UNIVERSITY OF CEBU College of Nursing Cebu City PEDIATRIC ASSESSMENT (1 month to 12 years) Name of Patient ________________ Date of Birth

___________ Sex ____

I. PRENATAL HISTORY (of mother) Maternal Age _______ Obstetric Score G __T__P__A__L___M___ Prenatal Check-up: ___ Regular ___ Irregular ___ None Done by: ___ Obstetrician ___ Nurse ___ Hilot Place : ___ Hospital ___ Clinic ___ RHU ___ Home Maternal Illness : ___ None ___ Fever ___ Rash ___ GDM ___ Asthma ___ Heart Disease ___ UTI ___ TB ___ Hepatitis ___ Allergy ___ Hypermesis ___ PIH Medications (mother) ________________________________________ II. NATAL HISTORY Date of Birth ___________ Birth Rank ________ Apgar Score _____ Place of Delivery ___ Hospital ___ Home ___ Lying-in Attendant ___ Midwife ___ Hilot ___ Others Gestation ___ Full term ___ Preterm ___ Post term Mode of Delivery ___ NSVD ___ Forceps___ C/S (indication) Presenting Part ___ Cephalic ___ Face ___ Breech ___ Transverse Medications ___ Eye Prophylaxis III. POST-NATAL HISTORY Feeding ___ Breastmilk Medical Problems ___ None ___ Sepsis ___ Vit. K ___ Hep. B

___ Milk Formula ___ Respiratory ___ Seizure

___ Mixed ___ Cyanosis ___ Jaundice

IV.

IMMUNIZATIONS 1st dose

__ No __ Yes at: __ Center __Private __ Both 2nd dose 3rd dose 1st booster 2nd booster None

BCG DTP OPV Hib Hep B Pneumoccocal Rotavirus Flu Varicella AMV MMR Others: Typhoid Hep. A Meningococcal HPV

V.

FEEDING HISTORY ___ Breastfeed ___ Milk Formula ___ Mixed ___ Breastfeed ___ Milk Formula ___ Mixed _________________ Type __________________ _________________ Allergies _______________ _________________ Type ____________ When started ____________ Amount _________ Duration ____________

0 6 months 6 12 months Age semisolid started Food preference : Food dislikes : Vitamin Supplements:

VI.

PAST MEDICAL/SURGICAL HISTORY ___ Unremarkable ____ Remarkable If remarkable : ______________________________________________ Date Diagnosis Intervention

Hospitalization (including operation) Date Hospital

Diagnosis

VII.

FAMILY HISTORY ___ No significant FH ___ Significant FH __ HPN __ Diabetes __ Asthma __ Heart Disease __ Blood Disorder __ Kidney disease __ Allergy __ Cancer __ TB __ Stroke __ Seizure __ Mental Disorder Others : _____________________________________

VIII. GROWTH & DEVELOPMENT First raised head _____ Rolled over _____ Sat alone _____ Pulled up _____ Walked with help _____ Walked alone _____ Talked _____ Urinary continence : Day _____ Night _____ Control of feces _____ Comparison of development with that of other siblings __________________ School Grade _____ Quality of Work _________________________

IX.

BEHAVIORAL HISTORY Does the child manifest behavior like thumb sucking ________ Masturbation ________ Temper tantrums ______ Negativism ________ b. Does the child have sleep disturbances ? ___ Yes ___ No c. Phobias __________________________________________________ d. Pica (ingestion of substances other than foods) ______________________ e. Abnormal Bowel habits (stool holding) ____________________________ f. Bedwetting _____________________________________________

a.

