Guide to the Comprehensive Pediatric
H&P Write Up
INSTRUCTIONS FOR USE OF THE SECTION ON PEDIATRIC HISTORY AND
PHYSICAL EXAM
The following outline for the Pediatric History and Physical Examination is comprehensive and detailed.
In order to assimilate the information most easily, it is suggested that you read through the whole section
before examining your first patient to get a general idea of the scope of the pediatric evaluation. Then, as
you encounter patients with specific problems, you may return to the individual sections most pertinent
to these patients to absorb the information in detail. Repeat practice with a variety of patients of different
ages is crucial to the acquisition of skills in data collection. You should use every opportunity possible to
evaluate patients in order to develop a sense of normal growth and development and appreciate the
variations in patient encounter that is necessary to perform appropriate evaluation children of different
ages.
OUTLINE FOR PEDIATRIC HISTORY
HISTORY
I. Presenting Complaint (Informant/Reliability of informant)
Patient's or parent's own brief account of the complaint and its duration. Use the words of the informant
whenever possible.
II. Present Illness
Begin with statement that includes age, sex, color and duration of illness, ex.: This is the first APH
admission for this 8 year old white male who has complained of headache for 12 hours PTA. When was
the patient last entirely well? How and when did the disturbance start? Health immediately before the
illness. Progress of disease; order and date of onset of new symptoms. Specific symptoms and physical
signs that may have developed. Pertinent negative data obtained by direct questioning. Aggravating and
alleviating factors. Significant medical attention and medications given and over what period.
Use day of admit (DOA) as the reference point for your timeline of present illness. Ever event/symptom
that occurs leading up to DOA should listed as # day prior to admission (PTA)
In acute infections, statement of type and degree of exposure and interval since exposure.
For the well child, determine factors of significance and general condition since last visit.
III. Past Medical History
• Birth
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: APGAR score; color, cyanosis, pallor, jaundice, cry, twitchings, excessive mucus,
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.
A common way to document birth history is as follows:
3445 g full term infant born to a 28 yo G2P2 O+ mother via normal spontaneous vaginal delivery
after a pregnancy where mother received prenatal care in the first trimester whose prenatal labs
were GBS-, HIV-, GC-, chlamydia -, RPR nonreactive. Mom reports no medications taken during
pregnancy or delivery. Delivery was uncomplicated. No resuscitation was required. APGARs were
8 at 1 min and 9 at 5 min. Nursery course was uncomplicated and infant went home with mom on
DOL#2.
• Past Illnesses
A comment should first be made relative to the child's previous general health, and then the specific areas
listed below should be explored.
A. Past medical history: including all diagnoses, infections, Accidents and Injuries (include
ingestions): Age, type/nature, severity, sequelae.
B. Past Hospitalizations: including operations, age. Include place of hospitalization and
duration of hospitalization.
C. Past Surgeries: where and by whom for what diagnosis
D. Allergies, with specific attention to drug allergies: detail type of reaction. Results of allergy
testing gif performed.
E. Medications patient is currently taking- prescribed, OTC, homeopathic. Include dose,
formulation, route and frequency.
• Immunizations and Tests
Be familiar with Advisory Committee on Immunization Practices (ACIP) recommendations for
immunizations. List date and type of immunization, facility providing immunization as well as any
complications or reactions. DO NOT LIST “Up to date per parent report” If no immunization record is
available, include this as a problem in the assessment and plan so it will be followed up.
Growth and Development
A.
Development
Motor and Mental Development First raised head, rolled over, sat alone, pulled up, walked
with help, walked alone, talked (meaningful words; sentences), formal screening when
appropriate.
Urinary continence during night; during day
Control of feces.
Comparison of development with that of siblings and parents.
School grade, quality of work.
Physical Growth including menarche and other pubertal developments
Behavioral History
Does child manifest any unusual behavior such as thumb sucking, excessive masturbation,
severe and frequent temper tantrums, negativism, etc.?
Sleep disturbances.
Phobias.
Pica (ingestions of substances other than food).
Abnormal bowel habits, ex. - stool holding.
