SUPPLEMENTAL HANDOUT 1

COMPONENTS OF THE HISTORY OF INFANTS AND OLDER CHILDREN

A. PEDIATRIC CLINICAL HISTORY GUIDELINES AND PROCEDURES

Overview:
Each of the components of a pediatric history are discussed here. Additional information is
likewise included to elaborate the concepts. This serves only as a guide. In your final report, ALL
components should be written in PARAGRAPH form except for the ROS, immunization history
and developmental history.

PARTS
DESCRIPTION & COMPONENT
OF THE ADDITIONAL REMARKS
OF EACH PART
HISTORY
I. General Full name
Data Age Include birthdate & birth place
Sex
Handedness Determined for children >7y/o
Race Or ethnicity
Religion
Present address/ Residence
Date & time of consult or admission Include number of times admitted
Name of informant & relation to patient
Reliability of the informant (in %) Reliability of the informant depends on the ff. factors:
a. Relationship to patient
b. If informant is the primary caregiver of the patient
c. Educational attainment
Sample:
Juana De La Cruz, 7years 1 month old, born on February 14, 2009 at Dasmarinas, Cavite, female, right handed, Filipino,Catholic,
presently residing at Blk5 Lot8 Amalfi Homes Subdivision, Paliparan Dasmarina City, Cavite, consulted for the 1st time at De La Salle
Medical Center outpatient clinic at 9:30AM. Informant is patient’s mother, Nelia De La Cruz with a 100% reliability.
II. Chief The most important symptom which prompted the • Preferably limited to one symptom
complaint consult • The answer to the question, “why was the patient
brought to the hospital?”
• Should not include diagnostic terms or names of
diseases
• Give the exact words of the informant whenever
possible
Samples:
“ubo”, “ubo at sipon”, “masakit ang tiyan”; “mahinang kumain”; “mataas na lagnat”, “sobrang likot”; well baby check up, immunization, for
follow-up
III. Steps in doing a complete HPI: • May be in months/ days/ hours/ age of patient at
History 1. Determine the specific time of onset of the time of occurrence
of symptoms prior to present consult
Present 2. Describe in chronological order the symptoms • Determine which symptom was experienced 1st ,
Illness experienced by the patient then give an accurate description of that symptom
(HPI) before describing the other associated symptoms
3. Elaborate on the symptoms as to:
*Based on a. Onset • Acute or chronic
the HPI
alone, the
b. Character • Important to include: quality, description,
physician frequency, extent, time of the day it occurs,
should precipitating factors
already • For pain as a symptom, describe as to:
have an o Location, radiation
initial o Description (colicky, gnawing, burning, etc)
impression o Severity using the pain scale & whether it
and interferes with activities
differential o frequency
diagnosis c. Aggravating and relieving factors • May be position assumed, activity, weather,
exposure to dust/ smoke/ other aero-allergens &
food, medications taken
d. Medications given and its effects • Generic and brand names
• Actual dose (mg/kg/day or mg/kg/dose)
• Duration of treatment
e. Previous medical consults done for the • Include any outside medical treatment,
present illness consultations or hospitalizations
• Find out where the child is getting medical care
prior to visit and the reason for change
 4. Associated symptoms • Must be described as to: onset, course,
chronology, intensity
• If the history suggests a particular disease, inquire
about signs & symptoms characteristic of this
disease
• Pertinent positives & negatives are of value in the
differential diagnosis
Sample:
The patient was apparently well until 1 month prior to consult when she experienced cough described as productive with mucoid,
yellowish, non-blood tinged phlegm on expectoration, non-paroxysmal, occurring anytime of the day with no precipitating factors noted.
The cough was noted to be aggravated by changes in weather and exposure to cigarette smoke and was temporarily relieved by
drinking a glass of water. Associated symptoms include fever characterized as intermittent, with temperature range of 38-38.5 C, usually
occurring at night, relieved by intake of Paracetamol (Tempra) 250mg/5ml syrup taken at 5ml every 4 hours (at 10mg/kg/dose). There
were no dyspnea, tachypnea, colds, sore throat, headache, loss of appetite nor body weakness noted. There were no medical consults
done nor other medications taken. This condition persisted for the following 2 weeks.
Two weeks prior to consult, there was worsening of the patient’s cough now with disturbance in sleep noted, but with the same
character of the phlegm. Fever of same character was still present. Other associated symptoms include loss of appetite, weight loss of
about 0.5kg and body weakness. The patient was then brought to the local health center where she was given the following medications:
Amoxicillin (Himox) 250mg/5ml suspension taken 5 ml 3x/day (at 30mg/kg/day), Carbocisteine (Solmux) 200mg/5ml syrup taken 5 ml
3x/day and advised to continue Paracetamol. However, there was no improvement in the symptoms noted despite good compliance for
the following 7 days. There were no pleuritic chest pain, dyspnea, tachypnea, orthopnea, urinary disturbance nor changes in sensorium.
This condition persisted for the following week.
On the day of consult, the patient was noted to have worsening of her chronic cough with the same associated symptoms of fever,
loss of appetite, body weakness and weight loss. Thus, her mother brought her to the OPD for another medical consult.
Note 1:
• For re-admissions: if previously admitted in a • This will now constitute the HPI
hospital or had OPD consults that appear related to • Previous admissions not related to the HPI are placed
the HPI, summarize the pertinent information under the Past medical history
(including pertinent laboratory date and results if • If the previous admissions are related to the present
known and the final diagnosis) illness, these should be written in the first part of the
• Following this comes the Interval history which paragraph of the HPI
describes the course of illness since the last hospital
admission/ consult related to the present illness
• And then elaborate on the present symptoms and
associated manifestations on the present admission
Sample:
The patient was previously admitted in another hospital 3 months prior to consult due to pallor. She stayed in the hospital for 7
days, referred to a pediatric hematologist and was worked up as a case of Acute leukemia. Laboratory work-ups including a bone
marrow aspirate test all confirmed the final diagnosis of Acute lymphocytic leukemia. Blood transfusion and the first cycle of
chemotherapy was done prior to discharge of the patient.
Interval history revealed that patient had improved wellbeing from time of discharge described as actively playing, with good appetite
and had no symptomatic complaints. There was no pallor, headache, fever, cough, colds, body weakness nor bone pains noted. This
condition persisted for the following 3 months.
However, 2 days prior to admission, the patient was noted to have… (describe present symptoms)
Note 2: • Include time of diagnosis, maintenance meds, follow-
• If the patient is a diagnosed case of any congenital ups, last attack/ admission
or chronic illness, then it should be stated in the 1st
part of the HPI
Sample:
The patient is a diagnosed case of Bronchial asthma since he was 2 years old. His last asthma attack was noted last month. He is
on the following maintenance medications: Montelukast (Kastair) 5mg chewable tablet taken 1 tablet once a day and Salmeterol
fluticasone (Seretide) inhaler, 2 puffs 2x/day. Regular consults with a pediatric pulmonologist done.
Then describe present symptoms experienced by the patient…

