Pediatric Assessment

Name of Patient: ________.____Date of Birth: ____________Sex: _______

I.
Prenatal History (of mother)
Maternal Age
_______ Obstetric Score G_ T _P _ A _ L _ M _
Prenatal Check-up:
_ Regular
__Irregular
__ none
Done by:
_ Obstetrician
_ Nurse
__ Hilot
Place:
Hospital
__ Clinic
__ RHU
Maternal Illness:
__ None
__ Fever
__ Rash
__ GDM
__ Asthma
__ Rash
__ UTI
__ TB
__ Hepatitis
__ Allergy
__ Hyperemesis
__ PIH
Medications (mother) ____Multivitamins___________________

__ Home

II. Natal History

Date of Birth _________
Birth Rank __
Apgar score __
Place of Delivery
__ Hospital
__ Home
__ Lying-in
Attendant
__ Midwife
__ Hilot
__Others (Doctor)
Gestation
__ Full term
__ Preterm
__ Post term
Mode of Delivery
__NSVD
__Forceps
__ C/S (indication C.P.D)
Presenting Part
__ Cephalic __ Face
__ Breech
__ Transverse
Medications

__Eye Prophylaxis

III. Post-Natal History

Feeding
__ Breast milk
Medical Problems
__None
__Sepsis
__ Seizure
IV. Immunizations

__ Vit. K

__ Hep. B

__Milk Formula
__ Respiratory
__ Jaundice

__Mixed
__ Cyanosis

__ No _ Yes at: __Center

1st
dose

BCG
DPT
OPV
HiB

Hep B
Pneumococcal
Rotavirus
Flu
Varicella

AMV
MMR
Others:
Typhoid
Hep. A
Meningococcal
HPV

2nd
dose

3rd
dose

_ Private

1st booster 2nd

booster

__ both
None

V. Feeding History
0 6 months
__ Breastfeed
__ Milk formula
__Mixed
6 12 months
__ Breastfeed
__Milk formula
__ Mixed
Age semisolid started
___________ Type ________
Food preference:
________________ Allergies _______
Food dislikes:
________ __ _____
Vitamin Supplements:
Type ______ ___
When started ______ __
Amount _______
Duration ___ ________
VI. Past Medical / Surgical History
_ Unremarkable
__ Remarkable
If Remarkable: ______________________
Date
Diagnosis
N/A
N/A
Hospitalization (including operation)
Date
Hospital
N/A
N/A

VII. Family History

__ No significant FH

Intervention
N/A
Diagnosis
N/A

__ Significant FH

__ HPN
__ Diabetes __Asthma
__ Blood Disorder
__ Kidney Disease
__ Allergy
__ Cancer
__TB
__ Stroke
__ Seizure
__ Mental Disorder
Others: ____________________________

__ Heart Disease

VIII. Growth and Development

First raised head __ Rolled Over __
Sat Alone __
Pulled up
__
Walked with help __
Walked alone __
Talked __
Urinary continence:
Day __
Night __
Control of Feces __
Comparison of development with that of other siblings __
School Grade __
Quality of Work __
IX. Behavioral History
A. Does the child manifest behavior like thumb sucking __
Masturbation __
Temper tantrums __
Negativism __
B. Does the child have sleep disturbances? __ Yes
__ No
C. Phobias __
D. Pica (ingestion of substances other than foods) __
E. Abnormal bowel habits (stool holding) __

F. Bedwetting __
X. Review of Systems
A. Skin:
Texture: ____
Color: ____
B. Eyes: _ Have the childs eyes ever been cross eyed?
_ Any foreign body?
_ Any infection?
C. Ears / Nose and Throat:
__ Frequent colds
__ Sore throat
__ Sneezing
__ Stuffy nose
__ Discharges
__ Post-nasal drip
__ Mouth breathing
__ Snoring
__ Otitis Media
__ Hearing Problem
D. Teeth:
Age of eruption of deciduous teeth ___
Age of eruption of permanent teeth ___
E. Cardio-respiratory:
__ Dyspnea
__ Chest pain
__ Cough
__ Sputum
__ Wheeze
__ Expectoration
__ Wheeze
__ Expectoration
__Cyanosis
__ Edema
__ Syncope
__Tachycardia
F. Gastrointestinal:
__ Vomiting
__ Diarrhea
__ Constipation
__ Abdominal pain / discomfort
__ Jaundice
Type of stools: _____________
G. Genitourinary:
__ Enuresis
__ Dysuria
__ Frequency
__ Polyuria
__ Pyuria
__ Hematuria
__ Vaginal Discharge
__ Abnormal penis / testes
Character of stream (urine): ____
Bladder control: ___
H. Neuromuscular:
__ Headache
__ Nervousness
__ Dizziness
__ Tingling Sensation
__ Convulsions
__ Spasm
__ Ataxia
__ Muscle or joint tolerance
__ Postural Deformities
__ Exercise tolerance
I. Endocrine
__ Disturbance of Growth
__ Excessive fluid intake
__ Polyphagia
__ Goiter
J. General
__ Unusual weight loss
__ fatigue
__ Temperature sensitivity
XI. Chief Complaints (History of Present Illness)

