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Reading: Bates pages 580-633

Goal: To introduce the significant anatomical, physiological and developmental norms for the 6 pediatric age groups (neonates,
infants, toddlers, pre-schoolers, school-aged children, adolescents) with regard to the basic history and physical exam skills.

Objectives: For each of the six pediatric age groups:


Know that to perform an adequate pediatric history and physical requires obtaining pertinent and specific historical information and
distinguishing normal from abnormal physical exam findings and vital signs.

Know what specific historical information is needed.


Know which specific physical exam findings are normal vs. abnormal.
Know which specific vital signs are normal vs. abnormal.
Know the importance of growth charts for assessing appropriate growth.
Know how to plot height, weight, and head circumference for a pediatric patient on a standard growth chart

Know that to accomplish an adequate pediatric history and physical, the physician must know and work with the specific emotional
and cognitive developmental stages of the pediatric patient as these stages impact on the general approach to the patient and
the sequence of the physical exam.
Lecture Outline: Pediatric History and Physical Examination

For neonates:
1. History
-maternal-related past medical and pre-natal history,
-maternal-related social history,
-perinatal history
2. Physical findings:
-normal findings for age,
-normal variant findings for age,
-minor and major problems common or unique for this age
3. Approach to history
-parents: issues and approach
4. Approach to physical exam:
-emotional and developmental issues as they pertain to the hands -on examination for this age
-emotional and developmental issues as they pertain to the sequence of the physical exam

For infants, toddlers, preschooler’s, school-aged children, and adolescents:


1. History:
-age-related past medial history,
-age-related immunizations,
-age-related social history
-age-related review of systems
2. Physical findings:
-normal findings for age,
-normal variant findings for age
-minor and major problems common or unique for this age
3. Approach to history:
-parents vs. patient: issues and approach
-emotional and developmental issues for the patient
4. Approach to physical exam
-emotional and developmental issues as they pertain to the hands -on examination for this age
-emotional and developmental issues as they pertain to the sequence of the physical exam for this age

A very detailed and comprehensive handout will be available at the lectures for this material
Pediatric History and Physical Examination

In general:
Reason for the detail of this outline:

Neonates are not just small infants


Infants are not just small children
Children are not just small adults

Anatomically, physiologically, cognitively, and emotionally there are significant differences for each pediatric age
group. This has important implications for obtaining the history, for knowing what must be included in the history,
for successfully doing a physical exam, and for knowing which physical findings are normal vs. variant vs.
pathological.

A more precise breakdown of the pediatric age group is:


• Neonates (~0-1 month),
• Infants (~1-12 months),
• Toddlers (~1-2 years),
• Preschoolers (~3-5 years),
• School-aged children (~6-12 years)
• Adolescents (≥ 13 years)

Some examples of this include:

-normal vital signs are different for different ages


-proportions of the head to torso to the extremities are different for different ages
-posture is different for different ages
a young infant has basically a “C” shaped spine with very little cervical and lumbar lordosis;
as the infant begins sitting up, cervical lordosis develops
as the toddler begins walking, the lumbar lordosis develops
-the primitive reflexes including an up-going Babinski are normal in a neonate but pathological at other ages
-the proportions of lymphoid tissue are different for different ages
-hormonal influences on the appearance of genital and breast tissue: maternal hormones have significant impact on the
normal appearance of both male and female breast tissue and genitalia in the newborn period; after this time, there is a
relative lack of hormonal influence on these tissues, until adolescence, when there are significant changes occurring.
-caloric and fluid and electrolyte requirements are based on weight:
--a 5 kg infant needs 500cc of fluid per day
--a 15 kg child needs 1250cc of fluid per day
the 15 kg child does not get 3 times the fluid that the 5 kg child gets
--a 5 kg infant needs 15-20 meq sodium per day
--a 25 kg child needs 48-64 meq sodium per day
the 25 kg child does not get 5 times the sodium that the 5 kg infant gets
-medication dosages are based on weight and so will vary with time as the weight changes

A general rule with pediatrics for young children is: if the patient is quiet and calm, do the least intrusive
examinations first. You may need to do the exam out of sequence (normally, HEENT before heart and lungs, etc.) Look
in the eyes, then listen to the heart and lungs, then assess the pulses, then palpate the abdomen, before you examine
the ears and mouth. Each patient is different and will respond differently to you, and so you need to make decisions at each
encounter how best to proceed with this patient on this occasion. You usually have a few minutes during each encounter,
generally during the history or at least during your general assessment of the patient to make this decision. As always, you
may need to reassess and change your plan as you go.

History

For the history at any age, you need to collect sufficient and pertinent information for each of the components of the history: chief
complaint, history of the present illness, past medical history, past surgical history, allergies, medications, family medical history, social
history, and review of systems. In most cases, with a n adequate history, youc an make your diagnosis —with the physical exam and
very selective labs/studies serving to confirm your diagnosis. It is easy (and a frequent temptation) to rush through he history and jump
to the physical exam hoping to save time. This usually fails, though. Take some time (at least 5 minutes) for your history. Be
methodical and collect sufficient and pertinent information for each of the components. Also, listen to your patient and family. Hear
out their concerns and thoughts as well as eliciting the information that you feel is pertinent. Ask them what they think the problem is.

For each age group, different historical information is pertinent. You must know what kinds of information you must collect for
each age or you will fail to make the diagnosis. Pregnancy and perinatal information are of utmost importance for a young infant, but
irrelevant to a patient 60 years old. A family medical history of heart disease in aging family members is very important for an adult’s
history, but not relevant for a toddler, other than as it may impact on the social history and family stressors.

For the class now (i.e. the written exam): know all of the points that have been high-lighted with bold-face print. These are things that
may be test questions. These are also things you ought to know next year in the fall as you go to your preceptor’s offices. These
preceptors are family practitioners and their practices may be 30% pediatrics. By next fall, you should be able to obtain an adequate
history on a pediatric patient seen in the office. By the time you are in your clerkships, you will be expected to obtain a adequate history
(containing sufficient and pertinent information for each of the historical components) on a pediatric patient being admitted to the
hospital as well as a patient being seen in the office for a well-child visit (including developmental assessment).

Physical examination

For the physical exam, at any age, you basically need to differentiate between normal physical findings, normal variants, and minor and
major problems. There are significant differences in normal findings and normal variants for each age group. There are also significant
differences in pathological findings —both for minor and major problems.

At this point, as first year (and soon to be second year) medical students, it is important to be able to recognize normal vs. pathological
findings. When examining a patient, you need to be able to answer the question: “is this a normal finding, a normal variant, or a
pathological finding?” TO help you over the next few years, as you examine pediatric patients, I have included a list of common
variants, and minor and major pathological findings. You don’t need to know all of these now. These conditions will make more sense
after you have studied them in the systems classes.

For the class now (i.e. the written exam): know all of the points that have been high-lighted with bold-face print. These are things that
may be test questions. These are also things you ought to know next year in the fall as you go to your preceptor’s offices. These
preceptors are family practitioners and their practices may be 30% pediatrics. By next fall, you should be able to obtain an adequate
history on a pediatric patient seen in the office. By the time you are in your clerkships, you will be expected to recognize and be able to
name most of the minor problems listed here and to at least recognize most of the major problems.

If you don’t know what to all a physical finding, describe it as exactly as you can: location, size, shape, color, nature, structure, etc.
Suggestions for obtaining the history and doing the physical exam
for the different age groups:

Neonates:

The history is primarily obtained from the pre-natal records in the maternal chart and/or the infant’s chart. When seeing the mother to
discuss the infant with her, do a basic review of the history. Ask her if there were any problems with the pregnancy or her health. If the
prenatal records are not available, you will need to gather as much of this information from the mother as possible. The obstetrician
should be able to provide information if needed as well, especially regarding the labor and delivery. The nurse at the delivery should
also be able to provide information regarding the labor and delivery and the infant’s condition after delivery.

The physical exam of a neonate is very important. The neonate is making enormous physiological changes after delivery. Sometimes
there are problems that occur during this period. These problems may result from either a congenital anomaly (such as a congenital
heart defect) or from difficulties arising from the transition period itself. This is generally the time that congenital anomalies are
recognized as well (unless diagnosed pre-natally with US). These anomalies may or may not present serious medical difficulties for the
infant. Congenital anomalies certainly do require adjustment from and sensitive and understandable explanation to the family,
regardless to the degree of medical difficulties.

The neonate needs to be examined very thoroughly for these reasons. It is important to completely undress the infant to accomplish
this. If the environment is cold, however, you may want to undress and re-dress the infant as you go to minimize hypothermia. Also
note that neonates tend to prefer being swaddled closely in their blankets. A fussy infant may calm if the blankets are wrapped snuggly
around him/her. Try to touch the infant gently and consistently. Also try to speak in a soft calming voice. If the infant is wrapped up
and calm as you begin the exam, consider examining the eyes for the red reflex. This is very difficult to do once the infant is crying as
they very tightly squeeze their already swollen eye shut. Once you begin unwrapping an infant, do it slowly and perhaps the infant
won’t notice right away and thus give you a chance to listen to the heart before starting to cry. When listening to the heart, be sure to
listen in all four listening posts, even though the chest seems small compared to the stethoscope. It is common to hear a murmur in
one spot and then not in a spot just a cm over. It takes considerably time to learn to listen for murmurs in infants with their fast heart
rate. It certainly is possible, though. Just keep trying. When listening to breath sounds, first listen in the front and then gently roll the
infant to one side to expose the back and listen there and then roll them to the other side to listen over there. Also try to assess the
femoral pulses while the infant is calm. Checking the hips and palpating the abdomen are also more fruitful if the infant is not crying
vigorously and resisting your. With the abdomen, even if the infant is crying, you can usually palpate quite deeply when they relax
briefly to inhale. Because infants have very little abdominal wall musculature, it is very easy to thoroughly examine the abdomen.
Things that tend to irritate infants the most are examining the ears and mouth and pharynx. So these are best done last (unless the
infant is already crying). If an infant is crying loudly or yawning and you have the otoscope ready, you may be able to get a good look
at the pharynx without a tongue depressor. When looking into an uncooperative infant’s mouth, hold the tongue depressor in one hand
and the otoscope in the other as usual. Use your pinkie fingers on the infant’s cheeks to steady the head and apply pressure between
the jaws to gently help open the mouth. Carefully work the tongue depressor back into the mouth along the surface of the tongue and
elicit the gag reflex. This should then give you a very quick but good look at the pharynx. In pediatrics, you learn to look fast. The
primitive reflexes are best assessed at the end of the exam since this also tends to make infants cry.
Pediatric History and Physical Examination

Suggestions for obtaining the history and doing the physical exam: Infants and toddlers

The history is obtained from the parents. Some parents will be better informed than others. Some will take quite a bit of prompting to get
any information from them. Young (teen) parents often do not have the foggiest idea what the FMH -is for themselves and their child.
They may still be adjusting to the idea

that they are parents and trying to understand exactly what the implications of this are. During the history-taking time, you establishing a
rapport with not only the parents but als o the child. Just as you are assessing the child's response to yourself, they are watching and
assessing you.

As far as the physical exam, for very young infants (< 2-3 months), much of the information for neonates applies here as well for the
physical exam. As infants get older, they become more interactive and so you need to interact with them.

A content infant or child is a relatively easy one to examine. In general, an infant or child who is taken away from the parent and placed
on an exam table is scared and unhappy and so cries and struggles to get back to the comforting parent. An infant or child left on the
parent's lap will feel more secure and be less likely to cry.

Infants older than 3-4 months old become very interested and curious in whatever you are doing. They think that you are playing with
them when you do an exam. So they want to play with the stethoscope when you are trying to listen to the chest and they want to see
the otoscope as you are trying to look in their ears. Distracting them with a toy or giving them a tongue depressor to play with can be
very helpful. Talk to them and basically play with them as you do the exam and they will be less likely to get unhappy with you and cry.

