THE PEDIATRIC CLINICAL HISTORY

I. General Principles:
Smile and greet parents, child if old enough.
Introduce yourself.
Establish rapport and try to make family feel comfortable.

II. Date of interview, source and reliability.

III. General Data: Name, age, sex, residence, number of times admitted and date of
present admission.

IV. Chief Complaint: Brief statement of the primary problem that caused the family to
seek medical attention, preferably using patient’s or informant’s own words.

V. History of the Present Illness:

1. Concise chronological account of the illness, from the onset to the present in
specific number of months, weeks, days, or hours. It belongs here if related to
the differential diagnosis for the chief complaint.
**Tip for describing symptoms if applicable: CLITAA
2. Describe main symptoms in terms of Character (quality), Location (and spread),
Intensity (quantity or severity), and Timing (onset, duration, frequency, setting)
3. Aggravating or relieving factors including
a) Medications (generic and brand names in actual doses) and duration of
treatment and effects
b) Consultations and hospitalizations, number of times, duration, and results
4. Associated signs and symptoms; pertinent positives and negatives that will aid in
the differential diagnosis

**If neonate, start HPI from birth.

VI. Medical/Personal Health History: General state of health as the parents or patient
perceives it.

A. Perinatal History: Particularly important in the first 2 years of life and when
dealing with neurologic and developmental problems; for >2 yr old, only if
related to illness or remarkable; get hospital records if needed
1. Neonates and Infants
Gestational or prenatal history: mother's age during pregnancy, gravida,
parity, abortions, health during pregnancy (bleeding, trauma, hypertension,
gestational diabetes,fever, infections, medications, radiation exposure, drugs,
alcohol, smoking, rubella immunity status, hepatitis B), nutrition including
weight gain and and duration of pregnancy
Birth history: labor and manner of delivery, including degree of difficulty,
analgesia used, complications encountered and persons who attended;
duration of rupture of membranes, meconium staining of amniotic fluid,
whether preterm, term or postterm; birth order, if multiple birth; birth weight
and APGAR scores at 1 and 5 minutes
2. All Children
Neonatal history: spontaneous respiration or required resuscitation; cry,
cyanosis, pallor, jaundice, convulsions, birth injury, hemorrhage, congenital
anomalies, respiratory or feeding difficulties, length of stay in nursery, if AGA,
SGA or LGA

B. Nutritional or feeding/dietary History: Particularly important in the first 2 years

of life and in dealing with problems of undernutrition and overnutrition
1. Infants (<2 years of age)
• Type, frequency and duration, reason if not breastfed, formula used with
dilution and amount, whether bottle- or cup-fed
• Complementary foods: age introduced, frequency, usual intake, amount
and quality compared with food pyramid
• Any peculiar eating habits (pica)
• Vitamin/mineral supplements: type, amount, frequency, length
2. Children and Adolescents (2-20 years of age)
• Early feeding not included unless pertinent, instead assess habits and
appetite, usual meal and snack, amount and compare quality with food
guide pyramid
• Eating problems, if any, like being a "picky eater", or weight concerns, and
parents’ reactions and attitudes
• Food, vitamin, and mineral supplements: type, amount, frequency, length

C. Growth and Developmental/Behavioral History

1. Physical growth: actual or approximate weight and height at 1, 2, 5 and 10
years, history of slow or rapid gains or losses; note dental eruption and loss
pattern
2. Developmental milestones and progression (<1-5 years of age):
 Domains or streams of development:
a) Gross Motor
b) Fine Motor
c) Language (receptive and expressive)
d) Cognitive
e) Socio-emotional (play and relationship with others, sleep patterns, habits,
personality, sexuality, and discipline and temperament)
f) Self-help or activities of daily living (eating, dressing, grooming, toileting,
and household chores)
3. School performance (6-10 years of age):
a) Language skills
b) Reading skills
c) Writing skills
d) Sequential concepts and math skills
e) Problem solving, reasoning and moral development
f) School failures or other problems, if any
4. Pubertal history (10-20 years of age)
a) Male
Age of onset
Genital Enlargement
Pubic Hair
b) Female
Age of onset
Breast
Pubic Hair
Age of Menarche, Frequency, Duration, LMP, Dysmenorrhea, Meds

