Professional Documents
Culture Documents
Pediatric Assessment 1 12 PDF
Pediatric Assessment 1 12 PDF
Pediatric Assessment 1 12 PDF
College of Nursing
Cebu City
PEDIATRIC ASSESSMENT
(1 month to 12 years)
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
1
V. FEEDING HISTORY
2
X. FAMILY HISTORY (insert the Genogram at the back of this page)
J. General
__ Unusual weight loss __ fatigue
__ Temperature sensitivity
3
PEDIATRIC PHYSICAL EXAMINATION
Name of Patient _______________________ Date of Birth ____________
1.
VITAL SIGNS
3. SKIN:
4. HEAD/EARS/NECK/THROAT
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 : ______________________________________________________
4
6. EARS
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 : ______________________________________________________
jalim11
5
8. MOUTH/THROAT
Comments: _______________________________________________________
9. RESPIRATORY/THORAX
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
Comments: _______________________________________________________
jalim11
6
11. GASTROINTESTINAL
Abdomen:
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: _____
7
Females & Males: Pubic Hair Male Genitalia Changes Breast Changes in Females
PH 1 No change G1 Testes volume <1.5 B1 Prepubertal breast with areola
Phallus childlike confined to the general chest line.
PH 2 Some slightly pigmented downy Testes 1.6 cc 6 cc Breast bud with some amount of
hair along the base of the Scrotum reddened, thinner, glandular tissue, areola widens
G2 B2
scrotum and phallus (male) or Larger
labia majora (female) Phallus no change
PH 3 Moderate amount of curly, Testes 6 cc 12 cc Breast is larger and more elevated
pigmented and coarse hair Scrotum more enlargement extending beyond areolar limit;
G3 B3
extending laterally areola continues to enlarge but
remains in contour with breasts
PH 4 Resembles adult hair in Testes 12 22 20 cc Breast is larger, more elevated;
curliness ad coarseness but Scrotum further enlargement, areola and papilla form a mound
G4 B4
does not extend to the medial darkened projecting form breast contour.
thigh. Phallus longer with increased
circumference
PH 5 Adult type extending to medial G5 Testes - > 20 cc. B5 Breast is adult size; areola and
thigh Scrotum & Phallus adult size breast on the same plane and
papilla projecting above areola.
13. NEUROLOGIC
B. Mental Status :
__ Awake __ Conscious __ Drowsy
__ Stupurous __ Coma __ Oriented
__ Disoriented
jalim11
8
II. Cranial Nerves:
III. Cerebellar:
IV. Sensory:
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
jalim11
9
14. REFLEXES
Priitive Reflex: __ NA
15. MUSCULOSKELETAL:
Comments: _______________________________________________________
jalim11
10
11