The ear exam in an infant: the EACs are small and usually at least minimally coated with cerumen, thus narrowing the EACs further.
Add to this an infant who wriggles around and an anxious parent. The ear exam can be very challenging in an infant and toddler. It is
important to have the infant securely restrained if needed. Show the parent how to gently but securely restrain their child. Sometimes
an infant or toddler will allow an ear exam without needing to be restrained. These are not the ones who scream when you walk into the
room, though. Sometimes a gentle but deliberate approach will allow for an unrestrained exam: after you've briefly talked with the
parent, while the infant is still sitting on the parent's lap, gently touching (but not tickling) the outer ear, getting a firm grasp on the pinna
while softly talking and complimenting the ears ("what nice, wonderful ears, you have, I'm going to take a look at them"), and then
gently but deliberately placing the otoscope into the EAC, still softly talking to the infant. You can not have any hesitation or anxiety
about this or the infant will pick up on it (they smell your fear) and try to get away from you. Even very young infants, however, will listen
to you talk to them and will respond. If you move the tip of the otoscope in the EAC, it will hurt and the infant will try to make an escape.
A firm, but not pinching, grasp on the pinna provides a distracting sensation for the otoscope tip in the EAC. If the infant is crying
vigorously, the TIVI may get quite flushed Oust as the infant's face does with crying). In this case, it can be difficult to tell if the TM is
red/pink from crying or from an infection. If you see fluid or pus behind the TM, this may correlate with an infected middle ear (OM). This
is certainly a case in which insufflation can help you determine whether or not there is an OM. When there is fluid in the middle ear, the
TM will have decreased mobility with insufflation.

Young infants are obligate nose-breathers. Nasal congestion can cause significant infant distress (crying and poor sleep and feeding). It
usually does not cause respiratory distress because the upset infant cries and with good air entry from the mouth, then breathes easily.

The heart and lung sounds are very easy to hear in infants since the chest wall is so thin without much muscular or adipose tissue. The
heart sounds are very fast though and it does a fair amount of practice to get reasonably good at listening for heart murmurs. It is
possible though, just keep practicing. It's like learning to feel the transverse processes. You need to evaluate the respiratory pattern
from the nose to
Pediatric History and Physical Examination

Suggestions for obtaining the history and doing the physical exam: Infants and toddlers (con't)

…the abdomen in infants and toddlers. Most infants and toddlers are abdominal breathers: they use the diaphragm more than the
intercostal muscles for inspiration. So the abdomen as well as the chest should expand with inspiration. Look for nasal flaring,
retractions, paradoxical abdominal movements (the abdomen expands with inspiration but the chest sucks inward, giving a see-saw
motion).

If the infant is not crying, it is very easy to do a thorough abdominal exam because there isn't much abdominal musculature. You can
easily palpate very deep. As long as you are gentle and steady, most infants won't resist. If the infant is crying, the muscle tense and it
is more difficult to do the exam. When they briefly pause to inspire, however, they abdominal muscles briefly relax, giving you a quick
window to palpate.

As the infant gets around 6 months old or so they may begin showing stranger anxiety and as they get around a year of age
they also start to develop a very strong sense of autonomy (i.e., they may become very uncooperative and resistant to the
examination: I don't feel like having the stethoscope on my back and so I'm going to fuss and cry and try to prevent you from invading
my body.). Either alone or in combination, these normal developmental stages add challenge to the exam. Basically the key here is to:
1) convince the infant/toddler that the exam is a cool thing that they should desire, 2) it won't hurt, 3) it's going to happen whether they
want it to or not. As you come into the room, you can get an idea of how resistance the infant/toddler is going to give you. If they start
crying when you look at them, they probably have fairly high levels of stranger anxiety. In this case try to avoid eye contact with them
and keep physical contact to a minimum. This is one time that you don't want to use both of your hands to listen to the heart. While the
child clings desperately to the parent, touch the child with the stethoscope alone (don't use your "comforting hand" on the shoulder
here).

With a resistant or frightened child, it may help to demonstrate your techniques on the child's doll or stuffed animal. This really does
work sometimes. It may also help to show the child that the otoscope tip is NOT sharp (it looks pointed and thus sharp to a child who
has gotten a lot of shots at your office). Hold the otoscope in front of the child and touch it to your finger and say, "look, no owies!"
Show them the light and tell them that's a special flashlight for looking at ears. While these techniques may not help at the first
occasion, they may help reduce the anxiety at the next visit. It only takes 1-2 minutes to tell a child what the otoscope is and what you
need to do with ft. This is time well spent in the long run. If the child is still unwilling to allow an unrestrained exam, calmly show the
parent how to effectively restrain their child, and do a quick but thorough exam. You can still say to the child as you- do the exam, "what
nice, wonderful ears you have, I'm going to take a look at them.'

Be gentle with children, move slowly, talk to them and explain what you're going to do. Even at 6-9 months old, infants have some
receptive language skills.

Preschoolers:

Again the history is basically obtained from the parents. Sometimes, though, the child may be able and willing to contribute as well.
Give them the chance. Not only may you get valuable information, but you also begin to teach the child that their contributions are
important.

Most preschoolers are quite interested in and cooperative with the physical exam. They like explanations of what you're doing and why.
They often want to use the equipment themselves (otoscopes, ophthalmoscopes, stethoscopes, etc.). This is usually feasible with close
supervision.

Until a child is about 4-5 years of age, however, many of them may still have some difficulty understanding and following some of your
instructions. They may not be able to allow you do perform a fundiscopic exam. Most will not understand the instructions, "take a big
breath." As a rule, they tend to either ignore you or hold their breath when you ask this of them. This is not all bad, because after they…
Pediatric History and Physical Examination

Suggestions for obtaining the history and doing the physical exam: Preschoolers (con't)

…hold their breath for a few seconds, then they do take a big breath. It is usually sufficient to listen to their normal respiration,
unless they are breathing very shallowly.

Preschoolers are usually willing and able to sit by themselves on-the exam table. However, it is not unusual for children of this
age to have times when they are scared and still need the comfort of their parent's laps. When children are scared they may
temporarily regress developmentally. Children of this age frequently develop some intense feelings of privacy. They may
completely melt down at the request to undress and put a gown on. In these cases, you can compromise by having the child
take the shirt off, examining the torso, putting the shirt back on, and then do the feet, etc. Have the parent help the child take the
clothes off as this is much less threatening then the physician doing ft.

School-aged children and adolescents:

With the history in these age groups, the parents still give most of the information. Sometimes, with or without coaching, the
child or adolescent will give a reasonable history. More often, ft seems though that children and adolescents prefer letting their
parent speak for them and give the history. It can be very difficult sometimes to get even adolescents to talk at all. It is not
unusual for the inforTnation from the parent and child to be contradictory. The child may have told the parent one thing at home
to avoid going to school or to avoid having to stay home. They may tell you that their throat doesn't hurt at all to avoid a throat
swab for a strep screen. Upon hearing their parent tell you the story, the child may then be able add to ft.

For the most part, the exam becomes fairly straight-forward in school-aged children and adolescents. As with younger children,
these children still do appreciate thorough explanations of what you are doing and why.

Some children do, however, get very ticklish abdomens. It helps sometimes to place the child's hand underneath yours and
palpate this way.

Also, as the child gets older, privacy issues regarding the genitalia become more important. It is always important to use gowns
and drapes. Always explain exactly what you will be doing: just looking, and not touching vs needing to touch the outside of the
labia in order to see the inside; checking to see if both testicles are in the scrotum, etc. Explain that ft is important, for~ you, as
the physician, to examine the entire body. That you have looked closely at the eyes, ears, mouth, heart, abdomen, feet, hands,
etc., and now need to see the genitals as well, to be sure that everything is growing properly and is OK Have the parent give
reassurance and permission to the child as well. Also explain that parents and physicians sometimes need to check the genitalia
to be sure that everything is OK, but no one else should be looking or touching and that the child should tell the parents if this
happens.

As far as doing a pelvic exam on an adolescent, be sure to explain exactly what you will be doing and why. Tell her what ft may
feel like: pressure with the speculum, possible cramping with the cervical swabs, etc. Before you begin describe some relaxation
techniques that she can use: deep cleansing breaths, relaxing the legs, looking at a picture that you've taped to the ceiling,
talking with you or the nurse. As with older patients, some adolescents like to hear exactly what you're doing as you do ft and
others prefer to talk about something else entirely and others don't want to talk at all. Respect your patient's preferences.
Pediatric History and Physical Examination

Neonate H & P

- technically a neonate is < 1 month old, here it basically pertains to < 2 weeks of age
- obtain the maternal hx from the mother's chart and from the mother

Maternal information: age, number of pregnancies and deliveries (G_, P_), blood type, serology and cultures: rubella, syphilis,
gonorrhea, chlamydia, HIV, hepatitis B, herpes, group B strep
social: alcohol, tobacco, drug use before and during pregnancy; social support

Prenatal course: uncomplicated or...


- general maternal health problems such as asthma, diabetes, seizures, hypothyroidism, etc., and note any specific medications
taken during pregnancy
- pregnancy-related maternal health problems such as gestational DIVI, pregnancy-induced HTN, pre-eclampsia, anemia, HELLP
syndrome, etc. and note any specific medications
- fetal conditions or tests/studies: Triple test, amniocentesis, etc., multiple gestation, oligo- or polyhydramnios, macrosomia, lUGR,
placenta previa
- pre-term labor or premature rupture of membranes and note any treatments or medications
- Medications included prenatal vitamins and ...

Labor and delivery: gestational age _, onset of labor spontaneous vs. induced (for ...) medications: labor augmented with pitocin, any
anesthesia, antibiotics, other medications
ROM (rupture of membranes): spontaneous vs. artificial, duration before delivery, color and nature of the fluid: clear vs. meconium,
foul-smelling, etc.
Delivery type: NSVD vs forceps, vacuum-extraction, C-section for...
Presentation of infant: vertex, breech, transverse, etc.
Complications such as maternal fever, placental abruption, dystocia. etc.

Resuscitation: describe the first response of the infant immediately after birth: tone, color, cry
tone limp vs. vigorous
color blue vs. acrocyanotic vs. pink cry
none vs. weak vs. lusty
Then describe the first 5-10 minutes of life with regard to what was done for the infant and the infant's response: brought to
"warmer" (in what state ... ) and (note what of the following was done) dried off, tactile stimulation bulb or Delee-suctioning;
oxygen blow by vs. bag and mask ventilation), laryngoscopy, endotracheal intubation, chest compressions, epinephrine or
albumin or narcan. The infant's response is described in terms of heart rate, respiratory effort, tone, color, etc.
Apgar score at 1 minute of life and 5 minutes of life:

Post-birth:

Nursing: birth weight and vital signs and feeding (breastfeeding vs bottle), and voiding and stooling.
Note any other nursing concerns.

Parents: note any parental concerns or issues.

Gestational age (GA) assessment: use either the Ballard or Dubowitz scoring systems
- best done at about 24 hours of age
- assesses the gestational age of the infant by rating neuromuscular development and physical appearance and then correlating
this with gestational age usually done if there appears to a discrepancy between the stated GA (by dates or US) and the
apparent GA of the infant once it's born.
Pediatric History and Physical Examination

Neonatal physical exam:

Document past and current vital signs and current weight.


Vital sign norms for term neonates: RR HR BP
40-60 90-180 60/40

Determine whether birth weight is appropriate for gestational age or small or large for the GA:
- AGA (appropriate for gestational age): weight between 10th % and 90th % for gestational age
- SGA (small for gestational age): weight < 10th % for gestational age
- LGA (large for gestational age): weight > 90th% for gestational age
Plot the height, weight, and head circumference on the graph to determine AGA/SGA/LGA

general: normal findings: alert, quiet, active, sleeping, content, crying vigorously major problems: - excessively irritable or listless;
these are sx of a "sick" baby, consider neuro, cardiac, infectious or metabolic causes.

skin: normal findings. pink (undertones of skin), warm, good turgor, no lesions
variants: -acrocyanosis: blue hands and feet with rest of the body pink (undertones of skin)
-lanugo (light covering of hair on back or face); vernix (cheesy white coating on skin)
-flaky/dry skin
-macular hemangiomas (stork bites' on nape of neck and "angel kisses” on eyelids and nose) –
these usually fade with time
-flame nevi: flat bright red birthmark, usually permanent
-cafe au lait spots: common birthmark; concern if of large size or numerous (neurofibromatosis)
-erythema toxicum: small white papule on erythematous base
-milia: multiple 1 mm white papules on face (very common on the nose)
-pustular melanosis: white papules/pustules which leave a pigmented spot when gone
-Mongolian spot: on lumbar/sacral area in dark-skinned infants
minor problems:
-icteric (yellow): jaundice may be pathological or physiological
-plethora (red): polycythemia (↑ Hg) may affect circulation by making the blood too viscous;
may cause respiratory distress
-hot/cold secondary to over or under dressing: should resolve quickly with appropriate clothing
-meconium stained skin: is risk factor for possible aspiration of meconium in utero
-excessive bruising: may increase the risk for jaundice
-flame nevi (flat bright red birthmark): concerning if located in the trigeminal nerve area
because may indicate neurological abnormalities
major problems: poor turgor. dehydration
-pallor (white/gray): consider anemia or ~ perfusion (shock: cardiac, infection, etc.)
-cyanotic (blue): consider respiratory or cardiac compromise
-hot (fever): consider infection
-cold: consider infection or I perfusion (shock: cardiac, infection, etc.)
-vesicular rash: may indicate herpetic infection

head: normal findings. normocephalic and atraumatic with fontanel flat, soft, appropriate size (0.5-3.5cm) variants: -
dolichiocephalic (long & narrow): common with very preterm infants
-molding/caput: common occurrences after a vaginal delivery
-craniotabes: soft parietal skull bones that indent and recoil with application of light pressure

minor problems: - plagiocephalic (assym)


