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Pediatric History Taking & Physical


Lecturer : dr. Fransisca Handy, Sp.A

This teaching material is copyrighted.

No part of this work may be reproduced, including photocopied, without written
permission of Universitas Pelita Harapan .

Are not little adult

Are not miniatur of human body
Are on growing and development periode
Growing: becoming bigger
Development: becoming mature in function
Age Descriptors

Newborn birth to 2 months

Infant 0-1 year
Toddler 1-2 years
Underfive 12-60 months
History Taking

Mostly alloanamnesis
1. Patient identity : child & parents / caregiver
2. Chief complain
3. History of present illness
4. Past medical history
Pregnancy and Perinatal history
a. Antenatal: Health of mother during pregnancy. Medical supervision,
drugs, diet, infections such as rubella, etc., other illnesses, vomiting, toxemia,
other complications; Rh typing and serology, pelvimetry, medications, x-ray
procedure, maternal bleeding, mother's previous pregnancy history.

b. Natal: Duration of pregnancy, birth weight, kind and duration of labor, type
of delivery, presentation, sedation and anesthesia (if known), state of infant
at birth, resuscitation required, onset of respiration, first cry.

C. Neonatal: color, cyanosis, pallor, jaundice, cry, paralysis, convulsions, fever,

hemorrhage, congenital abnormalities, birth injury. Difficulty in sucking,
rashes, excessive weight loss, feeding difficulties. You might discover a
problem area by asking if baby went home from hospital with his mother.

Esp for infant, suspected birth defect

Family history

a.Father and mother (age and condition of health).

b.Marital relationships.
c.Siblings. Age, condition of health, significant previous
illnesses and problems.
d.Stillbirths, miscarriages, abortions; age at death and
cause of death of immediate members of family.
e.Family health status: any infectious disease, chronic
diseases, hereditary disease
History of feeding status

Global Infant Feeding Golden Standard (WHO-UNICEF):

1. Initiation of early breastfeeding
2. Exclusive breastfeeding for 6 mo
3. Complementary feeding :
homemade, locally available
4. Continue to breastfeed up to 2 yr

History of growth and development
1. Gross motor
2. Fine motor
3. Language and communication skill
1 year : single word, 1 step order
2 year : 2 words, 2 steps order
3 year : 3 words or sentence, complex order
4. Social emotional & independency
History of immunization status
Pediatric Physical Examination

General tips

Minimize discomfort: Use appropriate games and distraction to decrease

fear and enhance cooperation.
Examine toddlers in parents lap if fearful of exam table.
Offer gown as appropriate. Explain to parent/child as appropriate.
Show them it doesnt hurt by examining the parent. Let the child examine
Flexibility: Adjust the sequence of the exam based on the childs
willingness and ability to cooperate.
Save the more invasive and fear-invoking maneuvers (i.e ear and throat
exam) until last.
General Appearance

Observe any signs of acute or chronic distress as

evidenced by skin color, respiration, hydration, mental
status, cry and social interaction.
Interpret the general appearance of the child including
size, morphologic features, development, behaviors
and interaction of the child with the parent and
Vital Signs

Measure heart rate, respiratory rate, BP

Determine temperature and oxygen saturation as

Newborn 2 40-60
months breath/min
2 months 1 30-50
year breath/min
1 year 20-40
Antropometry Scale

WHO Growth Chart 2005

Head and ENT

Identify the anterior and posterior fontanels and assess them

for fullness.
Observation of the head size,shape, and symmetry.
Note facial features, ear size and hair whorls as part of the
examination for dysmorphic features
Check red reflex (corneal opacities and intraocular masses)
Check for strabismus via corneal light reflex or cover test.
Assess dentition, oral mucosa and pharynx.
Assess hydration of the mucous membranes.
Examine the tympanic membranes using pneumatic otoscopy.

Palpate for lymph nodes (knowing anatomic areas they drain)

Recognize and demonstrates maneuvers that test for nuchal
In Older children- note thyroid size and texture

Assess rate, pattern and effort of breathing, recognizing normal

Recognize grunting, nasal flaring, stridor, wheezing,
crackles/rales and asymmetric breath sounds.
Distinguish between inspiratory and expiratory sounds.
Interpret less serious respiratory sounds such as transmitted
upper airway sounds.

Identify the pulses in the upper and lower extremities through

Observe and palpate precordial activity.
Assess cardiac rhythm, rate, quality of the heart sounds and
murmurs through auscultation.
Assess peripheral perfusion by capillary refill.
Assess for systemic signs of heart failure (enlarged liver, edema,

Palpate for and percuss out liver and spleen.

Examine the umbilical cord in newborns for number of vessels.
Identify granulation tissue and umbilical hernias.
Assess the abdomen for distention, local or rebound tenderness,
and masses through observation, auscultation and palpation.
Perform a rectal exam when appropriate.

Recognize the appearance of normal male and female

genitalia in the newborn.
Palpate the testes.
Recognize male genital abnormalities including
cryptorchidism, hypospadias, phimosis, hernias, hydrocele
and testicular mass.
Recognize female genital abnormalities including signs of
virilization, imperforate hymen, labial adhesions and signs of
Identify Tanner Stage.

Examine the hips of a newborn for dysplasia using the Ortolani

and Barlow maneuvers.
Evaluate gait/limp.
Recognize pathology such as restricted or excessive joint
mobility, joint effusions, signs of trauma and inflammation.
Contractures in chronic kids
Check for tibial bowing (rickets)
Neurologic examination

12 Cranial nerves
Elicit primitive reflexes
Assess the quality and symmetry of tone, strength and reflexes
using age-appropriate techniques.

Assess turgor, perfusion, color, pigmented lesions and rashes

through observation and palpation.
Identify jaundice, petechiae, purpura, vesicles and urticaria.
Examine the skin for common birthmarks and skin conditions
unique to children.
Thank You