NEWBORN HISTORY OUTLINE

I.

II.

III.

IV.

V.

VI.

VII.

General data (replaces chief complaint)

Ex. 1,100 g 30-week AGA male delivered by Cesarean section to a 22-year-old G1P0
mother for progressive pre-eclampsia
Maternal obstetrical history
include significant past history especially pregnancy losses, complications or
infertility problem
History of pregnancy
A. last menstrual period (LMP)
B. estimated date of confinement (EDC)
C. prenatal care
D. weight gain
E. medications or drugs including OTC preparations
F. illnesses or infections
G. alcohol or tobacco use
H. blood type/antibody screen
I. serology or cultures
J. gestational age dating (quickening, ultrasound, fundal height)
K. complication (bleeding or spotting, edema, abdominal pain)
Labor
A. onset of uterine activity (spontaneous, induced)
B. duration
C. intensity of contractions
D. membrane status (intact, ruptured spontaneously or artificially)
E. amniotic fluid (volume, color, character)
F. presentation (vertex, breech, transverse, etc)
G. augmentation (oxytocin)
H. monitoring (auscultation, electronic)
I. analgesia (type, route)
Delivery
A. mode (vaginal, abdominal)
B. assistance (forceps, vacuum extraction)
C. position
D. anesthesia or analgesia
E. complications
Immediate neonatal period
A. apgar scores (include breakdown)
B. resuscitation provided (ventilation, drugs, etc)
C. neonatal course (include procedures, labs)
Family history

VIII.

IX.

X.
XI.
XII.

Social history
A. Marital status
B. Planned pregnancy
C. Socioeconomic status
Physical examination
A. General appearance
B. Vital signs
PR=
HC= AC=
C. HEENT
D. Neck
E. Chest and lungs
F. Heart
G. Abdomen
H. Umbilicus
I. Genitalia
J. Extremities
K. Back
L. Anus
Neurologic examination
Gestational age assessment
Impression

CC=

RR=

Length=

Wt=

T=

NEUROLOGIC EXAMINATION OF THE NEWBORN

GENERAL PRESENTATION
1. Initial presentation:
( ) Symmetrical position
( ) Gross abnormalities of skeletal, vascular and skin development
2. Mental status:
( ) Spontaneous activity (alertness)
( ) Response to external stimulation
( ) Drowsiness
( ) Ease of consolability
( ) Orientation to visual and auditory stimuli
( ) Habituation to various stimuli
3. Posture of flexion:
( ) Limbs semi-flexed and legs partially abducted at the hips
( ) Head is slightly flexed and position at the midline or turned to one side
( ) Spontaneous motor activity of flexion and extension alternation between
arms and legs
( ) Forearms supinate with flexion at the elbow and pronate with extension
( ) Fingers are flexed with tight fist
( ) Low frequency and high frequency tremors of the arms, legs, and body
(vigorous crying or at rest during the 1st 48 hours of life)
( ) Negative flexion (hypotonia)
( ) Head and legs are extended (breech presentation)
( ) Legs abducted and externally rotated (frank breech baby)
( ) Tremors at rest (4 days after birth)
( ) Asymmetrical movement of arms and legs
(central/peripheral neurologic deficits, birth injuries or congenital anomalies)
HEAD
1. Inspection/palpation
Anterior fontanels: Size=
Tenderness
Contour:
( ) Bleeding ( ) Nodules ( ) Vascular lesion ( ) Defect
( ) Irregularities of bone densities of frontal and parietal bone
2. Head circumference: ___________ cm or inches
3. Auscultation
4. Transillumination: __________ cm (< or = to 1cm is abn)