- cephalohematoma: may increase the risk for jaundice
- fontanel sunken: may indicate dehydration
major problems: - microcephalic: may indicate a congenital anomaly
- macrocephalic: may indicate a congenital anomaly or increased intracranial pressure
- fontanel bulging indicates increased intracranial pressure
- craniosynostosis: premature fusion of the skull bones; requires surgery
Pediatric History and Physical Examination

Neonatal PE (con't):

eyes: normal findings: external lids & periorbital region grossly normal and PERRL, EOMI, RR b/l,
corneal light reflection symmetrical b1l
variants: - external lids/periorbital region with mild-moderate swelling
- conjunctiva-sclera hemorrhage: common occurrences after a vaginal delivery
minor problems:
- conjunctiva-sclera icterus: indicates jaundice
- conjunctiva exudate: may indicate conjunctivitis (chemical vs bacterial vs GC vs chlamydial)
- EOM not I or corneal light reflection not symmetrical: not uncommon in the newborn period
- Brushfield spots on ids: is a stigmata for Down's syndrome
major problems: - P not ERRL: may indicate a neurological problem (same for all ages)
- red reflex not present: may indicate congenital cataracts or glaucoma
- cloudy comea: may indicate glaucoma
- colobomas of iris or lens or retina: may affect vision

ears: normal findings: hearing grossly intact to startle response; external ear normal in size,
shape, position; EACs (R/L) patent; TMs (R/L) visible, shiny/dull, gray, intact
variants: - EACs (R/L) occluded with vernix and TMs not seen
minor problems: - preauricular skin tags or pits (may indicate urogenital anomalies sometimes)
major problems: - absent startle response to noise
- low-set ears: may indicate congenital anomalies or syndromes
- significant abnormal shape: may indicate congenital anomalies or syndromes

nose: normal findings. external nose normal with b/I patent nares
variants: - minor deformation due to birth
major problems: - occluded nares: indicate choanal atresia
- flaring nares: indicate respiratory distress

oropharynx (mouth-throat): normal findings: lips & oral mucosa pink and moist; palate intact;
gag reflex present, good suck and swallow
variants: - Epstein pearls: white nodules on palate or gums
minor problems: - teeth: may present an aspiration hazard
major problems: - cyanosis: consider respiratory or cardiac compromise
- micrognathia (very small jaw): Pierre-Robin syndrome..,
- dry, tacky/parched mucous membranes: indicates dehydration
- cleft palate or lip: gives difficulty in feeding, needs surgery and ENT evaluation
- macroglossia: may indicate a congenital anomaly
- excessive drooling: may indicate esophageal atresia
- weak-absent cry: may indicate neurological abnormality or "sick" baby (see general)
- hoarse cry: may indicate thyroid abnormality
- high-pitch cry: may indicate neurological abnormality

face: normal findings: symmetrical with normal facies and motor function
minor problems: - facial asymmetry due to facial nerve palsy (palsied side has decreased tone and
does NOT get pulled downward with crying) or intrauterine positioning
major problems: - abnormal facies may indicate a congenital anomaly

neck: normal findings: FROM, no masses


minor problems: - limited ROM or torticollis: may indicate neuro or musculoskeletal problem
- brachial cleft or thyroglossal duct cysts: usually benign; may indicate a congenital anomaly
major problems: - masses: may indicate a congenital anomaly or infection
note: location, size, shape, mobility, tenderness, erythema, consistency, texture
- webbed neck: may indicate Turner's syndrome
Pediatric History and Physical Examination

Neonatal PE (con't):

cardio: normal findings: regular rate and rhythm, no murmur, precordial activity normal, capillary
refill brisk, femoral & brachial pulses equal b/I and strong
variants: - transient bradycardia: may be normal unless any other abnormal cardiac findings are seen
- murmur may be benign if no other abnormal cardiac findings are seen and is systolic and a grade 1-2/6
minor problems:
- mild and transient tachycardia: may be normal unless any other abnormal cardiac findings are
seen or may due to elevated body temperature
major problems:
- murmur: may be benign or pathological; consider pathological if any other abnormal cardiac
findings are seen or if diastolic or more than grade 3/6
- precordial activity T or bounding pulses: may indicate patent ductus arteriosus
- weak pulses: consider hypotension or cardiac anomaly
- weak/absent femoral pulses with normal brachial pulses: consider aortic coarctation, which is a congenital
narrowing of the aorta, causing cardiac compromise
- capillary refill: consider hypotension
- cyanosis: consider respiratory or cardiac compromise
- bradycardia: may indicate infection or neurological problem, etc.

resp: normal findings: chest wall symmetrical, breasts slightly enlarged, breath sounds equal
and clear with good air movement
variants: - supernumerary nipples
- periodic breathing (pattern similar to Cheynes-Stokes); repeating pattern of 5-10 sec apneas followed by rapid
breathing
minor problems: - pectus excavatum or carinum: may compromise respiration, usually not though
- barrel chest: may indicate respiratory difficulties
- mild rales/wetness/coarse breath sounds: this should resolve within a few hours of birth
- mild respiratory distress (RR 50-70, mild grunting/nasal flaring/retractions, no cyanosis, sats > 95%): if these sx
resolve within a short time and don't worsen, this probably reflects a slightly rough transition from fetal circulation or
transient tachypnea of the new born; it does require very close observation and possibly more detailed evaluation
major problems:
- wide-spaced nipples: may indicate a congenital syndrome
- respiratory distress (RR>60, grunting/nasal flaring/retractions, possibly cyanosis or sats < 95%): this may indicate
pneumonia or other respiratory or cardiac problem
- unequal breath sounds: may indicate a pneumothorax or other respiratory problem
- difficult breathing while eating: may indicate a tracheal-esophageal fistula
- apnea: consider neurological, cardiac, infectious or metabolic causes.

abd: normal findings. soft and rounded, 3 vessel cord, patent anus, no hepatosplenomegaly or masses
variants: - umbilical hernia: usually closes on its own within a year
minor problems: - inguinal hernia: requires elective surgery
- 2 vessel cord: may indicate genitourinary anomalies
major problems: - masses: may indicate a congenital anomaly
- imperforate or stenotic anus: requires surgery
- distended abdomen: may indicate intestinal atresia or obstruction secondary to malrotation or meconium ilius
- scaphoid abdomen: may indicate diaphragmatic hernia with abdominal contents in chest cavity causing respiratory
distress and cardiac compromise
- hepatosplenomegaly (HSM): may indicate cardiac, infectious or metabolic problems
Pediatric History and Physical Examination

Neonatal PE (con't):

Abd: major problems (conl): abdominal wall defects:


- omphalocele: defect with abdominal contents herniating into umbilical cord/sac
- gastroschisis: abdominal contents externalized through abdominal wall defect
- lack of muscles/Prune belly syndrome: has other significant congenital anomalies

GU: normal findings:, normal male or female genitalia, testes descended b/I
variants: - edema: common especially with breech presentation
- hydrocele of scrotum/testes: transilluminate to be sure it isn't a hernia, should resolve over time
- white or minimally bloody vaginal discharge: normal hormonal influence
(estrogen withdrawal)
- redden or swollen labia and puffy, redundant hymen: normal hormonal influence
minor problems: - mild hypospadius: don’t circumcise, may need surgery
- undescended teste(s): watch, should descend over the first year of life
- imperforate hymen: needs to have at least a small opening made
major problems: - moderate/severe hypospadius: requires surgery
- ambiguous: requires immediate endocrinology and genetic evaluation;
early surgery is controversial now; may involve immediate adrenal gland issues

MS: normal findings-, full range of motion of all joints/muscles with good strength, hips in place b/I with
negative Ortolani/Barlow, clavicles intact, spine grossly normal, no obvious structural anomalies
variants: - intrauterine positioning: bowed tibias or curved but flexible feet
- sacral dimple: very common; be sure dimple is blind and not communicating with spinal
column; if dimple + tuft of hair or pigmentation, this may signal occult spina bifida; if any
neurological abnormalities, must evaluate further
minor problems: - arthrogryposis: decrease ROM of joints
- fractured clavicle: feel crepitus or abnormal contour or tenderness or decrease use of that upper
extremity; not uncommon, usually doesn’t present a problem; heals very well by self-, minimal
intervention needed
- fractures of extremities: feel crepitus or abnormal contour or tenderness or decrease use of that
extremity; consider osteogenesis imperfecta or abuse if history not consistent with findings
- polydactyly/syndactyly: usually familial; may indicate other occult anomalies
- clubfoot: curved inflexible foot; needs evaluation for possible corrective casting -or -surgery
major problems:
- scoliosis: usually secondary to abnormal vertebrate; may indicate other anomalies
- developmental dysplasia of the hips: have + Ortolani (dislocated hip) or + Barlow
(dislocatable hip) (with either the Ortolani or Barlow tests: + means that you feel a
"clunk" as you do the maneuver) or + Galeazzi (uneven knee heights) tests; hips may
look obviously asymmetrical; skin creases on thighs may be asymmetrical; there may be leg
length differences; more common with breech deliveries
- myelomeningocele/spina bifida (neural tube defect) in either cervical or lumbar/sacral areas:
causes muscle paresis and paralysis; can be minor defect or major anomaly
- deformed/absent bones/structures: consider genetic syndromes and other occult anomalies

neuro: normal findings: normal tone (flexed extremities), no focal deficits, normal neonate reflexes
including root, suck, grasp, Moro, Gallant, Perez, tonic neck; DTR 2/4
variants: - decreased tone may be normal for a neonate under a warmer
minor problems: - jittery: may have hypoglycemia; if excessive, consider maternal substance abuse
- palsies: paralysis of the upper or lower or entire arm (Duchenne-Erb: C5-6 or Klumpke's: C8-T1-2 or both,
respectively); most recover well with time
Pediatric History and Physical Examination

Neonatal PE (con't):

neuro (con't):
major problems:
- phrenic nerve palsy: cyanosis, tachypnea, difficulty in breathing
- seizures: in neonates the sx may be subtle complex partial (impaired level of consciousness with altered behavior and
automatisms: abnormal sucking or chewing motions, blinking, *bicycling" of legs, or apneic episodes; also can have
generalized or focal tonic-clonic seizures consider neurological, infectious, toxin/drug, or metabolic causes
- hypotonia: consider neurological, cardiac, infectious, muscular, or metabolic causes
- hypertonia: consider neurological causes or maternal substance abuse
- focal deficits: consider fracture as well as local neurological injury
- abnormal neonatal reflexes: consider neurological or musculoskeletal causes (focal or diffuse)

Imp: 1 . viable/non, term (38-40 wk)/preterm (:5 37 wk), SGA/AGA/LGA, F/M neonate
via (method of delivery)
2. any maternal, pre-natal, UD, infant complications or risk factors, etc.

Reccom: 1. "routine nursery care' vs any observation/evaluation necessary depending on the infant's condition
2. breast feeding or bottle feeding (or NPO if necessary)
3. any labs or studies indicated
4. any treatments indicated
5. anticipate discharge...

14
Pediatric History and Physical Examination

Historical information that is the same for all ages (except the neonate):
CC: _______day-old / week-old / month-old / year-old F/M with a CC of_________
HPI: chronological order of symptoms & pertinent negatives from ROS.
- be sure to include onset, duration, location, radiation, nature, frequency, factors that
make the problem better and worse, any associated symptoms
- start with an open-ended question, such as "What brings you in here/to the hospital today?

Examples of HPI:

Hospital Admission:
J.S., a previously healthy 10 y/o female, presents with a CC of "really bad stomach ache." The mother states that this abdominal
pain is sharp, located in the RLQ (right lower quadrant) and began this morning. Initially, the pain was in the umbilical region. It has
since localized to the RLO without any current radiation. It is constant in nature and exacerbated by movement. The child appears most
comfortable when lying quietly. The pain has become more severe over the course of the day. She also has a low-grade fever today of
about 100. She c/o anorexia, having eaten very little today: some cereal at breakfast and 2 bites of a sandwich at lunch. She has
urinated twice today. She had a formed brown BM last night, none today. No vomiting is noted, although she does have nausea. She
has no URI s x or sore throat (strep, throat can often present this way). She came home from school today at noon and spent the
afternoon on the couch. Her parents brought her to the ED tonight after a phone call discussion with her pediatrician because of the
worsening sx.