Name of Patient ___________________________________________________

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FAMILY HISTORY (insert the Genogram at the back of this page)

XI. REVIEW OF SYSTEMS A. Skin : Texture ____________ Color _____________ ___ Eruptions ___ Hydration ___ Edema ___ Hemorrhagic manifestations ___ Scars ___ Dilated blood vessels ___ Striae ___ Wrinkling B. Eyes : __ Have the childs eyes ever been crossed-eyed? __ Any foreign body? __ Any infection? C. Ears/ Nose and Throat: __ Frequent Colds __ Sore throat __ Sneezing __ Stuffy nose __ Discharges __ Post-natal drip __ Mouth breathing __ Snoring __ Otitis media __ Hearing problem D. Teeth : Age of eruption of deciduous teeth ____ Age of eruption of permanent teeth ____ E. Cardiorespiratory: __ Dyspnea __ Chest pain __ Cough __ Sputum __ Wheeze __ Expectoration __ Cyanosis __ Edema __ Syncope __ Tachycardia F. Gastrointestina: __ Vomiting __ Diarrhea __ Constipation __ Abdominal pain/discomfort __ Jaundice Type of stools ____________ G. Genitourinary: __ Enuresis __ Dysuria __ Frequency __ Polyuria __ Pyuria __ Hematuria __ Vaginal discharge __ Abnormal penis/testes Character of stream (urine) __________________________ Bladder control __________________________ H. Neuromuscular: __ Headache __ Nervousness __ Diziness __ Tingling sensation __ Convulsions __ Spasm __ Ataxia __ Muscle or joint pains __ Postural Deformities __ Exercise tolerance I. Endocrine __ Disturbance of growth __ Excessive fluid intake __ Polyphagia __ Goiter J. General __ Unusual weight loss __ Temperature sensitivity __ fatigue

I. CHIEF COMPLAINTS ( History of Present Illness) __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________________ .

PEDIATRIC PHYSICAL EXAMINATION

Name of Patient _______________________ Date of Birth ____________ 1. VITAL SIGNS BP ___ HR___ RR ___ TEMP. ___ WT. ___ HT. ___

2. GENERAL OBSERVATION ___________________________________ _________________________________________________________ _________________________________________________________

3.

SKIN: Color: __ Normal __ Cyanotic __ Pale __ Icteric __ Flushed ___ Ashen Texture: __ Normal __ Dry __ Oily Turgor: __ Good __ Poor Lesions __ None __ Rashes __ Burns __ Abrasions _ Lacerations __ Punctured wound __ Scars __ Decubitus Comments: _______________________________________________

4.

HEAD/EARS/NECK/THROAT
HEAD circumference : __________cm (up to 2 years & if significant) SHAPE : __ Round __ Ovoid __ Irregular SCALP: __ Normal __ Pustule __ Seborrhea __ Scales __ Lice FONTANELS: Anterior: Posterior __ Close __ Close __ Open __ Open __ Flat __ Flat __ Sunken __ Bulging __ Sunken __ Bulging

5.

EYES R L Normal Sunken Bulging Pupils Reactive Unreactive Equal Unequal Vision Normal Blurred Contact Lens
With correctional glasses

Eyelids Normal Laceration Inflamed Mass Puffy Drooping Sclerae Normal Icteric Red Discharges

Eyeballs

Comments : ______________________________________________________ Name of Patient ___________________________________________________

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EARS R L External Canal No Problem Discharge Pain Hearing Normal Deaf With hearing-aid R L

Pinna Normal Anomalies Symmetrical Tympanic Membrane Intact Perforated Discharge Mastoid Tenderness Swelling

Comments: _______________________________________________________

7.

NOSE/NECK/THYROID Nares No problem Nasal flaring Discharge Epistaxis Turbinates Normal Inflamed/congested Neck a. Normal b. Torticollis c. Opistothonus d. Inability to support head Lymph Nodes a. Swelling b. Tender Sternocleidomastoid a. Swelling b. Shortening Thyroid a. Size b. Contour c. Bruits d. Nodules e. Tenderness f. Enlarged g. Not Appreciated R L

Comments : ______________________________________________________

Name of Patient: ___________________________________________________

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Lips :

MOUTH/THROAT __ Pink __ Red __ Pale __ Cyanotic __ Dry __ Moist __ Swelling __ Thin __ Downturning __ Fissures __ Cleft __ Temporary __ Permanent __ No teeth __ Complete __ Incomplete __ Caries __ No problem __ Braces __ Mottling __ Discoloration __ Notching __ Malocclusion/malalignment __ Normal __ Inflamed __ Number __ Pink __ Coated __ Furrows __ Strawberry red __ Normal __ Thrush __ Discharge __ Ulcers __ Bleeding __ Normal __ Inflamed __ Exudates __ Normal __ Foul __ Not assessed __ Hoarseness __ stridor __ Grunting Type 0f Cry ____________ Type of speech ___________________

Teeth:

Gums: Tongue: Mucosa: Tonsils: Smell: Voice:

Comments: _______________________________________________________

9.

