PRECEPTORIAL # - “BLOCK NAME” HISTORY AND PHYSICAL EXAMINATION

Historian: Date: Month Day, Year

I. GENERAL DATA
Pt’s Name
(Chronologic) Age
Sex
Date of Birth
Place of Birth
Nationality
Religion
Address
Ward
Admission/s
Hospital
Date History Taken

Informant
Relation to Pt
Reliability

II. CHIEF COMPLAINT

One symptom only.

III. HISTORY OF PRESENT ILLNESS

Symptom with its onset duration, Attributes of the symptom (location, Treatment done by the Pt, if with relief,
events, and for how long it has quality, quantity or severity, timing, and Pt’s thoughts and feelings about the
persisted (from earliest to latest) setting, and aggravating factors) course of illness
Use mk dose for pediatric medications.
 Pull in the pertinent positives and negatives from the Review of Systems that are relevant. Other information may be relevant such as
risk factors for coronary artery disease in Pts with chest pain, or current medications in Pts with syncope. Symptoms NOT signs. Some
examples were only written as signs for the sake of brevity.

General Weight changes, weakness, fatigue, fever

Cutaneous Changes in skin and nails
HEENT Headache, dizziness, lightheadedness,
vision, redness, cataracts, hearing, ear
infections, tinnitus, vertigo, colds,
stuffiness, teeth and gums,
Neck Swelling, lumps, stiffness
Breasts Lumps, pain, discharges
Respiratory Cough, dyspnea, chest pain
Cardiovascular Palpitations, orthopnea, paroxysmal
nocturnal dyspnea, peripheral edema,
cyanosis, syncope
Gastrointestinal Trouble swallowing, heartburn, appetite,
nausea, bowel changes, abdominal pain
Genitourinary Urinary changes, discharges, menstrual
changes, sores, lumps
Musculoskeletal Muscle or joint pain, stiffness, weakness,
tenderness, limitation of motion
Neurologic Changes in mood, attention, speech,
fainting, paralysis, numbness, tremors,
seizures
Hematopoietic Anemia, easy bruising
Endocrine Heat and cold intolerance, excessive
sweating, thirst, hunger

IV. PAST PERSONAL HISTORY (Pediatric)

A. Prenatal/Gestational History
Diet and exercise
Prenatal vitamins
Ultrasound
Immunizations
Infections
Complications

B. Natal/Birth History
Birth description Mother delivered a full-term baby boy/girl at cephalic presentation via spontaneous delivery, weighing 3.5 kg at
birth (AGA).
APGAR Score
Amniotic fluid

C. Postnatal/Neonatal History
General changes Weight gain, jaundice, cyanosis
NBScreening
Infections
Hospitalizations

D. Feeding History
Type of Feeding and Appetite Duration and Volume Characteristics (dilution, etc.)
Early feeding history is not included in
childhood and adolescence unless it is
pertinent to present illness.
 E. Developmental/Behavioral History (<10 years old)
Or use the Denver II Test Form.
Gross Motor Skills Age Range of Attainment Age achieved (approximate)
Holds head steady while sitting 2-4 months
Pulls to sit, with no head lag 3-6 months
Brings hands together at midline 2-4 months
Bear weight on legs 2-4 months
Sat without support 5.5-7 months
Rolled over 2-5.5 months
Stand holding on 6.5-8.5 months
Pull to stand 8-10 months
Stand for 2 seconds 9.5-11.5 months
Run 15 months
Walk upstairs with rails 18 months
Jump with both feet 1 year
Jump forward 3 years
Ride a tricycle 3 years
Hop 4 years
Skip 5 years

Fine Motor-Adaptive Skill Age Range of Attainment Age achieved (approximate)

Grasp rattle 3-4 months
Hands together 2.5-4 months
Reaches 4-6 months
Thumb-finger grasp 7-10 months
Bang objects in hands 7-11 months
Spontaneous scribbling 15 months
Imitate stroke on paper 18 months
Imitate vertical lines 24 months
Draw circle with series of perseverating lines 30 months
Draw a circle or a person with 2 body parts 3 years
Draw a cross 3.5-4 years
Draw a square 4-4.5 years
Draw a triangle 5 years
Copy letters 6 years
Reverse some letters 6 years
Draw a person with 12 parts 6 years
Know right and left sides 7 years

Language Skill Age Range of Attainment Age achieved (approximate)