IV. • This is an elaboration of data not covered in • Reported by organ system

Review the HPI • Ask only symptoms that are applicable to the age
of • This will help uncover symptoms in other of the patient
Systems organs/ systems that may be related to the
(ROS) present illness
• Included are symptoms not mentioned in the
HPI but which are still important in arriving at a
diagnosis
Included are the following systems and its corresponding symptoms:
System Symptoms
(Ask only symptoms applicable to the age of the patient)
General weight loss weight gain loss of poor delay in
appetite activity growth
Skin rash pigmentation hair loss acne pruritus
Head-Eyes-Ears- headache vision hearing frequent toothache
Nose dizziness difficulties difficulties colds dental
use of ear pain nasal caries
glasses ear discharge use of
lacrimation discharge epistaxis braces
Neck & Throat mass muscle frequent
lymphadenopathy stiffness sore throat
Cardiovascular cyanosis orthopnea fainting easy palpitations
spells fatigability
 Respiratory cough dyspnea chest pain
Gastrointestinal vomiting abdominal encopresis food passage of
diarrhea pain jaundice intolerance worms
constipation
Genitourinary dysuria frequency discharge enuresis edema
Endocrine cold heat polyuria polydipsia polyphagia
intolerance intolerance
Nervous/ seizures weakness sleep behavioral memory
Behavioral eating mood problems changes loss
problems changes temper personality hallucinations
outbursts changes
Musculoskeletal myalgia joint pains joint limping limitation of
swelling motion
Hematopoietic pallor bleeding easy
bruisability
V.
Birth and Divided into these 3 components: 1. Prenatal 2. Perinatal and 3. Postnatal
Maternal
History
PRENATAL
Obstetric Score: ___ y/o G___ P ____ (___ ____ ___ ___)
Paternal Age:
Pregnancy Planned Unplanned
No. of Prenatal consults:
Maternal Illnesses:
None Bleeding/spotting Infection/ fever PROM Hypertension Diabetes Others:
Exposure to toxigens/substances:
None Alcohol Cigarette Radiation Prohibited drugs Substance abuse Others
Work-ups done:
None Ultrasound Amniocentesis CBC Urinalysis OGCT/OGTT Others
Hospitalization:
Medications:

PERINATAL
Duration & Details of Labor: Complications: None
Use of anesthetics: Yes No

POSTNATAL
Born: Type of Delivery: Place of Delivery: Attendant at Birth:
Term Normal / Vaginal Hospital Doctor
Pre-term Caesarian Section Lying-in clinic Nurse
Post-term Forceps Health Center Midwife
AOG: ______ wks Induced labor Home Traditional birth
attendant
Details of Delivery/Reason if C/S: Apgar Score: __________
BW: ______ kg HC: ______ cm
BL: ______ cm CC: ______ cm
AC: ______ cm
Admitted at NICU? Yes No Problems after delivery
Reason: None Sx of HIE (seizures,
Hospital: Poor activity irritability, coma,
Attending Physician: Feeding difficulties hypotonia, stupor)
Newborn Hearing Eye/Retinal Exam Cyanosis Congenital
Screening Screening Pallor abnormalities
Done ____________ Jaundice Birth Injury
Done Done Not Done Infection Brain imaging
____________ __________ Respiratory Problem (hemorrhage,
Not Done Not Done Need for oxygen hydrocephalus,
oxygen/ventilator structural anomaly)