Bed wetting (applicable only to child out of diapers).
Nutrition
A.
Breast or Formula: Type, duration, major formula changes, time of weaning, difficulties. Be
specific about how much milk or formula the baby receives. How does caretaker mix the
formula?
B.
Vitamin Supplements: Type, when started, amount, duration.
C.
"Solid" Foods: When introduced, how taken, types.
D.
Appetite: Food likes and dislikes idiosyncrasies or allergies, reaction of child to eating. An idea
of child's usual daily intake is important.
IV. Family History - use family tree whenever possible
A.
Age and health of family members (parents, grandparents, siblings)
B.
Stillbirths, miscarriages, abortions; age at death and cause of death of immediate members of
family
C.
Known genetic diseases
D.
Diseases with a genetic contribution: allergy, blood dyscrasias, mental or nervous diseases,
diabetes, cardiovascular diseases, kidney disease, rheumatic fever, neoplastic diseases,
congenital abnormalities, cancer, convulsive disorders, others
E.
Health of contacts- ill exposures (tuberculosis….)
V. Social History
A.
Type of habitat. Age of habitat, number of people in home and relationship to patient
B.
Marital status of parents and involvement with child
C.
Parents employment
D.
Child care or school
VI. Environmental History
A.
Environmental tobacco smoke
B.
Water source to home
C.
Pets
D.
Smoke and CO detectors
E.
Firearms
VII. System Review
A system review will serve several purposes. It will often bring out symptoms or signs missed in
collection of data about the present illness. It might direct the interviewer into questioning about
other systems that have some indirect bearing on the present illness (ex. - eczema in a child with
asthma). Finally, it serves as a screening device for uncovering symptoms, past or present, which
were omitted in the earlier part of the interview. There is no need to repeat previously recorded
information in writing a Review of Systems. Questions about health maintenance may be included
here such as last dental visit, last ophthalmology visit…
A. General: Unusual weight gain or loss, fatigue, temperature sensitivity, mentality. Pattern of growth
(record previous heights and weights on appropriate graphs). Time and pattern of pubescence.
B. Eyes: Have the child's eyes ever been crossed? Any foreign body or infection, glasses for any reason.
C. Ears, Nose and Throat: Frequent colds, sore throat, sneezing, stuffy nose, discharge, post-nasal drip,
mouth breathing, snoring, otitis, hearing, adenitis.
D. Teeth: Age of eruption of deciduous and permanent; number at one year; comparison with siblings.
E. Cardiorespiratory: Frequency and nature of disturbances. Dyspnea, chest pain, cough, sputum, wheeze,
expectoration, cyanosis, edema, syncope, tachycardia.
F. Gastrointestinal: Vomiting, diarrhea, constipation, type of stools, abdominal pain or discomfort,
jaundice.
G. Genitourinary: Enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of stream, vaginal
discharge, menstrual history, bladder control, abnormalities of penis or testes. Details of menarche and
menstruation for adolescent females
H. Neuromuscular: Headache, nervousness, dizziness, tingling, convulsions, habit spasms, ataxia, muscle
or joint pains, postural deformities, exercise tolerance, gait.
I. Endocrine: Disturbances of growth, excessive fluid intake, polyphagia, goiter, thyroid disease.
J. Hematologic: Bruise easily, difficulty stopping bleeds, lumps under arms, neck; fevers, shakes, shivers
K. Rheumatologic: Joints: pain, stiffness, swollen, variation in joint pain during day, fingers painful/ blue in
cold, dry mouth, red eyes, back, neck pain
L. Skin: Ask about rashes, hives, problems with hair, skin texture or color, etc.
OUTLINE FOR PEDIATRIC PHYSICAL EXAM
PHYSICAL EXAMINATION
Every child should receive a complete systematic examination at regular intervals. One should not restrict
the examination to those portions of the body considered to be involved on the basis of the presenting
complaint.
Approaching the Child
Adequate time should be spent in becoming acquainted with the child and allowing him/her to become
acquainted with the examiner. The child should be treated as an individual whose feelings and
sensibilities are well developed, and the examiner's conduct should be appropriate to the age of the
child. A friendly manner, quiet voice, and a slow and easy approach will help to facilitate the examination.
