How to report Pediatrics

Examination
 CNS Examination
• OFC is___ cm which is below or above the __ centile for age and sex and anterior fontanelle is
patent and measures __ by __ cm.

• Conscious and alert, oriented in time, person and place;

• Long and short term memories were intact

• Has above average intelligence, adequate speech and is right/left handed which suggests left/right
cerebral dominance respectively

• Neck is supple; Brudzinski, Kernig and Lasegue sign were all –ve

• Cranial nerves 1-12 are intact

• Muscle bulk is reduced/normal, Normotonia across all joints, Power at least grade 4 and
Normoreflexia

• Plantar reflex is flexor

• Normal gait and Posture

 Respiratory Examination
• Respiratory rate is __ c/min and regular which is/isn’t within the normal range for
age

• Anterior nares are clear and tonsils not enlarged

• In no obvious respiratory distress

• Chest wall is symmetrical and equal chest excursion

• Trachea is central, equal chest expansion at all lung zones, normal tactile fremitus

• Percussion is resonant in all lung zones except for areas of cardiac and hepatic
dullness

• Good air entry, breath sound is bronchio-vesicular(for <2yrs)/ vesicular (for >2yrs),
vocal resonance is normal and no added sounds.
 Cardiovascular System Examination
• Pulse is __b/min which is/isn’t within the normal range for age,
full volume and regular [FVR]

• There’s radio-radial, carotid and femoral synchrony; No

collapsing pulse

• BP is ___ mmHg [normal or elevated], JVP isn’t raised

[remember only done in >2yrs]

• Precordium is active, apex beat is at the 4th/5th LICS MCL. No

heave

• Heart sounds 1 and 2 were heard

 Digestive System Examination
• Good oral hygiene, Abdomen is full and moves with
respiration; umbilicus is ______

• No areas of tenderness, liver and spleen were not palpable

• Percussion is tympanic and Liver span is __cm, no

demonstrable ascites by shifting dullness

• Bowel sound is present and normoactive

• DRE: Good anal hygiene, no skin tag, no perianal

excoriation; mother didn’t give consent to put hand
 Urogenital System Examination
• Normal male/female external genitalia [for males:
with Tanner Staging of ___]

• External meatus is patent, 2 testicles palpable in

the scrotum

• There was no suprapubic and flank fullness,

bladder wasn’t palpable, kidneys weren’t
ballotable, no renal bruit
 Musculoskeletal System Examination
• No ulcer, no swelling, no area of skin discoloration
• N/B: If there’s any lesion or ulcer, characterize it in details
• Ulcer: Site
Size
Edge
Floor
Differential warmth
• Swelling: Site
Size
Consistency
Surface
Differential warmth
Attachment
Mobility
• Anthropometry: Height, Arm span, US/LS, Limb length (real and apparent)

• No differential warmth, no area of tenderness and no crepitus was heard in all limbs.

• Full range of movement across all joints

• No Gibbous