THE PEDIATRIC HISTORY

I. General Principles:
Smile and greet parents, child if old enough.
Introduce yourself.
Establish rapport and try to make family feel comfortable.

II. Date of interview, source and reliability.

III. General Data: Name, age, sex, residence, number of times admitted and date of
present admission.

IV. Chief Complaint: Brief statement of the primary problem that caused the family to
seek medical attention, preferably using patients or informants own words.

V. History of the Present Illness: Concise chronological account of the illness, from
the onset to the latest including any previous treatment with full description of
symptoms, pertinent positives and pertinent negatives. It belongs here if related to
the differential diagnosis for the chief complaint.

Tip for describing symptoms if applicable: CLITAA
C Character
L Location
I Intensity
T Timing
A Associated signs and symptoms
A Aggravating and relieving factors

If neonate, start HPI from birth.

VI. Medical History: General state of health as the parents or patient perceives it.

A. Birth History: Particularly important during the first 2 years of life and when
dealing with neurologic and developmental problems
1. Neonates and Infants
Prenatal history: mother's age, gravida, parity, abortions, health during
pregnancy (bleeding, trauma, hypertension, gestational diabetes,fever,
infections, medications, radiation exposure, drugs, alcohol, smoking, rubella
immunity status, hepatitis B, rupture of membranes), nutritional patterna and
specific illnesses
Natal history (Labor and Delivery): gestational age at delivery, spontaneous
or induced, duration of labor, duration of rupture of membranes prior to
delivery, complications, medications or anesthesia, vertex or breech
presentation, vaginal or cesarean section, meconium staining of amniotic
fluid, birth order, if a multiple birth and birth weight
2. All Children
Neonatal history: Apgar score, breathing problems, use of oxygen, need for
intensive care, problems in nursery ( e.g. meconium stained, birth injuries,
jaundice, feeding difficulty, respiratory distress), length of stay in nursery,
estimated gestational age by ballard score, if AGA, SGA or LGA

B. Nutrition/Dietary History
1. Infancy: breast or formula, frequency, amount, problems, when was the
introduction of solids and problems, any change in formula and why, peculiar
eating habits (pica), vitamin/mineral supplements
2. Childhood: good appetite or "picky eater", special diets, milk intake, "junk
foods", concerns about weight, vitamin/mineral supplements

C. Growth and Developmental History
1. Physical growth: actual or approximate weight and height at 1, 2, 5 and 10
years, history of slow or rapid gains or losses, tooth eruption and loss pattern
2. Developmental milestones:
Gross Motor:
Fine Motor:
Language:
Personal-Social: eating, dressing, grooming, household chores, toileting,
sleep patterns, habits, discipline and temperament, play and relationship
with others, personality
3. School Performance (Preschool and School Children)
a. Language skills
b. Reading skills
c. Writing skills
d. Sequential concepts and math skills
e. Problem solving, reasoning and moral development
4. Pubertal History (Adolescents)
a. Male
Age of onset
Genital Enlargement
Pubic Hair
b. Female
Age of onset
Breast
Pubic Hair
Age of Menarche, Frequency, Duration, LMP, Dysmenorrhea, Meds

D. Past Illnesses
1. Childhood illnesses, age, complications, treatment
2. Recent infection exposures, date, travel to other locations, animal exposure
3. Previous hospitalizations, age, length of stay, reason, location
4. Previous surgery/ transfusions age, reason for procedure, complication
5. Trauma/ injuries/ ingestions, age, circumstances surrounding event,
treatment, complication
6. Screening procedures
7. Allergies and drug reactions
8. Previous and current medications and disabilities

E. Immunization History: Don't rely on memory; ask to see record. Check if up to
date.
BCG
DPT
OPV
Hepatitis B
HIB
PCV
Rotavirus
Measles
Varicella
MMR
Typhoid
Hepatitis A
Meningoccocal
Flu
Booster doses
Others: Rabies,
HPV, Pneumo 23


VII. Family History
A. Illnesses: cardiac disease, hypertension, stroke, diabetes, cancer, abnormal
bleeding, asthma, epilepsy, kidney disease
B. Others: mental retardation, developmental delay, congenital anomalies,
chromosomal problems, miscarriages, infant or childhood deaths, growth
problems, consanguinity, ethnic background