Observation of the Patient
Although the very young child may not be able to speak, one still may receive much information from
him/her by being observant and receptive. The total evaluation of the child should include impressions
obtained from the time the child first enters until s/he leaves; it should not be based solely on the period
during which the patient is on the examining table. In general, more information is obtained by careful
inspection than from any of the other methods of examination.
Sequence of Examination
Skill, tact and patience are required to gather an optimal amount of information when examining a
child. There is no routine one can use and each examination should be individualized. Ham it up and
regress. Get down to the child's level and try to gain his trust. The order of the exam should conform to
the age and temperament of the child. For
example, many infants under 6 months are easily managed on
the examining table, but from 8 months to 3 years you will usually have more success substituting the
mother's lap. Certain parts of the exam can sometimes be done more easily with the child in the prone
position or held against the mother. After 4 years, they are often cooperative enough for you to perform
the exam on the table again.
Wash your hands with warm water before the examination begins. You will impress your patient's
mother and not begin with an adverse reaction to cold hands in your patients. With the younger child, get
to the heart, lungs and abdomen before crying starts. Save looking at the throat and ears for last. If part of
the examination is uncomfortable or painful, tell the child in a warm, honest, but determined tone that this
is necessary. Looking for animals in their ears or listening to birdies in their chests is often another useful
approach to the younger child.
If your bag of tricks is empty and you've become hoarse from singing and your lips can no longer bring
forth a whistle, you may have to turn to muscle. Various techniques are used to restrain children and
experience will be your best ally in each type of situation.
Remember that you must respect modesty in your patients, especially as they approach
pubescence. Sometime during the examination, however, every part of the child must have been
undressed. It usually works out best to start with those areas which would least likely make your patient
anxious and interfere with his developing confidence in you.
General Physical Examination
I. Vital Signs and Measurements
Temperature, pulse rate, and respiratory rate (TPR); blood pressure (the cuff should
cover 2/3 of the upper arm), weight, height, and head circumference. The weight should
be recorded at each visit; the height should be determined at monthly intervals during
the first year, at 3-month intervals in the second year, and twice a year thereafter. The
height, weight, and head circumference of the child should be compared with standard
charts and the approximate percentiles recorded. Multiple measurements at intervals
are of much greater value than single ones since they give information regarding the
pattern of growth that cannot be determined by single measurements.
II. General Appearance
Does the child appear well or ill? Degree of prostration; degree of cooperation; state of comfort,
nutrition, and consciousness; abnormalities, gait, posture, and coordination; estimate of intelligence;
reaction to parents, physician, and examination; nature of cry and degree of activity, facies and facial
expression. Be as descriptive as possible in this section so that your patient “can be picked out of a
crowd.”
III. Skin
Color (cyanosis, jaundice, pallor, erythema), texture, eruptions, hydration, edema, hemorrhagic
manifestations, scars, dilated vessels and direction of blood flow, hemangiomas, cafe-au-lait areas
and nevi, Mongolian (blue-black) spots, pigmentation, turgor, elasticity, and subcutaneous
nodules. Striae and wrinkling may indicate rapid weight gain or loss. Sensitivity, hair distribution
and character, and desquamation. Be particularly careful in this section to describe your physical
exam findings instead of just listing a diagnosis. Also pay particular attention to details that will
help determine progression or resolution of lesion at subsequent visits for example, size and
location…
*Practical notes:
A. Loss of turgor, especially of the calf muscles and skin over abdomen, is evidence of
dehydration.
B. The soles and palms are often bluish and cold in early infancy; this is of no significance.
C. The degree of anemia cannot be determined reliably by inspection, since pallor (even
in the newborn) may be normal and not due to anemia.
D. To demonstrate pitting edema in a child it may be necessary to exert prolonged
pressure.
E. A few small pigmented nevi are commonly found, particularly in older children.
F. Spider nevi occur in about 1/6 children under 5 years of age and almost ½ of older
children.
G. "Mongolian spots" (large, flat black or blue-black areas) are frequently present over
the lower back and buttocks; they have no pathologic significance.