VI.
Past Elicit the following factors and give details if present. State the age when contracted, it’s severity and
Medical complications.
History
Factors to include: Details
Past Illnesses None Measles Mumps Chickenpox
Past hospitalizations Yes. Details:
No
Operations/Surgeries & Injuries Yes. Details:
No
Medications Yes. Details:
No
VII.
Family This should encompass: 1. Any similar illness in the family and 2. History of heredofamilial diseases.
History
Condition Details
None Behavior problems (ADHD,ODD, CD) Alcohol addiction
Allergies/Atopy Congenital defects/ Genetic Drug addiction
Disorders
Asthma Developmental Disorder Emotional problems
Cancer (Autism, Asperger’s Disorder etc.) (Depression, anxiety, etc.)
Diabetes Hearing/Vision impairment Psychiatric Disorder
Heart disease Intellectual Disorder
Hypertension Learning difficulties Others:
Kidney disease (Reading, writing, spelling, math)
Lung disease Speech or language problem
Tuberculosis (Articulation, stuttering, etc.)
VIII.
Nutrition The following feeding history and practices should be reviewed:
al History
Feeding History Duration Complementary Feeding Current Feeding Practices
Breastfed Start of complementary Frequency of Usual consistency of food:
Formula feeding: _____ mos feeding/day Pureed Lumpy
Mixed Start of table food: Meals: Soft Table food
_____ mos Snacks:
Appetite: Food intolerance: No Yes Food preferences:
Good appetite Feeding difficulties: No Yes
Picky eater Multivitamins: No Yes

IX. Should include type of vaccines given, age when it was administered, reactions and complications (if any).
Immuni-
zation No. of Doses Age Given Reactions & Complications
BCG
History Hepatitis B
DPT
OPV/IPV
H. Influenza B
Pneumococcal
Rotaviral
Measles
MMR
Varicella
Influenza
Hepatitis A
Typhoid
Meningococcal
Others:

X. The following fundamental streams of development should be reviewed to screen any developmental
Develop- problems:
mental 1. Gross motor: Gross motor milestones focus on posture and large movements. The pattern follows a cephalocaudal route
and is dependent on the integrity of the nervous system, musculoskeletal system and the opportunity to execute certain skills.
History
2. Fine motor: Fine motor milestones are concerned with eye-hand coordination, object manipulation and problem-solving skills.
The pattern follows a proximo-distal route.
3. Language: Language milestones emphasize verbal expression (expressive language) and language comprehension
(receptive language). There are important prerequisites to language development such as intact auditory function, integrity o f
the oromotor structures, cognitive ability, and a stimulating environment. Language is the best predictor of later intelligence.
4. Personal-Social: Personal-social milestones involve self-help and adaptive skills and reflect the individual’s mastery over the
environment. It is related to environmental exposure and practice and, therefore, the most culturally-sensitive of all the
developmental streams.
Assess if the current skills of the child are at par with age by using the following steps:

1. Determine the exact age of the patient.

2. Focus on the particular age group and review its different developmental domains.
3. Once any developmental delay or concern is identified, it is vital to start reviewing the patient’s
acquisition of developmental milestones from the neonatal period.

Note: Any developmental delay or concern warrants further formal screening and referral to a
developmental specialist.
 Neonatal Period (0-28 days)
Domain Skills
Gross motor Prone: Arms/legs flexed; pelvis high
Ventral suspension: Head held below body
Supine: Arms/legs semi-flexed
Pull to sit: Complete head lag
Held upright: Legs extended
Fine motor Grasp reflex
Drop object immediately
Hands remain fisted
Sweeping movements towards object
Language Expressive: Crying/whimpering
Receptive: Startled by loud sound
Personal-social Gaze at faces, colored objects and bright lights

Infancy (0-12 months)

Domain Age Skills
Gross Motor 3 months Head hold
5 months Roll over
7 months Sitting
9 months Pull to stand
12 months Walk independently
Fine Motor 3 months Unfisted hands
5 months Midline hand play
7 months Transfer object from one hand to another
9 months Thumb-finger grasp
12 months Voluntary release (Throwing or bcasting
objects)
Expressive Language 3 months Cooing
6 months Babbling
9 months Mama/Papa non-specific
12 months Single words with meaning
Receptive Language 3 months Alert to human voice
6 months Localize sound
9 months Understand no
12 months Follow 1-step command with gesture
Toddler (1-3 years)
Domain Age Skills
Gross motor 15 months Run, pivot, walk backwards
18 months Walk upstairs with rails
24 months Jump with both feet
30 months Jump forward
Pedal tricycle
Fine motor 15 months Spontaneous scribbling
18 months Imitate stroke on paper
24 months Imitate vertical lines
30 months Draw a circle with series of perseverating
lines
Language 24 months Two-worded phrases
Able to follow-2-step commands
Preschool (3-6 years)
Domain Age Skills
Gross motor 3 years Ride a tricycle
4 years Hop
5 years Skip
Fine motor 3 years Draw a circle or a person with 2 body parts
3.5-4 years Draw a cross
4-4.5 years Draw a square
5 years Draw a triangle
Language 3 years 3-4 worded telegraphic sentences
Understand prepositions
4 years Complete sentences
Understand concept of size
5 years Understand concept of time
Follow 3-step commands
Personal-social 3 years Dress under supervision
4 years Dress independently/correctly
5 years Do simple errands
Help in household chores
School-age (6-12 years)
Domain Age Skills
Gross motor 7 years Climb
Run
Fine motor 6 years Copy letters
Reverse some letters
Draw a person with 12 parts
7 years Know right and left sides
Language 6 years Verbalize emotions
Follow 3-seiral commands
Personal-social 6 years Dress up completely; Tie shoe laces
XI. Family dynamics and living conditions may contribute greatly in understanding the present health status of
Personal the child.
& Social
Age Occupation Parents are: Parental status: Child lives with:
Father: Biological Married Both parents
Adoptive Living together Mother
Mother: Foster Separated Father
Primary Caretaker: Divorced Others:
Order in the family: TV/Gadget Age of introduction to Other
Exposure: Gadgets: Activities/Hobbies
Television of the child:
Video Games
Other members of the household: Smart phone Duration/Screen time per day:
Other Gadgets:

