UNIVERSITY OF CEBU

College of Nursing
Cebu City

PEDIATRIC ASSESSMENT
(1 month to 12 years)

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 ___ Home
Maternal Illness : ___ None ___ Fever ___ Rash
___ GDM ___ Asthma ___ Heart Disease
___ UTI ___ TB ___ Hepatitis
___ Allergy ___ Hypermesis ___ PIH
Medications (mother) ________________________________________

II. NATAL HISTORY

Date of Birth ___________ Birth Rank ________ Apgar Score _____
Place of Delivery ___ Hospital ___ Home ___ Lying-in
Attendant ___ Midwife ___ Hilot ___ Others
Gestation ___ Full term ___ Preterm ___ Post term
Mode of Delivery ___ NSVD ___ Forceps___ C/S (indication)
Presenting Part ___ Cephalic ___ Face ___ Breech ___ Transverse

Medications ___ Eye Prophylaxis ___ Vit. K ___ Hep. B

III. POST-NATAL HISTORY

Feeding ___ Breastmilk ___ Milk Formula ___ Mixed
Medical Problems ___ None ___ Respiratory ___ Cyanosis
___ Sepsis ___ Seizure ___ Jaundice

IV. IMMUNIZATIONS __ No __ Yes at: __ Center __Private __ Both

1st dose 2nd dose 3rd dose 1st booster 2nd booster None
BCG
DTP
OPV
Hib
Hep B
Pneumoccocal
Rotavirus
Flu
Varicella
AMV
MMR
Others:
Typhoid
Hep. A
Meningococcal
HPV

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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 Intervention

Hospitalization (including operation)

Date Hospital Diagnosis

VII. FAMILY HISTORY

___ No significant FH ___ Significant FH
__ HPN __ Diabetes __ Asthma __ Heart Disease
__ Blood Disorder __ Kidney disease
__ Allergy __ Cancer
__ TB __ Stroke
__ Seizure __ Mental Disorder
Others : _____________________________________

VIII. GROWTH & 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 _____________________________________________

Name of Patient ___________________________________________________

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X. FAMILY HISTORY (insert the Genogram at the back of this page)

XI. REVIEW OF SYSTEMS

A. Skin :
Texture ____________ Color _____________
___ Eruptions ___ Hydration
___ Edema ___ Hemorrhagic manifestations
___ Scars ___ Dilated blood vessels
___ Striae ___ Wrinkling
B. Eyes :
__ Have the childs eyes ever been crossed-eyed?
__ Any foreign body?
__ Any infection?
C. Ears/ Nose and Throat:
__ Frequent Colds __ Sore throat
__ Sneezing __ Stuffy nose
__ Discharges __ Post-natal drip
__ Mouth breathing __ Snoring
__ Otitis media __ Hearing problem
D. Teeth :
Age of eruption of deciduous teeth ____
Age of eruption of permanent teeth ____
E. Cardiorespiratory:
__ Dyspnea __ Chest pain
__ Cough __ Sputum
__ Wheeze __ Expectoration
__ Cyanosis __ Edema
__ Syncope __ Tachycardia
F. Gastrointestina:
__ 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
__ Diziness __ Tingling sensation
__ Convulsions __ Spasm
__ Ataxia __ Muscle or joint pains
__ Postural Deformities __ Exercise tolerance
I. Endocrine
__ Disturbance of growth __ Excessive fluid intake
__ Polyphagia __ Goiter

J. General
__ Unusual weight loss __ fatigue
__ Temperature sensitivity

I. CHIEF COMPLAINTS ( History of Present Illness)

__________________________________________________________
__________________________________________________________
__________________________________________________________
___________________________________________________ .

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 PEDIATRIC PHYSICAL EXAMINATION
Name of Patient _______________________ Date of Birth ____________

1.
VITAL SIGNS

BP ___ HR___ RR ___ TEMP. ___ WT. ___ HT. ___

2. GENERAL OBSERVATION ___________________________________

_________________________________________________________
_________________________________________________________

3. SKIN:

Color: __ Normal __ Cyanotic __ Pale __ Icteric __ Flushed ___ Ashen

Texture: __ Normal __ Dry __ Oily
Turgor: __ Good __ Poor
Lesions __ None __ Rashes __ Burns __ Abrasions _ Lacerations
__ Punctured wound __ Scars __ Decubitus
Comments: _______________________________________________

4. HEAD/EARS/NECK/THROAT

HEAD circumference : __________cm (up to 2 years & if significant)

SHAPE : __ Round __ Ovoid __ Irregular

SCALP: __ Normal __ Pustule __ Seborrhea __ Scales __ Lice

FONTANELS:
Anterior: __ Close __ Open __ Flat __ Sunken __ Bulging
Posterior __ Close __ Open __ Flat __ Sunken __ Bulging

5. EYES

Eyelids R L Eyeballs R L
Normal Normal
Laceration Sunken
Inflamed Bulging
Mass Pupils
Puffy Reactive
Drooping Unreactive
Sclerae Equal
Normal Unequal
Icteric Vision
Red Normal
Discharges Blurred
Contact Lens
With correctional glasses
Comments : ______________________________________________________

Name of Patient ___________________________________________________

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6. EARS

Pinna R L External Canal R L

Normal No Problem
Anomalies Discharge
Symmetrical Pain
Tympanic Membrane R L Hearing
Intact Normal
Perforated Deaf
Discharge With hearing-aid
Mastoid
Tenderness
Swelling

Comments: _______________________________________________________

7. NOSE/NECK/THYROID

Nares R L
No problem
Nasal flaring
Discharge
Epistaxis
Turbinates
Normal
Inflamed/congested
Neck
a. Normal
b. Torticollis
c. Opistothonus
d. Inability to support head
Lymph Nodes
a. Swelling
b. Tender
Sternocleidomastoid
a. Swelling
b. Shortening
Thyroid
a. Size
b. Contour
c. Bruits
d. Nodules
e. Tenderness
f. Enlarged
g. Not Appreciated

Comments : ______________________________________________________

Name of Patient: ___________________________________________________

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8. MOUTH/THROAT

Lips : __ Pink __ Red __ Pale __ Cyanotic __ Dry __ Moist __ Swelling

__ Thin __ Downturning __ Fissures __ Cleft
Teeth: __ Temporary __ Permanent __ No teeth
__ Complete __ Incomplete __ Caries
__ 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 0f Cry ____________ Type of speech ___________________

Comments: _______________________________________________________

9. RESPIRATORY/THORAX

Upper Airway: __ Normal __ Stridor __ Hoarseness __ Drooling of Secretions

Chest/Upper Trunk:
__ Normal __ Kyphosis __ Scoliosis __ Mass
__ Scars __ Abrasions __ Rash
Expansion: __ Equal __ Unequal
Retractions: __ Absent __ Present

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

Pulses: __ Strong __ Regular __ Weak __ Irregular
Heart Sound: __ Normal __ Splitting __ Murmurs
Rate: __ Regular __ Irregular
__ Normal __ Bradycardia __ Tachycardia
Capillary Refill Time: ______________________________

Comments: _______________________________________________________

Name of Patient : __________________________________________________

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11. GASTROINTESTINAL

Abdomen:

Inspection: __ Flat __ Scaphoid __ Distended __ Globular

Percussion: __ Tympanitic __ Dull __ Fluid Wave
Palpation: __ Normal __ Splenomegaly __ Mass
__ Hepatomegaly Liver edge ____________
Tenderness: Location_______ __ Direct __ Indirect

Bowel Sounds: __ Normal __ Hyperactive __ Hypoactive

Rectal Exam : ___________________________________________________

Comments : _____________________________________________________

12. GENITOURINARY
__ Normal __ Mass __ Tenderness (location) ____________
Genitals: __ Normal __ Discharges __ Anomaly
MALES:
Circumcised __ Yes __ No
Tanner Staging: Tanner Score: _____

FEMALES:
Menses started ________ __ Not Applicable
Length of Cycle: ________ __ Regular __ Irregular
Tanner Staging: Tanner Score: _____

Name of patient: __________________________________________________

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 Females & Males: Pubic Hair
PH 1 No change
PH 2 Some slightly pigmented downy
hair along the base of the
G2
scrotum and phallus (male) or
labia majora (female)
PH 3 Moderate amount of curly,
pigmented and coarse hair
G3
extending laterally
PH 4 Resembles adult hair in
curliness ad coarseness but
does not extend to the medial
thigh.
PH 5 Adult type extending to medial
thigh
Male Genitalia Changes
G1 Testes volume <1.5
Phallus childlike
Testes 1.6 cc 6 cc
Scrotum reddened, thinner,
Larger
Phallus no change
Testes 6 cc 12 cc
Scrotum more enlargement
Testes 12 22 20 cc
Scrotum further enlargement,
G4
darkened
Phallus longer with increased
circumference
G5 Testes - > 20 cc.
Scrotum & Phallus adult size
Breast Changes in Females
B1 Prepubertal breast with areola
confined to the general chest line.
Breast bud with some amount of
glandular tissue, areola widens
B2
Breast is larger and more elevated
extending beyond areolar limit;
B3
areola continues to enlarge but
remains in contour with breasts
Breast is larger, more elevated;
areola and papilla form a mound
B4
projecting form breast contour.
B5 Breast is adult size; areola and
breast on the same plane and
papilla projecting above areola.

13. NEUROLOGIC

A. Pediatric Glasgow Coma Scale (Teasdale & Bennet) Score

Eye Opening
Opens eyes spontaneously 4
Opens eyes in response to speech 3
Opens eyes in response to painful stimuli 2
Does not open eyes 1
Verbal Response
Smiles, oriented to sound, follow object, interacts 5
Confused, consolable crying, inappropriate actions 4
Inappropriate, persistently irritable, vocal sound, moaning 3
Incomprehensible, restless, agitated, cries 2
No verbal response 1
Motor Response
Obeys, infant moves spontaneously or purposefully 6
Localizes pain, oriented, follow, infant withdraws from touch 5
Infant withdraws from pain, consolable crying, interact 4
Abnormal flexion to pain in infants (decorticate response), inconsistently consolable crying 3
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 M4)
1 2 years = 12 2 5 years = 13 5 years = 14
(E4 V4 M4) (E4 V4 M5) (E4 V5 M5)

B. Mental Status :
__ Awake __ Conscious __ Drowsy
__ Stupurous __ Coma __ Oriented
__ Disoriented

Name of Patient ___________________________________________________

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II. Cranial Nerves:

CN I (Olfactory) __ Intact __ Anosmia __ Hyperosmia __ Not done

CN II (Optic) __ Intact __ Blindness __ Scotoma __ Diplopia

CN III, IV, XI ( Oculomotor, Trochlear, Abducens)

PUPILS: __ Reactive __ Non-reactive __ Equal __ Non-equal
EOM : __ Full ROM __ Palsy __ Ptosis

CN V (Trigeminal) __ Trismus __ Paresthesia __ Intact

Corneal Reflex __ Present __ Absent __ Right __ Left

CN VII (Facial) Facial Symmetry: __ Symmetric __ Assymetric

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

III. Cerebellar:

FTNT: __ Well-coordinated __ Not coordinated __ Not done

APST: __ Well-coordinated __ Not coordinated __ Not done
__ Ataxia __ Nystagmus
Rombergs: __ Positive __ Negative __ Not done

IV. Sensory:

Light Touch __ Intact __ Absent __ Not done

Pain __ Intact __ Absent __ Not done
Temperature __ Intact __ Absent __ Not done

V. Motor
R L Manual Scoring
Upper Extremity 5 Normal
Proximal 4 Can raise against slight resistance
Distal 3 Can raise against gravity
Lower Extremity 2 Gross movements but not against gravity
Proximal 1 Flicker of movement
Distal 0 No movements

Name of Patient ___________________________________________________

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14. REFLEXES

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

Priitive Reflex: __ NA

Present Absent Present Absent

Moro _____ _____ Tonic Neck _____ _____

Rooting _____ _____ Babinski _____ _____
Sucking _____ _____ Ankle Clonus _____ _____
Grasp _____ _____

15. MUSCULOSKELETAL:

__ Normal __ Fractures __ Deformities __ Tenderness __ Swelling

Comments: _______________________________________________________

Students Name _________________ Year & Section ___

Criteria: Accuracy (20) _______

Comprehensiveness (20) _______
Completeness (15) _______
Documentation (5) _______
TOTAL (60) _______

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