H. Cyanosis will not be evident unless at least 5 gm of reduced hemoglobin are present;
therefore, it develops less easily in an anemic child.
I. Carotenemic pigmentation is usually most prominent over the palms and soles and
around the nose, and spares the conjunctivas.
IV. Lymph Nodes
Location, size, sensitivity, mobility, consistency. One should routinely attempt to palpate occipital,
preauricular, anterior cervical, posterior cervical, sub mandibular, submental, axillary, epitrochlear, and
inguinal lymph nodes.
*Practical notes:
A. Enlargement of the lymph nodes occurs much more readily in children than in adults.
B. Small inguinal lymph nodes are palpable in almost all healthy young children. Small,
mobile, non-tender shotty nodes are commonly found in residue of previous infection.
V. Head
Size, shape, circumference, asymmetry, cephalhematoma, bosses, craniotabes, control, molding, bruit,
fontanel (size, tension, number, abnormally late or early closure), sutures, dilated veins, scalp, hair
(texture, distribution, parasites), face, transillumination.
*Practical notes:
A. The head is measured at its greatest circumference; this is usually at the midforehead
anteriorly and around to the most prominent portion of the occiput posteriorly.
B. Fontanel tension is best determined with the quiet child in the sitting position.
C. Slight pulsations over the anterior fontanel may occur in normal infants.
D. Although bruits may be heard over the temporal areas in normal children, the
possibility of an existing abnormality should not be overlooked.
E. Craniotabes may be found in the normal newborn infant (especially the premature)
and for the first 2-4 months.
F. A positive Macewen's sign ("cracked pot" sound when skull is percussed with one
finger) may be present normally as long as the fontanel is open.
G. Transillumination of the skull can be performed by means of a flashlight with a sponge
rubber collar so that it forms a tight fit when held against the head.
VI. Face
Symmetry, paralysis, distance between nose and mouth, distance between eyes, depth of nasolabial folds,
bridge of nose, distribution of hair, size of mandible, swellings, hypertelorism, Chvostek's sign, tenderness
over sinuses.
VII. Eyes
Photophobia, visual acuity, muscular control, nystagmus, Mongolian slant, Brushfield spots, epicanthic
folds, lacrimation, discharge, lids, exophthalmos or enophthalmos, conjunctivas; pupillary size, shape,
reaction to light and accommodation; media (corneal opacities, cataracts), fundi, visual fields (in older
children). At 2-4 weeks an infant will follow light. By 3-4 months, coordinated eye movements should be
seen.
*Practical notes:
A. The newborn infant will usually open his eyes if he/she is placed in the prone position,
supported with one hand on the abdomen, and lifted over the examiner's head.
B. Not infrequently, one pupil is normally larger than the other. This sometimes occurs
only in bright or in subdued light.
C. Examination of the fundi should be part of every complete physical examination,
regardless of the age of the child; dilatation of pupils may be necessary for adequate
visualization.
D. A mild degree of strabismus may be present during the first 6 months of life but should
be considered abnormal after that time.
E. To test for strabismus in the very young or uncooperative child, note where a distant
source of light is reflected from the surface of the eyes; the reflection should be present
on corresponding portions of the two eyes.
F. Small areas of capillary dilatation are commonly seen on the eyelids of normal
newborn infants.
G. Most infants produce visible tears during the first few days of life but consistent tear
production occurs after the first 4-6 weeks of life.
VIII. Nose
Exterior, shape, mucosa, patency, discharge, bleeding, pressure over sinuses, flaring of nostrils, septum.
At birth the maxillary antrum and anterior and posterior ethmoid cells are present. At 2-4 years
pneumatization of the frontal sinus takes place but is rarely a site of infection until the 6th - 10th
year. Though the sphenoid sinus is present at birth, it does not assume clinical significance until the 5th to
8th year.
IX. Mouth
Lips (thinness, down turning, fissures, color, cleft), teeth (number, position, caries, mottling, discoloration,
notching, malocclusion or malalignment), mucosa (color, redness of Stensen's duct, enanthems, Bohn's
nodules, Epstein's pearls), gum, palate, tongue, uvula, mouth breathing, geographic tongue (usually
normal).