CRANIAL NERVES
1. CN I = not tested
2. CN II =
( ) Fixed at an object placed 10-12 inches from the eyes and can follow it 60
( ) Pursuit is not enough
3. CN III, IV, VI:
( ) Symmetrical size of globe
( ) Dolls eye maneuver
( ) Nystagmus
( ) Ptosis
4. CN V: ( ) Sucking reflex
5. CN VII:
( ) Symmetrical face
( ) Ineffective sucking and drooling
6. CN VIII:( ) Moro reflex (loud sound)
7. CN IX, X:
( ) Evaluate babys cry
( ) Swallow
8. CN XI: ( ) Good SCM
9. CN XII:
( ) Tongue symmetrical
( ) Tongue atrophy
MOTOR
( ) Spastic

( ) Flaccid

( ) Hypotonic

REFLEXES
1. Primitive reflex (infantile automatism):
( ) Moro/startle reflex
( ) Babinski
( ) Stepping
( ) Palmar grasp
( ) Placing
( ) Rooting
incurvation
2. Deep tendon reflexes:
( ) Biceps
( ) Triceps
( ) Ankle
SENSORY
Response to pain:
( ) Awake
( ) Withdraw
( ) Change in facial expression

( )Tonic neck
( ) Plantar grasp
( ) Galant/truncal

( ) Knee jerk

Department of Pediatrics
History and Physical Examination
History Outline General
The following outline should be modified as appropriate for the age of the child and the
condition for which he is brought to the Physician.

Clinical History
I.

Identifying Information
Name, age, sex, residence, date of admission, number of admissions

II.

Source of History, Reliability

Good, fair and poor.

III.

Chief Complaint
Preferably in parents or informations words

IV.

History of Present Illness

Chronologic evaluation, if possible, with dates, of the patients illness, including initial
symptoms and date of onset, subsequent symptoms chronologically, pertinent negative
data, appetite and activity, medications given during present illness and effect. If
neonate, start history of present illness from birth.

V.

Past History
A. Hospitalizations: Record dates and reasons (accidents, poisoning, other
emergencies, tests, etc.) for hospitalizations.
B. Infections: Note the childs age at onset, type of infection, number and severity of
episodes.
C. Contagious Diseases: Record the childs age at exposure to the following infectious
diseases, measles, rubella, chickenpox, mumps, pertussis, diphtheria, and scarlet
fever. Note the presence and severity of complications.
D. Other Serious Noninfectious Illness: Obtain information about such illnesses as
neoplastic diseases and genetic disorders.

VI.

Family History
Any similar illness in the family, familial illnesses like PTB, diabetes, cancer, epilepsy,
hypertension, allergy, blood dyscrasias, mental or nervous diseases, cardiovascular
diseases, rheumatic fever, congenital abnormalities, and other heredofamilial disorders.

VII.

Birth History
A. Antenatal: Obtain basic information regarding the mothers health during
pregnancy, including prenatal care, diet infections (e.g. rubella) and other illnesses,
vomiting, bleeding, preeclampsia-eclampsia and other complaints. Ask about
serologic tests, pelvimetry medications, x-ray procedures, and amniocentesis.
B. Natal: Note the duration of pregnancy, kind and duration of labor, type of delivery,
sedation and anesthesia (if known), birth weight, state of infant at birth,
resuscitation required, onset of respirations, first cry, special procedures.
C. Neonatal: Ask about the childs Apgar score, color (cyanosis, pallor, jaundice) and
cry; and about any twitching, excessive mucus, paralysis, convulsions, fever,
hemorrhage, congenital abnormalities, or birth injuries. Record length of hospital
stay and the childs discharge weight.

VIII.

Nutrition
A. Breast or Formula Feeding: Record the type of feeding, duration, major formula
changes, time of weaning, difficulties.
B. Supplements: Note the addition of vitamins (type, amount duration).
C. Solid Foods: Ask when solid foods were introduced, how taken types, unusual family
dietary habits (e.g. Vegetarian)
D. Appetite: Childs food likes and dislikes, idiosyncrasies, allergies, and general attitude
to eating.

IX.

Developmental Milestones
Record the childs age when he or she first raised head, rolled over, sat alone, pulled up,
walked with help, walked alone, talked (meaningful words, sentences). Ask about
urinary continence during day and night, control of defecation; compare development
with that of sibling, record school grade, and quality of work.

