(3F) Pediatrics Pediatric History Dr.

Corazon Lopez

HISTORY TAKING
March 4 & 10, 2014
The mark of an excellent physician is the proficiency with which he takes the
history and performs the physical examination and then on the basis of the findings
utilizes the laboratory accurately and cost effectively, when necessary, to approach
a final diagnosis and initiate effective therapy
HISTORY TAKING

Unique and distinctive for the following reasons:

1. Content variations
a. Prenatal and birth history
b. Developmental history
c. Social history of family environmental risks
d. Immunization history
e. Feeding history
2. Indirect source of clinical information commonly given by parents
a. Parents interpretation of clinical features may affect accuracy of
data

Malaria convulsions

Measles rash
b. Reliability of parents vary
c. Parental behaviors/emotions are important
BASIC COMPONENTS OF A GOOD CLINICAL HISTORY

Start interview with parents or guardians on a positive note: first contact

is the most important connection

Be flexible in your approach to obtain clinical data

Pursue the symptoms relentlessly

Keep on track

Pursue the clinical features that enable the parents to reach conclusions

Keep an open mind and follow the clue

HISTORY
I.
GENERAL DATA

Name, age; sex; classification; race (ethnicity); religion; birth date; birth
place; present address; number and date of hospital admission.

Name of the informant and relation to the patient; reliability of informant

(%)
o
Reliability of informant depends on the following factors:
1. Relationship with the patient
2. Number of hours stay with the patient
3. Educational attainment
4. Involvement with the care of the patient

III.
A.

B.

Why was the patient brought to the hospital

Expressed in a word or two
Single symptom or a group of related symptoms
Duration of symptom
Not diagnostic terms or names of diseases
For OPD patients: follow-up, CP clearance, well- baby care, immunization
Give the exact words of the informant whenever possible*
HISTORY OF PRESENT ILLNESS
Signs and symptoms should be described in chronological order, from the
start of the illness
o
Use specific number of hours or days or weeks or months prior to
admission
o
Not last Monday or a few weeks ago
o
Chronic illnesses: state also the date and age at onset
o
If the patient is a newborn and or the present problems
are related to the prenatal and perinatal, the maternal and
birth history should be incorporated in the HPI.
Elaborate on the symptoms as to:
1. Onset (acute or chronic)
2. Intensity of symptoms: interference with activity, quality, location,
duration extent, severity and frequency
3.
Factors that aggravate or relieve the main symptoms
4. Medications (generic and brand names): ):* actual dose
(mg/kg/day or mg/kg/dose), duration of treatment; brand names
should be written in parenthesis

Include any outside medical treatment, consultations or

hospitalization

Find out medical care prior to the visit and the reason for
change
5. Associated symptoms described as to: onset, course, chronology,
intensity

If the history suggests a particular disease, inquire about

signs and symptoms characteristic of the disease.

Pertinent negatives are of value in the differential

diagnosis

Other symptoms*

Re-admissions: if previously admitted to this hospital or

had Out Patient Department consultations, obtain these
records from the hospital and summarize

Records of any admission to other hospitals should also

be obtained and summarized

If previous hospital admissions appear related to the HPI,

summarize the pertinent information (pertinent
laboratory date, final diagnosis)

II.

CHIEF COMPLAINT

Following this comes the Interval History which

describes the course of illness since the last hospital
admissions related to the present illness and then
elaborate the present symptoms and its associated
manifestations on this admission

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

IV.
A.

B.

C.

These will now constitute the HPI

Previous admissions not related to the HPI are placed
under Past Illnesses
If the previous admissions are related to the
present illness, these should be written in the first
paragraph of the HPI
Based on the HPI, the physician should already have an
initial impression and differential diagnosis

PERSONAL HISTORY
GESTATIONAL HISTORY (PRENATAL HISTORY)
Age of the mother during pregnancy, her parity, health, nutrition,
infections, intake of drugs, roentgen exposures, etc; duration of gestation
(when pertinent, especially in infants)
BIRTH (NATAL)
AOG: Term/premature/postmature
Hours of labor
Manner of delivery; NSD, LCCS (indication)
Bag of waters
Persons who attended the delivery
Birth weight
APGAR score