Pediatric Physical Examination

1. Vital Signs
BP: ______
Wt: ____

HR: _____
Ht: _____

RR: _____

Temp: _____

__ Icteric

__ Flushed

2. General observation:
3. Skin
Color: _ Normal
__ Cyanotic __ Pale
Texture: _ Normal
__ Dry
__ Oily
Turgor: _ Good
__ Poor
Lesions: _ None
__ Rashes
__ Burns
__ Punctured Wound
__ Scars
Comments: _________________

__ Abrasions
__ Decubitus

__ Ashen

__ Lacerations

4. Head / Ears / Neck / Throat

Head circumference: ____ ( up to 2 years & if significant)
Shape: _ Round
Scalp: _ Normal

__ Ovoid
__ Pustule

__ Irregular
__ Seborrhea

Fontanels:
Anterior: __ Close
Posterior: __ Close

__ Open
__ Open

__ Flat
__ Flat

5. Eyes
Eyelids
Normal
Laceration
Inflamed
Mass
Puffy
Drooping
Sclerae
Normal
Icteric
Red
Discharges

none

none

__ Scales
__ Sunken
__ Sunken

Eyeballs
Normal
Sunken
Bulging
Pupils
Reactive
Unreactive
Equal
Unequal
Vision
Normal
Blurred
Contact Lens
With
Correctional
glasses

__ Lice

__ Bulging
__ Bulging

Not assessed

Not assessed

6. Ears
Pinna

Normal
Anomalies
Symmetrical
Tympanic
Membrane
Intact
Perforated
Discharge

Mastoid
Tenderness
Swelling

Normal

Normal

External
Canal
No Problem
Discharge
Pain
Hearing

Normal
Not assessed
Deaf
With hearing
aid

Comments: ____________________
7. Nose / Neck / Thyroid
Nares
No Problem
Nasal Flaring
Discharge
Epistaxis
Turbinates
Normal
Inflamed / congested
Neck
Normal
Torticollis
Opistothonus
Inability to support head
Lymph Nodes
Swelling
Tender
Sternocleidomastoid
Swelling
Shortening
Thyroid
Size
Contour
Bruits
Nodules
Tenderness
Enlarged
Not Appreciated

Not assessed

8. Mouth / Throat
Lips:
__ Moist

_ Pink
__ Red
__ Pale
__ Cyanotic __ Dry
__ Swelling __ Thin
__ Down turning
__ Fissures __ Cleft
Teeth:
__ Temporary
__ Permanent
__ No teeth
__ No Problem
__ Braces
__ Mottling
__ Discoloration
__ Notching
__ Malocclusion / malalignment
Gums:
__ Normal
__ Inflamed
__ Number
Tongue:
__ Pink
__ Coated
__ Furrows __ Strawberry red
Mucosa:
__ Normal
__ Thrush
__ Discharge __ Ulcers
__ Bleeding
Tonsils:
__ Normal
__ Inflamed
__ Exudates
Smell:
__ Normal
__ Foul
__Not assessed
Voice:
__ Hoarseness
__ Stridor
__ Grunting
Type of Cry: ________
Type of Speech: ________________
Comments: __________________________
9. Respiratory / Thorax
Upper Airways:

__ Normal __ Stridor

__ Hoarseness __ Drooling of Secretions

Chest / Upper Trunk:

__ Normal
__ Kyphosis
__ Scoliosis
__ Scars
__ Abrasions
__ Rash
Expansion:
__ Equal
__ Unequal
Retractions: __ Absent
__ Present

__ Mass

Lungs:
_ Normal
__ Tenderness
__ Crepitations
_ Resonant
__ Tympanic
__ Dullness __ Flatness
__ Clear Breath Sounds
_Rales
__ Ronchi
__ Wheeze
Breast:
_ Normal for age
__ Symmetrical
__ Assymetrical
__ Lumps / masses
Comments:_______________________
10. Cardiovascular
Apical impulse:
Location: ________________________________
__ Precordial Bulging
__ Heaves
Pulse:
__ Strong
__ Regular
__ Weak
__ Irregular
Heart Sound: _ Normal
__ Splitting
__ Murmurs
Rate:
_ Regular
__ Irregular
_ Normal
__ Bradycardia
__ Tachycardia
Capillary Refill Time: ________
Comments: __________________________

