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PEDIATRIC HISTORY AND PE Contents of a Pediatric History

DR. ESTRADA/05.08.17  General data
FINALS: QUIZ #1
 Chief complaint
HISTORY  History of Present Illness
 Personal history
"The mark of an excellent physician is the  Prenatal
proficiency with which he takes the history and  Natal
performs the physical examination and then on the  Neonatal
basis of the findings utilizes the laboratory accurately
 Feeding
and cost-effectively, when necessary, to approach a
final diagnosis and initiate effective therapy."  Growth and Development
 Past Illness
History taking is unique and distinctive for the following  Immunization
reasons:  Family history
 Socioeconomic and Environmental History
1. CONTENT VARIATIONS, including:
a. Prenatal and birth history  Review of Systems
- For adults with congenital conditions, these are  This includes the following:
also important. - Name, age, sex, classification, race or ethnicity,
b. Developmental history religion, birth date, birthplace, present address,
c. Social history of the family (& Environmental Risks) number, and date of hospital admission
d. Immunization history
e. Feeding history  Also include the name of the informant and his/her
relation to the patient; state the reliability of the
"These are called Content Variations because they are informant (in percentage)
always present in a pediatric history but may or may not o The reliability of the informant will be
be present in the adult history on a case-to-case basis." reflected on the quality of data you obtain. If
there are missing data, is the informant really
2. INDIRECT SOURCE OF CLINICAL INFORMATION reliable? The percentage reliability should be
– commonly given by parents proportional to the quality of information you
a. Parents’ interpretation of clinical features may gather.
affect the accuracy of the data
- Parents may have different interpretation and FACTORS AFFECTING % RELIABILITY: Reliability is
may create their own diagnosis subjective. These are guidelines you can use to make it
b. Reliability of parents vary objective.
c. Parental behaviours/emotions are important  Relationship of the informant to the patient
 Number of hours the informant stays with the
BASIC CONCEPTS AF A GOOD CLINICAL HISTORY patient
 Start the interview with the parents or guardians on o Since the mother is the closest relative, she is
a positive note (To gather the data as accurately as supposed to be the most reliable source. But if
possible) the parents are working and the yaya takes
 Be flexible (Children are uncooperative at times. care of the child during daytime, the yaya
There is a factor of fear. So be flexible.) becomes more reliable.
 Pursue the symptoms relentlessly  Educational attainment of the informant
o If the person has a higher level of education,
 Keep “on track”
he is more reliable. However they can be
 Pursue the clinical features that enable the parents deceiving and manipulative.
to reach conclusions  Involvement of the informant in the care of the
 Keep an open mind and follow the clue patient (Accuracy of the data gathered)

I. GENERAL DATA II. CHIEF COMPLAINT

“It’s not supposed to be a memory work. All of these will  Reason why the patient is brought for consultation
have significance when you formulate your diagnosis.”  Asks “Why was the patient brought to the hospital?”
AGE – There are certain conditions which are present in a  Can be a single symptom or a group of related
specific age group. You can use this data to rule in or rule symptoms
out a diagnosis.  Laboratory results can also be a chief complaint (e.g.
RELIGION – There are some religious groups that will not ABNORMAL NEWBORN SCREENING RESULT in the
comply with a treatment option (e.g. Blood Transfusion). absence of manifestations)
This is important in determining your management.