X. Throat
Tonsils (size, inflammation, exudate, crypts, inflammation of the anterior pillars), mucosa, hypertrophic
lymphoid tissue, postnasal drip, epiglottis, voice (hoarseness, stridor, grunting, type of cry, speech). The
number and condition of the teeth should be recorded. (A child should have 20 teeth by age 2½
years. When the teeth begin to erupt is quite variable but most infants have their two lower central
incisors by 8-10 months.
A. Before examining a child's throat it is advisable to examine his mouth first. Permit the
child to handle the tongue blade, nasal speculum and flashlight so that he/she can
overcome his fear of the instruments. Then ask the child to stick out his tongue and say
"Ah" louder and louder. In some cases this may allow an adequate examination. In
others, if the child is cooperative enough, he/she may be asked to "pant like a puppy;"
while he/she is doing this, the tongue blade is applied firmly to the rear of the
tongue. Gagging need not be elicited in order to obtain a satisfactory examination. In
still other cases, it may be expedient to examine one side of the tongue at a time, pushing
the base of the tongue to one side and then to the other. This may be less unpleasant and
is less apt to cause gagging.
B. Young children may have to be restrained to obtain an adequate examination of the
throat. Eliciting a gag reflex may be necessary if the oral pharynx is to be adequately
seen.
C. The small child's head may be restrained satisfactorily by having the mother place her
hands at the level of the child's elbows while the arms are held firmly against the sides of
his head.
D. If the child can sit up, the mother is asked to hold him erect in her lap with his back
against her chest. She then holds his left hand in her left hand and his right hand in her
right hand, and places them against the child's groin or lower thighs to prevent him from
slipping down from her lap. If the throat is to be examined in natural light, the mother
faces the light. If artificial light and a head mirror are used, the mother sits with her back
to the light. In either case, the physician uses one hand to hold the head in position and
the other to manipulate the tongue blade.
E. Young children seldom complain of sore throat even in the presence of significant
infection of the pharynx and tonsils.
XI. Ears
Pinnas (position, size), canals, tympanic membranes (landmarks, mobility, perforation, inflammation,
discharge), mastoid tenderness and swelling, hearing (including hearing screen).
*Practical notes:
A. A test for hearing is an important part of the physical examination of every infant.
B. The ears of all sick children should be examined.
C. Before actually examining the ears, it is often helpful to place the speculum just within
the canal, remove it and place it lightly in the other ear, remove it again, and proceed in
this way from one ear to the other, gradually going farther and farther, until satisfactory
examination is completed.
D. In examining the ear, as large a speculum as possible should be used and should be
inserted no farther than necessary, both to avoid discomfort and to avoid pushing wax in
front of the speculum so that it obscures the field. The otoscope should be held balanced
in the hand by holding the handle at the end nearest the speculum. One finger should
rest against the head to prevent injury resulting from sudden movement by the child.
E. The child may be restrained most easily if he/she is lying on his abdomen.
F. Low-set ears are present in a number of congenital syndromes, including several that
are associated with mental retardation. The ears may be considered low-set if they are
below a line drawn from the lateral angle of the eye and the external occipital
protuberance.
G. Congenital anomalies of the urinary tract are frequently associated with abnormalities
of the pinnas.
H. To examine the ears of an infant it is usually necessary to pull the auricle backward
and downward; in the older child the external ear is pulled backward and upward.
XII. Neck
Position (torticollis, opisthotonos, inability to support head, mobility), swelling, thyroid (size, contour,
bruit, isthmus, nodules, tenderness), lymph nodes, veins, position of trachea, sternocleidomastoid
(swelling, shortening), webbing, edema, auscultation, movement, tonic neck reflex.
*Practical notes:
In the older child, the size and shape of the thyroid gland may be more clearly defined if the
gland is palpated from behind.
XIII. Thorax
Shape and symmetry, veins, retractions and pulsations, beading, Harrison's groove, flaring of ribs, pigeon
breast, funnel shape, size and position of nipples, breasts, length of sternum, intercostal and substernal
retraction, asymmetry, scapulas, clavicles.