Vocalizes (ooh/aah) 4 weeks-3 months
Turn to voice 4-6 months
Imitate speech sounds 3-9 months
Speaks dada/mama 6-9 months
Combine syllables 6-10 months
One word 10-15 months
Two-worded phrases 1 year
Able to follow 2-step commands 1 year
3-4 worded sentences 3 years
Complete sentences 4 years
Understand concept of size 4 years
Understand concept of time 5 years
Follow 3-step commands 5 years
Verbalize emotions 6 years
 Personal and Social Skills Age Range of Attainment Age achieved (approximate)
Regard face From birth
Smiled responsively 3 weeks-2 months
Feed self 5-6.5 months
Indicate wants 7-12 months
Wave bye-bye 7-14 months
Imitate activities 10-16 months
Drink from cup 9-17 months
Dress under supervision 3 years
Dress independently or correctly 4 years
Do simple errands 5 years
Tie shoelaces 6 years

F. Developmental/Behavioral History (≥10 years old)

Home
Education
Activities
Drugs
Sexuality
Safety
Suicide/Depression

G. Past Illnesses (Pediatric)

Contagious Includes measles, rubella, mumps, whooping cough,
Diseases chickenpox, rheumatic fever, scarlet fever, and polio.
Also included are any chronic childhood illnesses.
Hospitalizations Include surgeries

Allergies Atopic diseases and food or drug sensitivities

Injuries Include effects of the injuries as well.

V. PAST MEDICAL HISTORY (Adult)

Childhood Includes measles, rubella, mumps, whooping cough,
Illnesses chickenpox, rheumatic fever, scarlet fever, and polio.
Also included are any chronic childhood illnesses.
Also put in allergies, surgeries, past admissions.
Adult Illnesses Medical, Surgical, Obstetric/Gynecologic, Psychiatric

Maintenance Immunizations, Screening tests, Medications

VI. IMMUNIZATION HISTORY (Pediatric)

Vaccine No. of Doses Date Place Reactions

BCG 1 At birth Present/None
Hepatitis B 1 At birth Present/None
DTP 3 6th, 10th and 14th week Present/None
OPV 3 6th, 10th and 14th week Present/None
Rotavirus 2 6th and 10th week Present/None
Pneumococcal 3 6th, 10th and 14th week Present/None
Measles 1 9th month Present/None
MMR 1 12th month Present/None
VII. FAMILY HISTORY
Family Member Specific Illnesses Age and Cause of Death Heredofamilial Diseases

VIII. SOCIOECONOMIC HISTORY (Pediatric)

Living Place and nature of dwelling, number of persons living in the house
Circumstances
Economic Working members of the family and sources of funds
Circumstances

IX. ENVIRONMENTAL HISTORY (Pediatric)

Detrimental Exposure to cigarette smoke and other environmental pollutants (with specific pollutants and duration of
Environmental exposure), garbage disposal, sewage disposal, and water source.
Factors

X. PERSONAL AND SOCIAL HISTORY (Adult)

Education
Occupation
Household
Interests/Lifestyle
ADL
Exercise/Diet
Safety Measures
Sexual Orientation
and Practices
Alternative Health
Practices
XI. PHYSICAL EXAMINATION
A. General Survey
Observe the Pt’s general state of health, height, build, and
sexual development; posture of comfort, any distress, motor
activity, and gait; dress, grooming, and personal hygiene
and any odors; facial expressions and manner, affect, and
reactions to people and the environment. Listen to the Pt’s
speech, and note the state of awareness or level of
consciousness, and for any chromosomal disorder or
dysmorphic features representing a syndrome.

Vital Signs Results Normal Values Interpretation

Blood Pressure
Respiratory Rate
Cardiac Rate
Pulse Rate
Temperature

Oxygen Saturation

Anthropometric Measurements Results Z-score Interpretation

Height OR Length (cm)
Weight (kg)
BMI (kg/m2)
Head Circumference (cm)
Chest Circumference (cm)
Abdominal Girth (cm)

