PEDIATRIC HISTORY AND PHYSICAL EXAMINATION

General Pointers:
 Gather as much data as possible by observation first (You can do subjective and objective examination simultaneously)
 Position of child: parent’s lap vs exam table
 Stay at the child’s level as much as possible.
 Order of exam: least distressing to most distressing

General Data Name, Gender, Age, Birthdate, Religion

Place of residence
Number of admission (Date, Reason and Outcome)

This is the case of _____________________________________, ___months/year old, M/F,

_________ (Religion), born on ______________ in ____________________________________
presently residing at ______________________________________, admitted for the
___________time in this institution on _____________.
Informant
Relationship to the patient
Reliability
Chief Complaint “Why was the patient brought to the hospital?”
History of Present Illness Onset: specific; acute or chronic
Precipitating / relieving / aggravating factors
Quantity / quality
Radiation / extent
Severity / intensity
Timing / frequency
Past Personal and Medical History
 NOTE: The prenatal, natal, and neonatal history should be included only in patients less than 2 years of age, however, if it is
related to the illness for children more than 2 years old, it must be also included as part of history.
Birth Hx Prenatal Hx

-ups; maternal nutrition

The mother was ___years old, G__P__(_____), cognizant of pregnancy at ___

weeks AOG due to amenorrhea from a previously regular/irregular menstrual
cycle, confirmed by a pregnancy test done at home/clinic. Prenatal care was
instituted at ______weeks AOG by ____________. She had a total of
____prenatal checkups done regularly/irregularly. UTZ was done at ______weeks
AOG revealing _____________________________________________. There
is/are history of exposure(s) to VED/smoking/alcohol/radiation.
Natal Hx

APGAR score

Patient was born term/preterm via NSVD/LSCS at _______________ by

_____________. BW was _____kg and BL was _____cm. Patient had
pink/cyanotic body with good/weak/no cry and limp/active limb movements upon
birth. With/without resuscitative measures done. AS:_______ BS:__________
Neonatal Hx

Feeding difficulties

Patient was breastfed/bottlefed with good/poor suck, hospital stay ______.

Umbilical stump fell off after ____days/weeks with/without signs of infection.
Newborn screening results _________________________.
 Feeding Hx feeding
 Breastfeeding: exclusive / mixed (Exclusive breastfeeding until 6 months)
 Take note of the reason why there is mixed feeding
 How many times per day
 If not breastfeeding → give reason
 Identify formula used, dilution, & amount given per day
 Needed to compute the total caloric intake per day
 Indicate any reaction to the formula

 Age introduced
 What food initially, and subsequently introduced
 Consistency of food
 Frequency of feeding per day

 Usual food intake for breakfast, lunch, dinner, and snacks

 Food intolerance
 Intake of multivitamins and iron supplementation

Patient was breastfed/bottlefed per demand/schedule up to ______ months/years old.

Complementary milk was given at ___months/years old with _________ dilution consuming about
_____ml per feeding with a frequency of about _____
Semi solid foods were introduced at _______ months. At present, sample diet includes:
Breakfast
Lunch
Dinner
Snack

Multivitamins ______________________ were given to the patient at ____ old. At present, patient
is given with ________________________________________________.
Growth & Dev’t Hx Physical Growth Birth weight
Birth Length
Present weight
Present Height
Developmental Milestone Refer to Developmental Milestone table below

Developmetal milestone are at _______ with age

Social Development

Patients sleeps ______ in the evening and wajes up at ______ in the

morning. Non/toilet trained, interacts with family and peers with/without
discipline problems.
Immunization Hx See Immunization Schedule Below

Inactivated Vaccines Live Vaccines

Hep B vaccine BCG vaccine
DPT vaccine Measles vaccine
H. influenzae B vaccine MMR vaccine
Pneumococcal vaccine Varicella vaccine
Hep A vaccine Rotavirus vaccine
Meningococcal vaccine Influenza attenuated vaccine (intranasal)
Influenza trivalent vaccine Typhoid fever (oral) vaccine
Human papillomavirus vaccine Oral polio vaccine (OPV)
Typhoid fever vaccine (IM) Japanese encephalitis
Rabies vaccine
Inactivated polio vaccine (IPV)