NEONATAL HISTORY
Jaundice (age of onset); convulsions; hemorrhage; respiratory or feeding
difficulties, congenital abnormalities, birth injury (especially in infants or
when pertinent); blood type
The gestational birth and neonatal histories should be included
only in patients <2 y/o and if related to the illness of children >
2y/o

D. FEEDING HISTORY
INFANCY (<2 YEARS OLD)
1. Type of feeding: breastfeeding, exclusive or mixed; how many times
per day; how long each breast; if not breastfeeding, give reason;
formula used, dilution and amount given per day, bottle feeding or cup
feeding
2. Complementary foods: age introduced*; consistency of food
(pureed, soft, lumpy, table foods); frequency of feeding per day

3.

4.

5.
6.
7.

Sample diet*: breakfast, lunch, dinner, snacks (am, pm)

Assess if the 5 basic food groups (cereals/rice, fruits, vegetables,

meat/fish/chicken, beans/egg, milk, oil/sugar) are eaten daily
Compute for acute caloric intake (ACI) compare with Recommended
Energy & Nutrient Intake (RENI) or compare both the amount and
quality of food intake with the food guide pyramid*
Food intolerance
Multivitamins and iron supplements: dosage, frequency
Caregiver: mother, household help, grandparents, siblings

CHILDHOOD AND ADOLESCENTS (2-20 yrs): omit early feeding history

unless pertinent to the present illness
Assess:
1. Appetite: good, picky eater
2. Sample diet: breakfast, lunch, dinner, snacks (am, pm)
3. Assess if 5 basic food groups are eaten daily
4. Compute for ACI and compare with RENI or compare both the amount
and quality of food intake with the food guide pyramid
5. Food likes or dislikes; feeding difficulties
6. Multivitamins & iron supplements: dosage & frequency
E. GROWTH AND DEVELOPMENTAL
YOUNG CHILDREN (1-5 YRS)
1. Development using the Modified Developmental Checklist: motor;
adaptive/personal; language; social.
2. Dental eruption
3. Other behavioral problems: urinary continence, during day and night;
toilet training, started and completed; temper tantrums; head banging;
phobias; pica; night terrors; sleep disturbances

If there are indications of developmental delay, do a

Denver Developmental Screening Test II (DDST II)
MIDDLE CHILDHOOD (6-11 YRS)

Inquire about school performance and sexual development using Tanners

Maturity Rating
ADOLESCENCE (10-20 YRS)

Inquire about: HEADSSS: home, education, eating behavior or habits,

activities, drugs, sexual, suicidal ideations

Sexual development using TMR; females: include menstrual history

F.

2.
3.
4.

PAST ILLNESSES
Age when contracted; severity; complications
1. Contagious diseases: measles, varicella, mumps, pertussis, etc.

Describe the clinical course of the illness

Other medical illnesses: hospitalized?: where and for how long
Operations: surgical condition, type and place of operation

History
Allergy, eczema, asthma, food or drug sensitivities, etc.

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

5.

V.

Injuries: include effects if any (verify accuracy of diagnosis by inquiring into

signs, symptoms, course of illness)

IMMUNIZATON HISTORY AND TUBERCULIN TEST

Types of immunizations given, including ages when given, place (heath
center, doctors clinic) where given and untoward reactions
Tabulate

VI.

VII.

VIII.

