and others
BCG  Exposure to cigarette smoke and
other environmental pollutants
DPT
(include what pollutants and the
OPV duration of exposure)
Hepatitis B  Garbage disposal (Segregation,
Measles recycling)
MMR  Sewage disposal
 Water source: drinking, washing
HiB
 Pets
Influenza
Pneumococcal PSYCHOSOCIAL ASSESSMENT - HEADSSS (Adolescents 10-19 y/o)
Rotavirus ** Appendix B **
Home
Meningococcal
l Who lives with the young person?
Hepatitis A Where?
Varicella l Do they have their own room?
l What are relationships like at home?
Typhoid
l What do parents and relatives do for
a living?
** Appendix C ** l Ever institutionalized? Incarcerated?
l Recent moves? Running away?
l New people in home environment?

FAMILY HISTORY Education and employment

 Any communicable/non- l School/grade performance--any
communicable illnesses in the recent changes? Any dramatic past
immediate family members and changes?
household members? l Favorite subjects--worst subjects?
 Cardiac disease, HTN, DM, cancer, (Include grades)
l Any years repeated/classes failed
allergy, asthma: Controlled?
Suspension, termination, dropping
 Family history of mental out?
retardation? Congenital l Future education/employment plans?
anomalies? l Any current or past employment?
 Parents: l Relations with teachers, employers--
 State of physical and mental school, work attendance?
health
 If not living, age and cause of Activities
l On own, with peers (what do you do
death?
for fun?, where? when?)
 Siblings: Number, ages, state of l With family?
.

health l Sports--regular exercise?

l Church attendance, clubs, projects?
l Hobbies--other activities?
l Reading for fun--what?
SOCIOECONOMIC AND ENVIRONMENTAL HISTORY l TV--how much weekly--favorite
 Parents: shows?
l Favorite music?
 Age
l Does young person have car, use seat
 Occupation belts?
 Educational attainment l History of arrests--acting out--crime?
 Living circumstances:
 Place and nature of indwelling Drugs
 Number of persons living in the l Use by peers? Use by young person?
(include tobacco, alcohol)
house
l Use by family members? (include
 Ethnic and cultural environment tobacco, alcohol)
 Neighborhood
 Economic circumstances
l Amounts, frequency, patterns of II. PHYSICAL EXAMINATION
use/abuse, and car use while A. GENERAL SURVEY
intoxicated?  Mental state of sensorium
l Source--how paid for?  Level of activity
 Levels of consciousness
Sexuality  Cooperation
l Orientation?  Toxicity or Presence of cardiopulmonary distress (presence of cyanosis)
l Degree and types of sexual  Ambulatory or bedridden
experience and acts?  Nutritional state (well, under or over nourished)
 State of hydration
l Number of partners?
 Ill looking
l Masturbation? (normalize)
 Dysmorphology
l History of pregnancy/abortion?
l Sexually transmitted diseases-- B. VITAL SIGNS
knowledge and prevention? 1. Temperature (oral/axillary/rectal)
Contraception? Frequency of use?
2. Pulse rate
l Comfort with sexual activity, 3. Respiratory rate
enjoyment/pleasure obtained? History 4. Blood pressure (if > 3y/o)
of sexual/physical abuse?

