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Electronic Pediatric Patient History Form Pediatric Patient History Questionnaire Smile. Introduce yourself. Shake hands with parents, child if old enough. Try to help family feel comfortable, establish rapport. |
| 1. Identifying information |
| 2. Chief Complaint |
| 3. History of Present Illness |
4. Past Medical History
B. Previous hospitalizations C. Childhood illnesses D. Previous surgery/ transfusions age, reason for procedure, complications E. Trauma/ injuries/ ingestions, burns age, circumstances surrounding event, treatment, complications F. Allergies G. Medications H. Nutrition I. Immunizations and reactions Don't rely on memory; ask to see shot record J. Growth K. Development |
| 5. Family history |
| 6. Social History |
| 7. Review of Systems |
| PEDIATRIC PHYSICAL EXAMINATION |
| Pediatric medical emergencies |
| Child Care |
| Pediatrics |
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I. General principles Smile. Introduce yourself. Shake hands with parents, child if old enough. Try to help family feel comfortable, establish rapport. II. Identifying information: name of patient, date of birth, gender, date of interview. Identify source of history. III. Chief Complaint: ask the patient or parent, use their own words if possible. IV. History of Present Illness: What are the symptoms? How long have they been present? Who else is sick? (family members, daycare contacts) Has this patient ever had a similar illness? What treatments have been tried for this problem? Include pertinent ROS and past medical history. 5. Past Medical History A. Perinatal maternal history: mother's age, gravida, para (term, preterm), abortions (spontaneous or elective). pregnancy: LMP, EDC, onset of prenatal care, weight gain, complications (bleeding, preterm labor, infections, medications, gestational diabetes), rubella immunity status, RPR, PPD, hepatitis B, drugs, alcohol, tobacco use. labor and delivery: spontaneous or induced, duration, duration of rupture of membranes prior to delivery, complications, medications or anesthesia, vertex or breech presentation, vaginal or c-section, meconium staining of amniotic fluid. neonatal: birth weight, estimated gestational age, Apgar score, resuscitation in delivery room, problems in nursery (e.g. jaundice, feeding difficulty, respiratory distress), length of stay, reasons for prolongation of stay. B. Previous hospitalizations age, length of stay, reason, location C. Childhood illnesses or exposures age, complications, treatment recent exposures, date, nature of exposure travel to other locations, animal exposure D. Previous surgery/ transfusions age, reason for procedure, complications E. Trauma/ injuries/ ingestions, burns age, circumstances surrounding event, treatment, complications F. Allergies medications - name of medication, timing of reaction, signs and symptoms, who made the diagnosis of allergy. other allergies - signs and symptoms, therapy G. Medications current or recent, include OTC meds, dosage, frequency indications and reactions, timing of most recent dose H. Nutrition infants - breast or formula, frequency, amount, problems toddlers - introduction of baby foods and cereal, milk intake when did transition from formula/breast to cow's milk occur' problems, peculiar eating habits (pica) ' older children - good appetite or "picky eater", special diets, milk intake, "junk foods", concerns about weight I. Immunizations and reactions Don't rely on memory; ask to see shot record. Birth hepatitis Bl 2 mo hepatitis B2 DTP1 Hibl OPV1 4 mo DTP2 Hib2 OPV2 6 mo hepatitis B3 DTP 3 Hib3 15 mo Hib4 MMR1 18 mo DTP4 OPV3 4-6 yr DTPS OPV4 MMR2* 14-16 yr dT or MMR2 J. Growth weight, height, head circumference, rate of growth, concerns, puberty, menarche K. Development Gross motor milestones Fine motor milestones Social interactions, behavior Speech and language development School performance Hearing, vision VI. Family history Ask about parents, siblings, grandparents and extended family. Focus on Inherited diseases, diseases that "run in the family", miscarriages, infant or childhood deaths, congenital anomalies, developmental delay, mental retardation, seizures, early cardiovascular diseases, sickle cell disease, consanguinity, any