D. Past Illnesses
1. Childhood illnesses: age, complications, treatment
2. Recent infection exposures: date, travel to other locations, animal exposure
3. Previous hospitalizations: age, length of stay, reason, location
4. Previous surgery/transfusions: age, reason for procedure, complication
5. Trauma/injuries/ingestions: age, circumstances surrounding event, treatment,
complication
6. Screening procedures: ENBS, hearing, vision, developmental, anemia, etc.
7. Allergies and drug reactions
8. Previous and current medications and disabilities

E. Immunizations: Ask to see record. Check if up to date.

BCG Hepatitis B DPT OPV/IPV
Hib PCV13 Rotavirus Measles
Influenza Jap Enceph Varicella MMR
Hepatitis A HPV
Booster doses
Others: Meningoccocal, Rabies, Typhoid, Pneumo 23
VII. Family History
A. Illnesses: cardiac disease, hypertension, stroke, diabetes, cancer, epilepsy,
mental disorders, kidney disease, abnormal bleeding, PTB
B. Allergy: Asthma, atopic dermatitis, allergic rhinitis, drug/food allergy
C. Anomalies: mental retardation, developmental delay, congenital anomalies,
chromosomal problems, miscarriages, infant or childhood deaths, growth
problems, consanguinity
D. Pedigree: 3 generations, to assess inheritance pattern

VIII. Environmental/Socioeconomic/Personal-Social/Psychosocial History: An

outline or narrative description that captures important and relevant information
about patient as a person, patient’s lifestyle, home situation and significant others.

A. Infants and Older Children

1. Living conditions: place and nature of dwelling; safety issues including water
source, exposure to air and environmental pollutants, and duration; whether
attending daycare; leisure and physical activities
2. Family situation: occupation of parents; composition of family, home situation
and significant others; sources of stress; important life experiences
3. Religious and health beliefs of family

B. Adolescents (HEADSSS)
1. Home: What is the living arrangement? Any recent changes in the living
arrangement? Relationships in the home? Any issues that causes
arguments? Economic issues? Stresses in the home? Forms of discipline?
Anything the adolescent wishes to change in the family?
2. Education/Employment: Is patient currently in or out of school or employed?
Where? Favorite subject? Average last grading/semester? Any problems with
classmates or teachers? Ever been truant/suspended/expelled from school?
What are the patient’s future education/employment goals?
3. Activities: What does the patient do in spare time? Hobbies and interests?
How much time does he spend watching TV, playing computer games and
using the internet? With whom does the patient spend time with? Any close
friends? Are the patient’s friends attending school?
4. Drugs:Does the adolescent or any of his friends use tobacco, alcohol, drugs?
If yes, details (what, frequency, amount) and how/why started? Effects on
daily activities? Selling drugs?
5. Sexuality/Sexual Activity: Sexual orientation? Sexual development? Dating?
Details such as is patient having sex or have had sex? With whom, how often
or when was the last time? Any use of contraception? Having symptoms of
STD? Any history of physical or sexual abuse?
6. Suicide/Depression: Is the adolescent ever sad? Unmotivated? Hopeless?
Lonely? Why? What does he do when the feeling comes? Who does he talk
to? Has the adolescent ever thought of hurting others or himself?Has suicide
plan? If yes, assess seriousness and whether needs immediate referral.
 7. Safety: Does the adolescent use seat belts/helmets? Is he a member of a
fraternity or gang? Does he carry a weapon for protection? Is there a firearm
in the adolescent’s home? Experienced abuse/maltreatment? Threats?