Other pertinent information elicited:

XII.
Environ- Equally important is eliciting the following environmental circumstances:
mental
History Environmental circumstances Details
Exposure to cigarette smoke & other
pollutants
Garbage (segregation, recycling)

Sewage disposal

Water source (drinking/washing)

 SUPPLEMENTAL HANDOUT 2
COMPONENTS OF THE PHYSICAL EXAMINATION OF INFANTS AND OLDER CHILDREN

B. PEDIATRIC PHYSICAL EXAMINATION GUIDELINES AND PROCEDURES

B.1 OVERVIEW

The most challenging part of caring for pediatric patients is doing a comprehensive physical
examination (PE). Success would largely depend on the age-appropriate approach of the examiner.
When doing a physical examination on infants and children, the sequence may vary according to
the child’s age and comfort level. The secret is to perform non-disturbing maneuvers early and
potentially disturbing ones near the end of the examination. For example, examine early – palpation
of the head & neck, or auscultation of the heart & lungs; examine near the end – palpation of the
abdomen or inspection of the mouth & throat which is the most distressing exam for children. If the
child reports pain in one area, examine that part last. In addition, the examiner can make use of
situations during the examination, i.e. auscultate the heart & lungs while patient is sleeping or
inspect the throat while patient is crying.

Although the sequence of the PE may vary, the recommended written format should still be
followed.

B.2 TIPS FOR EXAMINATION ACROSS THE DIFFERENT AGE GROUPS

Anyone examining a pediatric patient should learn the art of playful interactions and apply
distraction techniques to decrease the anxiety of the child and to facilitate a comprehensive PE, as
discussed in Chapter 1. Provided here are some of the tips/ techniques that can be applied to
maximize comfortable examination for children:

Tips for Examining Newborns

Examine the newborn in the presence of parents
Swaddle and then undress the newborn as the examination proceeds
Dim the lights and rock the newborn to encourage the eyes to open
Observe feeding if possible, particularly breastfeeding
A typical sequence for the examination for minimal disruption :
Careful observation
Head, neck, heart, lungs, abdomen, genitourinary system
Lower extremities, back
Ears, mouth
Eyes, whenever they are spontaneously open
Skin, as you go along
Neurologic system
Hips
Tips for Examining Infants
Approach the infant gradually, using a toy or object for distraction
Perform much of the examination with the infant in the parent’s lap
Speak softly to the infant or mimic the infant’s sounds to attract attention
If the infant is cranky, make sure he/she is well fed before proceeding
Tips for Examining Toddlers (1 – 2 year olds)
Useful strategies for examination Useful toys and aids
Examine a child sitting on parent’s lap. Try to be at the child’s eye level “Blow out” the otoscope light
First examine the child’s toy, then the child Shine the otoscope through the tip of your finger,
“lighting it up” and then examine the ears
Let the child do some of the exam (ex. move the stethoscope), then go Make tongue depressors puppets
back and “get the places we missed”
Some toddlers believe that if they can’t see you, then you are not there; Use the child’s own toys for play
perform the exam while the child stands on the parent’s lap, facing the
parent
If 2 year olds are holding something in each hand (such as tongue Jingle your keys to test for hearing
depressors), they can’t fight or resist!

Older children and adolescents may be examined in much the same way as adults although play
interaction or distraction techniques may still be needed for some.

