I. History |
- 1. Chief Complaint
- a. Brief statement of primary problem (including duration) that caused family to seek medical attention
|
- 2. History of Present Illness
- a. Initial statement identifying the historian, that person's relationship to patient, and their reliability
- b. Age, sex, race, and other important identifying information about patient
- c. Concise chronological account of the illness, including any previous treatment with full description of symptoms (pertinent positives and pertinent negatives). Information relevant to the differential diagnosis of the chief complaint belongs here
|
- 3. Past Medical History
- a. Major medical illnesses
- b. Major surgical illnesses: list operations and dates
- c. Trauma: fractures, lacerations
- d. Previous hospital admissions with dates and diagnoses
- e. Current medications
- f. Known allergies (not just drugs)
- g. Immunization status: be specific, not just "up to date"
|
- 4. Pregnancy and Birth History
- a. Maternal health during pregnancy: bleeding, trauma, hypertension, fevers, infectious illnesses, medications, drugs, alcohol, smoking, rupture of membranes
- b. Gestational age at delivery
- c. Labor and delivery: length of labor, fetal distress, type of delivery (vaginal, cesarean section), use of forceps, anesthesia, breech delivery
- d. Neonatal period: Apgar scores, breathing problems, use of oxygen, need for intensive care, hyperbilirubinemia, birth injuries, feeding problems, length of stay, birth weight
|
- 5. Developmental History
- a. Ages at which milestones were achieved and current developmental abilities: smiling, rolling, sitting alone, crawling, walking, running, first word, toilet training, riding tricycle, etc.
- b. School: present grade, specific problems, interaction with peers
- c. Behavior: enuresis, temper tantrums, thumb sucking, pica, nightmares, etc.
- d. Feeding history
|
6. Review of Systems |
- 7. Family History
- a. Illnesses: cardiac disease, hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy and asthma, epilepsy
- b. Mental retardation, congenital anomalies, chromosomal problems, growth problems, consanguinity, ethnic background
|
- 8. Social environment
- a. Living situation and conditions: daycare, safety issues
- b. Composition of family
- c. Occupation of parents
|
II. Physical Examination |
- 1. General Approach
- a. Gather as much data as possible by observation first
- b. Position of child: parent's lap vs. exam table
- c. Stay at the child's level as much as possible. Do not tower!
- d. Order of exam: least distressing to most distressing
- e. Rapport with child
- f. Include child: explain to the child's level
- g. Distraction is a valuable tool
- h. Examine painful area last: get general impression of overall attitude
- i. Understand impact of developmental stage on child's response
- j. Assess level of consciousness, mental status, and ability to cooperate; nutritional and hydration status, and signs of toxicity
|
- 2. Vital signs (resting heart rate, respirations, blood pressure, temperature, body weight, length or height, and head circumference)
- a. Obtain accurate weight, height, and OFC
|
- 3. Skin and Lymphatics
- a. Birthmarks: nevi, hemangiomas, mongolian spots, rashes, petechiae, desquamation, pigmentation, jaundice, texture, turgor
|
- 4. Head
- a. Size and shape
- b. Fontanelle(s)
- c. Tension: supine and sitting up
- d. Sutures: overriding
- e. Scalp and hair
|
5. Eyes: stabismus, slant of palpebral fissure, hypertelorism or telecanthus, EOM, pupils, conjunctiva, sclera, cornea, red reflex, visual fields |
6. Ears: position of ears, hearing |
7. Nose: nasal septum, discharge, sinus tenderness |
8. Mouth, throat, neck: lips (color, fissures), gag reflex, tonsils (size, color, exudates), palate (intact, arch), teeth and gums (number, condition), posterior pharyngeal wall (color, bulging) |
9. Lungs and thorax: intercostal retractions, breathing pattern, hyper/hypoventilation and breathing regularity, stridor, air exchange, rales |
10. Cardiovascular: heart rate and rhythm, murmurs, thrills, and bruits |
11. Abdomen: tenderness and pain, bowel sounds, masses, fluid collections and tumors, hepatomegaly and spelenomegaly |
12. usculoskeletal: joint tenderness or erythema, increased or decreased tone, axial slippage to ventral and vertical suspension, atrophy, hypertrophy especially of calf, hammer toes, high arches, Gower sign, strength, pronator drift, scoliosis, and spinedimples or lumbar hair tufts |
- 13. Back
- a. Sacral dimple
- b. Kyphosis, lordosis, or scoliosis
- c. Joints: motion, stability, swelling, tenderness
- d. Muscles
- e. Extremities
- Deformity
- Symmetry
- Edema
- Clubbing
|
- 14. Gait
- a. In-toeing, out-toeing
- b. Bow legs, knock knee
- c. "Physiologic" bowing is frequently seen under 2 years of age and will spontaneously resolve
- d. Limp
- e. Hips
- f. Ortolani and Barlow signs
|
III. Neurological Examination |
- 1. Mental status
- 2. Cranial nerves
- 3. Muscle tone and strength
- 4. Sensation
- 5. Cerebellum
- 6. Infant reflexes
- 7. Deep tendon reflexes
|