PEDIATRIC EXAM

Gerald Hickson, MD
Joe Gigante, MD
 THE PEDIATRIC HISTORY

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.
V. 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
 The Pediatric History, page 2 Past medical history, continued
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

2mo hepatitis B2 DTP1 Hibl OPV1

4mo DTP2 Hib2 OPV2

6mo hepatitis B3 DTP3 Hib3

15mo Hib4 MMR1

18mo 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
The Pediatric History, page 3
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.

References
Algranati, PS. The Pediatric Patient: An Approach to history and Physical Examination. Williams & Wilkins, 1992.

Report of the Committee on Infectious Diseases 22nd ed. American AcademyofPediatrics, 1991.
 PEDIATRIC PHYSICAL EXAMINATION

Wash your hands. Introduce yourself. Say somethingcompliment

nice, or the child/parents (at the end of the session as well).
The .order of the exam can be individualized. Start
observation,
by introduce instruments and let the child checkout,them
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 palpate
and first.
The child has to be undressed for the exam, but this can be done gradually. Exam has to be thorough, even in the child.
uncooperative

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.
B P cuff should cover 1/2 to 2/3 of arm span.
H eart rate and repiratory rate.
H eight and w eight. H ead circum ference. C hest and abdom inal
circum ference if indicated. Plot them on charts.
Skinfoldthickness.

GENERAL APPEARANCE
N utritional status. C leanliness. Posture. R eluctance to m ove. A lertness, interest in surroundings, playfulness, cooperatio
D istress, consolability (paradoxical irritability). H ydration status. D evelopm ent. C ry or speech. G ross abnorm alities. M a
include a note about the fam ily.

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.Capillaryrefill.

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.
EY ES
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.
M OUTH
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 arrythm ia). Inspection, palpation,
percussion, ausculation.

ABDOM EN
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, m eatus location, circum cision, testicles (T descended), hydrocoele, r^rnia, crem asteric reflex. In girls, labia m
prom inent in the new born. D ischarge, adhesions. DTanner
iaper rash.
stage.

RECTAL
A nus (patency), anal w ink, fissures, fistula, prolapse,
hem orrhoids, m asses, stools, G uaiac. D iaper rash.
EXTREMITIES AND MUSCULOSKELETAL.
Posture, asymmetry, extra digits, clubbing, temperature,Hands
swelling.
and dermatoglyphics. Nails. Feet (clubbing). Genu
valgum,gait, hips (dislocation). Spine, scoliosis, sacral pit
tuft.orPulses.
hair Joints range of motion, arthralgias, arthritis.
Kernig's sign.

NEUROLOGICAL
S tate o f co n scio u sn ess. S p o n tan eo us m o v em en ts, ab n o rm al m o v em en ts. T o n e an d stren g th . S u p erficia l re fle x es, d
reflex es.Suck, root, grasp, Moro, tonic neck, Babinski, stepping, placing,L andau, parachute reflexes.Sensations.
C oordination, cerebellar signs. C ranial nerves. G ait. D evelopm ent Screening
(D enver
T e s t ) .M eningeal signs.

JAUNDICE Includes hands and feet

H ead alone B IL I L E V E L (m g /d l)
H ead and chest
T o knees 5-8
Includes arm s and low er legs 6-128-16 10-
18 ' 15-20+
APPEARS DISAPPEARS REFLEX ECCHYMOSES COLOR AGE (days)

Birth In fancy3-4 m o Suck Purple-Red Fresh

B irth Root D ark blue-brow1-4
n
B irth 3-7 m o M oro G reenish-yellow5-7
B irth Tonic neck Yellow >7
B irth B abinski
B irth 3-5 m o
S tep p in g
B irth P lac in g
3 mo 1-2 yrs
L an dau
7-9mo Parachute
e arly
Reference;
1 yr L . A . B arn e M
ss.a n u a l o f P e d ia tric P h y sic a l D ia g n o sis.
S ix th ed .
1 -2 y r
M osby Y earbook,1991.
R em ains
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 Female
I. Preadolescent. No pubic hair. Preadolescent. No pubic hair. Sparse distibution of long,
II. Sparse distibution of long, slightly pigmented straight hair appear bilaterally along
slightly pigmented hair at the base of the penis the medial border of the labia majora. The pubic hair
pigmentation increases; it begins to curl and spread
III. The pubic hair pigmentation sparsely over the mons pubis.
increases; it begins to curl and spread laterally in a
scantydistribution. The pubic hair continues to curl and become coarse in
IV. The pubic hair continues toand curlbecom e coarse in texture. The number of hairs continues to increase.
texture. An adult type of distribution
attained,
is but Mature. The pubic hair attains an adult feminine triangular
with fewer hairs. pattern, with spread to the surface of the medial thigh.
V. M ature. 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.

Male genital development.

I. Preadolescent.
I I. The testes enlarge. The scrotum enlarges, developing a reddishaltering
hue andin skin texture. The penis
enlarges slightly.
III. The testes and scrotum continue to grow. The length of the
increases.
penis
IV. The testes and scrotum continue to grow; the scrotal skin darkens.
penis The
grows in width, and the glans
penis develops.
V. M ature. The testes, scrotum, and penis are adult in size and shape.

Reference;
Tanner JM: Growth at adolescence. Oxford, Blackwell, 1962.