Suicide/Depression
l Sleep disorders (usually induction
problems, also early/frequent waking
or greatly increased sleep and
complaints of increasing fatigue)
Appetite/eating behavior changes
l Feelings of 'boredom'
l Emotional outbursts and highly
impulsive behavior
l History of withdrawal/isolation
l Hopeless/helpless feelings
l History of past suicide attempts,
depression, psychological counseling
l History of suicide attempts in family
or peers
l History of recurrent serious 'accidents'
l Psychosomatic symptomology C. ANTHROPOMETRIC DATA
l Suicidal ideation (including significant 1. Weight (in kg):
current and past losses)  Infant weighing scale if <2
l Decreased affect on interview,  Standard weighing scale if able to stand upright
avoidance of eye contact--depression 2. Length (cm) for <2 y/o; Height (cm) for >2 y/o
posturing 3. Head circumference in cm if <3 y/o
l Preoccupation with death (clothing,
media, music, art). D. SKIN
 Color
 Turgor
REVIEW OF SYSTEMS  Loss of subcutaneous tissue
General: ( ) febrile episodes, ( ) chills, ( ) weight loss, good oral intake, ( )irritability ( ) lethargy, ( ) restlessness  Rash or eruptions
Integument: ( ) rashes, ( ) pallor, ( ) jaundice, ( ) dryness ( ) diaphoresis  Hemorrhages
Head and Neck: ( ) trauma, ( ) nuchal rigidity, ( ) headache, ( ) pain, ( ) numbness  Scars
Eyes: ( ) discharges, ( ) redness, ( ) pain  Edema
Ears: ( ) hearing loss, ( ) discharges, ( ) pain  Jaundice
Nose: ( ) nasal congestion; ( ) bleeding, ( ) sneezing  Birthmarks
Mouth and Throat: ( ) dryness, ( ) circumoral pallor, ( ) ulcers, ( ) bleeding, ( ) tongue lesions, ( ) soreness  Nevi hemangioma
Respiratory: ( ) cough, ( ) colds, ( ) phlegm ( ) pain ( ) dyspnea  Petechiae
Cardiovascular: ( ) edema, ( ) cyanosis, ( ) orthopnea
GIT: ( ) abdominal distention, ( ) abdominal pain ( ) anorexia, ( ) vomiting, ( ) nausea ( ) diarrhea ( ) constipation, E. HEENT
( ) change in bowel habits 1. Head
GUT: ( ) dysuria, ( ) hematuria, ( ) frequency, ( ) discharge  Hair: Quantity, color, texture, strength, surface characteristic
Musculoskeletal: ( ) deformities, ( ) swelling, ( ) tenderness ( ) joint pains  Shape or contour
Hematological: ( ) easy bruisability ( ) pallor ( ) bleeding manifestations  Scalp
Endocrine: ( ) excessive sweating, ( ) chills, ( ) weight change, ( ) temperature intolerance  Fontanels and sutures
Nervous: ( ) altered sensorium ( ) dizziness, ( ) seizures  Auscultate for bruits (normal in 4/0 with fever)
 Face: deformities, unusual facies
2. Eyes
 Lids H. ABDOMEN
 Conjunctiva 1. Abdominal girth: measured over the umbilicus
 Sclera  Size
 Opacities  Shape
 Discharge  Flat, globular, protuberant (infants) or scaphoid (as they mature)
 Periorbital edema
 Eyeballs sunken or not 2. Auscultation
 Tears  Bowel sounds
 ROR (up to 24 months) o Gurgling; 5-10 seconds intervals or longer (10-30 secs in infants & younger); 5-34/min
 Corneal light reflex o High pitched and increased in diarrhea and obstruction
 Neurologic: Pupils, EOM, Vision, strabismus o Absent in ileus or obstruction
o Borborygmi: prolonged gurgles of hyperperistalsis
3. Ears and mastoids (Newborn and infants: upward – Older: Forward and downward)
 Shape 3. Percussion
 Size  Normally tympanitic
 Location  Detect presence of fluid in the peritoneal cavity: fluidwave and shifting dullness
 Position in relation to head  Determine the size of the liver: RMCL, scratch test
 Ear discharge
 Tympanic membrane 4. Palpation
 Ear canal

4. Mouth and throat I. SPINE

 Lips: color, moisture or dryness, excoriations cleft  Inspect for: deformities, sacrococcygeal dimple, pilonidal sinus and local tenderness
 Gums: color, ulcers, vesicles, bleeding  Screen for scoliosis: bend forward test
 Tongue  Under the musculoskeletal system:
 Mucous membranes o Inspect the areas of the back for sacral dimple and abnormal curvatures such as kyphosis,
 Dentition: 20 milk teeth at 24 months, pitting of enamel, dental caries lordosis, or scoliosis
 Palate  Joints are inspected for motion, stability, swelling, or tenderness
 Posterior pharyngeal wall: color, enanthems, congestion, exudates  Extremities are checked for symmetry, deformity, edema and clubbing

F. CHEST AND LUNGS J. NEUROLOGIC

1. Inspection:  Cerebrum
 Size and shape: round/barrel, shield, pectus excavatum, pigeon chest, rachitic rosary, harrison’s groove  Cerebellum
o Infancy: AP diameter = transverse diameter  Cranial Nerves
o After 2 yrs old: Transverse > AP diameter  Motor
 Movements with respiration  Sensory
o Newborns and young infants: abdominal  Deep Tendon Reflexes
o After 4-5 y/o: intercostal  Pathologic Reflexes (Brudzinski, Kernig)
 Chest retractions: subcostal, intercostal, supraclavicular
 Chest expansion: Symmetry

2. Palpitation
 Fremitus: “Tres tres” “Ninety nine”
 Increased: consolidation
 Decreased: atelectasis, pneumothorax, pleural effusion

3. Auscultation
 Normal breath sounds
o Bronchial: midline
o Vesicular: over the chest, axilla, infrascapulararea
o Bronchovesicular: infants with thin walls
 Abnormal: rales, wheezes, rhonchi, bronchial or tubular breath sounds, pleural friction rub, stridor,
grunting

G. CARDIOVASCULAR
 Precordium: dynamic or adynamic
 Murmurs: TILT: timing, intensity, location, transmission

 Visible pulsation
 PMI: 4th ICS LMCL until 7 y/o ---- 5th ICS LMCL after
APPENDIX A – Nelson’s 21st page 142 APPENDIX B – Nelson’s 21st page 186
APPENDIX C – NIP MOP BOOK3 https://doh.gov.ph/publication/non-serial/NIP-MOP-booklet3