IX. Review of Systems

A. General: fever, recent changes in weight, activity level, playfulness, appetite
changes, sleep problems, days of school missed, delay in growth
B. Skin, Lymphatics, & Blood: rashes, pigmentation changes, pruritus, hair loss,
adenopathy, lumps, easy bruising, bleeding, pallor
C. HEENT: headache, dizziness/fainting, seizures, strabismus, conjunctivitis, visual
problems, hearing, ear infections, draining ears, neck mass, stuffy or runny nose,
sore throat, mouth breathing, snoring, apnea, epistaxis, teeth or gum problem
D. Cardiovascular: orthopnea, cyanosis, heart murmurs, exercise tolerance, easy
fatigability, squatting, chest pain, palpitations
E. Respiratory: wheezing, chronic cough,dyspnea, asthma, hemoptysis
F. GIT: abdominal pain or colic, changes in appetite, vomiting, diarrhea, stool color
and character, constipation, hematemesis, jaundice, food intolerance, encopresis
G. GUT: discoloration of urine, burning sensation, urinary frequency, dysuria,
bladder control, genital discharge and itching, quality of urinary stream, previous
infections, facial/hand/feet edema, change in urinary pattern such as enuresis in
previously toilet trained child
H. Endocrine: breast asymmetry, pain, or discharge, nocturia, polyuria, polydipsia,
polyphagia, cold/heat intolerance, secondary sexual characteristics, menstrual
problems
I. Musculoskeletal: pain or swelling in joint, bone, or muscle; scoliosis, myalgia or
weakness, injuries, gait changes, limitation of motion, stiffness
J. Nervous/Behavioral: tremors, convulsions, weakness or paralysis, mental
deterioration such as memory loss or failing in school, personality or behavioral
changes, mood changes, temper outbursts, hallucinations
 THE PEDIATRIC PHYSICAL EXAMINATION

I. General Approach
A. To be able to do a good pediatric PE, keen observation skills, flexibility, and
attention to details are needed
1. Gather as much data as possible by observation first
2. The golden rule of “Head to foot and back, but forget not the ear, throat and
urine” is worthwhile to remember
3. But actually, there’s no definite order to follow, individualize according to
urgency of situation, age and cooperativeness , and suspected system
involvement
4. Although, it is better to proceed first from least distressing or invasive
examination to most distressing or invasive procedure with painful area last
B. Position of child: parent’s lap vs. examining table
C. Stay at the child’s level as much as possible. Do not tower!!!
D. Establish rapport with child
1. Explain to the child’s level
2. Distraction is a valuable tool
E. Be honest. If something is going to hurt, tell them in a calm fashion. Don’t lie or
you lose credibility!
F. Understand developmental stages’ impact on child’s response. For example,
stranger anxiety is a normal stage of development, which tends to make
examining a previously cooperative child more difficult.
G. For adolescents, while doing PE, teach females the breast self-exam and males
the testicular exam.

II. General Survey

• Developmental level (Any signs of developmental disability/exceptionality?)
• Presence of any dysmorphic features?
• Nutritional status?
´ Weight, Length (<2 years)/Height (>2 years)
´ Weight-for-Length (<2 years), BMI (kg/m2) (2-20 years)

• Presence or absence of distress

´ Respiratory distress, chest or abdominal pain, headache, or mental anguish?
• Type of cry or voice
´ High-pitched cry, incessant cry, weak cry, hoarse voice, absence of voice,
nasal twang, stridor, wheeze, grunting?
• Sensorium and orientation (AVPU and GCS)

• State of hydration
´ Ask about urine output-decreased, little or no urine?
´ Restless and irritable or lethargic or unconscious?
´ Sunkess eyeballs?
´ Drinks eagerly and thirsty or not able to drink or drinking poorly?
´ Skin pinch goes back slowly or very slowly
 • Posture (If bedridden)
´ Spinal curvature disorders: lordosis, kyphosis, scoliosis
´ Encephalopathy posturing: decorticate, decerebrate, flaccid
´ Opisthotonus
´ Torticollis
• Gait (If ambulatory)
´ Limping: antalgic gait, trendelenburg gait, circumduction or waddling gait,
steppage gait or foot drop
´ Torsional variations: in-toeing, out-toeing, genu varum, genu valgum, tibia
vara (Blount’s Disease), pes planus, pes cavus
´ Toe-walking gait with absent heel contact
´ Leg-length discrepancy
´ Neuromuscular: spastic gait, ataxic gait, ‘clumsy’ gait

• Well, mildly ill, or severely ill-looking

III. Vital Signs

Temperature
Heart rate (HR)
Respiratory rate (RR)
Blood pressure (BP): appropriate size cuff is 2/3 width of upper arm
Pulses (Full, weak, thready, or compressible?)
CRT
Oxygen saturation
Pain