Office "sick visit":


A.B., a previously healthy 6 m/o male, presents on 12-7 with a CC of ma cold for the last week that's getting worse now".
12-1: clear rhinorhea, nasal congestion, fever 99-100, dry cough
12-2: same as yesterday
12-3: same, but no fever today
12-4: clear rhinorhea, nasal congestion, no fever, cough became wetter sounding: "raffles in chest", decreased intake of
cereal/fruits/vegetables, though normal amounts of breastfeeding (though nursing with some difficulty because of nasal
congestion), parents are now using a suction bulb to help clear the nose of nasal secretions
12-5: rhinorrhea became thick and green and profuse, nasal congestion, fever 101-103 which comes down with Tylenol (using
every 6-8 hours), wet cough (increasing in frequency), acting fussy and wakes from naps, and night-sleeping crying
12-6: same as yesterday
12-7: same as yesterday
Also: No wheezing, vomiting, diarrhea, rash. No medications (Rx, OTC, herbal) are being used other than the Tylenol. BM's are
normal for patient (soft, brown, 1/d) and wetting about 8 diapers/d. Has 3 y/o sibling at home who had an URI last week. No
exposure to tobacco smoke.

Office "well-child check-up":


F.G., a previously healthy 18 m/o, presents today for her 18 month "well child check-up" and immunizations. She has no symptoms
of illness. Her parents have questions regarding her "picky eating," "temper tantrums," and "toilet training.' Diet: the parents
say that she drinks 30 oz of whole milk each day and 10 oz of fruit juice, refuses any meats and vegetables, though will eat
crackers, cheese, and peanut butter. Behavior: the parents say that F.G. will often indicate that she wants something such as
a toy in the store and when they tell her that she can't have it, she lays on the ground and screams and kicks her legs. Toilet
training: the parents say that their parents are pressuring them to "get her trained."
Pediatric History and Physical Examination

Historical information that is the same for all ages (except the neonate) (con't):

Allergies: List all medication allergies or NKMA (no known medical allergies).

Medications: List all current & pertinent past medications (Rx, OTC, herbal): include dosage, frequency, reason, and duration.

PSH:
List any surgeries that the patient may have had noting what, when, why, complications.
Example: Appendectomy 1987, no complications

FMH: Include mother, father, siblings, paternal and maternal grandparents.


Also include any aunts, uncles, cousins (blood relatives), etc. with a hereditary or familial condition.
Note for each of these people: current age or age at death, and current or past medical problems.
Also ask and note specifically if there is or isn't a FMH of any of the following: allergy, asthma, diabetes, cancer, seizures, TB,
blood dis orders, thyroid (hyper or hypo), the chief complaint, sudden death or MI before the age of 40-50; any family
members with problems with the heart, lungs, bowels, kidney, blood, brain, nerves, glands, etc.

Either draw out a family tree and label it with the above information.

OR simply list family members with the same information.

Example: list format


Mother 45 y/o and healthy
Father 45 y/o and has asthma
Brother 12y/o and healthy
Sister 1O y/o and has severe asthma
Paternal grandfather 70y/o and healthy
Paternal grandmother died at 60 y/o from MVA in 1986, no other medical problems
Maternal grandfather 75y/o and has adult-onset diabetes, diet controlled
Maternal grandmother 75 y/o and has hypothyroidism, treated with Synthroid
Maternal cousin 8y/o in remission from acute leukemia
No other FMH of allergy, seizures, TB, blood disorders, sudden death or MI before the age of 40-50; family members with
problems with the heart, lungs, bowels, kidney, blood, brain, nerves, glands .
Pediatric History and Physical Examination

Infant H & P: components that are age-specific


(see pages 14-15 for CC, HPI, PSH, allergies, meds, FMH)

Infant PMH (past medical history):

Pregnancy: was uncomplicated and full term.


Or_________: document any general or pregnancy-related maternal health problems including
STDs or substance use or abnormal fetal conditions/tests/studies and
gestational age if < 37 weeks.
Labor and delivery: was uncomplicated with a NSVD or C-S (for…), _____hours ROM.
Birth weight__________.
Infant remained the nursery for ______days without any complications or concerns.
Or_________: document any UD complications that occurred or if any resuscitation was needed;
- include Apgar scores if known;
- document whether there was a prolonged admission and for what reason;
- document whether there was admission to the NICU: reason, duration, other complications:
specifically ask about: problems with breathing, 02 requirements, feeding problems, IV's,
infections, meds, transfusions, bilirubin/photo therapy, seizures, etc.
Since birth, infant has been healthy (or_: specifically ask about and document a chronological order
of any of the following: URI, otitis media (ear infection), RSV bronchiolitis, pneumonia, croup, asthma,
apnea, gastroesophageal reflux, formula intolerance, urinary tract or kidney infection, seizures, any
problems with: eyes, ears, eating, breathing, heart, lungs, bowels, kidney, bladder, blood, skin).
She/he has/hasn't been seen by her/his physician for appropriate health maintenance visits
(2-5 days after birth and 2, 4, 6, 9, 12 months).
Document any prior admissions and ER visits (note when and for what reason).

Immunizations are UTD (up to date) including ...


- check the immunization card which the parents should carry with them
hospital or newborn office visit: Hepatitis B
2 month visit: Hepatitis B, Hemophilus influenza B (HIB), diphtheria/tetanus/pertussis (DTP or DTaP), Polio
4 month visit: Hepatitis B, HIB, DTP or DTaP
6 month visit: Hepatitis B, HIB, DTP or DTaP
12 month visit: varicella

Infant Development
- most items are the 75th% of the Denver developmental screen
-- i.e. 75% of the infants of that age have those particular skills
- based on language, social, fine and gross motor skills
birth: lift head; responds to bell; vocalizes; regards face
1 m: follows to midline
2m: lifts head up 450; "ooh/ahh"; follows past midline; smile spontaneously & responsively
3m: lifts head up 900; holds head steady; laughs/squeals; opens fists/brings hands together
4m: bears wt on legs; pulls to sit w/o head lag; rolls over; grasps toy; follows 1800
5m:tums head to hear rattling sound; regards a raisin; reaches for objects; works for a toy
6m: sits w/o support, turns to hear voice; imitates speech sounds; "rakes, to pick up object; feeds self finger foods
7-8m: stands while holding on; single syllables - combines syllables; transfers object hand to hand; takes 2 cubes
9m: pulls to stand; gets to sitting; cruises; jabbers; dadada & mamama; uses thumb-finger grasp; wave bye-bye
10-11 m: bangs 2 cubes together; plays patty-cake; stands for 2 sec.; uses dada/mama specifically
12m: stand alone; uses 1 word; puts block in cup; plays ball; imitates activities; indicates wants
Pediatric History and Physical Examination

Infant Social History:


(Patient) lives with_______(family/friends/etc.) in a house/apartment/etc. with_________ pets. There is no-one
around the baby who smokes or_________
Primary care-giver is_________. (Patient) does/doesn't attend day-care.
Diet includes (be specific):
dairy: breast milk or formula or cow's milk (whole, 2%, etc.) or other___________ oz/d;
juice: _____oz/d; water oz/d
approximate quantities of breads/cereal/pasta, fruits, vegetables, legumes/meats, other dairy:
__________.

Sleeping pattern consists of___________ (when, how long, where, waking, crying).
Major changes in home life?

Infant ROS
general: fever; irritable; crying; apnea; cyanosis; pallor,, delay in growth or development; weight change; recent changes in
feeding/voiding/stooling
Derm: rash; pruritus; easy bruising or bleeding; sores; birthmarks; lumps
HEENT: head trauma; squint; teething; thrush; rhinorrhea; congestion; epistaxis; brush teeth
Cardio-resp: cough; hoarseness; wheeze; retractions; shortness of breath or difficulty in breathing; activity intolerance; syncope;
feedings tolerated well (or tire with feeding, cyanosis/pallor, DIB, sweating, vomiting)
Abd: food intolerances; regurgitation; nausea; emesis; hematemesis, diarrhea; constipation; hematochezia; stool frequency, color,
consistency
GU: voiding frequency; dysuria; edema; hematuria
MS-neuro: swollen or painful or red muscles or joints; weakness; paresthesias; seizures; trembling

INFANT PE:

Vital sign norms for infants: RR HR BP


<3m 25-50 W-160 ave:95/60 low: 85/50 high: 115/80
3m-ly 20-40
Measure and record weight, height, head circumference and then plot these on the growth chart to determine percentiles and
consistency of growth.

general: normal findings: alert, quiet, active, awake, sleeping, content, crying though consolable, playful,
good eye contact, responds appropriately, well nourished, &,well hydrated
problems: - excessively irritable or listless; poor eye contact; apathetic:
these are symptoms of a "sick" baby:
consider neurological, cardiac, infectious or metabolic causes.
- weak-absent cry: may indicate neurological abnormality or "sick" baby (see general section)
- dehydrated: may be mild, moderate, or severe; specific findings from the rest of the PE must noted to determine the
degree of dehydration
- malnourished: looks excessively thin; specific findings from the rest of the PE must noted also

skin: normal findings. pink (undertones of skin); warm; good turgor, no lesions, rashes, bruises
variants: - alopecia: many infants have minimal hair or bald patches on the occiput (from rubbing)
- carotenemia: yellow skin (white sclera) from excessive intake of squash and carrots
- cafe au lait spots: common; consider neurofibromatosis if has > 5 spots that are > 0.5 cm
- infantile acne: not uncommon from 1-6 months of age; seen on face and shoulders minor problems: - bruises: likely
are normal in mobile infants but likely abnormal in infants < 5-6 months old; could indicate a bleeding disorder or
abuse
- capillary hemangiomas: red raised birthmarks; get bigger over the first year of life and then fade over the next 4-5
years; if very large can cause platelet trapping and consumption or congestive heart failure
Pediatric History and Physical Examination

Infant PE (con't):

skin: minor problems (con't):


- rash: may indicate infection (viral, bacterial or fungal),- infestation, allergic response, or a
rheumatological or autoimmune problem, etc.
describe: color, contour, pattern, size, shape, location, raised/flat
-- macular, papular, vesicular, pustular, petechial, ecchymotic, urticartial, oozy, scaly,
exfoliative, abraded, erythematous, pigmented, desquamated, plaque, nodule, etc.
NOTE: rash description will not be repeated for the other age groups
common infant rashes:
- diaper rashes: two common types
chemical: red and irritated shin, often sparing the creases; from wet or poopy diapers
yeast: bright red area with red dots around it (satellite lesions); often in the skin creases
- seborrhea dermatitis: red, rough, scaly, greasy skin on forehead and cheeks and behind ears
- cradle cap: seborrhea dermatitis of the scalp; greasy, yellow scales
- eczema: red, rough, sometimes oozy, itchy skin; especially on cheeks and flexor surfaces
- impetigo: red, crusty, oozy bacterial infection of the skin (often called "infantigo" by parents)
- milaria ("heat rash"): small red papules; basically clogged skin ducts
- chicken pox: multiple pruritic papulovesicules on an erythematous base and fever
- roseola: head to toe pink macules that appear just after resolution of a few days of high fever

head: normal findings: normocephalic and atraumatic with fontanel flat, soft, appropriate size (0.5-3.5cm)
variants: - dolichiocephalic (long & narrow): common with very preterm infants
- pulsatile fontanel
minor problems: - plagiocephalic (assym.): may be from laying supine too much
major problems: - microcephalic: may indicate a congenital anomaly
- macrocephalic: may indicate a congenital anomaly or increased intracranial pressure
- fontanel bulging: indicates increased intracranial pressure
- craniosynostosis: premature fusion of the skull bones; requires surgery

eyes: normal findings. external lids & periorbital region grossly normal and PERRL, EOMI, RR b/l,
corneal light reflection symmetrical b/l; eyes aligned and move conjugately
minor problems:
- watery eyes: consider lacrimal duct stenosis or congenital glaucoma
- conjunctiva injection or exudate: may indicate conjunctivitis, abrasion; or lacrimal duct stenosis
- EOM not I or corneal light reflection not symmetrical: not uncommon up to 4-6 months, abnormal after this point
major problems: - periorbital edema: consider a renal or cardiac problem
- red reflex not present: consider congenital cataracts or glaucoma or retinoblastoma (tumor)
- cloudy cornea or very large eyes: may indicate congenital glaucoma
- periorbital swelling with erythema: consider insect bite, periorbital cellulitis, orbital cellulitis

ears: normal findings. hearing grossly intact to bell or voice; external ear normal in size, shape, position;
EACs (R/L) patent; TMs (R/L) shiny, gray, intact and mobile with insufflation
NOTE: TM and EAC abnormalities will not be repeated for the other age groups
variants: - EAC occluded with cerumen
- PET (tubes placed in TM's for frequent otitis media) patent or obstructed with wax
- TM sclerotic: sequelae from frequent otitis media or PET
minor problems:
- EACs occluded with pus: indicates either otitis externa or ruptured TM from an otitis media
- EACs occluded with foreign body: children like to fill orifices and so do insects
- otitis media: TM erythematous (pink or red) or gray but injected and/or bulging with purulent fluid behind it
Pediatric History and Physical, Examination