FAMILY HISTORY
Parents: state of physical and mental health; if not living age of death,
cause and nature of symptoms, history of consanguinity
Siblings: number, ages, state of health; if not living age of death and
cause
Familial illness or anomalies: TB (state contact with patient); DM, syphyllis,
Ca, epilepsy, RF, allergy, hematologic disorders, MR, congenital defects, etc
Presence of illness similar to patients illness in other members of the
family or household
Family pedigree - if a genetic anomaly is suspected
SOCIOECONOMIC AND ENVIRONMENTAL HISTORY
Parents: age, occupation, educational attainment
Living circumstances: place and nature of dwelling, number of persons
living in the house
Economic circumstances: members of the family who work , source of
funds
Environmental circumstances: exposure to cigarette smoke and other
environmental pollutants (include what pollutants and the duration of
exposure)
Garbage disposal (segregation, recycling)
Sewage disposal
Water source: drinking, washing
REVIEW OF SYSTEMS:
Elaboration of data in systems not covered in the HPI. This will help uncover
symptoms in other organs or systems that may be related to the present
illness
Ask only symptoms applicable to the age of the patient
General: weight loss/gain; activity level, delay in growth
Cutaneous: rash; pigmentation; hair loss; acne; pruritus
Head: (include eyes, ears, nose, mouth, throat); headache; dizziness, visual
difficulties, lacrimation; hearing; aural discharge; otalgia; nasal discharge;
epistaxis; toothache; salivation; sorethroat
Cardiovascular: orthopnea, cyanosis, easy fatigability; fainting spells
Respiratory: chest pain; cough; difficulty of breathing

Gastrointestinal: vomiting, bowel movements diarrhea, constipation;

encopresis; passage of worms; abdominal pain; jaundice; food intolerance;
pica
Genitourinary: color of urine; burning sensation; frequency; discharge;
enuresis; swelling of hands and feet; in prepubertal female: ask about
discharge and itching; in pubertal and adolescent female get history of
menstrual periods (onset, frequency, regularity, pain), date of last period
Endocrine: breast asymmetry, pain or discharge; palpitations; cold/heat
intolerance; polyuria, polydipsia, polyphagia
Nervous/Behavioral: tremors, sleep problems; convulsions; weakness or
paralysis; mental deterioration; personality or behavioral changes; memory
loss; eating problems, school failures; mood changes; temper outbursts;
hallucinations
Musculoskeletal: pain in bone, joint or muscle; swelling in bone, joint or
muscle; limitation of motion; stiffness, limping
Hematopoietic: pallor; bleeding manifestations; easy bruisability

PHYSICAL EXAMINATION

Playful interaction and distraction

Minimum clothing

Can be carried by their caretaker or parent

Uncooperative patients: properly immobilized*

More unpleasant or uncomfortable parts of the PE are done last

I.

GENERAL SURVEY

Mental state of sensorium, level of activity

Presence of cardiopulmonary distress

Ambulatory or bedridden

Nutritional state (well, under or over nourished)

State of hydration

Ill looking

Refer to Table 1 Acute Illness Observational scale

Quality of
Cry

Reaction to
Parental
Stimulation
State
Variation

1
Strong cry with normal
tone
Contented and not
crying
Cries briefly and then
stops
Contented and not
crying
If awake, stays awake
If asleep and then
stimulated, awakens
quickly

Color

Pink

Hydration

Normal skin and eyes

2
Whimpering or
Sobbing

3
Weak cry, moaning,
or high pitched cry

Cries off and on

Cries continually or
hardly responds

Closes eyes briefly

when awake
Awakens with
prolonged
stimulation
Pale extremities or
Acrocyanosis
Normal skin and

Falls asleep or will

not arouse

Pale, cyanotic,
mottled or ashen
Doughy or tented

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

Response
(Talk, smile)
to Social
Overtures,
Over 2
months

II.

Moist mucous
membranes

eyes
Slightly dry mouth

Smiles
Alerts

Smiles briefly or
alerts briefly

skin
Dry mucous
membranes
Sunken eyes
No smile, anxious
face, dull expression
or does not alert

VITAL SIGNS

Temperature (C)

Oral T should not be taken in children who are too young or unable
to understand instructions; Axillary T are safer: O.5 degrees lower
than oral

Aural or rectal T can also be obtained

Never insert rectal thermometer into an infant who can sit on his
own

Cardiac rate (CR)/pulse rate (PR)

Respiratory rate (RR)

CR and RR should be correlated to the condition in which they

were taken to be considered clinically significant ( quiet, asleep,
active, crying, struggling; one full minute

Blood pressure (BP) if >3 y/o

Pediatric Blood Pressure (BP) Monitoring:

BP cuff should completely encircle the arm

Inflatable bladder should cover at least 2/3 of the upper arm

length and 80-100% of its circumference

A more accurate cuff size is one whose inflatable bladder width is

40% of the arm circumference midway between the olecranon and
the acromion
Age
Heart rate
Blood pressure
Respiratory rate
(bpm)
(mmHg)
(bpm)
Premature
120-170
55-75/35-45
40-70
0-3 months
100-150
65-85/45-55
35-55
3-6 months
90-120
70-90/50-65
30-45
6-12
80-120
80-100/55-65
25-40
months
1-3 years
70-110
90-105/55-70
20-30
3-6 years
65-110
95-110/60-75
20-25
6-12 years
60-95
100-120/60-75
14-22
12 years
55-85
110-135/65-85
12-18

III.
ANTHROPOMETRIC DATA
3 MAJOR GROWTH PARAMETERS
1. Weight (wt) Kg: infant weighing scale: <2y/o
2. Length (Lt) (for children <2y/o) or Height (Ht) (for children >2y/o) in cm

Length: 2 observers, supine, record to the nearest 0.1 cm

Height: upright, buttocks and heels or head are in contact with the
vertical board, record to the nearest 0.1 cm

3.

Head Circumference (HC)

(<3y/o) in cm: supraorbital ridge to occipital prominence

OTHER MEASUREMENTS FOR SPECIAL CIRCUMSTANCES

1. Chest circumference

(CC) in cm

Mid-inspiration

Xiphoid notch
2. Abdominal circumference

(AC) in cm

Infants: supine, across the umbilicus

Older children: upright, feet 25-30 cm apart, midway between the

inferior margin of the last rib and the crest of the ilium

Nearest 0.1 cm at the end of normal expiration

3. Arm span and U/L ratio for children with growth disorders

Tip of the right to the tip of the left middle finger

LOWER (L) SEGMENT OF THE BODY
0-3 years
Supine
>3 years

Standing

From umbilicus to tip of toes with feet flexed 90

degrees at heel
From anterior superior iliac spine to the floor

UPPER (U) SEGMENT

Length or height lower segment

Normal values for U/L ratio

o
At birth: 1.7
o
1 month-3 years: 1.3

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

o
>3 years old: 1.0
*With data on weight and length or height, calculate for the body mass index (BMI)

BMI = weight in kgs / height in m2

Wt, Lt, BMI, HC should be plotted on the WHO growth chart

Lt or Ht for age: identify children who are stunted or short due to

chronic malnutrition or repeated illness or those who are tall for age
due to genetic or endocrine problems

Plot as precisely as possible

Wt for age: reflects body weight relative to the age on a given day
and is used to assess whether a child is underweight or severely
underweight
o
Not used to classify a child as overweight or obese
o
a child can be underweight due to short Lt /Ht or thinness or both
o
Presence of edema: severely undernourished
o
Plot to nearest 0.1

Weight for Lt or Ht: reflects body wt in proportion to attained

growth in Lt or Ht
o
Especially useful if age is unknown
o
Low: wasted or severely wasted due to recent illness
o
High: risk of becoming overweight or obese

BMI for age: useful in screening for overweight or obesity

o
Similar results with Wt for Lt or Ht
o
Plot to nearest decimal
IV.
SKIN

Color, tissue turgor (wrinkling or loss of elasticity), loss of subcutaneous

tissue, rash or eruptions, hemorrhages, scars, edema, jaundice
V.

HEENT

HEAD: hair (quantity, color, texture, strength, surface characteristics);

shape or contour, scalp, fontanels, sutures, Auscultate the skull for bruits to
detect AV
malformation; (normal in <4 y/o with fever); face: unusual facies,
deformities, lumps and bumps

EYES: lids, conjunctivae, sclerae,, opacities, discharge, red orange reflex,

periorbital edema, eyeballs (sunken or not), tears

EARS AND MASTOIDS: size, shape, location and position of the ear in
relation to the rest of the head, ear discharge, tympanic membrane, ear
canal

