Pediatric History And Physical Exam

Front 1

I. Content Differences

Back 1

A. Prenatal and birth historyB. Developmental historyC. Social history of familyD. Immunization history

Front 2

II. Parent as Historian

A. Parent's interpretation of signs, symptoms

Back 2

1. Children above the age of 4 may be able to provide some of their own

2. Reliability of parents' observations varies

3. Adjust wording of questions - "When did you first notice Johnny was limping"? instead of "When did Johnny's hip pain start"?

Front 3

B. Observation of parent-child interactions

Back 3

1. Distractions to parents may interfere with history taking2. Quality of relationship

Front 4

C. Parental behaviors/emotions are important

Back 4

1. Parental guilt - nonjudgmental/reassurance

2. The irate parent: causes

Front 5

Brief statement of primary problem (including duration) that caused family to seek medical attention

Back 5

I. Chief Complaint

Front 6

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 hegatives.

Back 6

II History of Present Illness

Front 7

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

Back 7

III. Past Medical History

Front 8

A. Maternal health during pregnancy: bleeding, trauma, hypertension, fevers, infectious illnesses, medications, drugs, alcohol, smoking, rupture of membranes

B. Gestational age at delivery - premature/post mature

C. Labor and delivery - length of labor, fetal distress, type of delivery time (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

Back 8

IV. Pregnancy and Birth History

Front 9

A. Ages at which milestones were achieved and current developmental abilities- smiling, rolling, sitting alone, crawling, walking, running, 1st word, toilet training, riding tricycle, etc (see developmental charts)

B. School-present grade, specific problems, interaction with peers

C. Behavior- enuresis, temper tantrums, thumb sucking, pica, nightmares etc.

Back 9

V. Developmental History

Front 10

A. Breast or bottle fed, types of formula, frequency and amount, reasons for anychanges in formula

B. Solids - when introduced, problems created by specific types

C. Fluoride use

Back 10

VI. Feeding History

Front 11

VII. Review of Systems

A. recent changes, weight at birth

B. rashes, adenopathy, lumps, bruising and bleeding, pigmentation changes

C. headaches, concussions, unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, mouth breathing, snoring, apnea, oral thrush, epistaxis,

D. cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting

E. pneumonia, bronchiolitis, wheezing, chronic cough, sputum,hemoptysis, TB

F. stool color and character, diarrhea, constipation, vomiting, hematemesis,jaundice, abdominal pain, colic, appetite

G. frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary stream, polyuria, previous infections, facial edema

H. joint pains or swelling, fevers, scoliosis, myalgia orweakness, injuries, gait changesI. secondary sexual characteristics, menses and menstrual problems,pregnancies, sexual activityJ. urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions

Back 11

A. Weight

B. Skin and Lymph

C. HEENT

D. Cardiac

E. Respiratory

F. GastroIntestinal

G. Gastro Urinary

H. Musculoskeletal

I. Pubertal

J. Allergy

Front 12

VIII Family History

A. cardiac disease, hypertension, stroke, diabetes, cancer, abnormalbleeding, allergy and asthma, epilepsy

B. congenital anomalies, chromosomal problems, growth problems, consanguinity, ethnic background

Back 12

A. Illnesses

B. Mental retardation

Front 13

IX. Social

A. daycare, safety issuesB. Composition of familyC. Occupation of parents

Back 13

A. Living situation and conditions