Vaccine Spacing and Intervals

Antigen Combination
2 or more inactivated vaccines
Inactivated and live vaccines
2 parental live vaccines
Recommended Minimum Interval
Between Doses
None; can be given simultaneously or at any interval between
doses
None: can be given simultaneously or at any interval between
doses
May be given simultaneously at the same visit
 Past Medical History

a. Past hospitalization (where/when/why)

b. Childhood illnesses
c. Allergies
d. Current medications
Family History
o Age, occupation, state of health
o If not living, cause of death
o History of consanguinity

o Number
o Age
o State of health
-familial diseases

illnesses in the family

Both parents are well. There is family history of ( ) bronchial asthma, ( ) hypertension, ( ) DM, ( )
arthritis, ( ) CVD, ( ) CAD, ( ) malignancy (specify ___________________), ( ) twinning, Others:
Social and Environmental
History o Place and nature of dwelling
o Number of persons living in the house

o Members of the family who work

o Sources of funds

o Exposure to cigarette smoke and other environmental pollutants

o Garbage disposal practices
o Water source for drinking and washing

Father is ____y/o, currently working as a ____________________, graduate of _______________.

Mother is ____ y/o currently working as a ___________________, graduate of _______________.
Primary caregiver is the ______________. Patient is the __________child of _________siblings.

Family member with the same illness?

Patient lives along a non/congested neighborhood in a ________________ house with _____ rooms
with _____ occupants. Source of water for domestic purposes comes from _________________.
Drinking water comes from ____________________ and boiled/not boiled for _________ minutes.
They have ______ pets, garbage is collected regularly every ______________. Toilet is _________
type. Handwashing practices: __________

REVIEW OF SYSTEMS
General survey ( ) weight loss, ( ) febrile episode, ( ) chills, ( ) sweats, ( ) incessant crying, ( ) irritability, ( ) poor/fair/good
oral intake, ( ) lethargy
Integumentary ( ) cyanosis, ( ) pallor, ( ) lesions, ( ) dryness, ( ) rash, ( ) itching, ( ) moles, ( )sores, ( ) hives, ( )
pigmentation
Head and neck ( ) lesion, ( ) trauma, ( )swelling, ( ) headache, ( ) pain, ( ) stiffness
Eyes ( ) tearing, ( ) itching, ( ) redness, ( ) discharges, ( ) pain, ( ) diplopia, ( ) dryness, ( ) infection, ( ) corrective
lenses (age appropriate)
Ears ( ) discharges, ( ) pain, ( ) tinnitus, ( ) vertigo, ( ) hearing loss
Nose ( ) dryness ( ) congestion, ( ) colds, ( ) sneezing, ( ) pain, ( ) obstruction, ( ) smell, ( ) bleeding
Mouth and throat ( ) soreness, ( ) pain, ( ) infection, ( ) ulcers, ( ) hoarseness, ( ) dryness, ( ) gum bleeding, ( ) dental caries,
( ) tongue lesion, ( ) swallowing problems
Breast (for adolescent ( ) discharges, ( ) lump, ( ) bledding, ( ) infection
and breast complaint)
Respiratory ( ) cough (dry/productive), ( ) sputum (white/yellow/green), ( ) pain, ( ) dyspnea, ( ) hemoptysis, ( )
cyanosis, ( ) TB/PPKI
Cardiovascular ( ) edema, ( ) cyanosis, ( ) palpitations, ( ) murmur, ( ) known CHD, ( ) rheumatic fever/RHD
Gastrointestinal ( ) good/poor appetite, ( ) anorexia, ( ) abdominal pain, ( ) vomiting, ( ) nausea, ( ) diarrhea, ( )
constipation, ( ) flatulence, ( ) melena, ( ) hematochezia, ( ) change in bowel habits, ( ) hernia, ( ) use of
laxatives or antacids, ( ) jaundice, ( ) hepatitis
Urinary an Renal ( ) dysuria, ( ) hematuria, ( ) nocturia, ( ) incontinence, ( ) frequency, ( ) stones, ( ) infections
Genital ( ) pain, ( ) swellimg, ( ) discharges, ( ) tenderness, ( ) itch
Musculoskeletal ( ) deformities, ( ) pain, ( ) swelling, ( ) tenderness, ( ) cramps, ( ) weakness, ( ) trauma, ( ) sprains, ( )
fractures, ( ) stiffness, ( ) backache
Endocrine and ( ) polydipsia, ( ) polyphagia, ( ) hair change, ( ) weight change, ( ) temperature intolerance
Metabolic
Hematologic ( ) anemia, ( ) bleeding, ( ) bruising, ( ) transfusions, ( ) malignancy
Nervous system ( ) syncope, ( ) dizziness, ( ) seizures, ( ) convulsions, ( ) tremors, ( ) coordination problems, ( )sensory
disturbances, ( ) motor problems, ( ) memory problems

PHYSICAL EXAMINATION

General Survey Ambulatory or bed-ridden

LOC or activity and cooperation
Presence of cardiopulmonary distress
Vital Signs BP
arm and 80-100% of its circumference