B.3 TECHNIQUES OF EXAMINATION

The following are the essential regional examination needed for pediatric patients. The maneuvers/
procedures are basically the same as that of adults especially in the school-aged to the adolescent
age group. However, special techniques need to be followed including a more gentle, friendly and
non-distressing approach. Unique and important in the pediatric PE is the anthropometric
measurements. It is a process of assessing the growth of the child including deviations from normal
which are clues to presence of disorders. The table below shows the parts of the regional exam,
parameters that need to be assessed, the proper procedure and technique for doing it as well as
clinical implications of possible abnormal findings.
 Parts of the PE Parameters to be assessed/ Procedure
A. General Survey Take note of the following:
• Mental state or sensorium, level of activity
• If ill looking or not, state of hydration, color
• Nutritional state (well, under or over nourished)
• Developmental state (well or under developed)
• Ambulatory or carried or bedridden
• Presence or absence of cardiorespiratory distress
B. Vital signs
1. Cardiac rate/ • Should be correlated to the condition in which it was taken to be considered
Pulse rate significant, i.e. quiet, crying, struggling, etc.
(beats/ min) • Describe as to: rate, rhythm (regular or irregular) and volume (full, weak, thready
or compressible)
2. Respiratory rate • Correlate to the condition in which it was taken
(cycles/ min)
3. Temperature • Oral temp should not be taken in children who are too young and/or unable to
(degrees Celsius) understand instructions
• Rectal temp should not be obtained in infants who can sit up on his own
• Axillary temp is safer to obtain but usually 0.5C lower than oral temp
• Thermoscans when available are also recommended for use
4. Blood pressure • Done for children >3 y/o unless warranted by the present condition
(mmHg) • Different BP cuff sizes are available for the different pediatric age groups.
Important is to choose the BP cuff that can completely encircle the arm or one
whose inflatable bladder covers at least 2/3 of the upper arm length with the
olecranon and acromion as the landmarks.
• Using a too small or too large cuff can lead to falsely high or low BP readings,
respectively.
• Method followed is the same as that for adults
Note: See APPENDIX A for normal values of vital signs at various ages
C. Anthropometric
data
3 major parameters include:
1. Weight (in kg) • Preferably taken with minimal clothing on, using a calibrated scale
• An infant weighing scale should be used for children <2y/o
• A calibrated detecto/ bath scale is used for children >2y/o
2. Length for • Supine/ recumbent length measurements: By using a measuring board or a
children <2y/o measuring tray, measure the body length by placing the child supine. The crown
(cm); of the head should touch the stationary vertical headboard. The shoulders, hips,
buttocks, legs and knees should be flat on the surface. Shift the movable board
against the heels and record the length to the nearest 0.1cm.
Height for >2y/o • Standing height is measured using a vertical board with an attached metric rule
and a horizontal headboard that can be brought to contact with the uppermost
point on the head. Standing on the flat surface, the heels should be together,
arms on the sides, with the head, back, buttocks and heels in contact with the
vertical board. Record the height to the nearest 0.1cm
3. Head • Measured using a non-distensible plastic tape measure placed over the supra-
circumference orbital ridge in front and extended circumferentially to the most prominent part of
(cm) the occiput. Perform 3 times, the largest reading should be the recorded HC
4. Body mass index • Compute for the BMI = weight in kg
(BMI) (length or height in meter)2
Note: The values for weight, length/ height, head circumference and BMI should be plotted in the WHO growth
charts and their percentiles and z-scores determined for nutritional assessment. See APPENDIX B .
Other measurements for special circumstances, i.e. congenital anomalies, growth disorders
5. Chest • Measured during mid-inspiration with the tape placed circumferentially around the
circumference chest with the xiphoid notch as the reference point
(cm)
6. Abdominal • Measured around the umbilicus in infants
circumference • For older children: child stands with body weight evenly distributed on both feet
(cm) which are 25-30cm apart. Landmark is the midpoint between the inferior margin
of the last rib and the iliac crest, measured circumferentially, at the end of
expiration.
7. Arm span • Measured by asking the child to stand straight with arms outstretched sidewise
parallel to the ground and palms facing front. Measure from the tip of the right to
the tip of the left middle finger
Lower segment • For 0-3y/o: with child supine, measure from umbilicus to tip of toes with feet flexed
90 degrees at heel
For >3y/o: with child standing, measure from ASIS to the floor
Upper segment • Compute as follows: length or height minus lower segment
U/L segment • Normal values for U/L ratio:
ratio At birth = 1.7; 1 month to 3y/o = 1.3; >3y/o =1.0
Any deviations from the ratio warrants further evaluation and referral to a pediatric
endocrinologist
D. Skin • Note for color, jaundice, rashes, lesions, hypo/hyperpigmentation, scars, warmth,
edema, skin turgor
E. Head • Note for general shape or contour
• Scalp: assess for abnormal swelling (ex. hematoma, abscess, masses,
cephalhematoma, caput succedaneum)
• Hair: should be assessed for quantity, color, texture, presence of lice, strength
• Sutures: overlapping, molding, gaping
• Fontanels - There are 2 major fontanels at birth:
a. Anterior fontanel: located at the midline at the junction of coronal & sagittal
sutures; diamond-shaped, 2x2cm at birth, closes at 9-18mos
b. Posterior fontanel: located midline between the intersection of occipital &
parietal bones; triangular in shape; very small at birth; closes by 6-8weeks
F. Eyes • Lids: note for periorbital edema, drooping lids, lesions, scaling, crustings of
eyelashes
• Conjunctivae: pink or pale, note for subconjuctival hemorrhages, hyperemia,
opacities
• Sclerae: note for icteresia or any unusual color
• Pupils: size & reaction to light
• Red orange reflex (ROR): an orange color is normally seen when flashing
ophthalmoscope light through the infant’s pupil. Absence of ROR or its
replacement by a “white reflex” should alert you to the following possibilities:
congenital cataract, retinoblastoma, infestation with toxocara, retrolental
fibroplasias
• In addition, the following are to be checked in detail during specified ages:
6 mos – corneal light reflex (screens for presence of strabismus)
3 years – corneal light reflex; visual acuity testing using the LEA vision testing card
5 years – corneal light reflex: visual acuity testing using LEA or Snellen chart;
cross-cover test
(Note: see APPENDIX C for the description and procedure for these screening tests)