VIII. Psychosocial History: An outline or narrative description that captures important
and relevant information about patient as person, patients lifestyle, home situation
and significant others
A. Infants and Older Children
1. Living situation and conditions - daycare, safety issues including water source
2. Composition of family
3. Occupation of parents
4. Religious and health beliefs of family
B. Adolescents (HEADSSS)
1. Home: What is the living arrangement? Any recent changes in the living
arrangement? Relationships in the home? Any issues that causes
arguments? Economic issues? Stresses in the home? Forms of discipline?
Anything the adolescent wishes to change in the family?
2. Education/Employment: Is patient currently in or out of school or employed?
Where? Favorite subject? Average last grading/semester? Any problems with
classmates or teachers? Ever been truant/suspended/expelled from school?
What are the patients future education/employment goals?
3. Activities: What does the patient do in spare time? Hobbies and interests?
How much time does he spend watching TV, playing computer games and
using the internet? With whom does the patient spend time with? Any close
friends? Are the patients friends attending school?
4. Drugs/Other Substance of Abuse: Does the adolescent or any of his friends
use tobacco, alcohol, drugs? If yes, details (what, frequency, amount) and
how/why started? Effects on daily activities? Selling drugs?
5. Sexuality/Sexual Activity: Sexual orientation? Sexual development?
Dating? Details such as is patient having sex or have had sex? With whom,
how often or when was the last time? Any use of contraception? Having
symptoms of STD? Any history of physical or sexual abuse?
6. Suicide/Depression: Is the adolescent ever sad? Unmotivated? Hopeless?
Lonely? Why? What does he do when the feeling comes? Who does he talk
to? Has the adolescent ever thought of hurting others or himself?Has suicide
plan? If yes, assess seriousness and whether needs immediate referral.
7. Safety: Does the adolescent use seat belts/helmets? Is he a member of a
fraternity or gang? Does he carry a weapon for protection? Is there a firearm
in the adolescents home?

IX. Review of Systems
A. General: fever, recent changes in weight, also include patient's activity level,
playfulness, appetite, sleep habits, days of school missed
B. Skin and Lymph: rashes, adenopathy, lumps, easy bruising, bleeding,
pigmentation changes, eczema
C. HEENT: headache, dizziness/fainting, seizures, strabismus, conjunctivitis, visual
problems, hearing, ear infections, draining ears, neck mass, stuffy or runny nose,
allergic rhinitis, sore throat, mouth breathing, snoring, apnea, epistaxis, teeth or
gum problem
D. Cardiovascular: cyanosis, heart murmurs, exercise tolerance, squatting, chest
pain, palpitations
E. Respiratory: wheezing, chronic cough,dyspnea, asthma, hemoptysis, PTB
F. GIT: abdominal pain or colic, changes in appetite, vomiting, diarrhea, stool color
and character, constipation, hematemesis, jaundice/hepatitis
G. GUT: urinary frequency, nocturia, polyuria,dysuria, bladder control, hematuria,
discharge, quality of urinary stream, previous infections, facial edema! change in
urinary pattern such as enuresis in previously toilet trained child
H. Musculoskeletal: joint pains or swelling, scoliosis, myalgia or weakness,
injuries, gait changes
I. Reproductive (Adolescents): secondary sexual characteristics, menses and
menstrual problems, pregnancies, sexual activity, genital discharges






THE PEDIATRIC PHYSICAL EXAMINATION
I. General Approach
A. Gather as much data as possible by observation first
B. Position of child: parents lap vs. exam table
C. Stay at the childs level as much as possible. Do not tower!!
D. Order of exam: from least distressing to most distressing with painful area last
E. Establish rapport with child
1. Explain to the childs level
2. Distraction is a valuable tool
F. Be honest. If something is going to hurt, tell them in a calm fashion. Dont lie or
you lose credibility!
G. Understand developmental stages impact on childs response. For example,
stranger anxiety is a normal stage of development, which tends to make
examining a previously cooperative child more difficult.
H. For adolescents, while doing PE, teach females the breast self-exam and males
the testicular exam.