Newborns and infants: upward

Older children: forward and downward

Tympanic membrane: continuity (intact or perforated); color ( light

pink or transluscent); cone of light, bulging or concave; presence
of effusions or bubbles, mobility

NOSE AND PARANASAL SINUSES: patency of nares, alar flaring, presence

and character of discharge, position of septum, sinus tenderness (press
below both eyebrows and on both maxillary areas)

MOUTH AND THROAT: lips, gums, tongue, mucous membranes, dentition,

palate, posterior pharyngeal wall

NECK:

Lips: color (pale, cyanotic, cherry red), moisture or dryness,

excoriations cleft
Throat exam: use a bright light; patient says Aaahh
Gums: color, continuity (ulcers, vesicles), bleeding
Physical Examination
Tongue: size, moisture, color, milky white coatings, geographic
tongue, ankyloglossia (tongue-tie), ulcers
Oropharyngeal mucosa: thrush, vesicles, ulcers, enanthems
Palate and uvula area: symmetry, cleft, high arched
Posterior pharyngeal area: post nasal drippings
Dentition: 20 milk teeth at 24 months of age, color, mottling,
pitting of enamel (fluorosis), dental caries
Note for excessive drooling: not usual after 18 months of age
Tonsils: presence or absence, size, surface, color, exudates,
adherent membrane
Color of oral mucosa: pinkish-red; compare with color of tonsils
venous engorgement, flexibility, rigidity, masses, lymph nodes
Swelling: diphtheria, subcutaneous emphysema, webbing, obesity
Position: torticollis, opisthotonus
Masses: location, size, rate of growth, shape, margin, surface,
consistency, color, warmth, pulsation, adhesion to surrounding
structures; goiter

VI. CHEST AND LUNGS

A. Inspection

Size and shape: round/barrel, shield shape, pectus excavatum, pigeon

chest, rachitic rosary, harrisons groove
o
Infancy: AP diameter = transverse diameter
o
After 2 yrs.: transverse>AP diameter

Movements with respirations

o
Newborns and young infants: abdominal
o
After 4-5 yrs of age: intercostal

Chest retractions: subcostal, intercostals, supraclavicular

Chest Expansion: symmetry

B. Palpation

Vocal Fremitus: tres, tres, ninety nine; increased (consolidation) or

decreased (atelectasis, pneumothorax, pleural effusion)
C. Percussion

Direct: with one finger over the chest wall (small infants)

Indirect: middle finger (pleximeter) of the left hand is placed firmly on the
chest wall. Index or middle finger of the pleximeter is then struck with the
tip of the middle finger (plexor) of the right or dominant hand

Tap from side to side, top to bottom symmetrically

D. Auscultation

Stethoscope on a bare skin

Warm the chest piece; auscultate symmetrically from top to bottom, side to
side; compare

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

VII.

Clear breath sounds, rales, wheezes, rhonchi, bronchial or tubular breath

sounds, pleural friction rub, stridor, grunting
Normal breath sounds:
1. Bronchial: midline
2. Vesicular: over the chest, axilla, infrascapular area
3. Bronchovesicular: infants with thin walls
Abnormal or adventitious sounds
Altered voice sounds in lobar pneumonia:
o
Bronchophony: spoken words are louder and clearer when normally,
they are muffled and indistinct
o
Egophony: spoken ee is heard as ay
o
Whispered pectoriloquy: whispered words are heard louder and clearer
when normally they are faint and indistinct or not heard at all

HEART AND VASCULAR SYSTEM

Precordium, visible pulsations, apex beat, thrills, heart sounds, pulses

A. Inspection

Precordium: adynamic or dynamic

Visible pulsations on the chest and in the epigastrium

Apex beat: 4th ICS, LMCL until 7 y/o then shifts to the 5th ICS
B. Palpation

Thrills: purring vibratory sensations felt by the palm

Substernal thrust: presence of right ventricular volume or pressure

overload

Character of pulses
C. Auscultation

Diaphragm for high pitched sounds; bell for low pitched sounds

1st hear sound (s1) : closure of av valves (tricuspid and mitral); best heard
at the apex

2nd heart sound (s2): closure of semilunar valves (aortic and pulmonic); best
heard at the left and right sternal borders; split on inspiration

3rd heart sound (s3): gallop; best heard at the apex in mid-diastole, heart
failure

Murmurs: described according to TILT: timing (systole,diastole), intensity,

location, transmission

Grading of murmurs:
I.
Barely audible
II.
Medium intensity
III.
Loud but no thrill
IV.
Louder with thrill
V.
Loud & audible with stethoscope barely on the chest
VI.
Audible with the stethoscope off the chest

VIII.