G. Ears • Note for size, shape, location and position of the ears in relation to the rest of the
head. Normally, when an imaginary horizontal line is drawn between the two inner
canthi and extended to the ears, 20% of the total length of the ear lobe should be
located above this line (if less than this, low set ears should be recorded)
• Careful otoscopy should be done to note for any discharges from the ear canal,
and character of the tympanic membrane (intact/ perforated, color, presence or
absence of cone of light, effusions)
• Inspect & palpate also the post-auricular and mastoid areas
• Procedure for otoscopy: Proper positioning and immobilization is important. Distraction
techniques will help a lot. To visualize the TM, the otoscope should be inserted in the
appropriate angle into the ear canal. In newborns & infants, the direction of the ear canal is
upward, thus the pinna of the ear should be pulled downwards & posteriorly. In older
children, the direction of the ear canal is downward & forward, thus the pinna should be
pulled up & back. The speculum should be inserted in corresponding directions. The
handle of the otoscope should be held like a pen. When inserting the otoscope, the
knuckles of the fingers are steadied on the ipsilateral cheek of the child with the handle
held horizontally or in line with the child’s line of vision while the other hand is holding the
earlobe of the patient.
H. Nose and • Check for patency of the nares, alar flaring, presence & character of discharge,
paranasal position of septum
sinuses • Note also for any sinus tenderness by pressing below both eyebrows and on both
maxillary areas
• Procedure for better visualization of the nasal cavity: have patient seated, tilt head up facing
the examiner, press and lift the tip of the nose upward to enlarge the opening of the nares.
Place otoscope without the speculum near the nares with lights on & view through the
magnifying lens
I. Mouth & throat • Lips: check for color (pale, cyanotic, cherry red), moisture/ dryness, excoriations,
cleft
• Throat: Inspect the anterior structures, then the tongue & under, then the posterior
structures
o Gums: color, ulcers/ vesicles, bleeding
o Tongue: size, moisture, color, thrush, ankyloglossia, ulcers, abnormal
movements
o Oropharyngeal mucosa: thrush, vesicles, ulcers, Koplik spots
o Palate & uvula: symmetry, cleft, petechiae, vesicles, ulcers, high arched
palate
o Posterior pharyngeal area: postnasal discharge
o Tonsils: presence/ absence, size, color, exudates, adherent membrane
(For throat exam: ask the child to open mouth, use a tongue depressor only when the
posterior structures cannot be visualized to avoid trauma)

