Pediatric history and_physical_examination

1. PEDIATRIC HISTORY AND
PHYSICAL E X AMIN ATION
Dr. Harish Kumar Singhal
Associate Professor
University College of Ayurved
Dr. S. R. Rajasthan Ayurved University, Jodhpur
Email:-drharish_md@yahoo.co.in

2. PEDIATRIC HISTORY TAKING
• Identifying Data:
– Patient's name
• If minor then name of visitor to doctor who visit to clinic. Mention Name and
relationship to child of informant (e.g., patient, parent, legal guardian).
– Age
– Sex
– Address
– Habitat
– Socio - economic status
– Dietary pattern
– Provisional diagnosis
– Final diagnosis
– Date of admission & Date of Discharge

3. • Chief Complaint:
– Reason given for seeking medical care and the duration of the
symptom(s).
– Always recorded in chronological orders.
• History of Present Illness (HPI): Describe the course of the patient's
illness, including when it began and the character of the symptom(s);
aggravating or alleviating factors; pertinent positives and negatives.
Past diagnostic testing.
• Past Medical History (PMH): Past diseases, surgeries, hospitalizations;
medical problems; history of asthma. Birth History: Gestational age at
birth, whether preterm, obstetrical problems

4. • Developmental History: Motor skills, language development,
self-care skills.
• Medications: Include prescription and over-the-counter ,drugs,
vitamins, herbal products, homeopathic drugs, natural remedies,
nutritional supplements.
• Feedings: Diet, volume of formula per day.
• Immunizations: Up-to-date
• Drug Allergies: Penicillin, codeine
• Food Allergies
• Family History: Medical problems in family, including the patient's
disorder. Asthma, cancer, tuberculosis, HIV, diabetes, allergies.
• Social History: Family situation, living conditions, alcohol,
smoking, drugs. Level of education.

5. Gross Motor Milestones
Age Milestone
3 months
5 months
8 months
9 months
10 months
11 months
12 months
13 months
18 months
24 months
36 months
Neck holding
Sitting with support
Sitting without support
Standing with support
Walking with support
Crawling
Standing without support
Walking without support
Running
Walking upstairs
Riding tricycle

6. Age Milestone
4 months
5 months
7 months
9 months
Grasp a rattle when placed in hands
Reaches out to an object and hold it
with both hands (bidextrous grasp)
Holding objects with crude grasp from palm
(palmer grasp)
Holding small objects between index finger and
thumb (pincer grasp)
Fine Motor Milestones :

7. Language Milestones
Age Milestone
1 months
3 months
6 months
9 months
12 months
18 months
24 months
36 months
Turns head to sound
Cooing
Monosyllables ('ma' 'ba')
Bi syllables (Mama' 'baba')
Two words with meaning
Ten words with meaning
Simple sentences
Telling a story

8. Personal & Social Milestones :
Age Milestone
2 months
3 months
6 months
9 months
12 months
36 months
Social smile
Recognising mother
Smiles at mirror image
Waves 'bye-bye'
Plays a simple ball game
Knows gender

9. Immunization schedule
AGE VACCINES
BIRTH • BCG, OPV- Zero dose
• Hep B ( If endemic area / mother is hepatitis B
positive)
6 weeks Penta - 1 ( DPT + Hep B + Hibs B) & OPV-1
10 weeks Penta - 2 ( DPT + Hep B + Hibs B) & OPV2
14 weeks Penta - 3 ( DPT + Hep B + Hibs B) & OPV-3
9 months Measles +Vitamin A
16-24 months DPT (B),OPV(B)
4-6 years DT
10 years TT
16 years TT

10. REVIEW OF SYSTEMS (ROS):
• General: Weight loss or weight gain, fever, chills, fatigue, night sweats.
• Skin: Rashes, skin discolorations.
• Head: Headaches, dizziness, seizures.
• Eyes:Visual changes.
• Ears:Tinnitus, vertigo, hearing loss.
• Nose: Nose bleeds, nasal discharge.
• Mouth and Throat: Dental disease, hoarseness, throat pain.
• Respiratory: Cough, shortness of breath, sputum (color and consistency).
• Cardiovascular: Dyspnea on exertion, edema, valvular disease.
• Gastrointestinal: Abdominal pain, vomiting, diarrhea, constipation, blood in
stools .

11. • Genitourinary: Dysuria, frequency, hematuria.
• Gynecological: Last menstrual period (frequency, duration), age of
menarche; dysmenorrhea, contraception, vaginal bleeding, breast masses.
• Endocrine: Growth delay, polyphagia, excessive thirst/fluid intake, menses
duration, amount of flow.
• Musculoskeletal: Joint pain or swelling, arthritis, myalgias.
• Skin and Lymphatics: Easy bruising, lymphadenopathy.
• Neuropsychiatric:Weakness, seizures.
• Pain: Quality (sharp/stabbing, aching, pressure), location, duration

12. PHYSICAL EXAMINATION
• Observation: Child's facial expression (pain), response to social overtures.
Interaction with caretakers and examiner. Body position (leaning forward in
sitting position; epiglottises', pericarditis).Weak cry (serious illness), high-pitched
cry (increased intracranial pressure, metabolic disorder); moaning (serious illness,
meningitis), grunting (respiratory distress).
• Does the child appear to be: (1)Well, acutely ill/toxic, chronically ill, wasted, or
malnourished? (2) Alert and active or lethargic/fatigued? (3)Well hydrated or
dehydrated? (4) Unusual body odors?
• General appearance: Note whether the patient looks "ill,“ well, or
malnourished.
• Physical Measurements: weight, height; head circumference if less
than 36 months, body mass index (BMI). Plot on age-appropriate growth charts.