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 Should NOT include diagnostic terms or names of  Previous admission NOT RELATED TO THE HPI
diseases (Exception: FOLLOW-UP CHECK-UP e.g. are placed under Past Illnesses
Leukemia, for chemotherapy session)  If the previous admission are RELATED to the
 For OPD PATIENTS (asymptomatic patients), present illness, these should be written in the first
include: follow-up, CP clearance, well-baby care, paragraph of the HPI (e.g. in congenital conditions)
immunization  Based on the HPI, the physician should already
 Give the exact words of the informant whenever have an Initial Impression and Differential
possible* (Local dialect is discouraged because the Diagnosis.
medical report is considered a legal document.)
IV. PERSONAL HISTORY
III. HISTORY OF THE PRESENT ILLNESS (HPI)
A. Signs and symptoms should be described in A. GESTATIONAL HISTORY (PRENATAL HISTORY)
CHRONOLOGICAL ORDER, from the start of the 1. Age of mother during pregnancy
illness. 2. Parity
 Use specific number of hours/days/weeks/ 3. Health status
months prior to admission. (It is better to put the 4. Nutritional status
number of hours/days PTA rather than the specific 5. History of Past or Present Infections
date) 6. Drug Intake History
 DO NOT USE the phrases “last Monday” or “a few 7. Roentgen Exposures
weeks ago” 8. Duration of Gestation
9. etc
 For chronic illnesses: state also the date and
age at onset
B. BIRTH (NATAL) HISTORY
 If the patient is a NEWBORN and/or the present 1. AOG: Term/Premature/Postmature
problems are related to the prenatal and 2. Hours of Labor (Sepsis)
perinatal, the MATERNAL and BIRTH history 3. Manner of Delivery: NSD, LCCS (with indications)
should be incorporated in the HPI 4. Bag of Water rupture
5. Persons who attended the delivery
B. Elaborate on the Symptoms as to: 6. Birth weight
 Onset: whether acute or chronic 7. APGAR score
 Intensity of symptoms: are there any - A quick test performed on a baby at 1 AND 5
interferences in daily activities; What is the MINUTES AFTER BIRTH.
Quality? Location? Duration? Extent? Severity? - The 1-minute score determines how well the
Frequency? baby tolerated the birthing process.
 What factors aggravate or relieve the main - The 5-minute score tells the doctor how well the
symptoms? baby is doing outside the mother's womb.
 Medications - take note of the following:
1. Generic and brand names (brand names The APGAR score is based on a total score of 1 to 10.
should be written inside a parenthesis) The higher the score, the better the baby is doing after
2. Actual dose (mg/kg/day or mg/kg/dose birth. (You are trying to establish if there are resuscitative
- Check if it is within the empiric dose to know measures done during that time; but do not ask the mother
if dose is given correctly. or the informant. Rather than asking the score, take note of
the parameters.)
3. Duration of the treatment
 Describe associated symptoms as to: onset,
Interpretation:
course, chronology, and intensity
1. If the history suggests a particular disease,  A score of 7, 8, or 9 is normal and is a sign that
inquire about signs & symptoms the newborn is in good health.
characteristic of the disease  A score of 10 is very unusual, since almost all
2. Remember that pertinent negatives are of newborns lose 1 point for blue hands and feet,
value in the differential diagnosis which is normal for after birth
3. Note for other symptoms
 Re-admission: if previously admitted to this SIGN APGAR SCORE
hospital or had an OPD consultation, obtain these 0 1 2
records from the hospital and summarize them. Heart Rate Absent < 100 >100
Records of any admission to other hospitals Respiratory Absent Slow, Good cry
should also be obtained and summarized. Effort Irregular
(INTERVAL HISTORY - history of the patient from Muscle Tone Limp Some Active
the time of last admission until the present Flexion motion
admission, in relation to the same diagnosis) Reflex No Grimace Cry
Irritability Response

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Color Pale Body pink; All pink  OMIT EARLY FEEDING HISTORY UNLESS
Extremities PERTINENT to the present illness
blue  Assess:
TOTAL SCORE 1. Appetite: does the child have a good appetite or
is he/she a picky eater?
C. NEONATAL HISTORY 2. Sample diet: what does the child eat for
Note for the following: breakfast? Lunch? Dinner? Snacks? (am/pm)
 Jaundice (note the age of onset) 3. Assess if the 5 basic food groups are eaten
 Congenital abnormalities daily
 Convulsions
 Birth injury
 Hemorrhage
 Blood type
 Respiration or Feeding difficulties

The GESTATIONAL BIRTH and NEONATAL HISTORIES

should be included only in patients <2 Y/O and if
RELATED to the ILLNESS of children >2 Y/O.
- If < 2 y/o: Include prenatal and neonatal histories
- If > 2 y/o: These histories are omitted
- If present problem is related to incidents which
occurred during the prenatal, natal, and neonatal
period: include it in the HPI.