*Practical notes:
At puberty, in normal children, one breast usually begins to develop before the other. In
both sexes tenderness of the breasts is relatively common. Gynecomastia is not
uncommon in the male.
XIV. Lungs
Type of breathing, dyspnea, prolongation of expiration, cough, expansion, fremitus, flatness or dullness to
percussion, resonance, breath and voice sounds, rales, wheezing.
*Practical notes:
A. Breath sounds in infants and children normally are more intense and more bronchial,
and expiration is more prolonged, than in adults.
B. Most of the young child's respiratory movement is produced by abdominal movement;
there is very little intercostal motion.
C. If one places the stethoscope over the mouth and subtracts the sounds heard by this
route from the sounds heard through the chest wall, the difference usually represents the
amount produced intrathoracically.
XV. Heart
Location and intensity of apex beat, precordial bulging, pulsation of vessels, thrills, size, shape,
auscultation (rate, rhythm, force, quality of sounds - compare with pulse as to rate and rhythm; friction
rub-variation with pressure), murmurs (location, position in cycle, intensity, pitch, effect of change of
position, transmission, effect of exercise).
*Practical notes:
A. Many children normally have sinus arrhythmia. The child should be asked to take a
deep breath to determine its effect on the rhythm.
B. Extra systoles are not uncommon in childhood.
C. The heart should be examined with the child recumbent.
XVI. Abdomen
Size and contour, visible peristalsis, respiratory movements, veins (distension, direction of flow),
umbilicus, hernia, musculature, tenderness and rigidity, tympany, shifting dullness, tenderness, rebound
tenderness, pulsation, palpable organs or masses (size, shape, position, mobility), fluid wave, reflexes,
femoral pulsations, bowel sounds. If the liver is palpable below the right costal margin, its total span must
be recorded. A deep abdomen palpation must be done on every child.
*Practical notes:
A. The abdomen may be examined while the child is lying prone in the mother's lap or
held over her shoulder, or seated on the examining table with his back to the
doctor. These positions may be particularly helpful where tenderness, rigidity, or a mass
must be palpated. In the infant the examination may be aided by having the child suck at
a "sugar tip" or nurse at a bottle.
B. Light palpation, especially for the spleen, often will give more information than deep.
C. Umbilical hernias are common during the first 2 years of life. They usually disappear
spontaneously.
XVII. Male Genitalia
Circumcision, meatal opening, hypospadias, phimosis, adherent foreskin, size of testes, cryptorchidism,
scrotum, hydrocele, hernia, pubertal changes.
*Practical notes:
A. In examining a suspected case of cryptorchidism, palpation for the testicles should be
done before the child has fully undressed or become chilled or had the cremasteric reflex
stimulated. In some cases, examination while the child is in a hot bath may be
helpful. The boy should also be examined while sitting in a chair holding his knees with
his heels on the seat; the increased intra-abdominal pressure may push the testes into
the scrotum.
B. To examine for cryptorchidism, one should start above the inguinal canal and work
downward to prevent pushing the testes up into the canal or abdomen.
C. In the obese body, the penis may be so obscured by as to appear abnormally small. If
this fat is pushed back, a penis of normal size is usually found.
XVIII. Female Genitalia
Vagina (imperforate, discharge, adhesions), hypertrophy of clitoris, pubertal changes.
*Practical note:
Digital or speculum examination is rarely done until after puberty.
XIX. Rectum and Anus
Irritation, fissures, prolapse, imperforate anus. The rectal examination should be performed with the little
finger (inserted slowly). Note muscle tone, character of stool, masses, tenderness, sensation. Examine
stool on glove finger (gross, microscopic, culture, guaiac), as indicated.
XX. Extremities
A. General: Deformity, hemiatrophy, hemihypertrophy, bowlegs (common in infancy),
knock-knees (common after age 2), paralysis, edema, coldness, posture, gait, stance,
asymmetry.