A.

ABDOMEN
9 or 4 quadrants
Inspection

Size & shape: scaphoid, flat, globular, protruberant, distended

Prominent vessels: distended veins; pulsations
Striae, peristaltic movements, umbilical hernia
Movements in relation to respiration: paradoxical breathing

B.

Auscultation
Done prior to palpation and percussion
Listening to one spot is usually sufficient
Bowel sounds: gurgling in nature; occur episodically at 5-10 seconds
intervals or longer (10-30 secs in infants & younger); 5-34/min
Borborygmi: prolonged gurgles of hyperperistalsis
If absent , auscultate for at least 1-2 mins.
High pitched & increased in lbm and obstruction; absent in ileus; distant in
ascites and peritonitis

C.

D.

IX.

Percussion
Normally tympanitic
Detect presence of fluid in the peritoneal cavity: fluid wave and shifting
dullness
Determine the size of the liver: RMCL
Palpation
Patient lie supine with both lower extremities semi-flexed at the knees and
hips
Ask patient to inhale slowly and deeply
Use flat surface of the fingers
Palpate away from the site of pain proceeding gently to the painful area
o
Direct tenderness: pain is elicited on pressure
o
Rebound tenderness: pain is felt or is greater on release of fingers;
indicative of peritoneal irritation
Spleen: not palpable unless 2-3 x its size; shorts maneuver; castells
method
Psoas sign; obturator sign
Kidneys: best felt on deep inspiration; fixed
o
Costovertebral angle (CVA) tenderness: done only in older children
and adolescents; heel of a closed fist (ulnar side) strikes firmly on the
CVA (angle between the 12th rib and transverse process of the upper
lumbar vertebrae; place palm one hand on the CVA

INGUINAL REGIONS

Hydrocoele, undescended testes, lymph nodes

Fluctuation in size in relation to coughing and crying; spontaneously resolve

or not

Indirect inguinal hernia: the most common cause of swelling in the inguinal
area extending to the scrotum; males

Lymph nodes

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

X.

GENITALIA

Male
o
Prepuce should be easily retractable
o
Phimosis: preputial sac is very narrow and cannot be retracted
o
Urethra opens at the tip of the penis
o
Hypospadia - meatus located under surface of urethra
o
Epispadia - urethral orifice is on the dorsal surface of the penis
o
Left scrotum lower than the right but equal in size
o
Cryptorchidism, hydrocoele, hernia

XI.

XII.

Female
o
Gynecological exam: discharge, laceration, hymen
o
Sexual maturity testing

ANUS AND RECTUM

Left lateral decubitus with legs flexed against the abdomen

Look for location, patency, fissures, tags, hemorrhoids, presence of

pinworms, prolapse

Rectal exam: index finger in older children; little finger in young infants
o
Assess sphincteric tone, presence of mass or impacted feces and
tenderness
EXTREMITIES
Color of nail beds, peripheral pulses
Cyanosis, edema, mobility of joints, deformities, test for congenital hip
dislocation (neonates)

Clubbing: look from the side in profile; schamroths sign

Lymph nodes

XIII. SPINE

Inspect for deformities, sacrococcygeal dimple, pilonidal sinus and local

tenderness

Screen for scoliosis: bend forward test

XIV.

LYMPH NODES:*
Check size, number, location, consistency, tenderness, mobility, discrete,
matted

Most not palpable in the newborn

Not considered enlarged unless they exceed 1 cm for cervical and axillary
nodes and > 1.5 cm for inguinal nodes

Generalized lymphadenopathy: enlargement of >2 noncontiguous node

regions
o
Acute bacterial infection: tender, erythema and warmth of the
overlying skin

o
o

TB: matted, draining sinus

Malignancy: firm, nontender, matted or fixed to the skin or underlying
structures

NEUROLOGICAL EXAMINATION
I.
CEREBRUM

Mental state: general behavior & appearance, stream of talk, mood &
affective response, content of thought, intellectual capacity, sensorium

Sensorium: consciousness, attention span, orientation to place, person &

time, recent & remote memory, fund of information, insight, judgment &
planning, calculation

States of decreased consciousness:

o
Lethargy: difficulty to maintain the aroused state
o
Obtundation: responsive to stimulation other than pain
o
Stupor: responsive only to pain
o
Coma: unresponsive to pain

Speech: check articulation and comprehension

o
Dysphonia: disturbance in or lack of the production of sounds in the
larynx
o
Dysarthria: disorder in articulating speech sounds
o
Dysphasia: disturbance in the understanding or expression of words
as symbols for communication

II.

CEREBELLAR
Test coordination (finger to nose test), ataxia, intention tremors, dysynergia
o
Ask child to reach for and manipulate toys. Check for clumsiness and
incoordination
o
Check the ability to perform rapidly alternating movements: pat the
examiners hand; rapid pronation and supination of the hands; rapid
tapping of the foot

III.

CRANIAL NERVES
Olfactory Nerve (CN I): olfaction
o
Let the patient smell coffee, chocolate, vanilla using one nostril at a
time while the other is occluded
o
Anosmia: inability to appreciate odor
Optic Nerve (CN II): visual acuity, visual fields and fundi
o
Visual acuity: standard eye charts (snellen, jaegger, E): > 3y/o; blink
reflex
o
Visual fields: confrontation testing: an object is presented directly
infront while another stimulus (bright color) is presented from the
periphery
o
Fundoscopy: optic disc, salmon color older children; pale gray color
infants

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

Papilledema: elevation of optic disc, distended veins and lack of

venous pulsations; hemorrhages, blurring of nasal disc margins,
hyperemia of nerve head
Oculomotor, Trochlear, Abducens Nerves (CN III, IV, VI): extraocular
muscle movements
o
Position of the eyes on primary gaze and the size of palpebral fissures;
ask patient to track objects and check for limitation of extraocular
movements
o
Nystagmus & subjective complaint of double vision
o
Pupillary size, reactivity to light, accommodation and convergence
o
Look for abnormalities:
1. Strabismus: or squint or abnormal ocular alignment due to a
muscle imbalance
2. Ptosis: drooping of one or both eyelids
3. Limitation in extraocular movements
4. Nystagmus: involuntary rhythmic oscillation of the eyes
Trigeminal Nerve (CN V): facial sensation and muscles of mastication
o
Sensory: light touch, temperature & pain, corneal reflex

Test sensation using cotton or touch areas from vertex of the

head to the face and mandible (ophthalmic, maxillary and
mandibular divisions)

Corneal reflex: apply a wisp of cotton onto the cornea,

spontaneous blinking results with intact 5th and 7th cn
o
Motor: muscles of mastication: chew and swallow food; palpate
masseter and observe jaw deviation to the weak side
Facial Nerve (CN V): muscles of facial expression and taste sensation
over the anterior 2/3 of the tongue
o
Smile, frown, show teeth and close the eyes
o
Check for symmetry of movements
o
Central facial palsy: asymmetry of labial folds but wrinkling of the
forehead on raising eyebrows and eye closure are present and
symmetrical
o
Peripheral facial palsy: both upper and lower parts of the face are
affected and movements are asymmetrical
o
Test sense of taste by applying solutions of salt or sugar to previously
dried and protruded tongue
Vestibulocochlear Nerve (CN VIII): test for auditory and vestibular
functions
o
Hearing: response to sound
o
Weber test: vibrating tuning fork placed on the vertex of the head or
forehead
o
Rinnes test: vibrating tuning fork behind the ear over the mastoid
bone and just after the sound disappears, hold it beside the ear over
the external auditory canal
Vestibular function:
o