CR (Tachycardia is the first sign of shock in children)

RR
 Normal RR
Age Respiratory Rate (cpm)
Neonate – 2 months 40-60
2 months – 12 months 30-40
1 year – 6 years 20-30

Temp
Methods: tympanic, oral, axilla and rectal
Axillary temperature: 0.5-1.0°C lower than oral and rectal route
Rectal temperature: higher than oral by 0.4-0.5°C

O2 sat
Anthropometrics 3 major growth parameters
o Weights (kgs) (______ SD)
o Length (<2 y/o) or height (>2 y/o) in cms (______ SD)
o Head circumference (<3 y/o) in cms
- Landmarks: widest diameter of the glabella & occipital ridge

o Chest circumference (cms)

o Abdominal circumference (cms)
o Arms span; U/L ratio
o Body mass index (kg/m2) (______ SD)
Skin Examine the color, tissue turgor, loss of subcutaneous tissue, rash or eruptions, hemorrhage, scars, edema,
jaundice

( ) pallor, ( ) jaundice, ____________to touch, ___________skin turgor, ( ) rashes, ( ) petechiae, ( )

pigmentations
HEENT
Head (Quantity:hair distribution, color, texture, surface characteristics:nits and louse, Strength)
(Head circumference, Swelling and irregularity, Abnormal swelling, Shape)
- Cephalhematoma, caput succedaneum
Fontannels (Anterior vs Posterior)

( ) scars, ( ) lesions, ( ) gross deformities, ( )_________ hair distribution, non/sunken fontanels, ( ) tenderness
 Eyes : Strabismus, ptosis, slant of palpebral fissures, hypertelorism, and periorbital edema

: Size and reaction to light, opacities

: Icterisia, unusual color

non/sunken eyeballs, ( ) periorbital edema, an/icteric sclera, pale/pink palpebral conjunctiva,

____________corneal firm, pupils ERTL, ( )discharges
Ears size, position, and location of the ear in relation to the head (eg: low-set ears – common in Down
syndrome)

Otoscopy:

o If absent, signifies loss of luster of tympanic membrane (TM) due to inflammation

o Normal TM: good luster, pearly white, not bulging, no discharge, no perforation

( ) abnormally set ears, ( ) discharges, ( ) impacted cerumen, _________ tympanic membrane

Nose – midline

( ) discharges, ( ) congestion, ( ) alar flaring

Mouth and
pharynx

ymph, hyperplasia, koplik spots

______ lips, ______ buccal mucosa, ( ) circumoral cyanosis, ( ) TP wall congestion, ( ) ulcers, ( ) exudates, ( )
enanthems, ( ) pigmentation, ( ) dental caries
Neck supraclavicular and suprasternal retractions, ( ) neck vein engorgement, ( ) cervical LAD, ( ) tenderness
Chest and Lungs INSPECTION
o Infants: AP diameter = transverse diameter
o >2 y/o: transverse diameter > AP diameter

o Newborn and infants: mostly abdominal

Chest retractions
o Subcostal &/or intercostal: mild to moderate pulmonary distress
o Supraclavicular: severe pulmonary distress
PALPATION Chest y placing the palms of the hand symmetrically on the
Expansion posterior surface of the chest with the thumb touching each other in
the midline
o Ask the patient to inhale and exhale, and observe for lagging
equally as demonstrated by
the symmetrical movements of the thumbs moving away from the
midline with each inspiration and coming together during expiration
Vocal the word “tres-tres” or “ninetynine”
Fremitus repeatedly while the examiner palpates all areas of the chest and back
vibrations of equal intensity on
corresponding areas of the chest
PERCUSSION Indirect 2-finger technique
o Most common method for percussing the chest
o The pleximeter (non-dominant hand) is placed firmly on the chest wall and then
struck with the tip of the plexor (dominant)
 o The movement of the plexor should originate from the wrist and not from the elbow
systematically, comparing one side
to the other
AUSCULTATION wall
and compare breath
sounds

______________ chest expansion, ( ) lagging, ( ) retractions, __________ breath sounds, ( ) crackles, ( )

wheeze, ( ) rhonchi
Cardio INSPECTION adynamic or dynamic
and in the epigastrium
Apex beat
PALPATION Thrills
o “Purring” vibratory sensations felt by the palm placed over the precordium
o Palpable equivalent of murmurs and correlate with the area of maximal
auscultatory intensity of the murmur
AUSCULTATION -pitched sounds
-pitched sounds
sounds and their
variations with respiration
Murmur
o Should be described according to their intensity, pitch, timing (systolic and
diastolic) and variation in intensity with respiration, areas of maximal intensity and
radiation to other areas / to any part of axilla
o Grading
I Barely audible
II Medium intensity
III Loud but no thrill
IV Loud with thrill
V Loud and audible with stethoscope barely on the chest
VI Audible with stethoscope off the chest