X.

Personal-Social History
Parents and Grandparents: age, occupation, state of physical and emotional health,
living or dead, if dead cause and nature of death.
Siblings: ages, state of health and where living. If dead, age of death, cause and nature
of death.

Patient: age, school, activities, school status, living circumstances, sleeping

arrangements, number of persons living in home, members of the family who work,
general level of economic independence, caregiver (mother, yaya, etc.)
XI.

Immunizations and Tests

Indicate childs age at immunization, type and number of immunizations, boosters,
reactions if any. Record any tests done (e.g. PPD), medications given, long-term or
maintenance medications and indications.

XII.

Environmental History
A. Indoor Air Pollution: Note whether the childs health appears to be affected by
house dust, mold, animal dander, fumes from disinfectants or other chemicals,
ventilation problems, sick building syndrome.
B. Pesticides, and Lawn Care Products: Ask parents about accessibility of these
products and security of household storage, proper washing of fresh fruits and
vegetables.
C. Playground Hazards: For older children, note locations of play areas, local traffic
conditions, adult supervision, and sturdiness of play equipment.
Review of Systems
A. General Review: Record any unusual weight gains or losses, fatigue, fevers, growth
patterns, recent behavioral changes.
B. Skin: Check for rashes, lumps, itching, dryness, color changes, changes in hair or nails,
easy bruising.
C. Eyes: Record vision, date of last eye examination, use of glasses or contact lenses, pain
redness, excessive tearing, double vision, lazy eye.
D. Ears, Nose & Throat: Note the presence of frequent colds, sore throats, sneezing, stuffy
nose, nasal discharge or postnasal drip, mouth breathing, snoring, otitis, adenitis,
allergies, note hearing acumen.
E. Dental: Record childs age at eruption of deciduous and permanent teeth; note
presence of bleeding gums, pyorrhea, condition of teeth, etc.
F. Cardiorespiratory System: Record the frequency and nature of any disturbances; note
the presence of dyspnea, chest pain, cough, sputum, wheezing, history of pneumonia,
cyanosis, syncope, tachycardia.
G. Gastrointestinal System: Note the existence of any swallowing problems, spitting,
vomiting, diarrhea, constipation, type of stool, abdominal pain, or discomfort, jaundice,
changes in bowel movements, blood in stool.
H. Genitourinary System: Note the presence of enuresis, dysuria, frequency, polyuria,
pyuria, hematuria, character of urine stream, vaginal itching, or discharge; note

menstrual history, bladder control, abnormalities of genitalia, bruising or evidence of

trauma.
I. Neuromuscular System: Inquire about headache, nervousness, dizziness, tingling,
convulsions, habit spasm, ataxia, muscle or joint pains, postural deformities, exercise
tolerance, gait. Screen the child for scoliosis.
J. Endocrine System: Check for disturbances in growth, excessive fluid intake, polyphagia,
thyroid disease, goiter, age at onset of pubertal changes.

Physical Examination
Vital Signs:
T:

HR:

RR:

BP:

Ht:

Wt:

General Survey: Development, nutrition, sensorium, presence or absence of distress, gait,

