PEDIATRIC HISTORY AND PHYSICAL EXAM GUIDE

NAME OF STUDENT:
NAME OF PATIENT:
DATE & TIME

AGE:
IDENTIFYING DATA

SECTION:
SEX:
Name: __________________________
Age: ____________________________
Date of Birth: _____________________

DATE:
WARD:
Gender: _________________________
Race/Nationality: _________________
Religion: _________________________

Address: ___________________________________________________________
___________________________________________________________________
Number and Dates of Admissions: _______________________________________
___________________________________________________________________
SOURCE AND RELIABILITY

___________________________________________________________________

CHIEF COMPLAINT
(Complaint + Duration)

___________________________________________________________________
___________________________________________________________________

HISTORY OF PRESENT ILLNESS

Temporal Profile

PAST HISTORY
Birth History

Course of Pregnancy (PNCU, Vaccinations, Medications): _____________________

___________________________________________________________________
___________________________________________________________________
Term: ____________________________ GP TPAL: __________________________
Type of Delivery: ___________________ Discharge: ________________________
Condition at Birth: ____________________________________________________
Resuscitation: _____________________ Congenital Anomalies: _______________
Neonatal Course: ____________________________________________________
___________________________________________________________________

Feeding History

Breastfeeding (Interval, Duration, Volume): _______________________________

___________________________________________________________________
Formula (Interval, Duration, Volume): ____________________________________
___________________________________________________________________
Current Intake/Diet: __________________________________________________

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___________________________________________________________________
Vitamin Supplements: _________________________________________________
Solids: _____________________________________________________________
Adverse Food Reactions, Allergies: _______________________________________
Vomiting: ___________________________________________________________
Stool: ______________________________________________________________
Developmental History

Immunization History

MILESTONE
DATE/AGE
MILESTONE
DATE/AGE
Regard
First Step
Social Smile
Words
Turned on Abd
Sentences
Crawled
Bladder Ctrl
Sat Alone
Dentition
Stood
Walked
Present Milestones: __________________________________________________
___________________________________________________________________
___________________________________________________________________
VACCINE
BCG
DPT
Polio
Measles

DOSES AND DATES

Fully Immunized
Completely Immunized
Incomplete
Adverse Vaccine Reactions: ____________________________________________
Tuberculin Tests: _____________________________________________________
Past Diseases

Family History

Childhood Diseases (Measles, Rubella, Varicella, Mumps): ____________________

___________________________________________________________________
URTIs: _____________________________________________________________
Frequency and Severity of Illnesses: ______________________________________
Tonsillitis, Pyoderma: _________________________________________________
Convulsions: ________________________________________________________
Injuries: ____________________________________________________________
Surgeries: __________________________________________________________
Health Status of Living Relatives
NAME

AGE/SEX

RELATIONSHIP

HEALTH STATUS/
CAUSE OF DEATH

Heredofamilial Diseases
Cancer: __________________________________________________________
Diabetes: _________________________________________________________
Hypertension: _____________________________________________________
Allergy: __________________________________________________________
Mental Illness: ____________________________________________________
Heart Disease: _____________________________________________________
Others, specify: ____________________________________________________

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Pedigree

Social/Environmental History

PHYSICAL EXAMINATION
General Survey

Vital Signs

Interpretation
Anthropometrics

Skin

Fathers Educational Attainment: ________________________________________

Fathers Occupation: __________________________________________________
Mothers Educational Attainment: _______________________________________
Mothers Occupation: _________________________________________________
Adequacy of Income: _________________________________________________
Housing and Environment: _____________________________________________
State of Hygiene: _____________________________________________________
Access to Potable Water: ______________________________________________
Electricity: __________________________________________________________
Density of Population in Neighborhood: __________________________________
Typical Day of the Patient: _____________________________________________
___________________________________________________________________
LOC:
Conscious Drowsy
Stuporous
Coherence:
Coherent Incoherent
General Appearance: Cardio respiratory distress
Chronically ill
Grooming:
Well
Fairly
Development:
Endomorph
Mesomorph
Well
Fairly
Looks according to age
Nutrition:
Well nourished Obese
Emotional State: Calm
Restless
Gait: Coordinated
Uncoordinated
Shuffling
Stumbling
Walks with assistive devices

Comatose _______
Pain
Anxiety
Acutely ill
Poorly
Ectomorph
Poorly
Looks younger/older
Cachexic
Tense
Worried
Staggering
Unable to walk alone

T = ____________C, (Oral, Axillary, Rectal)

HR = ___________ breaths/min
PR = ___________ beats/min
BP = ___________ mmHg, (Sitting, Lying, Standing)
Ht %tile = ___________ SBP %tile = ___________ DBP %tile = ___________
HC = _____________cm
Height = ___________cm
Weight = __________kg
BMI = ____________