B. Physical Assessment
Skin Moisture, temperature, cyanosis/pallor,
lesions, hair and nails
Head Scalp, skull, face
Eyes Visual acuity, position and alignment,
eyelids, sclera and conjunctivae,
extraocular movements
Ears Auricles, canals, and drums, acuity and if
absent, Weber and Rinne Test
Nose and sinuses Nasal mucosa, septum, turbinates,
tenderness of frontal and maxillary sinus
Throat Lips, oral mucosa, gums, teeth, tonsils,
and pharynx
Neck Cervical lymph nodes, masses,
pulsations, deviation of trachea, sound
and effort of breathing, thyroid gland
Back Spine and muscles, shoulder symmetry
Thorax and Lungs Inspect, palpate, percuss, level of
diaphragmatic dullness, bronchial,
bronchovesicular, and vesicular breath
sounds, rate and rhythm, retractions,
adventitious sounds, transmitted voice
sounds
Breasts, Axillae, Inspect breasts with arms relaxed then
and Epitrochlear elevated then pressed on her hips,
Nodes axillary and epitrochlear nodes
Cardiovascular Blood pressure on all limbs, inspect for
System precordial bulge, sternal deformities,
pulsations, vein engorgements, jugular
venous pulsation (elevate head -30°),
palpate peripheral pulses, rate, rhythm,
PMI, thrills and heaves, auscultation of
rpm, clicks, snaps, friction rubs.
Grade (3+ = bounding; 2+ = brisk,
expected (normal); 1+ = diminished,
weaker; 0 = absent, unable to palpate)
the pulses: brachial, radial, femoral,
popliteal, and pedal.
Abdomen Inspect, auscultate (30 bowel sounds per
min is normal), percuss for liver,
kidneys, palpate for aorta and pulses
Genitourinary Lumps, discharges, external and internal
examination, and bimanual (women),
penis and testicles (men), herniations
Musculoskeletal Muscle or joint pain, stiffness, weakness,
tenderness, limitation of motion

C. Ballard Score (Neonate)

 D. FOUR (Full Outline of UnResponsiveness) Score

XII. NERVOUS SYSTEM (Special attention)

Mental Status Exam
General behavior Normal, hyperactive, agitated, quiet, or
and appearance immobile? If the Pt neat or slovenly?
Dressing in accordance with age, peers,
sex, and background?
Stream of talk Rapid, incessant, under great pressure,
or is it slow and lacking in inflection and
spontaneity?
Mood affective Euphoric, agitated, inappropriately gay,
responses giggling or silent?
Content of thought Correctly perceives reality or have
illusions, hallucination, delusions,
obsessions?
Intellectual Bright, average, dull, or obviously
capacity demented or mentally retarded?
Sensorium Consciousness; attention span;
orientation for time, place, and person;
memory, recent or remote; calculation;
fund of information; insight, judgment,
and planning
 Cranial Nerves Exam
Cranial Nerves Function Response
CN I Sense of smell Check for patency first. Use simple odors (e.g. peel of orange) and let the Pt
identify the smell with each nostril with eyes closed.
CN II Visual Acuity, Fields, and Have the Pt track an object and describe (usually a colored ball or a toy),
Ocular Fundi follow movement of fingers, and use a Snellen Eye Chart at 14 inches away.
CN II, III Pupillary Reactions Penlight for pupillary evaluation.
CN III, IV, VI Extraocular movements Use a colored object to track the 6 fields of cardinal gaze. A parent may need
to hold the Pt’s head.
CN V Corneal reflexes, facial Check for corneal reflexes and have the Pt close their eyes to test for
sensation, and jaw ophthalmic, maxillary, and mandibular sensation.
movements Have the Pt clench the teeth and chew or swallow some food.
CN VII Facial Movements Make the Pt grimace or smile.
CN VIII Hearing, Spatial Orientation Use tuning fork, music toys to elicit reflex response.
CN IX, X Swallowing See feeding gag reflex, assess quality of cry or speaking voice, rise of palate.
CN V, VII, X, XII Voice and speech Hoarseness, nasal quality, phonation.
CN XI Head Movement Shoulder and neck movements.
CN XII Tongue Movement Tongue symmetry, position, and movement.

Motor System
Inspection Posture, general activity level, tremors, and
other involuntary movements
Palpate Atrophic, hypertrophic; with tenderness or
muscles spasms
Strength Scapular winging; biceps, triceps, wrist Grade strength on a scale from 0 to 5 or describe as paralysis or
Testing dorsiflexors, grip, finger abduction, and severe, moderate, or minimal weakness, or normal. Record the
extension; umbilical migration during a sit pattern of any weakness such as proximal versus distal, right versus
up; hip flexors, abductors, knee flexors, left, or upper extremity versus lower extremity.
dorsiflexors, invertor’s and evertors
Muscle tone Manipulate the joints to test for spasticity,
and range of clonus, rigidity or hypotonia, and range of
movements movements
Percussion of Percuss the thenar eminence for percussion
muscle myotonia and test for a myotonic grip if the
Pt has generalized muscular weakness
Skin and Beevor’s sign (T8-T9), Cremasteric reflex
muscle (afferent L1, efferent L2), anal pucker
(superficial) reflex (S4-S5), bulbocavernosus reflex (S3-
reflexes S4), and plantar reflex (Babinski’s
maneuver; afferent S1; efferent L5-S1-S2)