Caloric testing: patient in supine position, head flexed at 30 degrees,

ice water (10ml) is injected over 30 secs into one external auditory
canal at a time
1. Conscious: coarse nystagmus toward ipsilateral ear, no eye
deviation
2. Obtunded: eyes tonically deviated ipsilaterally, nystagmus
contralaterally
3. Comatose: tonic deviation ipsilaterally, no nystagmus
4. Profound coma/ brain dead: no eye changes
Glossopharyngeal and Vagus Nerves (CN IX, X): test for palatal
movements, uvular position and movement, gag reflex, phonation, sucking
and swallowing
o
Have the child say ahh or stick the tongue out then observe
symmetry in movement of the uvula and soft palate
Spinal Accessory Nerve (CN XI): test the function of trapezius and
sternocleidomastoid muscle
o
Turn head against resistance and shrug the shoulders
o
Palpate for symmetry of muscle bulk, tone and contraction of the SCM
and trapezius during head turning and shoulder elevation
Hypoglossal Nerve (CN XII): test for tongue muscle
o
Observe for the position of the tongue at rest with the mouth open and
during protrusion
o
Look for atrophy, grooving, fasciculations, deviations
o

IV.
1.
2.
3.

V.
1.
2.
3.
4.

MOTOR
Gait and posture
Muscle bulk, tone, strength
Coordination
o
Check for gowers sign
o
Check for active and passive muscle tone
o
Look for spasticity, rigidity and hypotonia
o
Scoring system for muscle strength:
5 - normal power
4 - active movement against gravity and resistance
3 - active movement against gravity
2 - active movement with gravity eliminated
1 - flicker or trace of contraction
0 - no muscle contraction

SENSORY
Sensation of touch, pain, temperature
Position sense
Vibration sense
Romberg sign: closed eyes, feet together, both arms extend to sides
swaying and loss of balance indicate dorsal column dysfunction

(3F) Pediatrics Pediatric History Dr. Corazon Lopez

5.

VI.

VII.

Stereognosis, two-point discrimination, weight and size discrimination,

graphesthesia (figure-writing on palm) which are finer sensations

DEEP TENDON REFLEXES

Ankle and knee jerks, brachioradialis, biceps, triceps, pectoralis
Biceps jerk C5, C6 roots, musculocutaneous nerve: arm slightly
flexed, palpate the biceps tendon with the thumb an strike with examining
hammer. Look for elbow flexion and biceps contraction
Supinator jerk C6, C7 roots, radial nerve: strike the lower end of the
radius and watch for elbow and finger flexion
Triceps jerk C6, C7, C8 roots: strike elbow a few inches above the
olecranon process. Look for elbow extension and triceps contraction
Knee jerk L2, L3, L4 roots: leg hanging, tap the patellar tendon, observe
for quadriceps contraction
Ankle jerk S1,S2 roots: externally rotate leg, foot is slight dorsiflexion,
tap the achilles tendon, watch for calf muscle contraction and plantar
flexion
Superficial reflexes: abdominal, cremasteric
o
Abdominal: stroke the abdomen from all sides towards the umbilicus,
umbilicus moves towards the stroked area

PATHOLOGIC REFLEXES

Babinski and its modifications chaddock, oppenheim, gordon

Babinski: stroke the lateral aspect of the sole of the foot > dorsiflexion of
the big toe and fanning of the other toes (normal up to 2 y/o)
Oppenhein: stroke the shin
Gordon: squeeze the calf muscles
Bing: apply painful stimulus (pin) on big toe
Gonda: flick one of the lateral toes
Kernigs sign: supine, flex the hip and knee each to about 90 degrees,
with the hip immobile, attempt to extend the knee. With meningeal
irritation, there is resistance and pain in the hamstring muscles
Brudzinskis sign: supine, flexion of the neck results in involuntary flexion
of the knee
For infants, primitive and developmental reflexes (rooting, moro, grasp,
plantar, etc.) are age appropriate. Persistence, absence, asymmetry or
reappearance is pathological.

esmc