HISTORY-TAKING-AND-PHYSICAL-EXAMINATION Pediatrics

HISTORY TAKING AND
PHYSICAL EXAMINATION
HISTORY TAKING IN A
PEDIATRIC PATIENT
Information during history
taking in the pediatric
patient almost completely
depends upon the caregivers.
…remember
Make
Introduce
yourself
yourself.
presentable.
Practice
“common
Focus Tagalog
medical
terms”
COMPONENTS OF HISTORY AND PE
History of
Chief Past Medical Family
General Data Present
Complaint History History
Illness (HPI)
Personal and Birth and Growth and Nutritional

HEADSSS
Social Maternal Development (feeding)
(adolescents)
History History History History
Full name
GENERAL Date and place of birth
DATA Nickname
Contact information of the parents
Source of information (patient, parent,

caregiver) and reliabiity
CHIEF COMPLAINT
The most important symptom which

prompted the admission
•
HISTORY OF •
PRESENT ILLNESS
•
•
•
•
PAST MEDICAL •
HISTORY
FAMILY HISTORY
•
PERSONAL AND •
SOCIAL HISTORY
•
•
HEADSSS ASSESSMENT
(for adolescents)
•
•
•
•
•
•
•
BIRTH AND MATERNAL
HISTORY
For neonates, the HPI should
start with the birth and
maternal history
•
MATERNAL •
HISTORY •
•
•
•
•
PERIPARTUM •
•
•
•
•
•
•
GROWTH AND Important during infancy and childhood
and in dealing with problems of delayed
development and behavioral disturbances
DEVELOPMENT
Physical growth
Developmental milestones
NURTITIONAL (FEEDING) HSTORY
•
•
REVIEW OF SYSTEMS
Other symptoms related to each
organ system not included in HPI
PHYSICAL EXAMIANTION
GENERAL SURVEY
Describe the patient
SKIN
•
•
•
•
HEENT
•
•
CHEST AND LUNGS
Inspection Palpation Percussion Auscultation
• no masses, no • no tenderness, no • resonant upon • equal lung

lesions, masses, equal percussion sounds on both
deformities or tactile fremitus lung fields, no
defects on chest crackles,
wall, no lagging wheezing,
of respiratory rhonchi
movement,
symmetrical
chest expansion,
no retractions
Inspection
CARDIOVASCULAR • no precordial bulging nor lesions
on the chest
Palpation
• no heave or thrills, apex beat is at
the 4th ICS LMCL
Auscultation
• normal rate, regular rhythm, no
murmurs, bruits on carotid
arteries
flat, globular, distended or non-distended, no
Inspection
ABDOMEN
scars, no lesions, discoloration, visible veins
normoactive, hypoactive, hyperactive bowel

Auscultation
sounds
Percussion tympanitic all over, no CVA tenderness
soft, no tenderness on light and deep palpations, no

palpable masses, liver edge palpable 1 cm below the
Palpation right margins (NB: 3.5 cm below the right costal
margin, Children: 2 cm)
No masses, atrophy noted
EXTRMEMITIES No deformities
Normal range of motion
Full and equal pulses
No clubbing
No bipedal edema
GENITAL AND Normal external
genitalia, no skin
RECTAL lesions, no vaginal

discharge, descended
testes (bilateral)
DRE
EXAMINATION
Tanner staging-
adolescents
NEUROLOGIC EXAMINATION
PHYSICAL EXAMINATION OF THE
NEWBORN
•
•
Initial Exam •
(as soon after •

•
delivery) •
•
•
•
Second Exam •
(after 24 hours)
Discharge •
•
Examination
BASIC NEONATAL NEUROLOGIC
EXAMINATION
State I Quiet Sleep
LEVEL OF State II Active Sleep
ALERTNESS State III Semi-wakefulness
Awake, alert and

State IV cooperative
Awake, fussing, and
State V uncooperative
State VI Crying
CRANIAL NERVES
CN I: Olfactory Nerve
•
•
CN II: Optic Nerve
•
•
•
•
•
•
CN III, IV, VI: Occulomotor, Trochlear, Abducens Nerves
•
•
•
•
CN V: Trigeminal Nerve
•
•
CN VII: Facial Nerve
•
•
CN VIII: Vestibulocochlear Nerve
•
•
CN IX, X, XII: Glossopharyngeal, Vagus, Hypoglossal
•
•
•
•
CN XI: Spinal Accessory Nerve
•
•
MOTOR EXAMINATION
Done when the baby is alert.
POSTURE
Normal term Preterms-

newborns- extension
flexor attitude attitude
TONE
Passive tone –
determine the degree
Done through a gentle
of resistance to
flapping of the hands
passive movements of
and feet
the joint in an awake
infant (not crying)
TONE
Active tone-
gently pull the Hypotonic or
neonate from floppy infant->
supine to upright head lag
position
MOTOR
Symmetry of
movements as
Spontaneous Movements against
preferential
movements resistance
movement may
suggest hemiparesis
DEVELOPMENTAL Primitive reflexes- integrity of
the brainstem and spinal cord
REFLEXES
Their disappearance indicates
maturation of the cerebral
hemispheres
Persistence beyond the expected

date suggests maturational lag or
impaired CNS.
SENSORY TESTING
•
•
•
•
THANK YOU!

HISTORY-TAKING-AND-PHYSICAL-EXAMINATION Pediatrics

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HISTORY TAKING AND

Personal and Birth and Growth and Nutritional

GENERAL Date and place of birth

Contact information of the parents

Source of information (patient, parent,

The most important symptom which

• no masses, no • no tenderness, no • resonant upon • equal lung

normoactive, hypoactive, hyperactive bowel

Percussion tympanitic all over, no CVA tenderness

soft, no tenderness on light and deep palpations, no

RECTAL lesions, no vaginal

(as soon after •

LEVEL OF State II Active Sleep

ALERTNESS State III Semi-wakefulness

Awake, alert and

Normal term Preterms-

Persistence beyond the expected

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