11. Gastrointestinal
Abdomen:
Inspection:
__ Flat
__ Scaphoid
__ Distended
__ Globular
Tympanic
__ Dull
__ Fluid wave
Palpation
__ Normal
__ Splenomegaly
__ Mass
Tenderness: Location: _________
__ Direct
__ Indirect
Bowel Sounds:

__ Normal

__ Hyperactive

Percussion:

__ Hypoactive

Rectal Exam: ______

Comments: ___________________
13. Neurologic
A.
Pediatric Glasgow Coma Scale (Teasdale and Bennett)
Eye Opening
Open eyes spontaneously
Opens eyes in response to speech
Opens eyes in response to painful stimuli
Does not open eyes
Verbal Response
Smiles, oriented to sound, follow object, interacts
Confused, consolable crying, inappropriate actions
Inappropriate, persistently irritable, vocal sound, moaning
Incomprehensible, restless, agitated, cries
No verbal response
Motor Response
Obeys, infant moves spontaneously or purposefully
Localizes pain, oriented, follow infant withdraws from touch
Infant withdraws from pain, consolable crying, interact

6
5
4

Abnormal flexion to pain in infants (decorticate response), inconsistently consolable crying

Score
4
3
2
1
5
4
3
2
1

Extension to pain (decerebrate response), inconsolable, irritable, restless

2
No motor response
1
Aggregate Score (Normal)
0-6 months = 9
6-12 months = 11
(E4 V2 M3)
(E4 V3 M3)
1-2 years = 12 (E4 V4 M4)
2-5 years = 13
5 years = 14
(E4 V4 M5)
(E4 V5 M5)
B. Mental Status:
__ Awake

__ Conscious

__ Drowsy

__ Stupurous

__ Coma

__ Oriented

__ Disoriented

__

C. Cranial Nerves
CN I (Olfactory)
__ Intact
__ Anosmia
__ Hyperosmia
_ Not Done
CN II (Optic)
__ Intact
__ Blindess
__ Scotoma
_ Not Done
CN III, IV, XI (Occulomotor, Trochlear. Abducens)
Pupils:
_ Reactive
__ Non-reactive
_ Equal
__ Non-equal
ROM:
_ Full ROM __ Palsy
__ Ptosis
CN V (Trigeminal) __ Trismus
__ Paresthesia
_ Intact
Corneal Reflex
_ Present
__ absent
__ Right
__ Left
CN VII (Facial)
Facial Symmetry:
_ Symmetric
__ Asymmetric
Tongue (sensory)
_ Intact
__ Absent
Facial Muscle
_ Strong
__ Weak
CN VIII (Vestibulo-cochlear) Hearing:
_ Normal
__ Deafness
Balance:
_ Normal
__ Disequilibrium
CN IX, X (Glossopharyngeal) Gag Reflex: _ Present
__ Absent
__ Able to swallow __ Not done
CN XI (Spinal accessory) Shrug Shoulder: __ Able
__ Not Able
_ Not done
CN XII (Hypoglossal)
Tongue at rest: _ midline
__ Deviated __ R __ L
Protrusion:
__ Midline
__ Deviated __ R __ L
D. Cerebellar
FTNT:
APST:
__ Ataxia
Rombergs:

_ Well-coordinated
__ Not-coordinated
_ Well coordinated
__ Not-coordinated
__ Nystagmus
__ Positive
__ Negative

__ Not done
__ Not done
_ Not done

E. Sensory
Light Touch _ Intact
Pain
_ Intact
Temperature _ Intact

__ Absent
__ Absent
__ Absent

__ Not done
__ Not done
__ Not done

F. Motor
Upper Extremity
Proximal
Distal
Lower Extremity
Proximal
Distal

5
5

5
5

5
5

5
5

Manual Scoring
5 Normal
4 can raise against slight resistance
3 can raise against gravity
2 gross movements but not against gravity
1 flicker movements
0 No movements

14. Reflexes
Deep Tendon Reflex: _
Deep Tendon Reflexes
+ 4 = Very brisk, hyperactive
+ 3 = Brisker than average
+ 2 = Average; normal
+1 = Somewhat diminished
0 = No Response
< (-) Babinski
>(+) Babinski
Meningeal Signs:

_ None__ Nuchal Rigidity

__ Kernigs

__ Brudzinkis

Primitive Reflex:
Present
Moro
Rooting
Sucking
Grasp

Absent
_
_
_
_

__
__
__
__

Present
Tonic Neck
Babinski
Ankle Clonus

Absent
__
__
__

_
__
_

15. Musculoskeletal
_ Normal

__ Fractures

__ Deformities

Comments: _____________________________

__ Tenderness

__ Swelling