STANLEY T.

AGOR, MD, DPPS, MSPH

Department of Pediatrics
Cagayan Valley Medical center
1. GENERAL DATA
2. CHIEFT COMPLAINT
3. HISTORY OF PRESENT ILLNESS
4. REVIEW OF SYSTEMS
5. PAST PERSONAL HISTORY
6. IMMUNIZATION HISTORY
7. FAMILY HISTORY
8. SOCIO-ECONOMIC HISTORY
9. ENVIRONMENTAL HISTORY
1. GENERAL SURVEY
2. VITAL SIGNS
3. SPECIFIC SYSTEM
. Skin
. Head, Ears, Eyes, Nose, Throat (HEENT), Neck
. Chest and Lungs
. Heart and Blood vessels
. Abdomen
. Genitalia
. Anus and rectum
. Extremities
. Spine
. Lymph Nodes
 Take history carefully

 Perform physical examination

 Make a reasonably accurate working diagnosis

 List and prioritized laboratory examination cost-

effectively to approach a final diagnosis

 Initiate an effective therapy

 Art acquired through experience and patience
 History is unique
 Additional data in young infants
 Prenatal and birth history
 Developmental history
 Feeding history
 Immunization history
 Social history
 Environmental history
Distinct feature of pediatric history--> source of
information
 Physician
needs to have a good
communication skills

 Needs to gain the confidence and trust of the

child and his/her parents

 Genuine concern and empathy conveyed

through active and passive listening, and
taking note of verbal and non-verbal cues.
 GENERAL DATA

 Name, age, date and place of birth, sex, race, religion,

present address, number and date of hospital admission,
name of informants, relationship to the patients

 Reliability of the informant

 Assessed by %

 Depends on, (1) relationship to the patient, (2) amount of time

spent with the patient, (3) degree of involvement in the care of
the patient, (4) educational attainment
 CHIEF COMPLAINT

 Answers the question “Why was the patient brought to

the hospital?”

 single symptom or a group of related symptoms

 Should not include diagnostic terms or names of

disease
 HISTORY OF PRESENT ILLNESS (HPI)
- must include the following data

 The signs and symptoms

 in chronological order from the start of the illness
 include the specific number of hours, days, weeks, or
month
 Chronic illnesses- the date and age of onset
 Newborn – maternal and birth history should be
incorporated in the HPI
 HISTORY OF PRESENT ILLNESS (HPI)
- must include the following data

 The symptoms should be elaborated as to:

 Onset (acute or chronic)
 Intensity of symptoms: quality, location, duration, extent,
severity, frequency and whether there is hampering of
usual activity
 Aggravating and relieving factors
 Medications, duration of treatment
 Associated symptoms if any and their onset, course and
intensity
 REVIEW OF SYSTEM (ROS)
- further elicit relevant data about the disease
 Elaboration of data in systems not covered in the HPI
 Helps uncover related symptoms in other organ system
 Symptoms must be asked in a way understandable to
the patient
 There must be detailed description of the symptoms
 REVIEW OF SYSTEM (ROS)
 GENERAL
-Weight loss or gain, activity level, appetite, delay in growth

CUTENEOUS
- rash, pigmentation, hair loss, acne, pruritus

HEAD
- headache, dizziness, visual- hearing difficulties,
lacrimimation, aural discharge, nasal dsicharge,
epistaxis, toothache, salivation, sorethroat