Infant PE (con't):

ears: minor problems (con't):


- serous otitis media: TM gray with visible clear or cloudy fluid behind it or very dull with decreased mobility
to insufflation or retracted
- perforated TM: from infection or trauma; usually heals well
- bullae on TM (often with erythema): bullous myringitis; either viral or from mycoplasma infection
major problems: absent response to noise: hearing deficit
- EACs occluded with blood or hemotympaneum: indicates trauma

nose: normal findings. external nose normal with b/l patent nares; nasal mucosa pink without discharge
minor problems: NOTE: these nasal abnormalities will not be repeated for the other age groups
- turbinates swollen: congestion, usually from an URI
- nasal mucosa red with mucoid/mucopurulent/purulent discharge: URI, sinusitis, purulent rhinftis
- nare occluded with a foreign body
major problems: - flaring nares: indicates respiratory distress

oropharynx (mouth/throat): normal findings: lips & oral mucosa pink and moist; palate intact;
teeth absent or present (usually absent until at least 5-7 months)
variants: - may see epiglottis with gag reflex
minor problems: - pale mucous membranes: may indicate anemia
- thrush (yeast infection): white plaques on palate, mucosa, tongue, gums, lips; common and unconcerning if 0-6
months old; becomes progressively more unusual and concerning with increasing age
- pharyngeal/mucosal erythema/lesions/ulcers: pharyngitis; usually viral
- gingival or oral mucosa erythema/lesions/ulcers possibly with exudate: gingivostomatitis
likely from a 1* herpes infection; other viral infection are also possible
major problems:
- dry/tacky/parched mucous membranes: indicates dehydration if other related sx present

face: normal findings. symmetrical with normal facies and motor function,
problem: - flat affect: consider depression, hypothyroidism, botulism, etc.

neck: normal findings: FROM, no masses or adenopathy or rashes


variant: -“shotty" nodes: infants may have multiple, small, non-tender, mobile, un-inflamed nodes in the cervical region from
frequent viral infections
problems: - rashes: infants have deep neck creases and may get yeasty rashes here
- adenopathy: abnormal if large, tender, fixed, or with inflammation; indicates infection (adenitis) note: location, size,
shape, mobility, tenderness, erythema, consistency, texture
- masses: consider cystic hygroma, infected brachial cleft/thyroglossal duct cyst, tumor, adenitis

cardio: normal findings. regular rate and rhythm, no murmur, capillary refill brisk, femoral & brachial
pulses equal b/l and strong
variants: - tachycardia: occurs normally with fever or may pathological
- murmur: may be benign if no other abnormal cardiac findings are seen and is systolic and a grade 1-2/6; especially
if vibratory in nature
major problems:
- murmur: consider pathological if any other abnormal cardiac findings are seen or if diastolic or more than grade 3/6
- weak/absent femoral pulses with normal brachial pulses: consider aortic coarctation
- tachycardia: may be supraventricular tachycardia
Pediatric History and Physical Examination

Infant PE (con't):

resp: normal findings: chest wall symmetrical, breath sounds equal b/I and clear with good air movement;
no wheeze, rales, rhonchi, stridor
variants: - breasts may be slightly full from maternal hormones for first few months of life
minor problems: - transmitted upper respiratory congestion: may sound like rhonchi in the lungs
- laryngomalacia (floppy larynx): most common cause of stridor in infants < 6 weeks; resolves by 2 years of age
major problems:
- respiratory distress: from infection, asthma, aspiration, cardiac problems, etc.
Know what to look for to evaluate for respiratory distress: RR, oxygen saturations, level of consciousness,
color, nasal flaring, grunting, retractions, adequacy of air movement on auscultation, wheeze, rales, rhonchi,
stridor (either audible or auscultated)
mild: distress RR 50-70, mild grunting/nasal flaring/retractions, no cyanosis, sats > 95%
severe: RR>60, grunting/nasal flaring/retractions, possibly cyanosis or sats < 95%
- stridor (wheezy sound with inspiration): consider viral croup (most common from - 6 months to - 4 years; from vocal
cord/subglottic edema) or laryngomalacia, laryngeal/esophageal foreign body, or vascular ring
- wheeze (wheezy sound usually with expiration): RSV bronchiolitis (< 2years), asthma, foreign body, vascular rings,
cystic fibrosis, laryngeal web, etc.
- rhonchi/rales: pneumonia, congestive heart failure
- poor/decreased/absent air movement: obstruction (asthma, bronchiolitis, etc.)
- unequal breath sounds: may indicate a pneumothorax or other respiratory problem
- difficult breathing while eating: may indicate a tracheal-esophageal fistula

abd: normal findings. soft, rounded, no hepatosplenomegaly or masses or tenderness or hernia


If you need to do a rectal exam: use your pinkie-finger, always hemoccult any stool
variants: - umbilical hernia: usually closes on its own within a year
minor problems: - inguinal hernia: requires elective surgery
- anal fissures: usually caused by hard stools; causes stool to be streaked with blood; check anus with otoscope
(don’t insert it into the anus, just use it as a light source)
major problems: - hepatosplenomegaly: may indicate cardiac, infectious or metabolic problems
- masses: may indicate a congenital anomaly, tumor, organomegaly, pyloric stenosis, feces urinary obstruction
(bladder or kidneys), intestinal intussusception
- distended abdomen: may indicate intestinal atresia obstruction secondary to malrotation

GU: normal findings., normal male or female genitalia, testes descended b/l
variants: - hymen: progressively loses its puffy redundancy over the first year of life, becoming a thin membrane (of various
configurations) partially covering the vaginal opening
- hydrocele of scrotum/testes: transillum inate to be sure it isn't a hernia, should resolve overtime
minor problems:
- undescended teste(s): watch, should descend over the first year of life
- labial adhesions: labia minora adhere and fuse together
- penile adhesions: skin of shaft adheres to and fuses on glans
major problems:
- vaginal mass or bleeding: consider tumor or trauma (bleeding abnormal beyond 7-10 days old)

MS: normal findings: normal posture for age; full range of motion of all joints/muscles with good
strength, hips with negative Ortolani/Barlow (do up to -6 months, then check for ROM, leg
length, thigh skin crease symmetry); no somatic dysfunction or muscle or joint
pain/swelling/redness noted; no obvious bony/structural abnormalities
Pediatric History and Physical Examination

Infant PE (con't):

MS (con't):
variants:
- sacral dimple: very common; be sure dimple is blind and not communicating with spinal column; if dimple + tuft of
hair or pigmentation, this may signal occult spina bifida; if any neurological abnormalities, must evaluate further
- bowed legs: from intrauterine positioning; resolves by 2 years of age
- apparent flat feet: there's a fat pad on the bottom of the foot, masking the arch; not a problem
minor problems of the musculoskeletal system:
- fractures of extremities: feel crepitus or abnormal contour or tenderness or decrease use of that extremity; consider
osteogenesis imperfecta or abuse if history not consistent with findings
major problems:
- osteomyelitis or septic joint: consider with painful area & sx of infection/inflammation
- developmental dysplasia of the hips: have + Ortolani (dislocated hip)or Barlow (dislocatable hip) or Galeazzi
(uneven knee heights) tests; hips may look obviously asymmetrical; skin creases on thighs may be asymmetrical;
there may be leg length differences; more common with breech deliveries; infants need to evaluated by an orthopedic
surgeon ASAP

neuro: normal findings: CN 2-12 grossly intact (via close observation); DTR 214 & equal b1l; motor
function intact with good tone & strength; cerebellar function grossly, intact with normal
coordination; no developmental delay noted; normal infant reflexes including root, suck, grasp,
Moro, Gallant, Perez, tonic neck
Primitive reflex Gone by
root and palmar grasp 3-4 months
Moro and Perez 3 months
Gallant 2 months
tonic neck 6 months (may not appear until 2 months)

major problems:
- meningitis: lethargic or irritable infant usually with fever and other sx of infection
→ have a high index of suspicion since it may be very difficult to rule out in an infant by history and physical
alone (without a spinal tap) as the sx may be subtle and there's no nuchal rigidity for the first year or two
- inborn errors of metabolism: may see degenerative CNS disease with loss of devel. milestones
- botulism: hypotonia/weakness/paralysis, flat affect, constipation, respiratory depression; usually from ingestion of
honey in infants < 12 months old
- seizures: in infants the sx may be subtle complex partial (impaired level of consciousness with altered behavior and
automatisms: abnormal sucking or chewing motions, blinking, or bicycling of legs, or apneic episodes; also can have
generalized or focal tonic-clonic seizures consider neurological, infectious, toxin/drug, or metabolic causes
- developmental delay in any of the four areas (language, social, gross motor, fine motor)
- abnormal primitive infant reflexes (either absence of normal ones or persistence of the reflexes beyond the
expected age): consider neurological causes (focal or diffuse)
- hypertonia: consider cerebral palsy which is a non-progressive disorder of the CNS that occurs 20 to a perinatal
insult; it usually (75%) involves spasticity of the any or all of the extremities and may possibly involve seizures, mental
retardation, and/or speech or sensory defects
- hypotonia: consider neurological, infectious, muscular, or metabolic causes
- focal deficits: consider musculoskeletal as well as local neurological injury
Pediatric History and Physical Examination
Toddler H & P: components that are age-specific
(see pages 14-15 for CC, HPI, PSH, allergies, meds, FMH)

Toddler PMH (past medical history):

Pregnancy: was uncomplicated and full term.


Or________: document any major general or pregnancy-related maternal health problems
or substance use or abnormal fetal conditions/tests/studies and gestational age if < 34 Weeks.
Labor and delivery: was uncomplicated with a NSVD or C-S (for…). Birth weight_________.
Or________: document any UD or perinatal complications that occurred requiring resuscitation;
or admission to the NICU: including reason for admission, duration, other complications.
Since birth, infant has been healthy (or_______: specifically ask about and document a chronological order of any of the following:
URI, otitis media (ear infection), RSV bronchiolitis, pneumonia, croup, asthma, apnea, gastroesophageal reflux, formula
intolerance, gastroenteritis, urinary tract infection or kidney infection, seizures, diabetes, cancer, thyroid problems, sickle cell
anemia, cystic fibrosis, anemia; any problems with: eyes, ears, eating, breathing, heart, lungs, bowels, kidney, bladder, blood,
skin).
She/he has/hasn't been seen by her/his physician for appropriate health maintenance visits
(2-5 days after birth and 2, 4, 6, 9, 12, 15, 18, 24 months , 3 years).
Document any prior admissions and ER visits (note when and for what reason).

Immunizations are UM (up to date) including ...


- check the immunization card which the parents should carry with them
hospital or newborn office visit: Hepatitis B
2m visit: Hepatitis B, Hemophilus influenza B (HIB), diphtheria/tetanus/pertussis (DTP or DTaP), Polio
4m visit: Hepatitis B, HIB, DTP or DTaP
6m visit: Hepatitis B, HIB, DTP or DTaP
12m visit: varicella
15-18m visit: HIB, DTP or DTaP, Polio, measles/mumps/rubella (MMR)

Toddler Development
- most items are the 75th% of the Denver developmental screen
12m: stand alone; uses 1 word; puts block in cup; plays ball; imitates activities; indicates wants
14-15m: stoops & recovers; walks well; uses 2-3 words; imitates scribble; drinks from cup
16-18m: run; releases a raisin; 2 cube- tower, helps --in, house; uses -spoon/fork
19-21 m: walk up steps; kicks ball; uses 6 words; remove clothes; feeds doll
22-24m: throws ball overhand; jumps; combines words; names 6 body parts; 4-6 cube tower

Toddler Social History:


(Patient) lives with_______ (family/friends/etc.) in a house/apartment/etc. with _______ pets. There is no-one around the baby who
smokes or____________.
Primary care-giver is___________. (Patient) does/doesn't attend day-care.
Diet includes (be specific):
dairy: breast milk or formula or cow's milk (whole, 2%, etc. or other:_________ oz/d;
juice:__________ oz/d;
approximate quantities of breads/cereals/pasta, fruits, vegetables, legumes/meats, other dairy:

Sleeping pattern consists of____________(when, how long, where, waking, crying).