B. Joints: Swelling, redness, pain, limitation, tenderness, motion, rheumatic nodules,
carrying angle of elbows, tibial torsion.
C. Hands and feet: Extra digits, clubbing, simian lines, curvature of little finger, deformity
of nails, splinter hemorrhages, flat feet (feet commonly appear flat during first 2 years),
abnormalities of feet, dermatoglyphics, width of thumbs and big toes, syndactyly, length
of various segments, dimpling of dorsa, temperature.
D. Peripheral Vessels: Presence, absence or diminution of arterial pulses.
XXI. Spine and Back
Posture, curvatures, rigidity, webbed neck, spina bifida, pilonidal dimple or cyst, tufts of hair, mobility,
Mongolian spots, tenderness over spine, pelvis or kidneys.
XXII. Neurologic Examination
A. Cerebral Function: General behavior, level of consciousness, intelligence, emotional
status, memory, orientation, illusions, hallucinations, cortical sensory interpretation,
cortical motor integration, ability to understand and communicate, auditory-verbal and
visual-verbal comprehension, recognition of visual object, speech, ability to write,
performance of skilled motor acts.
B. Cranial Nerves:
1. I (olfactory) - Identify odors; disorders of smell
2. II (optic) - Visual acuity, visual fields, ophthalmoscopic examination, retina.
3. III (oculomotor), IV (trochlear), and VI (abducens) - Ocular movements,
ptosis, dilatation of pupil, nystagmus, pupillary accommodation, and pupillary
light reflexes.
4. V (trigeminal) - Sensation of face, corneal reflex, masseter and temporal
muscles, maxillary reflex (jaw jerk).
5. VII (facial) - Wrinkle forehead, frown, smile, raise eyebrows, asymmetry of
face, strength of eyelid muscles, taste on anterior portion of tongue.
6. VIII (acoustic) -
a. Cochlear portion - Hearing, lateralization, air and
bone conduction, tinnitus.
b. Vestibular - Caloric tests.
7. IX (glossopharyngeal), X (vagus) - Pharyngeal gag reflex, ability to
swallow and speak clearly; sensation of mucosa of pharynx, soft
palate,
and tonsils; movement of pharynx, larynx, and soft palate; autonomic
functions.
8. XI (accessory) - Strength of trapezius and sternocleidomastoid
muscles.
9. XII (hypoglossal) - Protrusion of tongue, tremor, strength of tongue.
C. Cerebellar Function: Finger to nose, finger to examiner's finger, rapidly alternating
pronation and supination of hands; ability to run heel down other shin and to make a
requested motion with foot; ability to stand with eyes closed; walk; heel to toe walk;
tremor; ataxia; posture; arm swing when walking; nystagmus; abnormalities of muscle
tone or speech.
D. Motor System: Muscle size, consistency, and tone; muscle contours and outlines;
muscle strength; myotonic contraction; slow relaxation; symmetry or posture;
fasciculations; tremor; resistance to passive movement; involuntary movement.
E. Sensory System: Hearing, vision, light touch, pain, position, vibration.
F. Reflexes:
1. Deep reflexes - Biceps, brachioradialis, triceps, patellar, Achilles;
rapidity and strength of contraction and relaxation.
2. Superficial reflexes - Abdominals, cremasteric, plantar, gluteal.
3. Pathologic reflexes - Babinski, Chaddock, Oppenheim, Gordon.
G. Newborn Neurological Examination
*Practical Points:
Observe the normal flexion of the term infant in contrast to the non-flexed, even flaccid
appearance of the normal resting premature. The shape of the premature skull is usually
dolichocephalic (long and narrow). Elicit the normal reflexes of grasping (hand and
foot), sucking, rooting, Moro and automatic walking. Palpate the head to identify the
anterior and posterior fontanelles as well as the sagittal, coronal, metopic and lambdoid
sutures.
Impression and Plan
I. Problem List
The problems can be definite diagnoses, symptoms, abnormal findings, or other concerns.
Probable or possible diagnosis ("rule out") should not be listed as problems. If your problem list
contains a number of symptoms or signs that initially do not fit together each should be listed
separately. They may on subsequent days be seen as manifestations of the specific disease. They
may then be combined into one problem.