J. Neck • Inspection
o Swelling: in severe diphtheria (bull neck), web neck or obesity
o Position: ex. preferential gaze to one side due to torticollis
o Hyperpigmentation: acanthosis nigrican for obese children
• Palpation
 o Masses: should be described as to location, size, rate of growth, shape,
margin, consistency, color, warmth, pulsation, adhesion to surrounding
structures, tenderness
o Lymph nodes: size, number, location, consistency, tenderness, mobility,
discrete/ matted (considered enlarged if >1cm for cervical and axillary
nodes; and >1.5cm for inguinal nodes)
K. Chest & lungs • Inspection:
o Best done when the infant is in a comfortable, non-irritable stage
o Size & shape: in infancy, AP diameter = transverse diameter; after 2
years, transverse diameter > AP diameter
o Retractions: subcostal, intercostal or supraclavicular (which denotes
severe respiratory distress)
• Palpation:
o Chest expansion: whether symmetrical or asymmetrical
o Asymmetrical expansion suggests presence of effusions, collapse or
consolidation of the lung on the side with decreased excursions of the
chest
o Procedure for chest expansion: Place the palms of the hand symmetrically on the
posterior surface of the chest with the thumbs touching each other in the midline.
Fingers are spread over the sides of the chest. Excursions of the palms are noted
with each inspiration. Normally, the palms move equally as shown by the
symmetrical movements of the thumbs moving away from the midline with each
inspiration and coming together during expiration.
o Vocal fremitus: whether equal on both sides or decrease/ increase
o Clinical implications: If decrease vocal fremitus (atelectasis,
pneumothorax or pleural effusion); if increase vocal fremitus
(consolidation)
o Procedure for vocal fremitus children >4y/o: Child is asked to repeat the word “tres
tres” or “ninety nine” repeatedly while the examiner palpates all areas of the
posterior chest. The palmar or ulnar surface of both hands should detect distinct
vibrations of equal intensity on corresponding areas of 2 sides of the chest.
• Percussion:
o Whether symmetrical or not
o Clinical implications: If resonant on all lung fields (normal); if dull (solid
structures such as in consolidation or fluid filled areas like in pleural
effusion); If hyperresonant (hollow or air-filled area like in pneumothorax,
emphysema)
o Not helpful in infants; hyperresonant throughout and it is difficult to detect
abnormalities on percussion
o Procedure for children >4y/o: the indirect, 2 finger technique can be used for
percussing the chest; for both chest & back, percuss from side to side, and top to
bottom systematically (See Appendix D)
• Auscultation:
o Listen for symmetry of breath sounds or presence of adventitious sounds
o Best for toddlers & preschoolers to breath normally; easiest when the
child barely notices it (as when in a parent’s lap)
o Starting at 4y/o, the child can be asked to “take deep breaths” just like in
adults
o Procedure: Place the warm bell of the stethoscope on the bare skin of the chest
wall. Auscultate systematically from top to bottom, side to side, back & front (See
Appendix E
L. Heart & • Inspection:
vascular system o Precordium: dynamic or adynamic
o Visible pulsations over various parts of the chest & epigastrium
o Locate the apex beat: the lowest & outermost point of cardiac impulse
(normally located at the 4th ICS LMCL until 7y/o when it shifts to the 5th
ICS LMCL
• Palpation:
o Thrills: “purring” vibratory sensations felt by the palm over the
precordium; the palpable equivalent of murmurs; specify if
systolic/diastolic plus its location
o Substernal thrusts/ heaves indicates presence of ventricular overload at
RV/LV
o Tap: indicates presence of pressure overload at RV/LV
o Character of pulses on all extremities should be assessed
o Clinical implications: full & equal (normal); bounding (PDA, aortic
insufficiency, AV malformation, increase cardiac output due to anemia or
thyrotoxicosis); decrease (cardiac tamponade, left ventricular outflow
obstruction, dilated cardiomyopathy); or absent/ weak femoral pulses
(coarctation of the aorta)
• Auscultation:
o Listen for individual heart sounds & their variations with respiration
S1: caused by closure of the AV (tricuspid & mitral) valves, best heard
at the apex
S2: caused by closure of the semilunar (aortic & pulmonic) valves, best
heard at the upper left and right sternal borders
 S3: best heard at the apex in in mid-diastole; heard as gallop rhythm;
frequently heard in children and are normal; reflect rapid ventricular
filling
o Listen for murmurs and describe according to intensity, timing (systolic/
diastolic), areas of maximal intensity and radiation to other areas
Grading of intensity of murmurs: I – barely audible; II – medium
intensity; III – loud but no thrill; IV – louder with thrill: V – loud & audible
with stethoscope barely on the chest; VI – audible with the stethoscope
off the chest
Procedure: Auscultate across the upper precordium, down to the left or right sternal border, out
to the apex and both axillas and also over the back
M. Abdomen • Inspection:
o Note size & shape of the abdomen, presence of prominent vessels,
pulsations, peristaltic movements, umbilical hernia, movement in relation
to respiration
o Clinical implications: scaphoid/ flat (diaphragmatic hernia, malnutrition);
Full or protuberant (normally seen in infants & toddlers due to weak
abdominal musculature, relatively large abdominal organs & lumbar
lordosis); peristaltic waves (may be normal in thin children, may signify
obstruction like pyloric stenosis or intussusception); distended veins
(obstruction of IVC if in the epigastric area or portal hypertension if in the
peri-umbilical areas); paradoxical abdominal movements with breathing
(diaphragmatic paralysis or impending respiratory failure)
o If there is abdominal distention, measure the abdominal circumference
• Auscultation:
o Note for the character & frequency of bowel sounds
Value of bowel sound findings is questionable because the
characteristics of the sounds are not diagnostic of specific
conditions except for the high pitched sounds associated with
bowel obstruction
Wide range of frequency = 5 – 34/min; occur episodically at 5-
10secs interval in infants & young children.
Procedure: Place the warm diaphragm of your stethoscope on the RLQ area. Bowel sounds are
widely transmitted throughout the abdomen, thus listening to one spot is sufficient.
• Palpation:
o It is easy to palpate an infant’s abdomen because infants like being
touched. This is more challenging for toddlers & preschoolers.
o Useful for determining the size of organs and abdominal masses as well
as location of the abdominal pain
o Procedure for palpation of liver & spleen:
A useful technique to relax an infant is to hold the legs flexed at the knees
and hips with one hand and palpate the abdomen with the other. Then start
gently palpating the liver low in the RLQ moving upward with your fingers
toward the right subcostal margin. Liver edge is normally felt 1-2cm below
the right subcostal margin. For toddlers and older children who are
uncomfortable/ uncooperative, use distraction techniques and start by
placing the child’s hand under yours. Eventually you will be able to remove
the child’s hand and palpate the abdomen fully. Flexing the hips & knees is
another technique used. The spleen is likewise felt easily in children using
the same technique but at the left side and felt 1-2cm below the left subcostal
margin.
Liver edge
- “If liver noted to be enlarged” describe liver edge as to
a. Sharp a blunted
b. Consistency (hard/soft)
c. Surface (smooth a nodular
In children with abdominal pain, let the child pinpoint the area of maximal pain
then the examiner starts palpating away from the site of pain moving gently
to the painful area.
In infants & young children unable to verbalize their feelings or
complains a lot, observe for their facial expressions such as grimacing,
wincing or sudden crying which are strongly suggestive of real pain.
o Palpate for other intra-abdominal organs or masses and describe as to:
location, upper and lower borders, at midline or crosses the midline,
attached to abdominal wall, firm/ hard/ soft/ cystic, move with respiration,
movable, with bruits, or pulsatile
o Palpation of the kidneys may also be done from infancy much like the
procedure followed for adults
o Procedure for palpation of the kidneys:
With the child supine and abdomen relaxed, place the palm of one hand
posteriorly at the right flank pushing the kidneys forward. With the other
hand placed anteriorly below the costal margin, push the abdominal wall
backwards and upwards. Kidneys are best felt at deep inspiration; it is
fixed and does not move with respiration.
To elicit CVA tenderness (done only in older children & adolescents):
with patient sitting up on examining table, use the heel of your closed
fist (ulnar side) to strike the patient firmly on the CVA (angle between
the 12th rib and transverse process of upper lumbar vertebrae). Another
technique is to place the palm of one hand over the CVA then gently
strike with the heel of the other closed fist. Presence of tenderness
indicates renal inflammation.
 • Percussion:
o Normally, the abdomen sounds tympanitic on percussion except when
percussed over solid areas like the liver, full bladder or a tumor (in such
cases, dullness will be noted). If highly tympanitic, suspect colic,
intestinal obstruction or ileus.
o Used to detect: (1)presence of fluid in the peritoneal cavity through 2
special maneuvers: fluid wave and shifting dullness, and (2) liver size or
span
o Procedure for determining the liver span: Percuss along the right MCL anteriorly
with the pleximeter finger held parallel to the ribs along the intercostal space.
Percuss downwards until resonance shifts to dullness. Mark as the upper border
of the liver. The lower edge of the liver is determined by either palpation or
percussion from the RLQ moving upward along the RMCL until the tympanitic tone
shifts to dullness. Measurement (in cm) of the 2 points is the liver span.
(Note: see APPENDIX F for the expected liver span of children)
N. Genitalia • Male genitalia:
o Grossly normal external male genitalia means that the prepuce is easily
retractable, urethral opening is at the tip of the penis and the testes of
about equal size are palpated in the scrotal sac
o Procedure: With the patient in supine position, hold the preputial folds on both
hands gently. A tunnel is formed and the meatal opening can be seen at the end
of the tunnel.
o Clinical implications: Phimosis is present if the preputial sac is very
narrow & cannot be retracted; Hypospadia is present if urethral orifice is
located on the under surface of the penis vs. Epispadia if on the dorsal
part. Left side of the scrotum is usually at a lower level than the right,
but should be about equal in size. A larger scrotum may be due to
hydrocoele/ hernia/ enlarged testis vs a smaller size due to
cryptorchidism (absent/ undescended testis)
• Female genitalia:
o Grossly normal external genitalia means that the labia majora completely
covers the labia minora; the peri-urethral & peri-hymenal areas as well
as visualized hymen is non-hyperemic, with no abrasions, hematoma,
lacerations nor discharge
o Gynecologic exam should be treated with extra gentle care to prevent
physical & psychological trauma with the procedure well explained first
to the patient.
o Procedure: With the patient in frog-leg position (may be supine or carried
on the lap of the mother), do gentle traction of the labia upward and
outward for exposure of the vaginal introitus.
• For patients brought for complaint of sexual abuse, genital exam is left to the
expert hands of a child protection specialist to avoid re-traumatization
O. Anus & Rectum • Inspection of the anus without a rectal exam may be enough for children except if
a gastro-intestinal pathology is considered.
• Inspect for location, patency, fissures, excoriations, tags, hemorrhoids, presence
of pinworms, prolapse
• Procedure: Place on left lateral decubitus with legs flexed against the abdomen to expose
the anus. If rectal exam is necessary, assume same position with head curled down as in a
fetal position. Use gloved, lubricated index finger for older children and little finger in infants
for digital exam. Assess for sphincter tone, presence of mass or impacted feces and
tenderness
P. Extremities • Inspect for clubbing, cyanosis, swelling, mobility of joints, gross deformities
• In newborns, test for congenital hip dislocation
• Character of peripheral pulses should be placed under the heart & vascular
system
• Procedure for detecting clubbing of digits: (1) look at the profile of the fingers from the side;
the vertical height at the proximal edge of the nail (Point A) should be equal to or less than
the height of the distal interphalangeal (DIP) joint. If A>DIP height then there is clubbing; (2)
Schamroth’s sign – appose the dorsal surfaces of the terminal phalanges of corresponding
fingers; normally there is a diamond-shaped space at the base of the nailbed; in clubbing
the space is lost.
Q. Spine • Inspect for deformities, sacrococcygeal dimpling, pilonidal sinus and scoliosis
• Palpate for local tenderness such as in osteomyelitis, tumor or disc inflammation
• Procedure for scoliosis screening (“bend forward test”): with the examiner
positioned at the back, ask the child to bend forward with both hands hanging
down as if to touch the feet; a hump due to shoulder elevation and prominence of
scapula on affected side can be observed if scoliosis is present.
R. Neurologic • Discussed in the neurology module
exam
 ADDITIONAL FILES NEEDED FOR THE WARD WORK ACTIVITY