posture, orientation, type of cry or voice.
Skin: Color, texture, turgor, pigmentation, eruptions, hydration, edema, hemorrhagic
manifestations, scards, dilated vessels, and direction of blood flow, hemangiomas, caf-aulait areas and nevi, Mongolian spots, elasticity, subcutaneous nodules, sensitivity, hair
distribution, character, desquamation.
Lymph Nodes: Examiner should note the location, size, sensitivity, mobility, and consistency
of the lymph nodes. Try to routinely palpate the suboccipital, preauricular, anterior cervical,
posterior cervical, submaxillary, sublingual, epitrochlear and inguinal nodes.
HEENT:
Head: Note size, shape, circumference, asymmetry, cephalhematoma, bossae, craniotabes,
molding, bruits, fontanelles (size, tension, number, abnormality), sutures, dilated veins,
scalp hair (texture, distribution, parasites), face, and transillumination.
Face: Check for asymmetry, paralysis, note the distance between the nose and mouth, the
depth of the nasolabial folds, bridge of the nose, distribution of hair, size of mandible,
swellings, hypertelorism, Chvosteks sign, and tenderness over the sinuses.
Eyes: Note if there is a photophobia, check visual acuity, muscular control and conjugate
gaze; check for nystagmus; Mongolian slant, Brushfields spots, epicanthic folds;
lacrimation; discharge; lids; exopthalmos or enophthalmos; condition of the conjunctivae;
papillary size, shape, reaction to light and accommodation; check for corneal opacities,
cataracts (congenital or acquired); fundi; visual fields (in older children).
Ears: Check the pinnas (position and size), canals, tympanic membranes (landmarks,
mobility, perforation, inflammation, discharge), mastoid tenderness and swelling, hearing.
Nose: Patency of the nares, flaring of the alae nasi; discharge; obstruction; septum.

Mouth and Throat: Note configuration of the lips (thinness, downturning, fissures, color,
cleft); teeth (number, position, caries, mottling, discoloration, notching, malocclusion or
misalighment); mucosa (color, enanthems, Bohns nodules, Epsteins pearls); also the gums,
palate, tongue, uvula, mouth breathing, geographic tongue.
Throat: Observe the tonsils (size, inflammation, exudates, crypts, inflammation of the
anterior pillars) epiglottis, mucosa, hypertrophic lymphoid tissue, postnasal drip, voice
(hoarsenesss, stridor, grunting, type of cry, speech)
Neck: Flexibility, swelling, thyroid enlargement, trachea in midline, size, consistency,
tenderness and mobility of lymph nodes, sternocleidomastoid (swelling and shortening),
webbing, edema, auscultation, movement, tonic neck reflex.
Chest and Lungs: Observe thoracic shape and symmetry, veins, retractions and pulsations,
beading; presence of Harrisons groove, flaring of ribs, pigeon breast, funnel shape; the size
and position of the nipples, breasts, intercostals or subcostal retraction, asymmetry,
scapulae, clavicles; the presence of scoliosis; check for type of breathing, dyspnea, cough,
femitus, flatness or dullness to percussion, rales, wheezing; check expansion, resonance,
quality of breath and voice sounds.
Heart:
Inspection: Precordial heave or bulge
Palpation: PMI diffuse or circumscribed, thrills, apex beat
Percussion: heart broders
Auscultation: Rate, rhythm, sounds (i.e. M1, M2, etc.), murmurs (timing, duration, intensity,
quality, transmission)
Abdomen: Check with regard to size and contour, visible peristalsis, respiratory
movements, veins (distension, direction of flow, umbilibus, hernia, musculature, tenderness
and rigidity, rebound tenderness, tympany, shifting dullness, pulsation, palpable organs or
masses (size, shape, position, mobility), fluid wave, reflexes, femoral pulsations, bowel
sounds.
Genitalia:
Male: Note circumcision if present, meatal opening, hypospadias, phimosis, adherent
foreskin, size of testes, cryptprchidism, scrotum, hydrocele, hernia, pubertal changes.
Tanner stage should be noted.
Female: Observe the vagina (imperforate, discharge, adhesions), size of vaginal opening (in
prepubertal children), clitoral hypertrophy, pubertal changes. Tanner stage should be
noted.
Rectum and Anus: Check for the presence of irritation, fissures, prolapsed, imperforate
anus. Note muscle tone, character of stool, masses, tenderness, sensation. (Perform rectal
examinations with your finger inserted slowly. Examine stool on gloved finger.