family members with similar problems to patient's current complaint. Draw a family tree. VII. Social History ONE OF THE MOST IMPORTANT COMPONENTS OF THE HISTORY1 Observe interactions between the family and child. Seek information about the home environment which will impact how the child and family cope with illness. Find out what resources are available for support for the child, mother, family. Find out if there are underlying concerns that have not yet been brought out (e.g. an neighbor died from a brain tumor, and the mother fears that this child's headache is a sign of a tumor.) Typical questions may include: Who lives at home? Who is the primary caregiver or disciplinarian? Does the child attend school, daycare or a babysitter? Who helps the mother? In the outpatient setting, important questions may include: Do you have a way to pay for this prescription? Do you have transportation to return if your child gets worse? VIII. Review of Systems Similar in general to adult patients with a few important differences: A. General: include fever, weight loss, etc. as in adults, but also include patient's activity level, playfulness, appetite, sleep habits, days of school missed. B. HEENT: include recent or past history of ear infections if not already included in PMH. C. GI: diarrhea, vomiting, constipation, etc. Young children will not complain of nausea. Encopresis. D. GU: change in urinary pattern such as enuresis in previously toilet trained child. E. Hydration status: tears, wet diapers, details of p.o. intake, details of losses (frequency of diarrheal stools, volume, frequency of emesis), activity level. PEDIATRIC PHYSICAL EXAMINATION Wash your hands. Introduce yourself. Say something nice, or compliment the child/parents (at the end of the session as well). The .order of the exam can be individualized. Start by observation, introduce instruments and let the child check them out, keep invasive or painful parts for the end. Explain everything you will be doing. Use age-appropriate non-threatening terms. Give feedback. In the newborn, observe, auscultate and palpate first. The child has to be undressed for the exam, but this can be done gradually. Exam has to be thorough, even in the uncooperative child. Special focus of the pediatric exam: Growth and Development. Points of special relevance to the newborn are in boldface. VITAL SIGNS Axillary- T° is 2° below rectal, oral is 1° below rectal. BP cuff should cover 1/2 to 2/3 of arm span. Heart rate and repiratory rate. Height and weight. Head circumference. Chest and abdominal circumference if indicated. Plot them on charts. Skin fold thickness. GENERAL APPEARANCE Nutritional status. Cleanliness. Posture. Reluctance to move. Alertness, interest in surroundings, playfulness, cooperation. Distress, consolability (paradoxical irritability). Hydration status. Development. Cry or speech. Gross abnormalities. May include a note about the family. SKIN Color, pigmentation. Jaundice. Cyanosis (acrocyanosis). Mottling. Pallor. Birthmarks (nevus flammeus, salmon patch). Texture. Scars. Rashes (erythema toxicum). Ecchymosis (color and age). Craddle cap. Capillary refill. Edema. Milia. Vernix caseosa. Desquamation. Mongolian spot. NAILS Cyanosis, clubbing. Pitting. Capillary refill. HAIR Lanugo. Alopecia (including occipital alopecia). Lice or nits. Pubic hair and Tanner stage. LYMPH NODES ' • HEAD Size and symmetry. Circumference. Sutures. Fontanelles, size (AT measured perpendicular to sides), bulging or depression, pulsatility. Caput succedaneum. Cephalhematoma. Craniotabes. Transillumination. Sinuses. FRONT metopic suture coronal sagittal lambdoid FACE Paralysis. Asymmetry. Anomalies, coarseness of features. Edema. Parotid glands. EYES Vision, visual fields. Scleral color. Strabismus (paralytic, non-paralytic). Nystagmus. Conjunctivitis, discharge. Hemorrhages (subconjunctival hemorrhages). Reaction to light. Iris (absence-). Ophthalmoscopy (red reflex, retinal hemorrhages, macula). EARS Position, shape. Discharge. Tenderness. Auricular pits or tags. Otoscopy (use the bigger speculum). Hearing. NOSE Discharge, obstruction, polyps (use otoscope). Bleeding. Flaring. MOUTH Drooling. Teeth (map, hygene). Cysts. Palate (cleft). Thrush. Gums. Tongue. Palate. Tonsils. Postnasal drip. VOICE