D. FEEDING HISTORY
E. GROWTH AND DEVELOPMENT HISTORY
INFANCY (<2 YEARS OLD)
YOUNG CHILDREN (1-5 YEARS OLD)
1. Type of Feeding:
a. Is the breastfeeding exclusive or mixed? 1. Development using the Modified Developmental
Checklist: Check for Motor, Adaptive/Personal,
b. How any times per day do you breastfeed?
Language, and Social
c. How long do you breastfeed with each breast?
d. If not breastfeeding, give the reason why. 2. Dental Eruption
e. What is the baby formula used? What is the 3. Other Behavioral Problems such as:
dilution and amount per day? Is it via bottle
feeding or cup feeding? a. Urinary incontinence: during day & night
b. Toilet training: when started & when completed
2. Complementary Food
c. Temper tantrums
a. Introduced at 4 months and up
d. Head banging
b. What is the consistency of the food? (Soft/
lumpy/ pureed/ table food) e. Phobias
c. What is the frequency of feeding per day? f. Pica
g. Night terrors
3. Sample Diet h. Sleep disturbances (sleeping patterns)
a. Breakfast, lunch, dinner, snacks (am/pm)
b. Assess if the 5 basic food groups (cereals/rice, NOTE: Tanner Scoring only done during this stage if there
fruits, vegetables, meat/fish/chicken, beans/egg, is precocious puberty.
milk, oil/sugar) are eaten daily
4. Compute for Actual Caloric Intake (ACI), compare MIDDLE CHILDHOOD (6-11 YEARS)
with Recommended Energy & Nutrient Intake (RENI) Inquire about the school performance and sexual
or compare both the amount and quality of food intake development using the Tanner’s Maturity Rating (TMR)
with the food guide pyramid.
5. Food intolerance
6. Multivitamins and Iron supplements: check the
dosage and frequency
7. Caregiver: Is it the mother/household help/
grandparents/siblings? (It can be a contributory factor.
Nutritional problem may boil down to the caregiver.)
CHILDHOOD TO ADOLESCENTS (2-18 YEARS OLD)

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- If not living – what was/were the age of death,
cause and nature of symptoms
- Was there a history of consanguinity

 SIBLINGS:
- Number, age, state of health
- If not living – note the age of death and cause

 FAMILIAL ILLNESS OR ANOMALIES:

- Contagious or genetically acquired
- This includes: TB, DM, Syphilis, CA, Epilepsy, RF,
Allergy, Hematologic Disorders, MR, Congenital
defects, etc.
o For TB, state the child’s contact with
patient
- Check for the presence of illness similar to the
patient’s illness in other members of the family
or household
ADOLESCENCE (12-20 YEARS) - Investigate on the family pedigree if a genetic
1. Inquire about: anomaly is suspected (family pedigree is
H – Home synonymous to ancestry/family history)
E – Education
E – Eating Behavior and habits VII. SOCIO-ECONOMIC AND ENVIRONMENTAL
A – Activities HISTORY
D – Drugs  Parents: Age, occupation, & educational attainment
S – Sexual
 Living circumstances: place and nature of dwelling;
S – Suicidal Ideations
number of persons living in the house
2. Sexual development using TMR in females – include  Economic circumstances: members of the family
menstrual history who work; source of funds (Economic status will have
an impact on your choice of management. They may
F. PAST ILLNESS not comply with the treatment if there is a problem
(Note the age when contracted, severity, and with their financial status.)
complications)  Environmental Circumstances: exposure to
 Contagious diseases such as measles, varicella, cigarette smoke and other environmental pollutants
mumps, pertussis, etc.  describe the clinical course (include what pollutants and the duration of
of the illness exposure)
 Other medical illnesses: was the patient  Garbage disposal (do they segregate or recycle?)
hospitalized? Where and for how long?
 Sewage disposal
 Operations: What was the surgical condition, the
type, and the place of the operation?  Water source (both drinking and washing)
 Allergy, eczema, asthma, food or drug sensitivities,
etc. VIII. REVIEW OF SYSTEMS
 This is a subjective data. Do not confuse it with the PE
 Injuries: include effects of the injuries if any; verify
 Ask only symptoms applicable to the age of patient
the accuracy of the diagnosis by inquiring into signs,
symptoms and the course of the illness. a. General: weight loss/ gain; activity level; delay in
growth
V. IMMUNIZATION HISTORY AND TUBERCULIN TEST b. Cutaneous: rash; pigmentation; hair loss; acne;
 Better if you tabulate this pruritus
 Check the types of immunizations given, including c. Head (include eyes, ears, nose, mouth and
ages when given, place where given (health center or throat): Headache, dizziness, visual difficulties,
doctor’s clinic) and untoward reaction lacrimation, hearing difficulties, aural discharge,
 You have to know the ideal schedule of the vaccine. Do otalgia, nasal discharge, epistaxis, toothache,
not ask about a certain vaccine if it is not indicated for salivation and sore throat.
the patient’s age.
d. Cardiovascular: orthopnea; cyanosis; easy
fatigability; fainting spells
VI. FAMILY HISTORY
In patients with congenital conditions, there is a degree
 PARENTS: of easy fatigability but you have to qualify it. Correlate
- What is the state of physical and mental health it with the activity (e.g. easy fatigability after feeding)
of the parents?
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e. Respiratory: chest pain; cough; difficulty
breathing  BMI = Wt in Kg / (Lt or Ht in meters) squared
f. Gastrointestinal: vomiting; bowel movements -  Wt, Lt, BMI, HC: plotted on the WHO growth
passage of diarrhea; constipation; encopresis chart and their percentiles and z-scores
(involuntary defecation associated with (standard deviation scores) determined for
emotional or psychiatric disturbance); passage of 3 MAJOR GROWTH
nutritional PARAMETERS
assessment.
worms; abdominal pain; jaundice; food 1. Weight (wt) Kg:
 Wasting and overweight
intolerance; pica - Infant weighing
- (0-5scale:
y/o): Z< score
2y/o on Wt for Lt/Ht charts
g. Endocrine: breast asymmetry; pain or - If patient is-able to stand upright,
(0-19 y/o): BMI z-scoreyou can use the
chart
discharge; palpitations; cold/heat intolerance; standard weighing scale.
 Stunting (0-19) Z-scores on Lt/Ht for age charts
polyuria; polydipsia; polyphagia 2. Length (Lt) (<2y/o) or Height (Ht) (>2y/o) in cm
h. Nervous/behavioral: tremors; sleep problems; - < 2 y/o: Length
convulsions; weakness or paralysis; mental - > 2 y/o: Height
deteriorations; personality or behavioral 3. Head Circumference (HC) (< 3y/o) in cm:
changes; memory loss; eating problems; school - supraorbital ridge to occipital prominence
failures; mood changes temper outbursts;
hallucinations  Presence of cardiopulmonary distress
i. Genitourinary: color of urine; burning  Ambulatory or bedridden
sensation; frequency; discharge; enuresis  Nutritional state (well, under, or overnourished)
(involuntary urination, esp. by children at night);  State of hydration
swelling of hands and feet  Ill-looking
- PREPUBERTAL FEMALE: discharge or itching
II. VITAL SIGNS
- PUBERTAL AND ADOLESCENT FEMALE: get
 There is no absolute reference range. They will vary
the history of menstrual periods (their onset,
depending on the age bracket.
frequency, regularity, pain); note LMP
 Temperature (C)
j. Musculoskeletal: pain in bone, joint or muscle;  Cardiac Rate (CR)/ Pulse Rate (PR)
swelling in bone, joint or muscle; limitation of  Respiratory Rate (RR)
motion; stiffness; limping
 Blood Pressure (BP) if >3y/o
k. Hematopoietic: pallor; bleeding manifestations;
easy bruising
PHYSICAL EXAMINATION  Lower (L) segment of the body:
- 0-3 y/o: supine, from umbilicus to tip of toes
- Make use of playful interaction and distractions with feet flexed 90 deg. at heel
- Minimum clothing - > 3 y/o: standing, from ASIS to the floor
- Can be carried by their caretaker or parent  Upper (U) segment: Lt or Ht – L segment
- For uncooperative patients: properly immobilized
- The more unpleasant or uncomfortable parts of the III. ANTHROPOMETRIC DATA
PE are done last  Other measurements for special circumstances:
- PARTS: 1. Chest Circumference (CC) in cm
1. General Survey 6. Chest & Lungs - Mid-inspiration
2. VS 7. Heart - Xiphoid notch
3. Anthrop measurements 8. Abdomen
2. Abdominal Circumference (AC) in cm
4. Skin 9. Genitalia
- Infants: Supine, across the umbilicus
5. HEENT 10. Anus
- Older Children: Upright, feet 25-30 cm apart,
11. Extremities
midway between the inferior margin of the last rib
and the crest of the ilium
I. GENERAL SURVEY
- Nearest 0.1 cm at the end of normal expiration
 Mental state of sensorium, level of activity
3. Arm Span & U/L ratio for children with growth
disorders:
- tip of the right to the tip of the left middle finger

Normal Values for U/L Ratio:

