c. Ask about high-risk social behaviors (smoking; alcohol/drug use; sexual activity, including diagnosis and treatment of sexually transmitted infections [STIs]; driving motor vehicle in reckless manner; use of guns; etc.).
E. Review of systems (ROS).
1. Age-appropriate ROS: Conduct in head-to-toe manner as identified in comprehensive physical examination
(
Table 2-2
).
II. INTERVAL HISTORY FOR ATHLETIC CHILD OR ADOLESCENT
A. Pre-participation sports history and physical have well-established guidelines; follow explicitly.
B. Interval history is integral part of assessment.
1. Question parent and child about significant family history changes (e.g., sudden death of relative who was 50 years old from cardiovascular condition). Include questions that elicit information about significant episodes (red flags) of chest pain, dyspnea, syncope, palpitations, loss of consciousness, history of concussions
(
Table 2-3
).
Table 2-3
Red Flags: The Interval History for the Athletic Child or Adolescent
| Interval history questions that may elicit red flag data | System | Red flag data |
| Any relatives < 50 years of age die as result of sudden unexpected cardiac death? | Cardiovascular | Change in family history Sudden death of relative < 50 years of age |
| Child report chest pain or palpitations, syncope during or after exercise? | | Chief complaint from child: Chest pain Palpitations |
| | | Syncope |
| Child report any breathing problems during or after exercise? | Respiratory | Chief complaint from child: Dyspnea |
| | | Wheezing |
| Child had any episodes of dizziness, syncope, fainting, concussion? | Neurologic | Chief complaint from child: Syncope |
| | | Loss of consciousness |
III. FOCUSED HISTORY
A. Focused history: Used to collect data about a specific problem, usually chief complaint identified by parent/child
(
Tables 2-4
and
2-5
).
B. Focus all questions on eliciting data about chief complaint.
C. Focused history usually limited to one or two systems.
IV. APPLYING DATA OBTAINED IN INTERVAL HISTORY TO CLINICAL PRACTICE
A. After completing interval history and physical examination, compare findings in comprehensive history to data obtained in interval history.
1. If no significant changes found in interval history, advise parent, infant/ child to continue to follow established health promotion plan.
Table 2-4
Sample Focused History: Medical
| Subjective data | Questions to focus the history |
| ''My child has a chronic cough.'' | What do you mean by a chronic cough? |
| “My child begins coughing each night. I cannot remember the last time he didn't cough at night.” | Does child cough during day or just at night? |
| | What time of night does child begin coughing? |
| | Describe the cough. |
| | Is cough productive or nonproductive? |
| | Does cough affect child's sleeping pattern? |
| | Any products currently being used in household that weren't being used before child began having this “chronic” cough? |
| | Pets in your household? |
| | Did you change pillow your child uses? |
| | Use any over-the-counter or prescription medications to treat this cough? |
| | Has child been evaluated for asthma or allergies? |
| | Anything make cough better or worse? |
Table 2-5
Sample Focused History: Mental Health
| Subjective | Questions to focus the history |
| “My child's behavior has become so difficult at home.” | Describe what you mean by “difficult behavior.” |
| | Does anything trigger these behaviors? |
| | What do you do when this behavior becomes “so difficult?” |
| | What is your child's response? |
| | Does this behavior pattern occur at school or outside the home, such as at a friend's house or relative's home? |
| | Has there been a change in your family lifestyle—such as parents arguing at home, parental separation, new family member living in the home? |
| | Has there been any change in your child's physical abilities–such as change in cognitive or psychomotor skills? |
| | Does your child complain of headaches? |
2. If significant changes are found in interval history, revise health promotion plan.
a. Example: If interval family history reveals family members have diabetes mellitus, evaluate and modify family/child exercise and dietary patterns.
3. If significant changes are found in interval history in relation to child's health, establish new health promotion plan with parent and child/adolescent active participation.
a. Example: If interval history reveals significant change in frequency of coughing and upper respiratory symptoms, complete a detailed focused history and establish a new health promotion plan.
BIBLIOGRAPHY
Bickley LS, Hoekelman RA.
Bates' Guide to Physical Assessment.
10th ed. Philadelphia, PA: Lippincott; 2008.
Burns CE, Dunn AM, Brady MA, et al.
Pediatric Primary Care.
4th ed. St. Louis, MO: Saunders; 2009.
Duderstadt KG.
Pediatric Physical Examination: An Illustrated Handbook.
St. Louis, MO: Mosby; 2006.
Johnson CP, Myers SA, and the Council on Children with Disabilities. Identification and evaluation of children with autistic spectrum disorders.
Pediatrics.
2007;120:1183-1215. American Academy of Pediatrics website:
http://www.aap.org/pressroom/AutismID.pdf
. Accessed June 1, 2011.
CHAPTER 3
Performing a Physical Examination
Mary Jo Eoff
I. INTRODUCTION
A. Pediatric physical assessment is a continual process that includes interviews, inspection, observation of children.
B. Physical growth, motor skills, cognitive, and social development change as the child matures.
C. The assessment of the pediatric patient must include what is considered to be normal within the child's age limits.
D. Children will differ among themselves at various stages of development.
E. The following is an outline that can be used as a guide in doing a comprehensive physical assessment.
II. PEDIATRIC PHYSICAL EXAMINATION
A. Growth measurements.
1. Length/height.
a. Recumbent (2 years).
b. Standing height.
2. Weight.
3. Head circumference (occipital frontal circumference [OFC]).
4. Chest circumference (up to 1 year).
5. Skinfold thickness.
B. Vital signs.
1. Temperature, heart rate, respirations, blood pressure.
C. General appearance.
1. Cleanliness, posture, hygiene.
2. Nutrition.
3. Behavior, ability to cooperate.
4. Development.
5. Alertness.
D. Skin.
1. Color: pallor, cyanosis, erythema, ecchymosis, petechiae, jaundice.
2. Texture.
3. Temperature.
4. Turgor.
5. Describe size, shape, and location of rashes, eruptions, and lesions.
6. Sweating.
E. Hair: color, texture, quantity, distribution, infestations (nits).
F. Nails.
1. Inspect color, texture, quality, distribution, hygiene.
2. Observe for nail biting.
G. Hands and feet.
1. Observe flexion crease on palm.
2. Assess for foot and ankle deformities.
H. Lymph nodes.
1. Palpate for nodes in following areas:
a. Submaxillary.
b. Cervical.
c. Axillary.
d. Inguinal.
2. Note size, mobility, or tenderness of any enlarged node.
I. Head.
1. Assess shape and symmetry.
2. Assess head control; should be well established by 6 months of age.
3. Palpate skull.
a. Fontanels (2 years of age).
b. Suture ridges and grooves (up to 6 months of age).
c. Nodes.
d. Any swelling.
4. Examine scalp for hygiene, lesions, signs of trauma, loss of hair, or discoloration.
5. Percuss frontal sinuses (children 7 years of age).