CARDIOVASCULAR
- orthopnea, cyanosis, easy fatigability, fainting spells
 REVIEW OF SYSTEM (ROS)
 RESPIRATORY
- chest pain, cough, difficulty in breathing
 GASTROINTESTINAL
- constipation, vomiting, bowel movements-diarrhea, jaundice,
passage of worms, frequency of discharge, enuresis, edema of
hands and feet
 ENDOCRINE
- breast assymmetry, pain or discharge, palpitations, cold/heat
intolerance, polyuria, polydipsia, polyphagia
 NERVOUS
- tremors, sleep problems, convulsions, weakness or paralysis,
mental deterioration, personality or behavioral changes,
memory loss, eating problems, school failures, mood
changes, temper outburst, hallucinations
 REVIEW OF SYSTEM (ROS)
 MUSCULOSKELETAL
- pain or swelling in bone, joint or muscle; limitation of motion;
stiffness
 HEMATOPOIETIC
- bleeding manifestations, pallor, easy bruisability
 PAST PERSONAL HISTORY
- yield a significant data that may be related to
the signs and symptoms of the disease
 Gestational History
- mother’s age during pregnancy, parity, health nutrition,
infections, intake of drugs, roentgen exposure,
duration of gestation
 Birth History
- term, preterm, or post term, manner of delivery; persons
who attended the delivery; birth weight

Neonatal History
- Apgar Score, spontaneous respiration or required
resuscitation, cyanosis, pallor, cry, jaundice ( age of
onset), convulsions, hemorrhage, respiratory or feeding
difficulties, congenital abnormalities, birth injury
 PAST PERSONAL HISTORY
 Feeding History
 Infancy (<2 y/o)
- Type of feeding: exclusive breastfeeding or mixed with
formula feeding; frequency per day; duration of feeding each
breast. If the patient is not breast fed, the reason for not
breastfeeding, formula used, dilution and amount given per
day, and whether the child is bottle fed or cup fed should
be started

- Complementary feeding : age introduced, frequency of

feeding per day, usual food intake, actual caloric intake
(ACI) compared with the Recommended Energy and
Nutrient Intake (RENI) or the amount and quality of food
intake compared with food guide pyramid
 PAST PERSONAL HISTORY
 Feeding History
 Childhood and Adolescence (2-18 y/o)
- early feeding history is not included unless it is pertinent
to the present illness
 Developmental/ Behavioral history
 Young Children (1-5 y/o)
- Modified Developmental Checklist, dental eruption, urinary
continence during day and night, beginning and
completion of toilet training, temper tantrums, head
banging, phobias, pica, night terror, sleep disturbances
and other behavioral pattern
- Denver Developmental Screening Test II (DSST) –
undertaken if there are indications for developmental delay
 PAST PERSONAL HISTORY
 Developmental/ Behavioral history
 Middle Childhood (6-11 year/old)
- school performance should be inquired, sexual development
must be determined using Tanner’s Maturity Rating
 Adolescence (10-20 years old)
- there should be discussion about HEEADSSS: Home,
Education, Eating behavior or habits
 Pass Illness ( age when contracted, severity complication)
- contagious disease: measles, varicella, mumps, pertussis
- other medical illnesses; hospitalization, where and how long
- operations
- allergy
- injuries
 IMMUNIZATION HISTORY
 Types of vaccine given
 Date and placed od administration
 Untoward reaction

FAMILY HISTORY
 Parents: age, occupation, state of physical and mental health; if
not living the age and cause of death, the nature of symptoms an
history consanguinity
 Siblings: number, ages, state of health, if not living, the age and
cause of death
 Familial illness or anomalies : tuberculosis, DM,
 ENVIRONMENTAL HISTORY
 Environmental factors that are detrimental to the child’s health
must be noted
 Exposure to cigarette smoke and other pollutants, garbage
disposal, sewage disposal, water source
 Performing a good and complete physical examination depends
largely on the approach of the examiner

 Reserve the more unpleasant or uncomfortable parts until the end

of the physical examination

 Learn the art of playful interaction and distraction to allay the

child’s anxiety
 GENERAL SURVEY
Mental state or sensorium, level of activity, shrieking cry,
grunting
Cardio-pulmonary distress, color, chest retractions
Gait if ambulatory, position if bedridden
Nutritional state
State of hydration
Well, mildly ill or severely ill-looking
 VITAL SIGNS
 Temperature
- oral, rectal, aural, or axillary
- oral- useful in children 5-6 years or older
- axillary- safer to obtain, 0.5 degrees lower than oral
- rectal – not advised in active children
 Cardiac Rate (CR), Pulse Rate (PR), Respiratory Rate (RR)
- correlated with the child’s condition when taken