Sensory System
Pain Let the Pt differentiate between sharp or
dull sensation.
Temperature This test is often omitted when pain
sensation is normal.
Light Touch Use a fine wisp of cotton and avoid testing
calloused skin
Vibration Use a relatively low-pitched tuning fork of
128 Hz. Tap it on the heel of your hand and
place it firmly over a distal interphalangeal
joint of the Pt’s finger, then over the
interphalangeal joint of the big toe.
Analgesia refers to absence of pain sensation, hypalgesia refers to
decreased sensitivity to pain, and hyperalgesia refers to increased
pain sensitivity.
Anesthesia is absence of touch sensation, hypesthesia is decreased
sensitivity to touch, and hyperesthesia is increased sensitivity.
Vibration sense is often the first sensation lost in a peripheral
neuropathy and increases the likelihood of peripheral neuropathy 16-
fold.
Causes include diabetes, alcoholism, and posterior column disease,
seen in tertiary syphilis or vitamin B12 deficiency.
 Proprioception Grasp the Pt’s big toe, holding it by its Loss of position sense, like loss of vibration sense, is seen in tabes
(Joint Position sides between your thumb and index finger, dorsalis, multiple sclerosis, or B12 deficiency from posterior column
Sense) then pull it away from the other toes. disease, and in diabetic neuropathy.
Demonstrate “up” and “down” as you
move the Pt’s toe clearly upward and
downward. Then, with the Pt’s eyes closed,
ask the Pt to say “up” or “down” when
moving the large toe in a small arc.
Discriminative Stereognosis, Number identification
Sensations (graphesthesia), two-point discrimination,
point localization, extinction

XIII. Reflexes (Pediatric)

Reflexes How to Illicit
Palmar Grasp Put a finger in the infant’s hand
Plantar Grasp Touch the sole at the base of the toes
Rooting Stroke the lip of the corner of the cheek of the infant with a finger
Sucking Bottle-feed the infant
Moro Reflex Support the infant behind the upper back of one hand and then drop the infant back 1 cm
Asymmetric Tonic Neck With baby supine turn head to one side holding jaw over shoulder
Landau Suspend the baby prone with one hand
Trunk Incurvation Support the baby prone with one hand and stroke one side of the back 1cm from midline from shoulder
(Galant’s) to buttocks
Glabellar Tap gently over the forehead
Neck-righting Turn the infant’s head sideways
Stepping Let the infant assume a posture close to standing

XIV. Reflexes (Adult)

Scale for grading reflexes: 5 – sustained clonus, 4 – very brisk, hyperactive, and with clonus; 3 – brisker than average; 2 –
average, normal; 1 – somewhat diminished, low normal; 0 – reflex absent.
Reflexes How to Illicit Remarks
Jaw Jerk (CN V) With the Pt’s jaw sagging loosely open, rest a finger across the tip
and strike it a crisp blow.
Biceps The Pt’s elbow should be partially flexed and the forearm pronated Observe flexion at the elbow, and
(C5, C6) with palm down. Place your thumb or finger firmly on the biceps watch for and feel the contraction
tendon. Aim the strike with the reflex hammer directly through your of the biceps muscle.
digit toward the biceps tendon.
Brachioradialis The Pt’s hand should rest on the abdomen or the lap, with the Watch for flexion and supination
(C5, C6) forearm partly pronated. Strike the radius with the point or flat edge of the forearm.
of the reflex hammer, about 1 to 2 inches above the wrist.
Triceps Flex the Pt’s arm at the elbow, with palm toward the body, and pull Watch for contraction of the
(C7, C8) it slightly across the chest. Strike the triceps tendon with a direct triceps muscle and extension at the
blow directly behind and just above the elbow. elbow.
Finger Flexion (C7-T1) Tromner’s method. The examiner supports the patient’s completely
relaxed hand and briskly flips the patient’s distal phalanx upward, as
though to flip a handful of water high into the air. The patient’s
fingers and thumb flex in response to the stretch of the finger flexor
muscles.
Hoffman’s method. The examiner depresses the distal phalanx and
allows it to flip up. The extension of the phalanx stretches the flexor
muscles, causing the fingers and thumb to flex. This method is
effective only with very brisk muscle stretch reflexes.
Quadriceps (Patellar) The Pt may be either sitting or lying down as long as the knee is Note contraction of the quadriceps
(L2, L3, L4) flexed. Briskly tap the patellar tendon just below the patella. Place with extension at the knee.
your hand on the Pt’s anterior thigh.
Achilles (Ankle) If the Pt is sitting, partially dorsiflex the foot at the ankle. Persuade Watch and feel for plantar flexion
(Primarily S1) the Pt to relax. Strike the Achilles tendon. at the ankle.
Abdominal Test the abdominal reflexes by lightly but briskly stroking each side Note the contraction of the
of the abdomen, above (T8, T9, T10) and below (T10, T11, T12). abdominal muscles and movement
Abdominal reflexes may be absent in both central and peripheral of the umbilicus toward the
nerve disorders. stimulus.
Toe Flexion (S1-S2) Rossolimo’s sign. A muscle stretch reflex. The maneuver is identical
with the finger flexion method. Tapping the ball of the foot also
elicits toe flexion.
Plantar Response Stroke the lateral aspect of the sole from the heel to the ball of the Dorsiflexion of the big toe is a
(L5, S1) foot, curving medially across the ball. positive Babinski response, arising
from a CNS lesion affecting the
corticospinal tract.
Anal Using a broken applicator stick or pinprick, lightly scratch the anus Watch for reflex contraction of the
(S2, S3, S4) on both sides. external anal sphincter.

XV. Cerebellar Exam

Test How to Illicit Remarks
Rapid Alternating Arms. Show the Pt how to strike one hand on the thigh, raise the Observe the speed, rhythm, and
Movements hand, turn it over, and then strike the back of the hand down on the smoothness of the movements.
same place. Urge the Pt to repeat these alternating movements as Repeat with the other hand.
rapidly as possible. The nondominant hand may
Fingers. Show the Pt how to tap the distal joint of the thumb with perform less well.
the tip of the index finger, again as rapidly as possible.
Legs. Ask the Pt to tap the ball of each foot in turn as quickly as
possible on your hand or the floor. Note any slowness or
awkwardness. Normally the feet do not perform as well as the hands.
Point-to-Point Arms: Finger-to-Nose Test. Ask the Pt to touch your index finger Observe the accuracy and
Movements and then his or her nose alternately several times. Move your finger smoothness of movement, and
so that the Pt has to change directions and extend the arm fully to watch for any tremor.
reach your finger.
Now hold your finger in one place so that the Pt can touch it with Normally the Pt
one arm and finger outstretched. Ask the Pt to raise the arm overhead touches the examiner’s finger
and lower it again to touch your finger. After several repeats, ask the successfully with eyes open or
Pt to close both eyes and try several more times. Repeat on the other closed. These maneuvers test
side. position sense and the function of
Legs: Heel-to-Shin Test. Ask the Pt to place one heel on the both the labyrinth of the inner
opposite knee, then run it down the shin to the big toe. Observe this ear and the cerebellum.
movement for smoothness and accuracy. Repetition with the Pt’s
eyes closed tests for position sense. Repeat on the other side.
Gait Walk across the room and come back. Observe posture, balance, Normally balance is intact, the
swinging of the arms, and movements of the legs; Tandem walking: arms swing symmetrically at the
walk heel-to-toe in a straight line; Walk on the toes, then on the sides and turns are smooth.
heels; Hop in place; Do a shallow knee bend; Rise from a sitting
position and step up on a sturdy stool
Stance The Romberg Test: This is mainly a test of position sense. The Pt Note the Pt’s ability to maintain an
should first stand with feet together and eyes open and then close upright posture. Normally any
both eyes for 30 to 60 seconds without support. Test for Pronator swaying is minimal.
Drift. The Pt should stand for 20 to 30 seconds with eyes closed and Normally Pts hold this arm
both arms held straight forward with palms up. position well.
 XVI. Meningeal Signs
Test for these important signs whenever you suspect meningeal inflammation from meningitis or subarachnoid hemorrhage.
Meningeal Signs How to Illicit Remarks
Neck Mobility/Nuchal With the Pt supine, place your hands behind the Pt’s head and flex
Rigidity the neck forward, if possible until the chin touches the chest.
Normally the neck is supple, and the Pt can easily bend the head and
neck forward.
Brudzinki Sign As you flex the neck, watch the hips and knees in reaction to your
maneuver. Normally they should remain relaxed and motionless.
Lasegue’s Sign The Pt lies supine with the legs relaxed. Grasp the calf or heel of the
affected limb, dorsiflex the foot, and elevate it gently as far as
possible, flexing the hip while keeping the knee straight.
Both maneuvers stretch the sciatic nerve and elicit pain if the nerve
roots are inflamed, compressed, or imprisoned by a mechanical
lesion.
Kernig Sign Flex the Pt’s leg at both the hip and the knee, and then slowly extend
the leg and straighten the knee. Discomfort behind the knee during
full extension is normal but should not produce pain.