APPENDIX A
Vital signs at various ages

Age CR (beats/min) RR (beats/min) BP

Preterm 120-170 40-70 55-75/35-45
0-3 mo. 100-150 35-55 65-85/45-55
3-6 mo. 90-120 30-45 70-90/50-65
6-12 mo. 80-120 25-40 80-100-55-65
1-3 y 70-110 20-30 90-105/55-70
3-6 y 65-110 20-25 95-110/60-75
6-12 y 60-95 14-22 100-120/60-75
> 12 y 55-85 12-18 110-135/65-85

APPENDIX B
WHO CHILD GROWTH STANDARDS AND ITS INTERPRETATION

Interpretation of Growth Charts

Compare the points plotted on the child’s growth charts with the z-score lines to determine
whether they indicate a growth problem. Measurements in the shaded boxes are in the normal
range.
Growth Indicators
Z-score Length/height Weight for age Weight for BMI for age
for age length/ height
Above 3 See note 1 Obese Obese
Above 2 See note 2 Overweight Overweight
Above 1 Possible risk of Possible risk of
overweight (See overweight (See
note 3) note 3)
0 (median)
Below – 1
Below – 2 Stunted (See Underweight Wasted Wasted
note 4)
Below - 3 Severely stunted Severely Severely wasted Severely wasted
(see note 4) underweight

Notes:
1. A child in this range is very tall. Tallness is rarely a problem, unless it is so excessive
that it may indicated an endocrine disorder such as a growth hormone producing tumor.
Refer a child in this range for assessment if you suspect an endocrine disorder (e.g. if
parents of normal height have a child who is excessively tall for his or her age).
2. A child whose weight for age falls, in this range may have a growth problem, but this is
better assessed from weight for length/height or BMI for age.
3. A plotted point above 1 shows possible risk. A trend towards the 2 z-score line shows
definite risk.
4. It is possible for a stunted or severely stunted child to become overweight.

** You may download WHO Growth Charts from the internet