5 Areas for listening to the heart (APETM)

1. Aortic
2. Pulmonic
3. Erb’s point
4. Tricuspid
5. Mitral

A/dynamic precordium, PMI at ______ ICS LMCL, _________ rate and _________ rythym, ( ) thrills, ( )
murmurs
Breast NOTE: Tanner Staging (Sexual Maturity Rating)
Abdomen INSPECTION vessels, striae, pulsations,
peristaltic movements and umbilical hernia
circumference
AUSCULTATION palpation and percussion to
avoid alteration of findings
first then place the diaphragm lightly on the RLQ area or mid-
abdomen. Note the character and frequency of the bowel sounds
thus listening in one spot
is usually sufficient
PERCUSSION Tympanitic Normal (except over solid organs / full
Dull Fluid, or tumor
Highly tympanitic Colic, intestinal obstruction, or ileus

It is used to detect presence of fluid in the peritoneal cavity: Fluid wave

- The examiner palpates the flank of the abdomen with one hand and taps on the
opposite flank with fingers of the other hand
- Ask the patient to place his hand on the midline to obliterate the feeling of
stretching of the skin which may affect the transmission of the fluid waves
- If fluid is present, waves will be felt by the palpating palm

Determine liver size and liver span

o Percuss along the right midclavicular line anteriorly with the pleximeter finger
o Percuss downward until resonance shifts to dullness. Mark this space as the
upper border of the liver.
o The lower edge of the liver is determined by either palpation or percussion from
the RLQ moving upward along RMCL until the tympanitic tone changes to
dullness. Mark this area as the lower liver edge and measure the 2 points as the
liver span.
PALPATION extremities semi-flexed at the
knees and hips

the abdomen, then use the

flat side of the fingers of the examiner’s dominant hand to palpate the abdomen
the area of maximal pain
o Start palpating away from the site of pain proceeding gently to the painful area
other intra-abdominal organs or masses and describe their characteristics
o Location, upper and lower borders, do they cross midline or are they in midline

flat/globular/scaphoid/flabby, non/distended, hypo/normo/hyperactive bowel sounds, tympanitic,dull, soft/rigid.

( ) tenderness, ( ) masses, ( ) organomegaly, liver span ____cm
Genitalia NOTE: Tanner Staging

grossly ________, SMR _______

MALE Prepuce should be easily retractable so that when the preputial folds are held up by both
hands, a tunnel is formed and the meatal opening can be easily seen
Phimosis
o Present if the preputial sac is very narrow and cannot be retracted
Urethra (Hypospadia vs Epispadia)

o Left side of the scrotum is usually lower than the right but both sides should be equal
in size
o If unequal:
- Larger side: may be due to presence of hydrocele, hernia or enlarged testes
- Smaller side: may be associated with absent testes (cryptorchidism)
FEMALE patients should be treated with extra care to prevent
psychological trauma

Vulvovaginal area
o Position patient in frog leg position followed by the knee-chest position to allow
adequate assessment of the introital lower third vaginal area
o Gentle traction on the labia upward and outward helps expose the vaginal introitus for
assessment
o Presence of discharges and laceration should be noted

Anus & Rectum with head curled down as in fetal position to expose the anus
pinworms, prolapse, etc.
feces, bleeding and tenderness
Extremities for clubbing, cyanosis, signs of joint inflammation, range of motion and joint deformities
Schamroth’s sign
o Appose the dorsal surfaces of the terminal phalanges of corresponding fingers
o Normal: there is a diamond-shaped space at the base of the nail bed
o Clubbing: the space is lost

( ) gross deformities, __________ peripheral pulses, _______capillary refill time

Neuro Exams Cerebral function:
Cerebellum function: ( ) tremors, ( ) nystagmus, ( ) ataxis
Carnial nerve function test:
CN I: ( ) smell
CN II: ( ) see
CN II and III: pupillary light reflex ____________
CN III, IV and VI: extraocular muscle movements
CN V: ( ) corneal reflex, ( ) chew
CN VII: a/symmetric nasolabial folds on smiling
CN VIII: ( ) sense of hearing
CN IX and X: uvula at mdline/deviated to R/L, ( ) gag reflex
CN XI: _________ to shrug shoulder, ________ to move head from side to side
CN XII: _________ to protrude tongue, ( ) deviation, ( ) fasciculations

Sensory: Motor: Reflexes:

Babinski:
Ankle clonus:
Kernig’s sign:
Brudzinski sign: