Pediatrics Physical Diagnosis Form Version 3
-
Upload
stephen-jao-ayala-ujano -
Category
Documents
-
view
224 -
download
1
Transcript of Pediatrics Physical Diagnosis Form Version 3
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
1/15
University of Northern PhilippinesTamag, Vigan City, Ilocos Sur
College of Medicine
DATE & TIME._________________
I.GENERAL DATA.Name: _________________________
Age: __________Sex: [M] [F]Marital Status: [S] [M] Oters:__________________
A!!ress: ________________________________________________________________________________"eligion: ________________________________________________________________________________"ace #$tnicity#Citi%ensi&: _________________________________________________________________Num'er an! (ate o) *os&ital A!missions: _____________________________________
_____________________________________Source o) In)ormation: _____________________________________________________"e)erral: ________________________________________________________________"elia'ility: _____________
II.CHIEF COMPLAINT._____________________________
III.HISTORY OF PRESENT ILLNESS.
+NOT$- . State in cronological or!er )rom te start o) te illness/. 0se s&eci)ic num'er o) ours or !ays1 )or cronic illness, state !ate an! age o) onset/. I) ne2'orn, an!#or &resent &ro'lem is relate! to &renatal 3 &erinatal &erio!, inclu!e maternal an! 'irt istory/
. $la'orate O45"ST +onset, &reci&itating )actors, 6uality1 locali%ation1 !uration1 )re6uency, relie7ing#aggra7ating )actors, associate! signs an! sym&toms3 its O45"ST-1 in!icate mg#8g !ose )or me!ications an! s&eci)ic !ilution )or mil8 )ormula/
. Inclu!e 4ast *istory i) rele7ant to &resent illness +e/g/ &re7iously !iagnose! 2it a !isease relate! to current com&laint#illness-
*istory Ta8ing an! 4ysical $xaminatio+4e!iatrics- Version 9/
Create! 'y Ste&en A/ 0;an
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
2/15
IV. PAST HISTORY.
A. Childhood Illnesses:
=/ Measles
>/ Mum&s9/ "u'ella
?/ 4oliomyelitis@/ Varicella/ 4ertussisB/ "eumatic )e7er / Scarlet )e7erD/ Oters:
_____________________
B. Medical:+tu'erculosis, e&atitis, astma, or allergies, in;uries#acci!ents, os&itali%ations [!ate1 &lace1 !iagnosis1 treatment]-
C. Surgical:+!ate1 &lace1 in!ication1 ty&e o) o&eration-
D. !stetric"#ynecologic: +inclu!e caesarian sections an! reason1 ®nancy com&lications-
OE *istory: [ ] 4[ ] T[ ] 4[ ] A[ ] G[ ] M[ ] Menstrual *istory: ____________________________
Age o) Menarce: _______________ GM4: ______________
$. Psychiatric:+Illness, time )rame, !iagnosis, os&itali%ations, treatments-
V. IMMUNIZATION HISTORY AND TUBERCULIN TEST.
I%%uni&ation Age #iven"Date Place Unto'ard (eactions
)st *nd +rd ,th -th" Boosters
BC#
epatitis B
P/
DP0
MM(
0etanus 0o1oidPentavalent
D0aP 23y"o"0Dap 4 3y"o
/aricella
Pneu%ococcal
Influen&a
(otavirus
thers:
0u!erculin 0est:
ther Screening 0ests:
Age Co%plications
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
3/15
VI. FAMILY HISTORY.
Me%!er Age ccupation ealth Status Age of Death Cause of Death4aternal ran!moter
4aternal ran!)ater
Fater:
Maternal ran!moterMaternal ran!)ater
Moter:
Si'lings:
5a%ilial Illnesses:+tu'erculosis, (M, sy&ilis, cancer, e&ile&sy, "*F, mental#&syciatric, congetinal-
+NOT$- Ma8e a genogram o) te )amily i) rele7ant an! note )or consanguinity/
VII. PERSONAL HISTORY.
+NOT$- For H> y#o &atient or > y#o 2it relation to current illness/
A. #estational istory: +NOT$- Age o) moter !uring ®nancy1 &arity1 ealt, nutrition1 in)ection1 !rug#alcool use1 ra!iation ex&osure1 !uration o)gestation i) &ertinent es&ecially in in)ants/
B. Birth istory: +NOT$- Term, &remature or &ostmature1 manner o) !eli7er an! reason i) C.section1 atten!ing &ersons1 'irt2eigt i) &ertinent es&ecially inin)ants/
C. Neonatal istory: +NOT$- A4A" Score1 s&ontaneous res&iration or re6uire! resuscitation1 cyanosis1 &allor1 cry1 ;aun!ice -inclu!e onset-1 emorrage1con7ulsions1 res&iratory o) )ee!ing !i))iculties1 congenital 'irt in;ury i) &ertinent es&ecially in in)ants-
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
4/15
D. 5eeding istory
Infancy 62* y"o7:
A. 0ype of 5eeding: Ereast)ee!ing1 exclusi7e or mixe!1 )re6uency1 !uration &er 'reast1 i) not 'reast )ee!ing: gi7e reason, )ormula use! 3 !ilution,amount &er !ay, 'ottle or cu& )ee!ing1 in!icate s&eci)ic !ilution )or mil8 )ormula
B. Co%ple%entary 5oods:Age intro!uce!1 initial an! su'se6uent )oo!s intro!uce!1 consistency o) )oo!1 )re6uency o) )ee!ing#!ay
C. Usual 5ood Inta8e:Erea8)ast1 lunc1 !inner1 snac8s1 assess )i7e 'asic )oo! grou&s1 &re)erre! )oo!s
D. Co%pute for Caloric Inta8e9 Co%parison 'ith ($NI or food inta8e to 5ood #uide Pyra%id+See re)erence )or com&utation1 See A&&en!ix A )or te "$NI-
$. 5ood Intolerance:
5. Multivita%ins"Supple%ents:(ose1 )re6uency
#. Caregiver:Moter1 ouseol! el&, gran!&arents1 si'lings
Childhood and Adolescents 6**; y"o7: +NOT$- Omit early )ee!ing istory unless it is &ertinent to &resent illness/
A. Descri!e Appetite:
B. Usual 5ood Inta8e: Meals an! snac8s &er !ay1 amount
C. Assess 5ive Basic 5ood #roups:
D.Co%pute for Caloric Inta8e9 Co%parison 'ith ($NI or food inta8e to 5ood #uide Pyra%id +See re)erence )or com&utation1 See A&&en!ix A )or te "$NI-
$. Multivita%ins"Supple%ents:(ose1 )re6uency
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
5/15
$. Develop%ental " Behavioral istory /
A. Infancy 62) y"o7:
+NOT$- Jou can use ($NV$" II )or H= y#o as a gui!e !uring te inter7ie2
B.
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
6/15
D. Adolescence 6);*; y"o7
I. $ADS"S"5I(S0
o%e: S&ace#measurement1 &ri7acy1 )re6uent geogra&ic mo7es1 neig'oroo!
$ducation"School: Fre6uent scool canges, re&etition o) su';ect, teacerKs re&orts, 7ocational goals, e!ucational clu's# grou&s, learning !isa'ilities,acie7ements, a'sences1$ating a!its"Behaviors/
A!use:4ysical, sexual, emotional, 7er'al a'use, &arental !isci&line
Drugs:to'acco, alcool, mari;uana, inalants, clu' !rugs, ra7e &arties, !rug o) coice, age o) initiation, )re6uency1 mo!e o) inta8e1 rituals, alone#2it &eers, 6uitmeto!s an! num'er o) attem&ts
Safety:Seat 'elt, &rotecti7e gears, s&orts sa)ety measures, a%ar!ous acti7ities1 !ri7ing 2ile intoxicate!1SuicidalAtte%pts" Ideation.
Se1uality" Se1ual Identity: "e&ro!ucti7e ealt, use o) contrace&ti7es, &resence o) STI, )eelings, ®nancy1 sexual &ractices, sexual &artners/
5a%ily" 5riends:Family constellation, genogram, ci7il status#relationsi&s, ty&e o) )amily, )amily occu&ations, istory o) a!!iction = stan! >n!!egreerelati7es, &arental attitu!e on !rugs, &arental rules, &eer cli6ues, gangs, &re)erre! )rien!s
I%age:*eigt an! 2eigt &erce&tions, 'o!y musculature an! &ysi6ue, a&&earance, sel).image
(ecreation:Slee&, exercise, s&orts1 acti7ities, total ours s&ent )or recreations/
Spirituality @ Connectedness:*o&e or security )or )uture1 religion1 &ersonal s&irituality &ractices, e))ects o) me!ical care an! li)e issue in7ol7ement
0hreats" /iolence: Sel).arm, arm to oters, running a2ay, cruelty to animals, guns, )igts, arrest, stealing, )igt in scool
II. 5or 5e%ale:
Age o) Menarce: ____________
Menstrual *istory +cycle, regularity, )re6uency, !uration, &ain-:_______________________________________________________
GM4: _____________
Sel). Ereast $xamination 4ractices:
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
7/15
VIII. SOCIOECONOMIC HISTORY
+NOT$- ?iving circu%stances:&lace an! nature o) !2elling, num'er o) &ersons li7ing in te ouse1 $cono%ic circu%stances:mem'ers o) )amily 2o 2or81
source o) income#)un!s
IX. ENVIRONMENTAL HISTORY:
+NOT$- $nviron%ental circu%stances:ex&osure to cigarette smo8e an! oter &ollutants +s&eci)y an! !uration o) ex&osure-1 #ar!age disposal9 Se'agedisposal9 ater source for drin8ing and 'ashing.
X. REVIEW OF SYSTEMS
#eneralL eigt loss or gainL FatigueL Fe7er or cillsL ea8nessL Trou'le slee&ingL Acti7ity le7elL (elay in gro2t
S8inL "asesL Gum&sL ItcingL (ryness
L AcneL Color cangesL *air an! nail canges
eadL *ea!aceL *ea! in;uryL Nec8 4ain
$arsL (ecrease! earingL "inging in earsL $araceL (rainage
$yes
L Vision Goss#CangesL lasses or contactsL 4ainL "e!nessL Elurry or !ou'le 7isionL Flasing ligtsL S&ec8sL laucomaL CataractsL (rynessL GacrimationL Gast eye exam 3result:_________________
NoseL Stu))inessL (iscargeL ItcingL *ay )e7erL Nose'lee!sL Sinus &ain
0hroat"MouthL Elee!ingL (enturesL Sore tongueL (ry moutL Sore troatL *oarsenessL TrusL Non.ealing soresL Tootace
Nec8L Gum&sL S2ollen glan!sL 4ainL Sti))ness
BreastsL Gum&sL 4ainL (iscargeL Sel).exams
(espiratoryL CougL S&utumL *emo&tysisL SOE#(OEL ee%ingL 4ain)ul 'reating
CardiovascularL Cest &ain or !iscom)ortL TigtnessL 4al&itations
L $asy )atiga'ilityL Orto&neaL Fainting s&ellsL Cyanosis
#astrointestinalL S2allo2ing !i))icultiesL *eart'urnL Cange in a&&etiteL Nausea#VomitingL Cange in 'o2el a'itsL "ectal 'lee!ingL Consti&ationL (iarrea
L Foo! intoleranceL A'!ominal &ainL 4ica
#enitourinaryL Fre6uencyL 0rgencyL Eurning or &ainL Eloo! in urineL IncontinenceL Cange in urinary strengtL Cange in urine colorL $nuresisL(iscargeL $!ema o) an!s an! )eetL 4re&u'ertal: !iscarge an!
itcingL *istory o) Menstrual 4erio!:+onset, )re6uency, regularity,&ain an! GM4-__________________________________________
Peripheral /ascularL Cal) &ain 2it 2al8ingL Geg cram&ingL Varicose 7eins
Musculos8eletalL Muscle or ;oint &ainL Sti))nessL Eac8 &ainL "e!ness o) ;ointsL S2elling o) ;ointsL TraumaL Gim&ingL Gimitation o) motion
Neurologic"BehavioralL Ner7ousnessL Stress
L (e&ressionL Memory lossL (i%%inessL FaintingL Sei%uresL ea8nessL Num'nessL TinglingL TremorL 4aralysisL $ating &ro'lemsL 4ersonality or 'ea7ioralcangesL Tem&er out'urstsL *allucinations
e%atologicL $ase o) 'ruisingL $ase o) 'lee!ingL 4ast trans)usions an!reactions: ______________
$ndocrineL *eat or col! intoleranceL S2eatingL Fre6uent urinationL 4oly!i&siaL 4oly&agiaL 4al&itations
PHYSICAL EXAMINATION
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
8/15
GENERAL SURVEY
+NOT$- Mental state#sensorium1 le7el o) acti7ity1 eigt1 grooming, !ress an! &ersonal ygiene1 &resence o) C4 !istress or color1 am'ulatory or 'e!ri!!en1 nutritionalstate +2ell, un!er, or o7er nourise!-, state o) y!ration, ill.loo8ing +2ell, mil!, or se7ere: re)er to In!ex A )or Acute Illness O'ser7ational Scale-
VITAL SIGNS
Blood Pressure:R-Arm____________ mm*gL-Arm____________ mm*gCardiac"Pulse (ate:________ '&m(espiratory (ate:_________ c&m1ygen Saturation:________
0e%perature:Rectal:__________Oral:__________
Axillary:___________Tympanic:_________Temporal Artery:__________
Pain Scale:________________
+NOT$- . O'tain E4 i) 9 y#o/ . Correlate C"#4" an! "" to cil!Ks con!ition 2ere it is clinically signi)icant, +i/e/ 2as te cil! aslee&, acti7e, a)e'rile + @.B c&m # C 9B C-, crying, struggling etc/
. "" to C" ration is a'out =:?/
ANTHROPOMETRIC MEASUREMENTS
eigt: ___________ 8g (Percentile: ___)Gengt +H> y#o-: __________cm (Percentile: ___)*eigt +P > y#o-: __________cm (Percentile: ___)
*ea! Circum/ +H9 y#o-: _______ cm (Percentile: ___)Cest Circum/: _________ cm
A'!ominal Circum/: _________ cm
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
9/15
EMI: _____________ (Percentile: ___)
5or children 'ith gro'th disorders:Arm S&an:___________cm0#G "atio:__________
+NOT$- Q See A&&en!ix A )or te &ercentiles/
HEAD TO TOE PHYSICAL EXAMINATION:
SIN:A)ter )irst year o) li)e, tecni6ues are te same 2it a!ults/ Goo8 )or color, tissue#s8in turgor, ras or eru&tions, emorrages, scars, e!ema, ;aun!ice/ Note
)or milia, erytema toxium, lanugo, $&stein &earls, Mongolian s&ots etc/
$AD: Assess )or air, sa&e, contour, scal&, )ontanels, sutures1 *air is !escri'e! 'ase! on 6uantity, color, texture, sur)ace caracteristics, an! strengt/1 Goo8)or s2elling, ca&ut succe!aneum, ce&alematoma/
5AC$: Ins&ect )or symmetry, ex&ression, unusual )acies, !e)ormities, lum&s, 'um&s1 an! a!enoi! )acies/
$
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
10/15
C$S0 AND ?UN#S: Ins&ect si%e an! sa&e, mo7ement 2it res&irations, cest retractions, cest ex&ansion, 7ocal )remitus, cec8 'reast contour an!!iscarge +re)er to Tanner Staging-/ 4ercuss, an! auscultate )or 'reat soun!s/
$A(0 AND P$(IP$(A? /ASCU?A(: O'ser7e &recor!ium, 7isi'le &ulsations, a&ex 'eat, trills, eart soun!s an! &ulses/
ABDM$N:Ins&ect si%e, sa&e, &rominent 7essels, striae, &ulsations, &eristaltic mo7ements, mo7ement in relation to res&iration, um'ilical ernia, a'!ominal!istention, a'!ominal circum)erence, auscultation o) 'o2el soun!s, &ercussion, &al&ation o) li7er s&an, s&leen, ten!erness, masses/ Assess )or 8i!neys an!costro7erte'ral angle ten!erness/ Cec8 inguinal regions )or y!rocele, lym& no!es an! ernias/
MA?$ #$NI0A?IA: Ins&ect &enis, &re&uce an! glans, !iscarges, s8in lesions, uretral ori)ice, &al&ate )or te testes/
5$MA?$ #$NI0A?IA:Ins&ect 7ul7o7aginal area )or lesions an! cec8 )or !iscarges, 7aginal introitus, lacerations an! !iscarges, an! sa&e o) ymen/
ANUS AND ($C0UM:Gocation, &atency, )issures, lesions, tags, emorroi!s, &in2orms or &rola&se/ In rectal exam, assess )or s&incter tone, mass,im&acte! )eces an! ten!erness/
UPP$( AND ?$( $0($MI0I$S:Cec8 )or clu''ing, cyanosis, signs o) in)lammation, range o) motion an! ;oint !e)ormities1 i& !islocations inne2'orn an! 7erte'ral s&ine/ Assess )or &eri&eral &ulses, lym& no!es1 an! e!ema/
Musculos8eletal:
Peripheral /ascular:
(adial 5e%oral Popliteal Dorsalis Pedis Posterior 0i!ial
(ight
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
11/15
?eft
N$(/US: Assess )or sensations1 gait1 strengt an! coor!ination1 !ee& ten!on re)lexes1 !e7elo&ment1 cere'ellar )unction an! cranial ner7es/
Mental Status: +See also Mini.Mental Status $xamination at APP$NDI A-
Cere!ellar: +4er)orm ra&i! alternating mo7ement1 Finger.to.nose1 *eel.to.seen-
#ait"Stance"Balance: +ait#Stance: as8 te &atient to 2al8 across te room1 Ealance: Test )or "om'erg an! 4ronator (ri)t-
Motor and Strength: +ra!e o) muscle strengt 'ilaterally1 see APP$NDI A-
Sensory: +Test )or sensations 'ilaterally1 see APP$NDI A-
Cranial Nerves:
Cranial Nerves"5unction (e%ar8s
I . Ol)action
II . Visual Acuity
III, IV, VI Q $xtraocular Mo7ements
V . Motor an! Sensation
VII . Facial
VIII . *earing
IR, R Q S2allo2ing an! ag "e)lexRI Q S&inal Accessory
RII . *y&oglossal
(efle1es:
Biceps 0riceps Brachioradiali
s
Patellar Achilles Plantar
(ight
?eft
Develop%ent: +For cil!ren 9 y#o-/ As8 to !ra2 a &icture or co&y o';ects, an! !iscuss teir &ictures to test also )or )ine motor coor!ination, cognitionan! language or 0S$ ($NV$" II1 S$$ APP$NDI A-
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
12/15
APP$NDI A
MiniMental Status $1a%ination
Points Patient>s Score
Orientation
Name: season#!ate#!ay#mont#year +=&t/ )or eac name- +@-
Name: os&ital#)loor#to2n#state#country +=&t/ )or eac name- +@-(egistration
I!enti)y tree o';ects 'y name an! as8 &atient to re&eat +9-
Attention and calculation
Serial Bs1 su'tract )rom = +e/g/, D9QQBDQB>Q@- += &t/ )or eac su'traction- +@-
(ecall
"ecall te tree o';ects &resente! earlier +9-
?anguage
Name &encil an! 2atc +=&t/ )or eac o';ect- +>-
"e&eat No i)s, an!s, or 'uts +=-
Follo2 a 9.ste& comman! +e/g/, Ta8e tis &a&er, )ol! it in al), an! &lace it on te ta'le-+=&t/ )or eac comman!-
+9-
rite close your eyes an! as8 &atient to o'ey 2ritten comman! +=-
As8 &atient to 2rite a sentence +=-
As8 &atient to co&y a !esign +e/g/, intersecting &entagons- +=-
0otal +9-
Muscle Strength $1a%ination
Maor Muscle #roups: (ight ?eft
$l'o2)lexion +C@, C'ice&s-extension +C, CB, Ctrice&s-
rist extension +C, CB, C, ra!ial ner7eextensor car&i ra!ialis longus an! 're7is-
ri& +CB, C, T=-
Finger a'!uction +C, T=, ulnar ner7e-
O&&osition o) te tum' +C, T=, me!ian ner7e-
Flexion at te i& +G>, G9, G? ilio&soas-A!!uction at te i&s +G>, G9, G?a!!uctors-
A'!uction at te i&s +G?, G@, S=gluteus me!ius an! minimus-
$xtension at te i&s +S=gluteus maximus-
Flexion at te 8nee +G?, G@, S=, S>amstrings-
(orsi)lexion +mainly G?, G@ti'ialis anterior-
4lantar )lexion +mainly S=gastrocnemius, soleus- at te an8le
Sensory $1a%ination
Sensory Syste% (ight ?eft
A. Spinothala%ic:&in&ric8, tem&erature, ligt touc (Rate !"# $%$$'
Soul!ers +C?-
Inner an! outer as&ects o) te )orearms +C an! T=-
Tum's an! little )ingers +C an! C-Fronts o) 'ot tigs +G>-
Me!ial an! lateral as&ects o) 'ot cal7es +G? an! G@-
Gittle toes +S=-
Me!ial as&ect o) eac 'uttoc8 +S9-
B. Posterior Colu%n: (I)ta*t "! N"t
4osition sense
Vi'ration
C. Sensory Corte1 +(iscrimination- (I)ta*t "! N"t
Stereognosis
ra&estesia
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
13/15
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
14/15
-
7/26/2019 Pediatrics Physical Diagnosis Form Version 3
15/15