Major changes in home life?
Pediatric History and Physical Examination

Toddler ROS
general: fever; irritable; crying; apnea; cyanosis; pallor, delay in growth or development; weight change; recent changes in
feeding/voiding/stooling
Derm: rash; pruritus; easy bruising or bleeding; sores; birthmarks; lumps
HEENT: head trauma; squint; otalgia; teething; sore throat; rhinorrhea; congestion; epistaxis; brush teeth
Cardio-resp: cough; hoarseness; wheeze; retractions; shortness of breath or difficulty in breathing; activity intolerance; syncope
Abd: abdominal pain; food intolerances; regurgitation; nausea; emesis; hematemesis, diarrhea; constipation; hematochezia; stool
frequency, color, consistency
GU: voiding frequency; dysuria; edema; hematuria; toilet training
MS-neuro: swollen or painful or red muscles or joints; weakness; paresthesias; limping; stumbling; seizures; trembling
Psych: anxious or sad; excessively active or inattentive

Toddler Physical Exam:

Vital sign norms for toddlers: RR HR BP


1-3y 20-40 90-160 ave: 95/60 low:85/50 high:115/80
Measure and record weight, height, head circumference and then plot these on the growth chart to determine percentiles and
consistency of growth.

general: normal findings: alert, quiet, active, awake, sleeping, content, crying though consolable, playful,
good eye contact, responds appropriately, well nourished & well hydrated
problems:
- excessively irritable or listless; poor eye contact; apathetic (these are symptoms of a sick baby): consider
neurological, cardiac, infectious or metabolic causes
- dehydrated: may be mild, moderate, or severe; specific findings from the rest of the PE must noted to determine the
degree of dehydration
- malnourished: looks excessively thin; specific findings from the rest of the PE must noted also

skin: normal findings. pink (undertones of skin); warm; good turgor, no lesions, rashes, bruises
variant: - cafe au lait spots: common; consider neurofibromatosis if > 5 spots that are > 0.5 cm in size
minor problems: see infant section for description of rashes
- bruises: likely are normal, especially on' shins;- could indicate a bleeding disorder or abuse
- eczema: red, rough, sometimes oozy, itchy skin; especially on cheeks and flexor surfaces
- impetigo: red, crusty, oozy bacterial infection of the skin (often called “infantigo” by parents)
- chicken pox: multiple pruritic papulovesicules; on an erythematous base and fever
- roseola: head to toe pink macules that appear just after resolution of a few days of high fever

HEENT-N: see infant section for description of abnormal findings for ears and nose
head: normal findings: normocephalic and atraumatic with fontanel fiat, soft, appropriate size (0.5-1.Ocm)
Note: fontanel usually closes by 18 months of 9ge.
eyes: normal findings. external lids & periorbital region grossly normal and PERRL, EOMI, RR b/l,
corneal light reflection symmetrical b/l; eyes aligned and move conjugately
minor problems: - conjunctival injection with exudate: consider conjunctivitis
- painful conjunctival injection: consider abrasion
major problems: - periorbital edema: consider a renal problem or congestive heart failure
-conjunctival injection without exudate: consider Kawasaki's syndrome if has other related sx
- periorbital swelling with erythema: consider insect bite, periorbital cellulitis, orbital cellulitis
- orbital cellulitis: painful erythematous swelling of periorbital area with inability to use EOM
- EOM not I or corneal light reflection not symmetrical: abnormal; indicates strabismus
- red reflex not present: consider cataracts, retinoblastoma (tumor)
Pediatric History and Physical Examination

Toddler PE (con't):

HEENT (con't):
ears: normal findings: hearing grossly intact to bell or voice; external ear normal in size, shape, position;
EACs (R/L) patent; TMs (R/L) shiny, gray, intact
nose: normal findings: external nose normal with b/I patent nares; nasal mucosa pink without discharge
oropharynx (mouth-throat): normal findings., lips & oral mucosa pink and moist; palate intact;
gag reflex present; teeth in good repair (usually have 8 incisors and 4 molars by 18 months)
variants: - may see epiglottis with gag reflex
minor problems:
- dental caries (especially of incisors): from excessive bottles with juice or milk, especially has bottle in bed
- pharyngeal/mucosal erythema/lesions/ulcers: pharyngitis; usually viral
- gingival or oral mucosa erythema/lesions/ulcers possibly with exudate: gingivostomatitis likely from a 1 0 herpes
infection; other viral infection are also possible
major problems:
- dry/tacky/parched mucous membranes: indicates dehydration if other related sx present
face: normal findings. symmetrical with normal facies and motor function
problem: - flat affect: may indicate depression or metabolic problem
neck: normal findings: FROM, no masses
variant: - “shotty" nodes: infants and children often have multiple, small, non-tender, mobile, un-nflamed nodes in the
cervical region from frequent viral infections
problems:
- adenopathy: abnormal if large, tender, fixed, or with inflammation; indicates infection (adenitis) note: location, size,
shape, mobility, tenderness, erythema, consistency, texture
- masses: consider cystic hygroma, infected brachial cleft/thyroglossal duct cyst, tumor, adenitis

cardio: normal findings. regular rate and rhythm, no murmur, capillary refill brisk, femoral & brachial
pulses equal b/I and strong
variants: - murmur: may be benign if no other abnormal cardiac findings are seen and is systolic and
a grade 1-2/6; especially if vibratory in nature
major problems: - murmur: consider pathological if any other abnormal cardiac findings are seen or if
diastolic or more than grade 3/6

resp: normal findings: chest wall symmetrical, breath sounds equal b/l and clear with good air movement;
no wheeze, rales, rhonchi, stridor
minor problems: - transmitted upper respiratory congestion: may sound like rhonchi in the lungs major problems:
- respiratory distress: from respiratory infection, asthma, aspiration, cardiac problems, etc. mild: distress RR 50-70,
mild grunting/nasal flaring/retractions, no cyanosis, sats > 95% severe: RR>60, grunting/nasal flaring/retractions,
possibly cyanosis or sats < 95%
- stridor (wheezy sound with inspiration): consider viral croup (most common from - 6 months to - 4 years; from vocal
cord/subglottic edema), laryngea/esophageal foreign body or vascular ring
- wheeze (wheezy sound usually with expiration): RSV bronchiolitis (< 2years), asthma, foreign body, vascular rings,
cystic fibrosis, laryngeal web, etc.
- rhonchi/rales: pneumonia, congestive heart failure
- poor/decreased/absent air movement: obstruction (asthma, bronchiolitis, etc.)
- unequal breath sounds: may indicate a pneumothorax or other respiratory problem
Pediatric History and Physical Examination

Toddler PE (con't):

abd: normal findings: soft, rounded (often has a "pot-belly"), no hepatosplenomegaly or masses or tenderness or hernia
minor problems: - inguinal hernia: requires elective surgery
- anal fissures: usually caused by hard stools; causes stool to be streaked with blood; check anus with otoscope
(don't insert it into the anus, just use it as a concentrated light source)
major problems: - hepatosplenomegaly: may indicate cardiac, infectious or metabolic problems
- masses: may indicate a tumor, organomegaly, feces, urinary -obstruction (bladder or kidneys), intestinal
intussusception
- distended abdomen: consider obstruction secondary to malrotation, or other causes

GU: normal findings: normal male or female genitalia, testes descended b/I
minor problems: - labial adhesions: labia minora adhere and fuse together
major problems: - undescended teste(s): needs surgery at this point
- vaginal blood or discharge: usually from a foreign body, consider abuse also

MS: normal findings., normal gait (often wide-based with foot pronation) and posture without scoliosis
or kyphosis (often has slightly increased lumbar lordosis); full range of motion of all joints
and muscles with good strength (grade 5/5); no somatic dysfunction or muscle or joint
pain/swelling/redness noted; no obvious structural anomalies
variants: - bowed legs: from intrauterine positioning; resolves by 2 years of age
- toe-in (“pigeon-toed”) with walking: a normal developmental stage; will resolve on its own by 2-3 years of age
- apparent fiat feet: there's a fat pad on the bottom of the foot, masking the arch; not a problem
minor problems: toe-walking: may have tight calf muscles or may have muscular disease
- fractures of extremities: feel crepitus or abnormal contour or tenderness or decrease use of that extremfty; consider
osteogenesis imperfecta or abuse if history not consistent with findings
- toxic synovitis: aseptic inflammation of the hip, associated with recent viral illness; usually occurs in 2-8 year old
children
major problems: osteomyelitis or septic joint: consider with painful area & sx of infection/inflammation
- limp: consider trauma, developmental dysplasia of the hips, osteomyelitis or septic joint, juvenile rheumatoid
arthritis, toxic synovitis of the hip
- muscular dystrophy: progressive weakness, -usually has its onset in 2-6 year old males

neuro: normal findings., CN 2-12 grossly intact (via close observation); DTR 2/4 & equal bilaterally
(biceps, brachioradialis, triceps, patellar, ankle); Babinski down bilaterally; motor function intact
with good tone & strength (grade 5/5); cerebellar function grossly intact with normal gait and
stance and coordination; no developmental delay noted
problems: - ataxia: otitis media, post viral cerebellar ataxia (resolves on its own), brain tumor
- meningitis: lethargic or irritable infant usually with fever and other sx of infection, may have nuchal rigidity; continue
to have a high index of suspicion since it may be very difficult to rule out in a infant by history and physical alone
(without a spinal tap) as the sx may be subtle
- inborn errors of metabolism: may see degenerative CNS disease with loss of developmental milestones
- seizures: consider generalized or focal tonic-clonic seizures, complex partial (impaired level of consciousness with
altered behavior and automatisms), myoclonic seizure; consider neurological, infectious, toxin/drug, or metabolic
causes
- developmental delay in any of the four areas (language, social, gross motor, fine motor)
- hypertonia: consider cerebral palsy which is a non-progressive disorder of the CNS that occurs 20 to a perinatal
insult; it usually (75%) involves spasticity of the any or all of the extremities and may possibly involve seizures, mental
retardation, and/or speech or sensory defects
- focal deficits: consider musculoskeletal as well as local neurological injury
Pediatric History and Physical Examination

Pre-schooler H & P and School-aged Child H & P: components that are age-specific
(see pages 14-15 for CC, HPI, PSH, allergies, meds, FMH)

Child PMH:
Pregnancy & labor/delivery were uncomplicated (or____________), and full-term (or______________). Note whether
there was a NICU admission.
Since birth, child has been healthy (or________: specifically ask about and document a chronological order of any of the following: URI,
otitis media (ear infection), sinusitis, RSV bronchiolitis, pneumonia, croup, asthma, apnea, gastroenteritis, urinary tract infection or
kidney infection, seizures, diabetes, cancer, thyroid problems, sickle cell anemia, cystic fibrosis, anemia; any problems with: eyes,
ears, eating, breathing, heart, lungs, bowels, kidney, bladder, blood, skin).
Child has/has not been regularly seen by their physician for health maintenance visits (every 1-2 years from 2 years and on).
Document any prior admissions and ER visits (note when and for what reason).