At Birth 1.7
1 mo. – 3 y/o 1.3
>3 y/o 1.0

 Wt for Age: used to assess whether a child is

underweight or severely underweight

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- A child can be underweight due to short Lt / Ht or - Newborns & Infants: UPWARD
thinness or both - Older Children: FORWARD & DOWNWARD
- Presence of edema: severely undernourished
- Tympanic Membrane: continuity (intact or
- Plot to nearest 0.1
perforated); color (light pink or translucent);
 Lt or Ht for Age: identify children who are stunted
cone of light, bulging or concave; presence of
or short due to chronic malnutrition or repeated
effusions or bubbles, mobility
illness or those who are tall for age due to genetic or
endocrine problems.  NOSE & PARANASAL SINUSES: patency of nares, alar
- Plot as precisely as possible flaring, presence and character of discharge, position
of septum, sinus tenderness
 BMI for Age: useful in screening for overweight or  MOUTH & THROAT: Lips, gums, tongue, mucous
obesity membranes, dentition, palate, posterior pharyngeal
- Similar results with Wt for Lt or Ht wall
- Plot to nearest decimal - Lips: Color (pale, cyanotic, cherry red), moisture
or dryness, excoriations, cleft
- Gums: Color, continuity (ulcers, vesicles),
bleeding
- Tongue: Size, moisture, color, milky white
coatings, geographic tongue, ankyloglossia
(tongue-tie), ulcers
- Dentition: 20 milk teeth at 12 mos of age, color,
mottling, pitting of enamel (fluorosis), ulcers
- Oropharyngeal mucosa: thrush, vesicles, ulcers,
enanthems
- Palate and uvula area: symmetry, cleft, high-
arched
- Throat exam: use a bright light; patient says
“Aaaahh”
- Posterior pharyngeal area: post nasal
drippings
- Excessive drooling: not usual after 18 mos. age
- Tonsils: Presence or absence , size, surface,
color, exudates, adherent membrane
- Color of oral mucosa: pinkish-red; compare
with color of tonsils.
 NECK: Venous Engorgement, flexibility, rigidity,
masses, lymph nodes, abnormal enlargement of the
thyroid glands
- Masses: Location, size, rate of growth, shape,
margin, surface, consistency, color, warmth,
IV. SKIN pulsation, adhesion to surrounding structures;
 Color, tissue turgor (wrinkling or loss of elasticity), goiter
loss of subcutaneous tissue, rash or eruptions,
hemorrhages, scars, edema, jaundice VI. CHEST AND LUNGS
 If the patient has rashes on his extremities, include the A. INSPECTION:
rash under the “skin” and omit it from the “extremities”  Size & shape: Round/Barrel, Shield shape, Pectus
to avoid redundancy. Excavatum, Pigeon chest, Rachitic Rosary, Harrison’s
groove
V. HEENT - INFANCY: AP diameter = Transverse diameter
 HEAD: hair (quantity, color, texture, strength, surface - AFTER 2 Y/O: Transverse > AP Diameter
characteristics); shape or contour, scalp, fontanels,
sutures; Auscultate the skull for bruits to detect AV  Movement with respirations
malformation; (normal in <4 y/o with fever); face: - Newborns & young infants: ABDOMINAL
unusual facies, deformities - After 4-5 years of age: INTERCOSTAL
 EYES: Lids, conjunctivae, sclerae, opacities,  Chest retractions: Subcostal, Intercostals,
discharge, red-orange reflex, periorbital edema, Supraclavicular
eyeballs (sunken or not), tears  Chest Expansion: Symmetry
 EARS AND MASTOIDS: Size, shape, location and
position of the ear in relation to the rest of the head, B. PALPATION:
ear discharge, tympanic membrane, ear canal
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 Vocal Fremitus: “tres, tres”, “ninety nine”; increased
(consolidation) or decreased (atelectasis,
pneumothorax, pleural effusion) VIII. ABDOMEN: 9 or 4 QUADRANTS
You may opt to divide the abdomen into 4 or 9 quadrants.
C. PERCUSSION: The significance of this is to be able to localize what organ/s
 DIRECT: with One Finger found in these areas, so that depending on the complain of
 INDIRECT: use two fingers: Pleximeter and plexor the patient, you may be able to consider what organ is
 Tap from side to side, top to bottom symmetrically affected.

D. AUSCULTATION: Stethoscope on bare skin A. INSPECTION:

 Clear breath sounds, rales, wheezes, rhonchi,  Size & shape: flat, globular, protuberant, distened,
bronchial or tubular breath sounds, pleural friction scaphoid
rub, stridor, grunting  Prominent vessels: distended veins, pulsations
 Normal breath sounds:  Striae, peristaltic movements, umbilical hernia
1) Bronchial: Midline  Movements in relation to respiration: paradoxical
2) Vesicular: Over the chest, axilla, infrascapular area breathing
3) Bronchovesicular: infants with thin walls
 Abnormal or adventitious sounds B. AUSCULTATION:
 Altered voice sounds in lobar pneumonia:  Done prior to palpation and percussion
- Bronchophony: Spoken words are louder &  Listening to one spot is usually sufficient
clearer when normally, they are muffled and  Bowel sounds: gurgling;
indistinct - 5-10 seconds intervals or longer
- Egophony: Spoken “ee” is hear as “ay” - 10-30 secs in infants & younger
- Whispered pectoriloquy: whispered words are - 5-34/min.
heard louder and clearer when normally they are  Borborygmi: prolonged gurgles or hyperperistalsis
faint and indistinct or not heard at all.  If absent, auscultate for at least 1-2 mins.