- RR should be taken for full minute

- normal ratio of CR to RR id 4:1
- pulse can be described based on rate, rhythm, and
volume
 VITAL SIGNS
 Blood Pressure (BP)
- routine taking starts at 3 years old
- correct BP cuff
- encircle and cover at least 2/3 of the upper arm
- measured after 3-5 minutes of rest in seating position
- reading should be correlated with the norm for age
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https://www.youtube.com/watch?v=DewBQdAPw4c

 VITAL SIGNS
 Anthropometric data
- Weight (Wt) in kg
- Length (Lt) – for children < 3 y/o in cm
- Height (Ht) – for children > 3 y/o in cm
- Head Circumference (HC) - < 3 y/o in cm
 VITAL SIGNS
 Anthropometric data
- Head Circumference (HC)
- Chest Circumference (CC)
- Abdominal Circumference (AC)
- Arm span
- Upper (U) Segment
- Lower (L) segment
- Nutritional Status
https://www.youtube.com/watch?v=P_SUkeyNjfk
https://www.youtube.com/watch?v=RIZ3aXGkE-s
https://www.youtube.com/watch?v=Hf-HwUenZrU
 SKIN
 Touch your patient
 Check for hypo/ hyperpigmentation
 Lesions, masses
 Cyanosis
HEENT
 Head: symmetrical, mass, hair distribution, texture, distribution
 Eyes: relationship of eyelid to the eyeballs, sunken, anicteric
sclerae , pink palpebral conjunctivae
 Ears: mobile pinna, no discharge
 Nose: Symmetry, midline septum, shape of your nares, discharge
 Oral Cavity: moist, no lesions, mass, no TPC
 Neck: no lymhadenopathy, no palpable mass
 CHEST AND LUNGS
- Inspection: no mass, defect in the chest wall, no
lagging of respiratory movement, regular
and symmetrical breathing, retractions

- Palpation: tenderness, masses, lesions, equal tactile

fremitus

- Percussion: resonant in inspection

- Auscultation: equal lung sounds on both fields, no

crackles/wheezing
- https://www.youtube.com/watch?v=gRWSyqatWQQ
 CARDIOVASCULAR SYSTEM
Inspection : no precordial bulging, lesions

Palpation: heave, thrills, apex beat

Auscultation: heart sounds, rate and rhythm , murmus,

bruit on carotid arteries

https://www.youtube.com/watch?v=XU_xeUMJ3Zc
 ABDOMEN
Inspection: flat, non distended, scars or lesions,
discoloration. Visible veins, visible peristalsis
Auscultation: normo-active bowel sounds
Palpation: soft, tenderness, mass, liver span
Percussion: tympanic all over

https://www.youtube.com/watch?v=PYAnF6GJY2I
 EXTREMITIES
Masses, atrophy
Symmetry of muscles on extremities
Joint tenderness,
Normal range of motion
Full and equal pulses, no clubbing, no edema
https://www.youtube.com/watch?v=oezvV-MqSak

https://www.youtube.com/watch?v=jgwOrpVuTJU
 GENITAL ANF RECTAL EXAMINATION
Normal external genitalia, skin lesions, vaginal
discharge, bilaterally descended testes
Rectal vault
Tanner staging
https://www.youtube.com/watch?v=jMHsbgsJ-1g
https://www.youtube.com/watch?v=bK1GTLpL_F8
 Cranial Nerves
https://www.youtube.com/watch?v=sJBpai74tlU
https://www.youtube.com/watch?

v=LjlqP1uMUo0
https://www.youtube.com/watch?v=Jz_sE4A0nWA