Immunizations are UTD (up to date) including ...


school-aged children: should have completed their primary series (see infant and toddler sections)
- booster: need DTaP, polio, MMR between 4-6 y
- be sure that they have had their hepatitis immunizations
- find out their chicken-pox/varicella status: there's an immunization for this now "
- some may have had an influenza shot as well

Child Development:
2y: throws ball overhand; jumps up; combines words; name 6 body parts; speech is 1/2 understandable;
4-6 cube tower; with help: brushes teeth, wash/dry hands, dress self
3y: 8' broad jump; balance on I foot x 1 sec.; uses 2 adjectives; name 1 color; speech is understandable
4y: hop on each foot; balance on 1 foot for 3 sec.; name 4 colors; by self: brush teeth & dress self, knows age & gender
5y: heel-toe walk for 4 steps; count 5 objects; draw 6-part person; knows address & phone number
6y: can write name; has basic reading and counting skills
> 6y: ask about school level and progress

Child Social History:


(Patient) lives with __________(family/friends/etc.) in a house/apartment/etc. with pets. There is no-one around the child who smokes
or_________________
(Patient) attends preschool/school on a regular basis/etc. and is in ________ grade. School is/isn't going well, and is/isn't enjoyed,
without/with any delay or advances.
(Patient) gets along well/poorly with other kids and has/doesn't have friends.
(Patient) is also involved in _____________(sports, community activities, church, etc.) and has_________ hobbies.
Diet: follows standard/vegetarian/lactose-free/etc. diet with 3 meals (or______________) each day
with snacks_______________(or___________) and appropriately includes foods from each of the food groups
(breads/cereal/pasta, fruits, vegetables, legumes/meats, dairy) with minimum/average/excessive
fatty/salty/etc. food (please be specific). There are/aren't any foods that are avoided. Vitamin supplements are/aren't taken.
Sleeping pattern consists of ______________(when, how long).
Major changes in home life?
Pediatric History and Physical Examination

Child ROS:
general: fever; fatigue; delay in growth or development; weight change; polydipsia
Derm: rash; pruritus; easy bruising or bleeding; sores; birthmarks; lumps
HEENT: problems or change in vision, hearing, or smell; headache; head trauma; squint; vertigo; otalgia; sore throat; rhinorrhea;
congestion; epistaxis; brush teeth; see dentist yearly
Cardio-resp: cough; hoarseness; wheeze; chest pain; shortness of breath or difficulty in breathing; activity intolerance; syncope
Abd: abdominal pain; food intolerances; indigestion; nausea; emesis; hematemesis, diarrhea; constipation; hematochezia; stool
frequency, color, consistency
GU: voiding frequency; dysuria; edema; hematuria; enuresis
MS-neuro: swollen or painful or red muscles or joints; weakness; numbness; tingling; limping; stumbling; seizures, tremor, loss of
consciousness
Psych: anxious or sad; excessively active or inattentive

Child Physical Exam:

Vital sign norms for children: RR HR BP ave low high


3y 20-40 4y 80-120 <6y 95160 85/50 115180
4-12y 15-30 5-12y 60-100 7-12y 110/`72 95160 125/85
Measure and record weight and height and then plot these on the growth chart to determine percentiles and consistency of
growth.

general: normal findings: alert, quiet, active, awake, sleeping, content, crying though consolable, playful, good eye contact, responds
appropriately, oriented x 3; well nourished & well hydrated
problems: - agitated: consider psychological or neurological problem
- excessively irritable or listless, lethargic, obtunded, stuporous or comatose, poor eye contact, apathetic, disoriented
(sick child): consider neurological, cardiac, infectious or metabolic

skin: normal findings. pink (undertones of skin); warm; good turgor, no lesions, rashes, bruises, alopecia
variant: - cafe au lait spots: common; consider neurofibromatosis if > 5 spots that are > 0.5 cm in size
- nevi: check for malignant changes
minor problems: see infant section for description of rashes
- bruises: likely are normal, especially on shins; could indicate a bleeding disorder or abuse
- eczema: red, rough, sometimes oozy, itchy skin; especially on extensor surfaces
- impetigo: red, crusty, oozy bacterial infection of the skin (often called “infantigo” by parents)
- chicken pox: multiple pruritic papulovesicules; on an erythematous base and fever
- alopecia: consider fungal infection, tight hairstyles, autoimmune, etc.

HEENT-N: see infant section for description of additional abnormal findings for ears and nose
head: normal findings. normocephalic and atraumatic
eyes: normal findings. visual acuity ______; visual fields normal; external lids & periorbital region grossly normal conjunctiva pink;
PERRL, EOMI, RR b/l; fundiscopic exam reveals optic discs sharp b/l
minor problems: - allergic shiners: consider allergic rhinitis
- conjunctival injection with exudate: consider conjunctivitis
- painful conjunctival injection: consider abrasion
major problems: - periorbital edema: consider a renal problem or congestive heart failure
- conjunctival injection without exudate: consider Kawasaki's syndrome if has other related sx
- periorbital swelling with erythema: consider insect bite, periorbital cellulitis, orbital cellulitis
- orbital cellulitis: painful erythematous swelling of periorbital area with inability to use EOM
- red reflex not present: consider retinoblastoma (tumor)
Pediatric History and Physical Examination

Child PE (con't):

HEENT (con't):
ears: normal findings: hearing grossly intact; EACs (R/L) patent; TMs (R/L) shiny, gray, intact
nose: normal findings: external nose normal with b/I patent nares; nasal mucosa pink without discharge
minor problem: - allergic rhinitis: allergic nasal crease; pale boggy turbinates
- nasal polyps: consider allergic rhinitis or cystic fibrosis
oropharynx (mouth-throat): normal findings: lips & oral mucosa pink and moist; palate intact; teeth and gums in good repair; tonsils
and pharynx without erythema or exudate
variant: - large tonsils (though not touching)
- may see epiglottis with gag reflex
minor problem: - mouth-breather: consider allergic rhinitis or large adenoids
- pharyngeal cobblestoning: consider allergic rhinitis
- pharyngeal erythema with/out exudate, lesions: pharyngitis; consider strep if has beefy red pharynx possibly with
exudate, and sx of headache, sore throat, fever, tender cervical adenopathy, nausea, vomiting
- dental caries
major problems:
- dry/tacky/parched mucous membranes: indicates dehydration if other related sx present
face: normal findings., symmetrical with normal facies and motor function; no sinus tenderness
neck: normal findings: FROM, no masses; negative kernig-brudzinski signs; thyroid minimally palpable
variant: -“shotty" nodes: children often have multiple, small, non-ender, mobile, un-inflamed nodes in the cervical region from
frequent viral infections
problem: - b/I enlarged tender adenopathy: consider strep infection if has other related sx
- one enlarged node: consider Kawasaki's syndrome (if has other related sx), adenitis, tumor, cat-scratch disease

cardio: normal findings: regular rate and rhythm, SI & S2 normal with physiologic splitting, no murmur,
capillary refill brisk, pulses equal b/I and strong (radial and dorsalis pedis); no peripheral edema,
clubbing, cyanosis
variants: - murmur: may be benign if no other abnormal cardiac findings are seen and is systolic and a grade 1-2/6;
especially if vibratory in nature

resp: normal findings: chest wall symmetrical, breath sounds equal b/I and clear with good air movement;
no wheeze, rales, rhonchi, stridor
major problems:
- respiratory distress: from respiratory infection, asthma, aspiration, cardiac problems, etc.
mild: distress RR 50-70, mild grunting/nasal flaring/retractions, no cyanosis, sats > 95% severe: RR>60,
grunting/nasal flaring/retractions, possibly cyanosis or sats < 95%
- stridor (wheezy sound with inspiration): consider viral croup (most common from - 6 months to - 4 years; from vocal
cord/subglottic edema), laryngeal/esophageal foreign body
- wheeze (wheezy sound usually with expiration): asthma, foreign body, vascular rings, cystic fibrosis, laryngeal web,
etc.
- rhonchi/rales: pneumonia, congestive heart failure
- poor/decreased/absent air movement: obstruction (asthma, bronchiolitis, etc.)
- unequal breath sounds: may indicate a pneumothorax or other respiratory problem

breasts: normal findings: no appreciable glandular development


variant: - some glandular development may be normally seen in girls after the age of 8 years
Pediatric History and Physical Examination

Child PE (con't):

Abd: normal findings: abdomen is soft and flat; bowel sounds normoactive; scars consistent with
surgeries; anus without lesions, normal tone, no tenderness, stool hemoccult negative;
no hepatosplenomegaly, masses, tenderness, hernia
major problems: - hepatosplenomegaly: may indicate cardiac, infectious or metabolic problems
- masses: may indicate a tumor, organomegaly, feces, urinary obstruction (bladder or kidneys), intestinal
intussusception
- rebound, guarding, positive heel tap, obturator or psoas sign: indication of inflammatory process, usually indicating
appendicitis
- bruit: usually indicates vascular abnormality (renal arteries or aorta)
- Lloyd's sign: renal - Murphy's sign: gall bladder Rovsing's sign: appendicitis

GU female: normal findings: labia/vestibule without mass, lesion, erythema, infestation; mucosa
pink & moist without lesion or erythema or discharge, Tanner stage_________
variant: - physiologic leukorrhea: thin clear or white (yellows with drying) vaginal discharge; may occur several months before
menarche
problem: - abuse: may see signs of trauma or may see nothing abnormal at all
- vulvovaginitis: erythema, maceration, possible vaginal discharge; caused by any one or combination of poor
hygiene, foreign body, respiratory or enteric pathogens, STD's, yeast, pinworms, etc.
- precocious puberty: consider genetic or endocrine problem

GU male: normal findings. penis/scrotum without mass, lesions, erythema, infestation, discharge; testes
normal size for age, without mass or tenderness; Tanner stage_____________
variant: - retractile testes: have child sit with his legs crossed (Tailor-style) and examine in this position, starting at the inguinal
ligament and work towards the scrotum (pg 618 Bates)
problem: - painful scrotum/testes: consider torsion, trauma, infection, hernia
- precocious puberty: consider genetic or endocrine problem

MS: normal findings. normal gait and posture without scoliosis or kyphosis; full range of motion of all
joints and muscles with good strength (grade 5/5); good rib excursion b/l; negative standing and
seated flexion and stork tests; negative Fabere and straight leg raising tests; no somatic
dysfunction or muscle or joint pain/swelling/redness noted
variant: - knock-knees: commonly seen in 3-8 year olds minor problems:
- idiopathic scoliosis: 20% occur in 4-10 year old children, the rest in adolescents
- somatic dysfunction: findings of asymmetry, pain, motion limitation, or abnormal end point feel
- toxic synovitis: aseptic inflammation of the hip, associated with recent viral illness; usually occurs in 2-8 year old
children
major problems:
- osteomyelitis or septic joint: consider with painful area & sx of infection/inflammation
- limp: consider trauma, osteomyelitis or septic joint, juvenile rheumatoid arthritis, toxic synovitis, avascular necrosis
of the hip, slipped femoral capital epiphysis
- avascular necrosis of the hip (Legg-Calve-Perthes disease): usually occurs in 2-12 year olds
- slipped femoral capital epiphysis: shift of the growth plate at this location; requires pinning
- juvenile rheumatoid arthritis
- fractures of extremities: feel crepitus or abnormal contour or tenderness or decrease use of that extremity; consider
osteogenesis imperfecta or abuse if history not consistent with physical findings
- muscular dystrophy: progressive weakness; usually has its onset in 2-6 year old males
Pediatric History and Physical Examination

Child PE (con't):

Neuro: normal findings: CN 2-12 grossly intact; DTR 2/4 & equal bilaterally (biceps, brachioradialis, triceps, patellar, ankle); Babinski
down bilaterally; sensory dermatomes; intact (to light touch, sharp & dull) without deficit; motor function intact with
good tone & strength (grade 5/5); cerebellar function intact (to rapidly alternating pronation and s uppination; finger to
nose movement; opposition of fingers; running heel down shin of opposite leg; normal gait and stance and
coordination); no ankle clonus or tremors noted, Rhomberg negative; speech fluent; affect is normal; appears content
problems:
- ataxia: otitis media, post viral cerebellar ataxia (usually occurs in 2-6 year olds, associated with recent viral illness,
resolves on its own), brain tumor
- meningitis: lethargic or irritable child usually with fever and nuchal rigidity
- seizures: consider generalized or focal tonic-clonic seizures, absence seizures (frequent blank stares, often
associated with poor school performance), complex partial (impaired level of consciousness with altered behavior and
automatisms), myoclonic seizure; consider neurological, infectious, toxin/drug, or metabolic causes
- focal deficits: consider musculoskeletal as well as local neurological injury
Pediatric History and Physical Examination

Adolescent H & P: components that are age-specific


(see pages 14-15 for CC, HPI, PSH, allergies, meds, FMH)

Adolescent PMH
Birth was uncomplicated (or_____________________)
Since birth, adolescent has been healthy (or_______________: specifically ask about and document a chronological order of any of the
following: sinusitis, mono, bronchitis, pneumonia, asthma, urinary tract infection or kidney infection, seizures, diabetes, cancer,
thyroid problems, sickle cell anemia, cystic fibrosis, anemia; any problems with: eyes, ears, eating, breathing, heart, lungs, breasts,
bowels, kidney, bladder, testes or ovaries or uterus, blood, skin, brain/nerves).
Adolescent has/has not been regularly seen by their physician for health maintenance visits (every 1-2 years).
Document any prior admissions and ER visits (note when and for what reason).

Immunizations are UM (up to date) including ...