VII. HEART AND VASCULAR SYSTEM C. PERCUSSION:

A. INSPECTION:  Normally tympanitic
 Precordium: adynamic or dynamic  Detect presence of fluid in the peritoneal cavity: fluid
 Visible pulsations on the chest and in the epigastrium wave & shifting dullness
 Apex beat: 4th ICS, LMCL until 7 y/o then shifts to  Determine the size of the liver: RMCL, scratch test
the 5th ICS
D. PALPATION:
B. PALPATION:  Patient lies supine with both lower extremities semi-
 Thrills: purring vibratory sensations felt by the palm flexed at the knees and hips
 Substernal thrust: presence of right ventricular  Ask patient to inhale slowly & deeply
volume or pressure overload  Use flat surface of the fingers
 Character of pulses  Palpate away from the site of pain proceeding gently
to the painful area (DIRECT & REBOUND
C. AUSCULTATION: Tenderness)
 (S1): closure of AV valves (tricuspid & mitral); best  Spleen: not palpable unless 2-3x its size; short’s
heard: apex maneuver; castell’s method (percussion in the 8th or
 (S2): closure of Semilunar valves (aortic & 9th ICS: RESONANT is normal. DULL is splenomegaly)
pulmonic); best heard at the left & right sternal  Psoas sign; obturator sign
borders; split on inspiration  Kidneys: best felt on deep inspiration; fixed
 (S3): gallop; best heard at the apex in mid-diastole,  COSTOVERTEBRAL ANGLE (CVA) TENDERNESS:
heart failure done only in older children and adolescents; heel of a
 Murmurs: closed fist (ulnar side) strikes firmly on the CVA
- TILT: (Timing, Intensity, Location, (angle between the 12th rib and transverse process
Transmission) of the upper lumbar vertebrae)
- Grading of murmurs:
I. Barely Audible IX. INGUINAL REGIONS
II. Medium Intensity  Hydrocoele, undescended testes, lymph nodes
III. Loud but no thrill  Fluctuation in size in relation to coughing and crying;
IV. Louder with thrill spontaneously resolves or not.
V. Loud & audible with stethoscope barely on the  Indirect inguinal hernia: most common swelling in
chest the inguinal area extending to the scrotum; males
VI. Audible with the stethoscope off the chest

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X. GENITALIA
A. MALE:
 Prepuce should be easily retractable
> PHIMOSIS
 Urethra opens at the tip of the penis
> HYPOSPADIA – meatus under surface of urethra
> EPISPADIA – dorsal surface of the penis
 Left scrotum lower than the right but equal in size
> CRYPTORCHIDISM, HYDROCOELE, HERNIA

B. FEMALE:
 Gynecological exam: discharge, laceration, hymen
 Sexual maturity testing

XI. ANUS AND RECTUM

 Left Lateral Decubitus with legs flexed against the
abdomen
 Look for location, patency, fissures, tags,
hemorrhoids, presence of pinworms, prolapse
 Rectal exam: Assess sphincteric tone, presence of
mass or impacted feces and tenderness

XII. EXTREMITIES
 Color of nailbeds, peripheral pulses
 Cyanosis, edema, mobility of joints, deformities, test
for congenital hip dislocation (neonates)
 Clubbing: look from the side in profile; Schamroth’s
sign
 Lymph nodes

XIII. SPINE

 Inspect for deformities, sacrococcygeal dimple,

pilonidal sinus and local tenderness
 Screen for scoliosis: bend forward test

XIV. LYMPH NODES

 Check size, number, location, consistency,
tenderness, mobility, discrete, matted
 Most not palpable in the newborn
 Not considered enlarged unless they exceed 1 cm for
cervical and axillary nodes and > 1.5 cm for inguinal
nodes

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TRANSCRIBERS: COMPELIO, K., LANGPUYAS, I. & PASCUA, A. Page 8 of 8