II. General Survey
Development
Nutritional status: weight, height, BMI (kg/m
2
)
Presence or absence of distress
Sensorium and orientation
Type of cry or voice
State of hydration (ask about urine output)
Posture and gait

III. Vital Signs
Temperature
Heart rate (HR)
Respiratory rate (RR)
Blood pressure (BP): appropriate size cuff is 2/3 width of upper arm
Other anthropometric measurements
Head circumference (HC) during 1st 3 years
Chest circumference (CC)
Abdominal circumference (AC)
Pain

IV. Skin and Lymphatics
A. Birthmarks: nevi, hemangiomas, mongolian spots, etc
B. Color: pale or sallow, cyanotic, flushed, jaundice
C. Lesions: rashes, petechiae, desquamation, pigmentation, infections
D. Texture: turgor, moisture, CRT
E. Lymph node: enlargement, location, mobility, consistency
F. Scars or injuries, especially in patterns suggestive of abuse

V. HEENT
A. Face: expression, asymmetry, paralysis, facies
B. Head: contour, bossing, texture of hair, scalp, fontanelles
C. Eyes: conjunctivae, sclerae, PERLA, strabismus, EOM, ptosis, red orange reflex,
vision, eye contact and visual tracking
D. Ears: position, deformities, hearing, discharges, ear canals, tympanic
membranes, mastoid tenderness
E. Nose: patency, flaring of the alae nasi, discharges, nasal septum, nasal mucosa
color, polyps, sinus tenderness
F. Mouth and Throat: color of lips and buccal mucosa, fissures, lesions or sores,
tongue color and character, dental caries, color and character of gums, size,
color and exudates of tonsils and pharynx, gag relex
G. Neck: thyroid enlargement, trachea at midline, masses, sizes and character of
lymph nodes, presence or absence of nuchal rigidity

VI. Chest and Lungs
A. Inspection: contour of thorax and spine, symmetry of expansion, rate and
regularity of respiration, use of accessory muscles, retraction location
B. Palpation and percussion often not possible and rarely helpful
C. Auscultation: equality of breath sounds, stridor, wheezes, rhonchi, rales

VII. Heart
A. Inspection: precordial bulge or heave
B. Palpation: PMI diffused or circumscribed, thrills
C. Percussion: heart borders
D. Auscultation: rate, rhythm, murmurs, quality of heart sounds

VIII. Abdomen
A. Inspection: distended or scaphoid, visible veins, visible masses, umbilical
infection or hernia
B. Palpation: masses, organomegaly, direct and rebound tenderness
C. Percussion: tympanitic, dullness
D. Auscultation: bowel sounds

IX. Genito-Urinary Tract
A. Male: circumcision, phimosis, meatus, descent of testes, hydrocoele, inguinal
hernia, Tanner staging or SMR in adolescents
B. Female: external examination only, vulva, clitoris, discharge, Tanner staging or
SMR in adolescents

X. Rectal
Look for fissures, hemorrhoids, prolapse, sphincter tone, masses, tenderness, stool
in ampulla

XI. Extremities
A. General: deformity, symmetry, color, warmth, clubbing, edema
B. Pulses: presence, quality, equality
C. Joints: motion, stability, swelling, tenderness
D. Hips: Ortolanis and Barlows signs
E. Back: sacral dimple, kyphosis, lordosis or scoliosis
F. Gait: in-toeing or out-toeing, bow legs or knock knees, limping

XII. Neurologic
A. Cranial nerves I-XII (mnemonic: On Old Obando Tower Top A Filipino Army
Guard Villages And Huts)
B. Motor: paresis, paralysis, spasticity, romberg, rigidity, flaccidity, clonus,
carpopedal spasm, tics, tremors, athetosis
C. Reflexes: DTRs (biceps, triceps, radial, knee, ankle), superficial (abdominal,
cremasteric, primitive (moro, rooting, sucking, grasp, ATNR)
D. Sensory: superficial and deep sensations, pin-prick, touch, sense of position,
vibratory sense
E. Cerebellar signs: incoordination ataxia, intention tremor, past pointing,
dysdiadochokinesia, nystagmus on extreme lateral gaze