History History and Physical Exam of the Pediatric Patient Colleen A. Kraft, M.D., FAAP Richmond Pediatric Associates, Inc. Source Who is giving the history? Is this the patient s primary caretaker? 1 2 Chief Complaint In the patient s or the historian s words History of Present Illness How long has the problem been going on? Specific symptoms location, quality Severity of symptoms What makes symptoms better? Any other family members affected? Current and past meds being used 3 4 Pregnancy Gestational age at delivery GxPxAx and age of mother at delivery Associated problems with pregnancy Drug (legal or illicit) use Multiple pregnancy 5 Labor and Delivery Vaginal or cesarean section If C/S, why? Birth weight appropriate for gestational age Apgar scores Did infant leave hospital with mother? 6
History of Hospitalizations What age Duration Reason Medications Current, with doses Past if appropriate Drug and alcohol use in adolescents OTC Medications Herbal or homeopathic remedies 7 8 Allergies Immunizations Up to date? to medications to foods or other substances HBV DTaP IPV Hib Pneumococcal Conjugate MMR Varicella 9 10 Diet History Infants Breast fed or formula fed first year Solids at 4-6 months age Solids primary source of nutrition after 1 yr Specific Development Age appropriate milestones Observe specific milestones Gross motor Fine motor Language Social / emotional 11 12
Development School age children School performance Poor performance = developmental problem Family History Focus on conditions that may pertain to your patient s diagnosis Mental Retardation Early infant deaths and causes, if known Seizures..ask if hx as child Asthma ask if hx as child Behavioral or psychiatric disorders 13 14 Social History Who lives with child? Primary caretaker? Day care? Left alone? Social History Current Health Status Sleep Elimination Safety concerns.bike helmet? Guns? Pets? Smoke detector? Sexual activity/contraception 15 16 Physical Examination Remember to compare your findings to what is normal for your patient s age Position for Examination Newborn to 6mo.fully undressed, on exam table 6 months to 2-3 years in parent s lap 3 years to mid school age parents present Adolescent draped, parent not present unless requested by adolescent 17 18
Vital Signs Height Weight Head circumference Position on the growth curve Temperature Pulse Respirations Blood Pressure Vital Signs 19 20 Head Circumference Scalp Sutures Anterior/posterior fontanelle Eyes Red reflex Sclera/conjunctivae Vision Extraocular movements.strabismus Eye drainage 21 22 Ears Pinna Rash behind ears..seborrheic dermatitis canal tympanic membrane * light reflex * color * mobility 23 Nose Mucosa should be pink * gray and boggy allergy * red and inflamed.infection 24
Mucosa * ulcerations * oral thrush Mouth and Throat Mouth and Throat Teeth * first by 12 months * dentition milk bottle syndrome? 25 26 Mouth and Throat Tonsils * appear larger in children when compared to adults * tonsils smaller, pharynx larger with age Lymph Nodes Shotty nodes (0.5 to 1.0cm) in anterior cervical and inguinal regions Greater than 2cm significant 27 28 Skin Note areas of abnormality * rashes * birthmarks.nevus flaameus, hemangiomas, café-au-lait spots Chest Skeletal anomalies Tanner stage of breast development Breast exam in adolescents 29 30
Respiratory rate Lungs * Most accurate indicator of presence or absence of respiratory pathology * Can be elevated by fever or congestion in young infants Lungs Observe for * intercostal retractions * nasal flaring, grunting * rhonchi, wheezes, rales * symmetry 31 32 Norms for heart rate and blood pressure For school age and up 95% * 100 + 2(age) /70 + 1.5(age) * for 8yr old.116/82 Point of Maximal Impulse * right sided in newborns, shifts to the left by 5-6 months of age 33 34 Murmurs * Innocent Still s murmur Vibratory hum Abnormal Murmurs * radiate to back * may be heard across the precordium * Grade IV / VI, associated with thrill 35 36
Pulses * Femoral pulses * symmetry/character.bounding? absent? Abdomen Soft vs. hard Tenderness assess while child is distracted Hernias umbilical, inguinal Bowel sounds Rectal not routinely done 37 38 Genitalia Testicles descended in males? Hypospadias Hydroceles Ambiguous genitalia rash or drainage, either sex Tanner stage for pubic hair Musculoskeletal Exam Developmental dislocation of hip * hip click in newborns * repeat exam until walking 39 40 Musculoskeletal Scoliosis Gait * observe with diaper off * symmetry * limping * tibial torsion, metatarsus adductus Neuro Exam Infant * primitive reflexes moro, root, grasp, suck * symmetry * lethargy, irritability 41 42
Neuro Exam Older child * cranial nerves * strength * sensation * deep tendon reflexes * cerebellar * coordination History and Physical Exam of the Pediatric Patient Colleen A. Kraft, M.D., FAAP Richmond Pediatric Associates, Inc. 43 44