Extremities:
A. General: note the presence of deformities, hemiatrophy, bowleg (common in infancy),
knock-knee (common at age 2-3 years), paralysis, asymmetry, edema; note temperature,
posture, gait and stance.
B. Joints: Check for swelling, redness, pain, limitations, tenderness, motion, rheumatic
nodules, carrying angle of elbows tibial torsion.
C. Hands and Feet: Note the Presence of extra digits, clubbing, simian lines, curvature of
little fingers, nail deformities, splinter hemorrhages, flatfeet (feet commonly appear flat
during the first 2 years of life); abnormalities of feet; dermatoglyphics; width of thumbs and
big toes; syndactyly, length of various segments; dimpling of dorsa; temperature.
D. Peripheral Pulses: Observe the presence, absence, or diminution of arterial pulses.
Spine and Back: Check the childs overall posture, curvatures, rigidity, webbed neck; spina
bifida; pilonidal dimple or cyst; tufts of hair, mobility, Mongolian spots; tenderness over
spine, pelvis, and kidneys.

Neurologic Examination
A. Mental Status: Note level of consciousness (alert, drowsy, stuporous, comatose),
intelligence, memory, orientation, ability to understand and communicate, auditory-verbal
and visual0verbal comprehension, visual recognition of objects, speech, ability to write,
performance of skilled motor skills.
B. Cranial Nerves:
I. Olfactory identification of odors; disorders of smell
II. Optic visual acuity, visual fields, ophthalmoscopic examination
III. Oculomotor elevation of upper lids, EOM superior, inferior, medial recti, inferior
oblique, motor arc of papillary constriction (dilation if via cervical sympathetics)
IV. Trochlear EOM - superior oblique
V. Trigeminal facial sensations, corneal reflex, masseter and temporal muscle reflexes,
maxillary reflex (jaw jerk)
VI. Abducens external rectus
VII. Facial wrinkling forehead, frowning, smiling, raising eyebrows, asymmetry of face,
strength of eyelid muscles, test on anterior portion of the tongue.
VIII.
Vestibulocochlear
a.
Cochlear hearing, lateralization, air and bone conduction, tinnitus;
b.
Vestibular caloric tests
IX. Glossopharyngeal test on posterior 1/3 of the tongue; elevation of palate, sensory arc
of gag reflex
X. Vagus swallowing, elevation of epiglottis, movements of vocal chords.
a. Cranial deviation of epiglottis, movements of vocal chords;
b. Spinal innervates sternomastoid and trapezius; atrophy, drooping and inability to
shrug shoulders
XI. Accessory strength of trapezius and sternocleidomastoid muscles

XII. Hypoglossal protrusion of tongue, tremor, strength of tongue

C. Cerebellar Function: Examiner should ask the child to perform the following maneuvers:
touch finger to nose and finger to examiners finger, rapidly alternate pronation and
supination of hands; run one heel down the other shin and make a requested motion with
foot; stand with eyes closed, walk normally, then walk heel to toe. Also check for tremor,
ataxia, general posture; arm swing when walking, nystagmus, abnormalities of muscle tone
and speech.
D. Motor System: Muscle size, consistency and tone; muscle contours and outlines; muscle
strength; myotonic contraction; slow relaxation; symmetry of posture, fasciculations;
tremor, resistance to passive movement; involuntary movement.
E. Reflexes: Check for the presence of the following reflexes:
1. Deep biceps, brachioradialis, triceps, patellar, and Achilles; rapidity and strength of
contraction and relaxation
2. Superficial abdominal, cremasteric, plantar and gluteal
3. Neonatal Babinski, Landau, Moro, rooting, sucking, grasping, and tonic neck
F. Sensory Examination: Pain, temperature and light touch, vibration and position sense
G. Meningeal Signs: Neck rigidity, Kernigs sign, Brudzinksy sign
H. Autonomic Function: Urinary, bowel incontinence or retention, sweat patterns

Diagnosis and/or Impression: List in order of importance

Basis for Impression: a brief summary of pertinent history and physical findings and
discussion of the different diagnoses and of the problem as presented by the patient
Plan of Management: all diagnostic studies and rationale, diet, therapeutic regimen