HC-for-Age Z Score = ____________

Ht-for-Age Z Score = ____________
Wt-for-Ht Z Score = _____________
BMI-for-Age Z Score = ___________

General Color: Pallor

Jaundice
Flushing
Cyanosis
Moisture:
Dry
Wet/Clammy
Oily
Turgor:
Good
Fair
Poor
Texture:
Smooth
Rough
Others: ______________
Temperature: Warm
Cool
Others: ______________
Lesions/Rashes (Distribution, Color, Pruritus, Etc.): __________________________
___________________________________________________________________
Hemorrhages: Petecchiae Ecchymoses
Hematoma
Hair:
Fine
Coarse
Dry
Normal distribution
Alopecia
Clean
With dandruff
With lice
Nails: Pink Pale
Cyanotic
Inflamed
Clubbed
Edema, grade: ________
Non-pitting
Pitting
Pedal R L

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 Symmetrical
Edema R L
Ptosis R L
Edema
Sunken
W/discoloration
Pinkish
Pale
Discharge
Lesions: ________________________________________
Sclera:
Anicteric
Icteric
Hemorrhages
Cornea & Lens:
Smooth
Clear
Lesions
Opacity
Arcus Senilis
Signs of inflammation
Exophthalmos
Tension

Eyes

Lids:
Periorbital region:
Conjunctiva:

Head

Symmetrical

Ears

Nose

Patency:

Both Patent
Obstructed R L
Masses/Lesions: _____________________________________
Midline
Deviated
Perforated
Pinkish
Pale
Reddish
Serous
Purulent
Mucoid
Bloody
Non-tender
Tender: ________________________

Pallor
Midline
Fasciculations
Complete
Caries
Upper

Cyanosis
Dryness/Cracks Lesions
Deviation R L
Atrophy
Lesions: ________________________________
Missing ________________________________
Dentures
Braces/Retainers
Lower

Gums:
Mucosa:

Pinkish
Pinkish

Pale
Pale

Uvula:
Mucosa:
Tonsils:

Midline
Pinkish
Not inflamed

Deviation to R L
Pale
Reddish
Inflamed
Exudates

Lips:
Tongue:
Teeth:

Throat

Masses: _________________________

Normoset
Symmetrical
Asymmetrical
Tender
Gross abnormalities/lesions: _________________________________________
Discharge:
Foul smelling
Serous
Purulent Mucoid
Gross Hearing: Symmetrical
Deafness R L
Impacted cerumen
Tympanic membranes:
Intact
Infiltrated

Septum:
Mucosa:
Discharge:
Sinuses:
Mouth

Asymmetrical

Bleeding
Cyanotic

Tender

Neck

Trachea:
Midline
Deviation to R L
Lymph nodes:
Nonpalpable
Palpable/enlarged
Tender
Thyroid:
Nonpalpable
Enlarged
Normal ROM
Neck Rigidity
NVE at _______ Angle R L
Masses: __________________________________________________________

Breast

Masses: ________________________ Discharge: ______________________

Inverted nipple
Others: ________________________

Chest and lungs

Shape:
Barrel
Funnel
Pigeon
APL ratio: ________ : ________
IE Ratio: ________ : ________
Breathing Pattern: Eupnea
Hyperpnea
Tachypnea
Dyspnea
Alar flaring
Retractions
Use of accessory muscles
Chest surface:
Tenderness
Deformities
Masses

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Chest expansion:
Tactile Fremitus:
Percussion:
Breathe sounds:

Consolidation:
Abnormal BS:
Cardiovascular

Symmetrical
Decreased/Lag R L
Symmetrical
Dec/Inc at _____________ lung field
Resonant
Dullness at ____________________
Hyper resonant at ________________________________
Vesicular at _____________________________________
Bronchovesicular at ______________________________
Bronchial at _____________________________________
Egophony Bronchophony Whispered petriloquy
Wheezes
Ronchi
Rales
Friction rub

Symmetrical
Pectus excavatum Pectus carinatum
Flat
Bulging
Scars
Normodynamic Hyperdynamic
Heaves/thrills
JVP at _________ cm, with HOB at _________ angle Hepatojugular reflex
PMI at ______________
Apex beat at ______________
Heart Sounds:
Distinct
Faint
S1 ______ S2 at base
S1 ______ S2 at apex
S3
S4
Murmur, grade ________ best heard at ________________________________
Pericardial friction rub
Other sounds: _____________________
Configuration:
Precordial Area:

PULSE
Carotid
Radial
Brachial

GRADE

PULSE
Dorsalis Pedis
Posterior Tibial
Femoral

GRADE

Abdomen

Configuration:
Symmetrical
Asymmetrical
Flat
Flabby Globular
Protuberant Scaphoid
Skin: Dilated veins
Striae
Scars
Rashes
Lesions at __________________________________________________
Umbilicus:
Sunken
Bulging
Bowel Sounds: ________/min
Normoactive
Hyperactive
Hypoactive
Absent
Bruit: Absent Present at ________________________________________
Percussion:
Tympanitic
Hypertympanitic
Fluid wave
Shifting dullness
Dullness at ________________________________________
Traubes Space:
Intact
Obliterated
Palpation:
Muscle guarding
Tenderness (Direct, Rebound)
Rigidity
Masses: _______________________
Kidneys:
Palpable (size, contour): _____________________________
Nonpalpable
Tenderness
CVA tenderness
Urinary Bladder: Smooth, round
Tenderness

Genitalia

Pubic hair: None

Sparse
More adult-like, at base of penis
Adult type, smaller area Adult type, up to medial thigh surface
Male
Penis:
Circumcised
Uncircumcised
Tenderness
Discharge: ___________________________
Nodules/lesions at _______________________________________
Scrotum: Equal
Tenderness
Enlargement R L
Undescended R L Nodules/lesions at ____________________
Others:
Hernia
Hydrocele
Tortuous veins
Female
Labia:

Symmetrical
Pinkish
Discharge:
Purulent
Others:
Swelling

Asymmetrical, lesions at ____________

Discoloration
Edema
Bloody
Foul-smelling
Lumps/Nodules at _________________

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Neurologic
Mental Status Exam
(Temporal & Occipital)

(Frontal)

(Parietal Dominant)

(Parietal Nondominant)
Cranial Nerve I
II

III, IV, VI
V
VII

VIII
IX, X
XI
XII
Motor

Sensory
Cerebellar
Deep Tendon Reflexes

Oriented to: Time (Time of day, day, month, year) Person

Place (Country, region, city, town, barangay, building)
Object* naming (at least three)
Color naming (at least three)
Memory:
Immediate*
Recent
Remote
Attentiveness:
Good
Fair
Poor
Conccentration:
Good
Fair
Poor
Expressive Language: Normal rate
Normal rhythm
Normal pitch
Normal loudness Spontaneous
Insight:
Able to interpret proverb
Judgement:
Good
Fair
Poor
Planning:
Good
Fair
Poor
Calculation (Note educational attainment): Able to do serial 7s
Intact left and right orientation
Finger naming: ______/10 fingers
Graphesthesia: ______/3 letters/numbers Stereognosis: ______/3 objects
Apraxia:
Able to dress self
Able to button up
Drawing: Circle
Triangle
Square
Intersecting pentagons
Gross Smell:
Symmetrical
Olfactory Deficiency R L
Visual Acuity:
_____/_____
Wears eyeglasses/contact lenses
Fundoscopy Findings: _________________________________________________
Pupil Size:
Equal = ______ mm
Unequal R=______ mm
L=______ mm
Light Reaction: R Brisk
Sluggish
Fixed
L Brisk
Sluggish
Fixed
Reaction to Accommodation:
Uniform
Unequal
Convergence:
Uniform
Unequal
EOMS:
Intact
Dysconjugate Gaze
Nystagmus
Facial Sensation:
Symmetrical
Inc/Dec at ______________________
Normal masseter tone
Normal temporalis tone
Facial Expressions:
Symmetrical
Lag at __________________________
Anterior 2/3 Taste:
Intact
Absent
Nasolabial Fold:
Symmetrical
Shallowing
Gross Hearing:
Intact
Decreased R L
Weber:
Symmetrical
Lateralizes R L Rinne
Able to swallow
Uvula deviation R L
Gag reflex
Shrug (Trapezius)
SCM test
Tongue: Midline
Deviation R L
Atrophy
Speech: Intact
Slurred
Aphasic
Symmetrical
Asymmetrical
Atrophic
Muscle Tone: Normal
Flaccid
Spastic
Muscle Strength: R Upper extremity _________ R Lower extremity _________
L Upper extremity _________ L Lower extremity _________
ROM:
Full
Decreased at ________________________
Touch Pain/Dullness
Gait: Natural
Finger to nose
REFLEX

On heels
Heel to sheen

GRADE

Biceps
Triceps

Babinski
Meninges

Temperature

Vibration

Proprioception

On toes
Tibial tapping

Tandem
Pro/supination

REFLEX
Brachioradialis
Patellar

Clonus

Nuchal rigidity

GRADE

REFLEX

GRADE

Ankle

Others: _______________________________
Kernigs sign

Brudzinski sign

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