PEDIATRIC HISTORY TAKING & PE SIMULATION

STUDENT’S TASK DONE NOT DONE

Greets the informant and the patient
Introduces oneself as a junior intern of SBUM
Asks the name of the informant and the patient

Answer: Ako po si _______, and pangalan ng pasyente ay

____
Asks the relationship of the informant with patient.

Answer: Ako po ay __________

Asks about the general data of the patient

How old is the patient?

Where do they live
Religion
Birthday

Answer: 10 months old, female

Asks if this is the first time to consult

Answer: OPO
Asks for the chief complaint ( Ano po ang dahilan ng pag
punta niyo ditto or pagpapa check up?

Answer: Rashes
Asks about the history of present illness.
1) When did the rashes start?
2) Where did the rashes start?
3) Asks to describe the rashes?
4) Asks for other associated signs and symptoms such as
fever, cough and colds, lbm and vomiting
5) Asks if the rashes were itchy or pruritic
 6) Asks whether consultation was done or medications
applied?

Answer:
One week PTC, I noted multiple small vesicular lesions with
erythematous base on patient’s left outer ear. (-) aural
discharge, (-) colds, (-) fever noted. No other skin lesions
No medications given

4 days PTC, occurrence of multiple small vesicular lesions at

the base of the nose
(+) erythematous and crusted lesions on left ear

3 days PTC, Occurrence of multiple small vesicular lesions on

both inferior nostrils
(-) nasal discharge, (-) colds, (-) fever noted.
(+) erythematous and crusted lesions at the base of the nose

1 day PTC, Lesions inferior nostrils became erythematous and

crusted
(-) nasal discharge, (-) colds, (-) fever
No medications given
Persistence of symptoms led to consult.
7) Asks for the Review of Systems:

Answer:
General: (-) weight loss, (-) night sweats
HEENT: (-) excessive tearing, (-) nasal discharge, (-)
aural discharge,
Respiratory: (-) cough (-) dyspnea
Genitourinary: (-) hematuria
Musculoskeletal: (-) joint stiffness, (-) swelling,
Hematopoietic:
(-) abnormal bleeding, (-) easy bruisability, (-) pallor
Neurologic/:
(-) seizures, (-) loss of consciousness

8) Asks about the maternal history

ANSWER:
• Maternal age 24; G1P1 (1-0-0-1)
• Illness: none
• Pre-natal care: (+), hospital
• Diet: adequate, 3x/day
• Meds: iron and folic acid
• (-) alcohol, (-) smoking, (-) exposure to xray
 9) Asks about the birth history:

ANSWER:
• Caesarian section
• Gestational age: 42 weeks
• Birth wt: 8.9 kg
• BL and HC: unrecalled
• Complications: (-)
• Newborn and hearing screening: normal

10) Asks about the Developmental Milestones

Answer:
• GROSS MOTOR:Crawls and to stand, can cruise
around furniture
• FINE MOTOR: With thumb and forefinger
apposition, holds bottle
• LANGUAGE: Can say “mama” or “dada”
• SOCIAL: Waves bye-bye

11) Asks about the nutritional history

Answer:
• Breastfeeding
– Still breastfed
– Duration of exclusive breastfeeding: 1 month
– Frequency: once a day
– Duration of feeding per breast: 30mins
• Complementary feeding
– Introduced at 6 months
– Frequency: 3x/day
– Rice porridge
12) Asks about the immunization history

Answer:
Vaccine Date Given

BCG Birth
 Hep B Birth
Unrecalled
Unrecalled
Unrecalled

DPT/DTaP Unrecalled
Unrecalled
Unrecalled

OPV/IPV Unrecalled
Unrecalled
Unrecalled

Hib Unrecalled
Unrecalled
Unrecalled

Measles Not yet given

MMR Not yet given

13) Asks where the vaccines were given and if there were
untoward incidents or reaction.

