Pediatric Physical Diagnosis

Dr. Grandelee Taquiqui | September 07, 2021

Trans by: Agarpao, Anzia, Gumpad, Soriano

OUTLINE  Patient should be described with the day of life, instead of days
prior to admission
I. Main Heading II. Content Formatting
 Look for risk factors for sepsis
A. Subheading III. Review Questions
B. Subheading Font and IV. Citation  Maternal group B streptococcus infection
Sub-subheading V. References  UTI
 Pneumonia
 Prematurity
I. PATIENT HISTORY  Chorioamnionitis
 Thorough history is paramount to arriving at a correct diagnosis  Prolonged rupture of membranes
 The reliability of the informant should be evaluated depending C. PAST MEDICAL HISTORY
on who accompanies the child (Relatives, guardians)  History of hospitalization or operation
A. GENERAL DATA  Leukemia
 Name  Chronic problems that may predispose child to recurring
 Age infections
 Sex D. PERSONAL SOCIAL HISTORY
 Nationality  Order of child if in a brood
 Religion  Socio-economic status
 Address  Occupation of parents
 Number of Admission  Living in what type of house
 Date of Admission  How many people live
 Chief Complaint  Source of drinking water
 The symptom that prompted admission/consultation E. FAMILY HISTORY
 You should ask open-ended questions for the chief complaint
 Pertinent history
B. HISTORY OF PRESENT ILLNESS  Asthma,
 Common symptoms associated with the chief complaint  Tuberculosis
 Fever  Cancer
 Ask when the fever started
F. GROWTH AND DEVELOPMENT
 Characterize
 Prenatal history
 Intermittent/Remittent
 Prenatal check
 Low/high grade
 Rural health center
 Paracetamol dose if took
 Intake of multivitamins (what type)
 Look for associated symptoms (coughs, colds)
 History of illness
 Cough
 Exposure to radiation
 Productive/nonproductive
 Ask if associated with difficulty breathing  Smoking, drug intake of mother
 For infants, look for feeding patterns
 Interrupted feeding
 Fast feeding
 Loose Bowel Movement
 Watery/mucoid
 Bloody/non-bloody
 Frequency per day
 Approximate amount
 Assessment for fluid loss
 Vomiting
 Projectile/nonprojectile
 Bilous/non bilpus
 Approximate amount
 Altered mental status
 Ask for associated symptoms
 Fever
 Headache
 Medications in household
 Possibility of trauma
 Seizures
 Important to ask if associated with fever
 Characterize
o Tonic-clonic
 Duration
 Associated loss of consciousness
 Episodes
Neonates
 History includes maternal obstetric information and birth history

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