Stridor, hoarseness, cry (weak, high-pitched). Vocalization, speech. NECK Position, motility, webbing. Nodes, masses. Neck stiffness, Brudzinski sign. CHEST Inspection,"palpation, percussion, ausculation. Pectus (carinatum, excavatum). Harrison's groove. Respiratory rate, chest expansion, symmetry, retractions, paradoxical breathing. Grunting. Flaring, use of accessory muscles. Cough (characteristics, frequency). Breast size, milk discharge, symmetry, Tanner stage. HEART Rate and rythm (sinus arrythmia). Inspection, palpation, percussion, ausculation. ABDOMEN Inspection, palpation, percussion, ausculation. Shape (scaphoid, pot-belly). Circumference. Umbilicus (cord stump), umbilical hernia. Diastesis recti. Gastric waves. Liver, spleen, masses. Unimanual palpation of the kidneys. Bladder. Superficial reflexes. Inguinal areas, femoral pulses, lymph nodes. GENITALIA Penis size, meatus location, circumcision, testicles (Tdescended), hydrocoele, r^rnia, cremasteric reflex. In girls, labia minora prominent in the newborn. Discharge, adhesions. Diaper rash. Tanner stage. RECTAL Anus (patency), anal wink, fissures, fistula, prolapse, hemorrhoids, masses, stools, Guaiac. Diaper rash. EXTREMITIES AND MUSCULOSKELETAL. Posture, asymmetry, extra digits, clubbing, temperature, swelling. Hands and dermatoglyphics. Nails. Feet (clubbing). Genu valgum, gait, hips (dislocation). Spine, scoliosis, sacral pit or hair tuft. Pulses. Joints range of motion, arthralgias, arthritis. Kernig's sign. NEUROLOGICAL State of consciousness. Spontaneous movements, abnormal movements. Tone and strength. Superficial reflexes, deep tendon reflexes. Suck, root, grasp, Moro, tonic neck, Babinski, stepping, placing, Landau, parachute reflexes.Sensations. Coordination, cerebellar signs. Cranial nerves. Gait. Development (Denver Screening Test). Meningeal signs. JAUNDICE Head alone Head and chest To knees Includes arms and lower legs Includes hands and feet BILI LEVEL (mg/dl) 5-8 6-12 8-16 10-18 ' 15-20+ ECCHYMOSES COLOR AGE (days) APPEARS 3 mo 7-9 mo DISAPPEARS Infancy 3-4 mo 3-7 mo 3-5 mo 1-2 yrs early 1 yr 1-2 yr Remains REFLEX Fresh 1-4 5-7 > 7 Purple-Red Dark blue-brown Greenish-yellow Yellow Suck Root Moro Tonic neck Babinski Stepping Placing Landau Parachute STAGES OF PUBERTY (TANNER STAGES) Female breast. I. Preadolescent. The breast has an elevated papilla (nipple) and a small flat areola. II. Breast bud. The papilla and areola elevate as a small mound, and the diameter of the areola increases. III. The breast bud further enlarges. The areola continues to enlarge. No separation of breast contours is noted. IV. The areola and papilla separate from the contour of the breast to form a secondary mound. V. Mature. The areolar mound recedes into the general contour of the breast. The papilla continues to project. Pubic hair. Male I. Preadolescent. No pubic hair. II. Sparse distibution of long, slightly pigmented hair at the base of the penis III. The pubic hair pigmentation increases; it begins to curl and spread laterally in a scanty distribution. IV. The pubic hair continues to curl and become coarse in texture. An adult type of distribution is attained, but with fewer hairs. V. Mature. The pubic hair attains an adult distribution, spreading to the surface of the medial thigh. Pubic hair grows along the linea alba in 80% of males. Female Preadolescent. No pubic hair. Sparse distibution of long, slightly pigmented straight hair appear bilaterally along the medial border of the labia majora. The pubic hair pigmentation increases; it begins to curl and spread sparsely over the mons pubis. The pubic hair continues to curl and become coarse in texture. The number of hairs continues to increase. Mature. The pubic hair attains an adult feminine triangular pattern, with spread to the surface of the medial thigh. Male genital development. I. Preadolescent. II. The testes enlarge. The scrotum enlarges, developing a reddish hue and altering in skin texture. The penis enlarges slightly. III. The testes and scrotum continue to grow. The length of the penis increases. IV. The testes and scrotum continue to grow; the scrotal skin darkens. The penis grows in width, and the glans penis develops. V. Mature. The testes, scrotum, and penis are adult in size and shape. |