Pediatric History & Physical

Question 1

History: HPI

Answer 1

Chronologic account of CC
Duration of symptoms
Severity of symptoms
Feeding history (breast/formula, amount/frequency, recent change)
Elimination history (wet/stool)

Question 2

History: Mother Pregnancy History

Answer 2

Other children
Prenatal care
Bleeding
Trauma
HTN
Fevers
Infections
Meds
Drug use
ETOH
Smoking
Early rupture of membranes

Question 3

History: Labor & Delivery

Answer 3

Gestational age at delivery
Setting (home or hospital)
Length of labor
Fetal distress
Delivery type (vaginal or c-section)

Question 4

History: Neonatal Period

Answer 4

APGAR scores
Respiratory problems
Hyperblirubinemia
Birth injuries
Length of hospitalization
Birth weight
Mother & baby blood type

Question 5

History: Infant Medical/Surgical History

Answer 5

Medical Illness
Surgeries
Fractures
Dislocations
Meds & Allergies
Immunizations

Question 6

History: Family History:

Answer 6

Cancer
Diabetes
Hypertension
Heart disease
Bleeding disorders
Stroke
Seizures
Age/health (grand)parents
Chromosomal abnormalities
Developmental delays
Growth problems
ADHD or autism

Question 7

History: Social History

Answer 7

Where does the child live
Where does the child sleep
Caregivers + daycare
Occupation of parents
Pets in the home
Smoke exposure
Concerns about safety

Question 8

History: ROS General

Answer 8

Fever or sweats
Weight history/growth charts
Sleeping habits
Irritability
Ill contacts

Question 9

History: ROS HEENT

Answer 9

Head shape & injuries
Fontenalles 
Hearing test post delivery
Ear, nose or eye drainage
EENT abnormalities
Abnormal cry

Question 10

History: ROS Skin & Lymph

Answer 10

Rashes, eczema
Lumps/lymphadenopathy
Birth marks
Pigment changes
Bruising

Question 11

History: ROS Cardiac

Answer 11

Cyanosis
Dyspnea
Murmurs
Distress during feeds
Sweating during feeds

Question 12

History: ROS Respiratory

Answer 12

Wheezing
Infections
Cough
Apneic episodes

Question 13

History: ROS GI

Answer 13

Stool color, frequency, & consistency
Diarrhea/constipation
Blood in stool
Vomiting
Jaundice
Colic

Question 14

History: ROS GU

Answer 14

Urine color changes
Urine odor
Hematuria
Vaginal or penile discharge

Question 15

History: Musculoskeletal

Answer 15

Joint swelling/redness
Joint abnormalities
Moving all extremities
Extremity abnormalities (fingers, toes, legs, feet)

Question 16

History: Neurological

Answer 16

Seizures
Meningitis
Post-partum depression

Question 17

Physical: General

Answer 17

Hand washing/ clean stethoscope
Distress
Tone

Question 18

Physical : Skin

Answer 18

Birthmarks
Color
Lesions

Question 19

Physical: Head

Answer 19

Measure circumference
Measure chest circumference
Palpate fontanelles
Check sutures

Question 20

Physical: Face

Answer 20

Asymmetry

Stigmata

Question 21

Physical: Eyes

Answer 21

Red reflex
Pupillary reflex
Irises same color

Question 22

Physical: Nose

Answer 22

Nares symmetrical

Patent

Question 23

Physical: Mouth

Answer 23

Cleft palate/lip

Teeth or masses

Question 24

Physical: Lungs

Answer 24

Auscultation of lung sounds

Question 25

Physical: CV

Answer 25

Murmur
Regular rate/rhythm
Femoral pulses

Question 26

Physical: Abdomen

Answer 26

Normal contour
Masses
Evaluation of the umbilical cord
Auscultation for bowel sounds

Question 27

Physical: Male Genitalia

Answer 27

Normal penile meatus

Testes palpable

Question 28

Physical: Female Genitalia

Answer 28

Labia majora/minora
Normal vaginal opening
Normal size clitoris

Question 29

Physical: Rectal

Answer 29

Anal patency

Question 30

Physical: Extremities

Answer 30

# toes/fingers
Musculoskeletal abnormalities
Evaluation for clavicle fracture
Perform Barlow
Perform Ortolani
Hips abduct fully
Extremity length symmetrical

Question 31

Physical: Back

Answer 31

Spine straight

Abnormalities midline

Question 32

Physical: CNS

Answer 32

Infants cry strong
Moro reflex
Grasp reflex
Plantar reflex
Rooting reflex
Stepping reflex