Answer: Given in the health center and no reactions

14) Asks about the past medical history

Answer: No previous hospitalizations, surgeries, blood

transfusions, injuries, allergies and accidents
15) Asks about the family history

Answer:
▪ No other family member with the same illness
▪ (+) Asthma – sibling
▪ (-) HTN
▪ (-) DM
▪ (-) Allergy (seafood) – father
▪ (-) PTB
▪ (-) Thyroid disease
▪ (-) Cancer
 ▪ (-) Seizures

16) Asks about the social history

Answer:
• Source of Income: Father, Mother
• Primary caregiver: Aunt
• Family Relationships: Harmonious
• Residence: Adequate, well-lit and well-ventilated one
storey house with good source of drinking water
17) Asks about environmental exposre

Answer:
▪ Recent Travel: none
▪ Tobacco: none
▪ Pet: (+) dog
▪ Exposure to covid patient or in the community
18) Recaps the history and asks the informant if the data
gathered was correct.

PHYSICAL EXAMINATION

STUDENT’S TASK DONE NOT DONE

1) Asks permission to
examine the patient

2) Sanitizes the hands

before touching the
patient

3) States that they will

check first the
General Survey
Vital Signs
Anthropometric
Measurements

Answer:
• General Survey: active,
alert, not in
cardiorespiratory
distress, well
nourished, well
hydrated
• Anthropometrics:
 o Wt= 7.6kg
(below 0)
o Lt = 73cm
(below 0)
o HC = 47cm
(below 0)
o WFL (below -1)
• Vital signs: CR: 101
bpm, RR: 20 cpm
regular, Temp: 37.1˚C

4) State that they will

check the
SKIN
HEAD
EYES
EARS
NOSE
MOUTH
NECK
CHEST/LUNGS
HEART
ABDOMEN
GENITALIA
EXTREMITIES
PULSES
ANSWER:

• Skin: honey-colored
crusting with
erythematous base on
left ear, base of the
nose and nostril, moist
skin, with good skin
turgor, (-) jaundice, no
pallor, no cyanosis

• Head: generalized
distribution of hair, no
deformities, (-) masses,
(-) lesions

• Eyes: (-) matting of eye

lashes; anicteric
sclerae; pink palpebral
conjunctivae; pupils 2-3
mm, ERTL; (-)
periorbital edema, (-)
 redness, (-) excessive
tearing

• Ears: Normal set ears,

(-) preauricular skin
tags, (-) gross
deformities, (-) tragal
tenderness, (+)
retained cerumen AD,
non-hyperemic EAC;
tympanic membrane
intact; (-) aural
discharge

• Nose: Midline nasal

septum, (-) alar flaring,
(+) clear watery nasal
discharge, turbinates
not congested

• Mouth: moist buccal

mucosa, (-) oral ulcers,
non-hyperemic
posterior pharyngeal
wall, uvula midline,
tonsils not enlarged

• Neck: thyroid not

enlarged, no palpable
cervical
lymphadenopathies

• Chest/ Lungs: No
deformities,
symmetrical chest
expansion, no use of
accessory muscles of
respiration, no
retractions, no
tenderness, no lagging,
resonant on
percussion, clear
breath sounds

• Heart: neck veins not

distended, adynamic
precordium, apex beat
 4th left intercostal
space midclavicular
line, (-) RV heave, (-)
thrills, (-) lifts, no
murmurs

• Abdomen: soft, flabby

abdomen, no visible
pulsations, no visible
peristalsis, no scars,
normoactive bowel
sounds 7/min,
tympanitic on all
quadrants, no palpable
masses

• Genitalia: normal
looking
• Extremities: (-)
Clubbing, (-) cyanosis;
(-) edema

• Pulses: +2 pulses on all

extremities

5) States that they will do

the neurologic exam
Answer: normal
** says “ thank you to the
informant for allowing to be
interviewed and examine the
patient.
** Asks the informant if they
have any other concerns they
would like to discuss
** Explains the initial
impression to the informant.

Answer: IMPETIGO

FEEDBACK: tell the student what they were able to do good during the interview, followed by
what they can improve on. Then followed by positive comments again.