RESPIRATORY/THORAX __ Normal __ Stridor __ Hoarseness __ Drooling of Secretions __ Kyphosis __ Abrasions __ Equal __ Absent __ Scoliosis __ Rash __ Unequal __ Present __ Crepitations __ Dullness __ Rales __ Wheeze __ Mass

Upper Airway:

Chest/Upper Trunk: __ Normal __ Scars Expansion: Retractions: Lungs:

__ Normal __ Tenderness __ Resonant __ Tympanic __ Clear breath sounds __ Ronchi Breast:

__ Flatness

__ Normal for age __ Symmetrical __ Assymetrical __ Lumps/masses Comments: ______________________________________________________

10.

CARDIOVASCULAR __ Heaves __ Irregular

Apical impulse: Pulses: Heart Sound: Rate:

Location __________ __ Precordial Bulging __ Strong __ Regular __ Weak __ Normal __ Splitting __ Murmurs __ Regular __ Irregular __ Normal __ Bradycardia __ Tachycardia Capillary Refill Time: ______________________________

Comments: _______________________________________________________

Name of Patient : __________________________________________________

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GASTROINTESTINAL

Abdomen: Inspection: __ Flat __ Scaphoid __ Distended __ Globular Percussion: __ Tympanitic __ Dull __ Fluid Wave Palpation: __ Normal __ Splenomegaly __ Mass __ Hepatomegaly Liver edge ____________ Tenderness: Location_______ __ Direct __ Indirect Bowel Sounds: __ Normal __ Hyperactive __ Hypoactive

Rectal Exam : ___________________________________________________ Comments : _____________________________________________________ 12. GENITOURINARY __ Normal __ Mass __ Tenderness (location) ____________ Genitals: __ Normal __ Discharges __ Anomaly MALES: Circumcised __ Yes __ No Tanner Staging: Tanner Score: _____

FEMALES: Menses started Length of Cycle: Tanner Staging:

________ __ Not Applicable ________ __ Regular __ Irregular Tanner Score: _____

Name of patient: __________________________________________________

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Females & Males: Pubic Hair

Male Genitalia Changes

Breast Changes in Females

PH 1 PH 2

No change

G1

PH 3

Some slightly pigmented downy hair along the base of the G2 scrotum and phallus (male) or labia majora (female) Moderate amount of curly, pigmented and coarse hair G3 extending laterally Resembles adult hair in curliness ad coarseness but does not extend to the medial thigh. Adult type extending to medial thigh

Testes volume <1.5 Phallus childlike Testes 1.6 cc 6 cc Scrotum reddened, thinner, Larger Phallus no change Testes 6 cc 12 cc Scrotum more enlargement

B1 B2

Prepubertal breast with areola confined to the general chest line. Breast bud with some amount of glandular tissue, areola widens Breast is larger and more elevated extending beyond areolar limit; areola continues to enlarge but remains in contour with breasts Breast is larger, more elevated; areola and papilla form a mound projecting form breast contour. Breast is adult size; areola and breast on the same plane and papilla projecting above areola.

B3

PH 4

G4 G5

PH 5

Testes 12 22 20 cc Scrotum further enlargement, B4 darkened Phallus longer with increased circumference Testes - > 20 cc. B5 Scrotum & Phallus adult size

13.