Other anthropometric measurements

´ Head circumference (HC) during 1st 3 years of age
´ Chest circumference (CC)
´ Abdominal circumference (AC)
´ Middle upper arm circumference (MUAC)
´ Body proportions (U/L body segment ratio and arm span)
 IV. Skin and Lymphatics
A. Birthmarks: nevi, hemangiomas, mongolian spots, etc
B. Color: pale or sallow, cyanotic, flushed, jaundice
C. Lesions: rashes, petechiae, desquamation, pigmentation, infections
D. Texture: turgor, moisture, CRT
E. Lymph node: enlargement, location, mobility, consistency
F. Scars or injuries, especially in patterns suggestive of abuse

V. HEENT
A. Face: expression, asymmetry, paralysis, facies
B. Head: contour, bossing, texture of hair, scalp, fontanelles
C. Eyes: conjunctivae, sclerae, PERLA, strabismus, EOM, ptosis, red orange reflex,
vision, eye contact and visual tracking
D. Ears: position, deformities, hearing, discharges, ear canals, tympanic
membranes, mastoid tenderness
E. Nose: patency, flaring of the alae nasi, discharges, nasal septum, nasal mucosa
color, polyps, sinus tenderness
F. Mouth and Throat: color of lips and buccal mucosa, fissures, lesions or sores,
tongue color and character, dental caries, color and character of gums, size,
color and exudates of tonsils and pharynx, gag relex
G. Neck: thyroid enlargement, trachea at midline, masses, sizes and character of
lymph nodes, presence or absence of nuchal rigidity

VI. Chest and Lungs

A. Inspection: contour of thorax and spine, symmetry of expansion, rate and
regularity of respiration, use of accessory muscles, retraction location
B. Auscultation: equality of breath sounds, stridor, wheezes, rhonchi, crepitant rales
C. Palpation and percussion often not possible and rarely helpful

VII. Heart
A. Inspection: precordial bulge or heave
B. Palpation: PMI diffused or circumscribed, thrills
C. Percussion: heart borders
D. Auscultation: rate, rhythm, murmurs, quality of heart sounds

VIII. Abdomen
A. Inspection: distended or scaphoid, visible veins, visible masses, umbilical
infection or hernia, striae, pulsations, peristaltic movements and movements in
relation to respiration
B. Auscultation: bowel sounds (increased and high-pitched associated in intestinal
obstruction and diarrhea), observe bowel sounds change over a period of time
C. Palpation: masses, organomegaly, direct and rebound tenderness
D. Percussion: tympanitic, dullness
IX. Genito-Urinary Tract
A. Male: circumcision, phimosis, meatus, descent of testes, hydrocoele, inguinal
hernia, Tanner staging or SMR in adolescents
B. Female: external examination only, vulva, clitoris, discharge, Tanner staging or
SMR in adolescents

X. Rectal
Look for fissures, hemorrhoids, prolapse, sphincter tone, masses, tenderness, stool
in ampulla

XI. Extremities
A. General: deformity, symmetry, color, warmth, clubbing, edema
B. Pulses: presence, quality, equality
C. Joints: motion, stability, swelling, tenderness
D. Hips: Ortolani’s and Barlow’s signs
E. Back: sacral dimple, curvature
F. Pediatric GALS examination

XII. Neurologic
A. Cranial nerves I-XII (mnemonic: On Old Obando Tower Top A Filipino Army
Guard Villages And Huts)
B. Motor: paresis, paralysis, spasticity, romberg, rigidity, flaccidity, clonus,
carpopedal spasm, tics, tremors, athetosis
C. Reflexes: DTRs (biceps, triceps, radial, knee, ankle), superficial (abdominal,
cremasteric, primitive (moro, rooting, sucking, grasp, ATNR)
D. Sensory: superficial and deep sensations, pin-prick, touch, sense of position,
vibratory sense
E. Cerebellar signs: incoordination ataxia, intention tremor, past pointing,
dysdiadochokinesia, nystagmus on extreme lateral gaze