Health Maintenance should be included on the problem list for all children. We list it as a
problem to remind us that our major goal is to not let the immediate disease obscure our view of
the whole patient. Include here the follow up plan, even from the start. That will help remind the
inpatient care team to communicate with the primary care provider.
An example of a problem list follows for a child who is hospitalized with fever, vomiting and
pyuria. You find in the past history that he had an allergic reaction to penicillin 6 months ago. In
this case the problem list might be put in the chart as:
Fever
Vomiting
History of penicillin allergy
Health Maintenance
Any new problems can be added as the database expands.
II. Impression
A diagnostic impression should be developed. A problem list can be useful for beginners
to try to synthesize a patient’s findings into a coherent diagnosis and is highly encouraged in
your formal write ups. One useful way to synthesize this information is to first describe the
anatomy of each abnormality, then to describe the pathologic process (e.g., neoplastic,
inflammatory, infectious), finally arriving at a coherent diagnosis. The cycle of data collection,
hypothesis setting, hypothesis testing, and action is put into place. The selection of a diagnostic
pivot, or unique finding, may assist in narrowing down the differential diagnosis. The rules of
parsimony, chronology, and plausibility should be remembered. Common diagnostic errors, such
as premature closure (i.e., reaching a conclusion before there is enough data to support it)
should be avoided. Common and catastrophic diagnoses are the most important ones to address.
III. Plan
A diagnostic and therapeutic plan should address each diagnostic impression. Tests
should be ordered only if the result will alter the plan. Pediatricians tend to be fairly
conservative in prescribing medication, especially for self-limited diseases, such as the
common cold. One useful way to delineate a plan is by systems (e.g., cardiovascular, pulmonary,
hematologic, infectious, fluid/electrolytes/nutrition, etc.).
IV. Discussion
A concise discussion of one or more aspects of our patient's medical problem should follow. The
topic should be pertinent to your patient. The goal is not to exhaust the medical literature on a
given topic, but to stimulate patient-oriented reading and to encourage you to synthesize your
thoughts.
For example, on a patient admitted with sickle cell disease and fever, you might choose to discuss
the immune problems of children with sickle cell and their clinical importance. You would not be
expected to discuss the molecular biology of sickling and all the various problems this creates.
After you have demonstrated outside reading on a topic, the most important step in the
discussion is to apply that reading to the care of your patient. Write at least a concluding
paragraph in your discussion that directly relates what you have read to the care of your patient.
For example, when writing about immune problems in sickle cell disease, you might conclude
with a paragraph of your patient's probable immune problems given his sickle cell disease. This
will show interpretation of your reading and application to your patient's care based on his age,
past medical history, and current presenting symptoms.
If you are unsure about a topic, or need help with sources, discuss this with your attending.
Include a list of references used at the end of your discussion. At least one basic text and in
addition one recent article from the peer reviewed literature should be included as references.
References
Barness LA in McMillan JA, ed., Oski’s Pediatrics, 3rd ed., Philadelphia:Lippincott, 1999, pp. 39-52.
Boyle WE and Hoekelman RA, in Hoekelman RA, ed., Primary Pediatric Care, 3rd ed., St. Louis:Mosby,
1997, pp. 45-54.
Department of Pediatrics, USUHS. Outline for Pediatric Data Base. USUHS brochure.
Gundy JH, in Hoekelman RA, ed., Primary Pediatric Care, 3rd ed., St. Louis:Mosby, 1997, pp. 55-97.
Hartman AL, Problem Solving in Medicine, lecture notes 12/99, NMCSD.
Hoekelman RA, in Bates B, A Guide to Physical Examination and History Taking, 4th ed.,
Philadelphia:Lippincott, 1987, pp. 525-597.
Weston WL, Lane AT, and Morelli JG, Color Textbook of Pediatric Dermatology, 2nd ed., St.
Louis:Mosby, 1996, pp. 11-13.
Zitelli BJ and Davis HW, Atlas of Pediatric Physical Diagnosis, St. Louis:Mosby-Wolfe, 1997.