NEUROLOGIC
Score

A. Pediatric Glasgow Coma Scale (Teasdale & Bennet) Eye Opening Opens eyes spontaneously Opens eyes in response to speech Opens eyes in response to painful stimuli Does not open eyes Verbal Response Smiles, oriented to sound, follow object, interacts Confused, consolable crying, inappropriate actions Inappropriate, persistently irritable, vocal sound, moaning Incomprehensible, restless, agitated, cries No verbal response Motor Response Obeys, infant moves spontaneously or purposefully Localizes pain, oriented, follow, infant withdraws from touch Infant withdraws from pain, consolable crying, interact
Abnormal flexion to pain in infants (decorticate response), inconsistently consolable crying

4 3 2 1 5 4 3 2 1 6 5 4
3

Extension to pain (decerebrate response), inconsolable, irritable, restless 2 No motor response 1 Aggregate Score (Normal) 0 6 months = 9 6 12 months = 11 (E4 V2 M3) (E4 V3 M4) 1 2 years = 12 2 5 years = 13 5 years = 14 (E4 V4 M4) (E4 V4 M5) (E4 V5 M5)

B. Mental Status : __ Awake __ Stupurous __ Disoriented

__ Conscious __ Coma

__ Drowsy __ Oriented

Name of Patient ___________________________________________________

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II.

Cranial Nerves: __ Intact __ Intact __ Anosmia __ Hyperosmia __ Not done __ Blindness __ Scotoma __ Diplopia __ Non-equal

CN I (Olfactory) CN II (Optic)

CN III, IV, XI ( Oculomotor, Trochlear, Abducens) PUPILS: __ Reactive __ Non-reactive __ Equal EOM : __ Full ROM __ Palsy __ Ptosis CN V (Trigeminal) Corneal Reflex CN VII (Facial) __ Trismus __ Paresthesia __ Intact __ Present __ Absent __ Right Facial Symmetry: __ Symmetric Tongue (sensory) __ Intact Facial Muscle __ Strong __ Normal __ Normal

__ Left

__ Assymetric __ Absent __ Weak __ Deafness __ Disequilibrium

CN VIII (Vestibulo-cochlear) Hearing : Balance : CN IX,X (Glossopharyngeal) Gag reflex: CN XI ( Spinal Accessory) CN XII (Hypoglossal) Shrug shoulder: Tongue at rest : Protrusion :

__ Present __ Absent __ Able to swallow __ Not done __ Able __ Not able __ Not done

__ Midline __ Deviated __ R __ L __ Midline __ Deviated __ R __ L

III. FTNT: APST:

Cerebellar: __ Well-coordinated __ Not coordinated __ Not done __ Well-coordinated __ Not coordinated __ Not done __ Ataxia __ Nystagmus Rombergs: __ Positive __ Negative __ Not done Sensory: __ Intact __ Intact __ Intact __ Absent __ Absent __ Absent __ Not done __ Not done __ Not done

IV.

Light Touch Pain Temperature V. Motor

R Upper Extremity Proximal Distal Lower Extremity Proximal Distal

Manual Scoring 5 Normal 4 Can raise against slight resistance 3 Can raise against gravity 2 Gross movements but not against gravity 1 Flicker of movement 0 No movements

Name of Patient ___________________________________________________

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REFLEXES Deep Tendon Reflexes + 4 Very brisk, hyperactive + 3 Brisker than average + 2 Average; normal + 1 Somewhat diminished 0 No response < (-) Babinski > (+) Babinski

Meningeal Signs: Priitive Reflex:

__ None __ NA Present

__ Nuchal Rigidity

__ Kernigs

__ Brudzinkis

Absent

Present

Absent _____ _____ _____

Moro Rooting Sucking Grasp

_____ _____ _____ _____

_____ Tonic Neck _____ _____ Babinski _____ _____ Ankle Clonus _____ _____

15.

MUSCULOSKELETAL: __ Fractures __ Deformities __ Tenderness __ Swelling

__ Normal

Comments: _______________________________________________________

Students Name _________________ Year & Section ___

Criteria: Accuracy (20) Comprehensiveness (20) Completeness (15) Documentation (5) TOTAL (60) _______ _______ _______ _______ _______

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