-adolescents: be sure that they have had their hepatitis immunizations and MMR booster
- a tetanus shot must be up-dated every 5-10 years
- find out their chicken-pox1varicella status: there's an immunization for this now and an adolescent should definitely
have this immunization if they haven't had the chicken pox yet
- some may have had an influenza shot as well

Adolescent Development: ask about school level and performance

Adolescent Social History:

(Patient) lives with______________(family/friends/etc.) in a house/apartment/etc. with__________ pets. There is no-one


around the adolescent who smokes or______________
(Patient) attends preschool/school on a regular basis/etc. and is in_____________ grade. School is/isn't going
well, and is/isn't enjoyed, without/with any delay or advances.
(Patient) gets along well/poorly with other teens and has/doesn't have friends.
(Patient) is also involved in _____________(sports, community activities, church, etc.) and has_______________ hobbies.
(Patient) is employed at _________ doing____________ for_________ hours/week.
(Patient) has____________________ as future plans. (Patient) does/doesn't drive a car.
(Patient) admits to/denies any current or past alcohol/tobacco/drug use, which consists of_________________
(note type, quantity, frequency, and duration of substance),
Diet: follows standard/vegetarian/lactose-free/etc. diet with 3 meals (or________________) each day
with snacks_______________(or__________) and appropriately includes foods from each of the food groups
(breads/cereal/pasta, fruits, vegetables, legumes/meats, dairy) with minimum/average/excessive
fatty/salty/etc. food (please be specific). There are/aren't any foods that are avoided. Vitamin supplements are/aren't taken.
Sleeping pattern consists of _______________________(when, how long).
Major changes in home life?

Adolescent ROS:
general: fever; fatigue; delay in growth or development; weight change; polydipsia
Derm: rash; pruritus ; easy bruising or bleeding; sores; birthmarks; lumps
HEENT: problems or change in vision, hearing, or smell; headache; head trauma; squint; vertigo; otalgia; sore throat; rhinorrhea;
congestion; epistaxis; brush teeth; see dentist yearly
Cardio-resp: cough; hoarseness; wheeze; chest pain; shortness of breath or difficulty in breathing; activity intolerance; syncope
Abd: abdominal pain; food intolerances; indigestion; nausea; emesis; hematemesis, diarrhea; constipation; hematochezia; stool
frequency, color, consistency
Pediatric History and Physical Examination

Adolescent ROS (con't):


GU: voiding frequency; dysuria; edema; hematuria; enuresis; polyuria
female: self breast exam; breast lumps, pain, discharge, changes; vulvar or vaginal lesions or itching;
vaginal discharge (color, odor, consistency, amount);
menstrual periods (FDLIVIP, frequency, duration, flow); dysmenorrhea; menarche;
most recent pelvic exam
ever pregnant? If so document the following:
GP-TPAL (gravida = # of pregnancies, para = # of births, term = # full-term pregnancies, pre-term = # of premature
deliveries, abortions = # spontaneous & elective abortions, living = # of living children)
male: self testicular exam; penile discharge or lesions; ever father a child?
both: sexually active (with men, women, both); age at 1st intercourse; number of partners; birth control methods;
condom use
MS-neuro: swollen or painful or red muscles or joints; weakness; numbness; tingling; limping; stumbling; seizures; tremor; loss of
consciousness
Psych: anxious or sad; hallucinations; excessively active or inattentive

Adolescent PE:
Vital. sign norms for adolescents:
RR HR BID average low high
12-15y 15-30 >12y 60-80 14-17y 1-20/75 100/65 130/90
>16y 12-20 >18y 120/80 105165 140/90
Measure and record weight and height and then plot these on the growth chart to deteffnine percentiles and consistency of
growth.

general: normal findings: alert, content, good eye contact, responds appropriately, oriented x 3; well nourished & well hydrated;
appearance is well kept
problems: - agitated: consider psychological or neurological problem
- excessively irritable or listless, lethargic, obtunded, stuporous or comatose, apathetic, disoriented: consider
neurological, cardiac, infectious or metabolic causes.

skin: normal findings. pink (undertones of skin); warm; good turgor; no lesions, rashes, bruises, alopecia
variant: - cafe au lait spots: common; consider neurofibromatosis if > .5 spots that are > 0.5 cm in size
- nevi: check for malignant changes
minor problems: see infant section for description of rashes
- bruises: likely are normal, if have a consistent hx; could indicate a bleeding disorder or abuse
- eczema: red, rough, sometimes oozy, Itchy skin; especially on extensor surfaces
- alopecia: consider fungal infection, tight hair styles, autoimmune, etc.
- acne

HEENT-N: see infant section for description of abnormal findings for ears and nose
head: normal findings. normocephalic and atraumatic
eyes: normal findings: visual acuity _________; visual fields normal; external lids & periorbital region grossly normal conjunctiva pink;
PERRL, EOMI, RR b/I; fundiscopic exam reveals optic discs sharp b/l
minor problems: - allergic shiners: consider allergic rhinitis
- conjunctival injection with exudate: consider conjunctivitis
- painful conjunctival injection: consider abrasion
ears: normal findings: hearing grossly intact; EACs (R/L) patent; TMs (R/L) shiny, gray, intact
nose: normal findings: external nose normal with b/I patent nares; nasal mucosa pink without discharge
minor problem: - allergic rhinitis: allergic nasal crease; pale boggy turbinates
- nasal polyps: consider allergic rhinitis
Pediatric History and Physical Examination

Adolescent PE (con't):

HEENT-N (con't):
oropharynx (mouth-throat): normal findings: lips & oral mucosa pink and moist; palate intact; teeth and gums in good repair, tonsils
and pharynx without erythema or exudate
minor problem: - pharyngeal cobblestoning: consider allergic rhinitis
- pharyngeal erythema with/out exudate, lesions: pharyngitis; consider strep or mono if has beefy red pharynx
possibly with exudate, and other related sx
- dental caries
face: normal findings: symmetrical with normal facies and motor function; no sinus tenderness
neck: normal findings: FROM, no masses; negative kernig-brudzinski signs; thyroid minimally palpable
problem: - b/I enlarged non-tender adenopathy: consider mono infection if has other related sx
masses: consider adenitis, tumor

cardio: normal findings: regular rate and rhythm, S1 & S2 normal with physiologic splitting, no murmur,
capillary refill brisk, pulses equal b/I and strong (radial and dorsalis pedis); no peripheral edema,
clubbing, cyanosis - problem areas would be essentially the same as adult

resp: normal findings: chest wall symmetrical, breath sounds equal b/I and clear with good air movement;
no wheeze, rales, rhonchi, stridor
major problems: - unequal breath sounds: may indicate a pneumothorax or other respiratory problem
- respiratory distress: from respiratory infection, asthma, aspiration, cardiac problems, etc.
mild: distress RR 50-70, mild nasal flaring/retractions, no cyanosis, sats > 95%
severe: RR>60, nasal flaring/retractions, possibly cyanosis or sats < 95%
- stridor (wheezy sound with inspiration): consider laryngeal/esophageal foreign body
- wheeze (wheezy sound usually with expiration): asthma, foreign body, vascular rings, cystic fibrosis, laryngeal web,
etc.
- rhonchi/rales: pneumonia, congestive heart failure
- poor/decreased/absent air movement: obstruction (asthma, bronchiolitis, etc.)

breasts (female): normal findings: symmetrical without lesions, masses, discharge; Tanner stage__________
variant: - fibrocystic changes: the cysts are of varying sizes, round/oval, smooth, well-circumscribed, mobile, often tender;
they are most noticeable just before the menstrual period begins
problem: - fibroadenoma: common, benign breast mass; firm, rubbery, mobile, well-defined, usually < 4 cm, usually in the
upper/outer quadrant, does not change with the menstrual cycle
- mass: describe location (by *clock" or quadrant and
cm from nipple), size (mm or cm), shape (round, oval, disk, irregular), consistency (soft, hard, firm, smooth),
delimination (well-circumscribed or not), mobility (mobile or fixed), tenderness
- nipple discharge: consider pituitary problem or tumor (unusual in adolescence)

breasts (male): normal findings: no appreciable glandular development


variant: - pubertal gynecomastia: either uni- or bilateral minimal glandular development, usually less than 2-3 cm, may
be slightly tender, most common around age 14 years, resolves on its own within 1-2 years, found in about
2/3 of adolescent males.
- pseudo-gynecomastia: adipose tissue accumulation without glandular development
Pediatric History and Physical Examination

Adolescent PE (con't):

Abd: normal findings: abdomen is soft and flat; bowel sounds normoactive; scars consistent with surgeries; anus without lesions,
normal tone, no tenderness, stool hemoccult negative; no hepatosplenomegaly, masses, tenderness, hernia minor problems: -
splenomegaly: consider mono, among other things (see below) major problems: hepatosplenomegaly: may indicate cardiac,
infectious or metabolic problems - masses: may indicate a tumor, organom egaly, feces, urinary obstruction (bladder or
kidneys), - rebound, guarding, positive heel tap, obturator or psoas sign: indication of inflammatory process, usually indicating
appendicitis - bruit: usually indicates vascular abnormality (renal arteries or aorta) - Lloyd's sign: renal - Murphy's sign: gall
bladder - Rovsing's sign: appendicitis

GU female: normal findings. labia/vestibule without mass, lesion, erythema, infestation; vaginal mucosa pink & moist without lesion or
erythema, vaginal mucus clear & odorless; cervix pink without lesion or erythema, with/without eversion, cervix
nulliparous/multiparous; adnexa unremarkable; uterus ante- vs retroverted, not enlarged; PAP & Cx done; Tanner
stage_________________
variant: - physiologic leukorrhea: thin clear or white (yellows with drying) vaginal discharge
- cervical eversion: may be normal
- hymen becomes thicker as it responds to the increasing levels of estrogen with puberty
problems: - infected Bartholin's gland: tender, red, swelling of posterior labia
- vulvovaginitis: erythema, maceration, possible vaginal discharge; caused by any one or combination of poor
hygiene, foreign body, respiratory or enteric pathogens, STD's, yeast
- STD's: herpes, condyloma (human papilloma virus), GC, chlamydia, syphilis, HIV, trichomonas
- vaginitis: yeast, bacterial vaginosis, trichomonas
- cervicitis: GC, chlamydial infection causing erythema, pain, discharge of the cervix or adnexa
- pelvic inflammatory disease: GC, chlamydial infection causing fever, pelvic/abdominal pain, etc.
- enlarged uterus/adnexa: pregnancy, fibroids, ovarian cyst
- amenorrhea or delayed puberty: consider endocrine or genetic disorder

GU male: normal findings. penis/scrotum without mass, lesions, erythema, infestation, discharge; testes normal size for age, without
mass or tenderness; Tanner stage______________
problem: - painful scrotum/testes: consider torsion, trauma, infection, hernia
- testicular mass: consider tumor (testicular cancer is most common between 15 & 35 years)
- penile discharge or lesion: consider STD - STD's: herpes, condyloma (human papilloma virus), GC, chlamydia,
syphilis, HIV, trichomonas - delayed puberty: consider endocrine or genetic disorder

MS: normal findings. normal gait and posture without scoliosis or kyphosis; full range of motion of all joints and muscles with good
strength (grade 5/5); good rib excursion b/l; negative standing and seated flexion and stork tests; negative Fabere
and straight leg raising tests; no somatic dysfunction or muscle or joint pain/swelling/redness noted
minor problems: - idiopathic scoliosis: a minor curve may worsen during a growth spurt
- patellofemoral pain syndrome: painful knees usually in active adolescents from a variety of causes including
chondromalacia, patellar tracking disorders, etc.
- Osgood-Schlatter's disorder: apophysitis of tibial tubercle
- somatic dysfunction: findings of asymmetry, pain, motion limitation, or abnormal end point feel
major problems: - juvenile rheumatoid arthritis
- osteomyelitis or septic joint: consider with painful area & sx of infection/inflammation
- limp: consider trauma, osteomyelitis or septic joint, juvenile rheumatoid arthritis, slipped femoral capital epiphysis
- slipped femoral capital epiphysis: shift of the growth plate at this location; requires pinning
Pediatric History and Physical Examination

Adolescent PE (con't):

Neuro: normal findings: CN 2-12 grossly intact; DTR 2/4 & equal bilaterally (biceps, brachioradialis, triceps, patellar,
ankle); Babinski down bilaterally; sensory dermatomes intact (to light touch, sharp & dull) without
deficit; motor function intact with good tone & strength (grade 5/5); cerebellar function intact (to
rapidly alternating pronation and suppination; finger to nose movement; opposition of fingers;
running heel down shin of opposite leg; normal gait and stance and coordination); no ankle clonus
or tremors noted, Rhomberg negative; speech fluent; affect is normal; appears content
problems: - ataxia: consider brain tumor, substance abuse
- meningitis: lethargic or irritable adolescent usually with fever and nuchal rigidity
- seizures: consider generalized or focal tonic-clonic seizures, absence seizures (frequent blank
stares, often associated with poor school performance), complex partial (impaired level of
consciousness with altered behavior and automatisms), myoclonic seizure; consider neurological,
infectious, toxin/drug/substance abuse, or metabolic causes