13. • Vital Signs: Temperature, heart rate, respiratory rate, blood pressure.
• Skin: Rashes, scars, moles, skin turgor, capillary refill (in seconds).
• Lymph Nodes: Cervical, axillary, inguinal nodes: size, tenderness.
• Head: Bruising, masses, fontanels.
• Eyes: Pupils: equal, round, and reactive to light and
accommodation (PERRLA); extra ocular movements intact (EOMI).
Funduscopy (papilledema, hemorrhages, exudates).
• Ears: Acuity, tympanic membranes (dull, shiny, intact, infected, bulging).

14. • Mouth and Throat: Mucous membrane color and moisture; oral
lesions, dentition, pharynx, tonsils.
• Neck: Thyromegaly, lymphadenopathy, masses.
• Lungs: Breathing rate, depth, expansion, prolongation of expiration, fremitus,
dullness to percussion, breath sounds, crackles, wheezing, rhonchi.
• Heart: Location of apical impulse. Regular rate and rhythm (RRR), first and
second heart sounds (S1, S2); gallops (S3, S4), murmurs (location, position in
cycle, intensity grade 1-6, pitch, effect of change of position, transmission).
Comparison of brachial and femoral pulses.
• Breast: Discharge, masses; axillary masses.
• Abdomen: Bowel sounds, bruits, tenderness, masses; hepatomegaly,
splenomegaly; guarding, rebound, percussion note (tympanic), suprapubic
tenderness.
• Genitourinary: Inguinal masses, hernias, scrotum, testicles.
• Pelvic Examination: Vaginal mucosa, cervicaldischarge, uterine size, masses,
adnexal masses, ovaries.
• Extremities: Joint swelling, range of motion, edema (grade 1-4+);
cyanosis, clubbing, edema (CCE), peripheral pulses.
• Rectal Examination: Sphincter tone, masses, fissures; test for occult blood

15. • Neurological: Mental status and affect; gait, strength(graded 0-5), sensation,
deep tendon reflexes (biceps,triceps, patellar, ankle; graded 0-4+).
• Labs: Electrolytes [sodium, potassium, bicarbonate, chloride, blood urea
nitrogen (BUN), creatinine], CBC (hemoglobin, hematocrit, WBC count,
platelets, differential); X-rays, ECG, urine analysis (UA), liver function tests
(LFTs).
• Assessment (Impression): Assign a number to each problem and discuss
separately. Discuss differential diagnosis and give reasons that support the
working diagnosis; give reasons for excluding other diagnoses.
• Plan: Describe therapeutic plan for each numbered problem, including
testing, laboratory studies, medications.

16. PROGRESS REPORT
• Daily progress notes should summarize developments in a patient's hospital course, problems that remain active, plans to
treat those problems, and arrangements for discharge. Progress notes should address every element of the problem list.
• Example Progress Note
• Date/time:
• Identify Discipline and Level of Education: eg, Pediatric resident PL-3
• Subjective: Any problems and symptoms of the patient should be charted. Appetite, pain, or fussiness may be included.
• Objective:
• General appearance.
• Vitals, including highest temperature (Tmax ) over past 24 hours. Feedings, fluid inputs and outputs (I/O), including oral and
parenteral intake and urine and stool volume output. Physical exam, including chest and abdomen, with particular attention
to active problems. Emphasize changes from previous physical exams.
• Labs: Include new test results and flag abnormal values.
• Current Medications: List all medications and dosages.
• Assessment and Plan: This section should be organized by problem. A separate assessment and plan should be written
for each problem.

17. DISCHARGE NOTES
• The discharge note should be written in the patient's chart prior to
discharge.
• Discharge Note
• Date/time:
• Diagnoses:
• Treatment: Briefly describe treatment provided during hospitalization,
including surgical procedures and antibiotic therapy.
• Studies Performed: Electrocardiograms, CT scans.
• Discharge Medications:
• Follow-up Arrangements:

18. DISCHARGE SUMMARY
• Patient's Name and Medical Record Number:
• Date of Admission:
• Date of Discharge:
• Admitting Diagnosis:
• Discharge Diagnosis:
• Attending or WardTeam Responsible for Patient:
• Surgical Procedures, Diagnostic Tests, Invasive Procedures: History, Physical Examination
and Laboratory Data: Describe the course of the patient's disease up until the time that the
patient came to the hospital, including pertinent physical exam and laboratory data.
• Hospital Course: Describe the course of the patient's illness while in the hospital, including
evaluation, treatment, medications, and outcome of treatment.
• Discharged Condition: Describe improvement or deterioration in the patient's condition,
and describe the present status of the patient. Disposition: Note the situation to which the
patient will be discharged (home), and indicate who will take care of the patient. Discharge
Medications: List medications and instructions for patient on taking the medications.
Discharge Instructions and Follow-up Care: Date of return for follow-up care at clinic; diet.
• Problem List: List all active and past problems.
• Copies: Send copies to attending, clinic, consultants.

19. PRESCRIPTION WRITTING
• Patient's name:
• Date:
• Drug name, dosage form, dose, route, frequency
(include concentration for oral liquids or mg strength for
oral solids):Amoxicillin 125mg/5mL 5 mL PO tid
• Quantity to dispense: mL for oral liquids, mg for oral solids
• Refills: If appropriate
• Signature

20. Thankyou…….

21. Queries are invited ?