Newborn and Pediatrics History and Pe

NEWBORN HISTORY OUTLINE

I. General data (replaces chief complaint) Ex. 1,100 g 30-week AGA male delivered by Cesarean section to a 22-year-old G1P0 mother for progressive pre-eclampsia

II. Maternal obstetrical history include significant past history especially pregnancy losses, complications or

infertility problem III. History of pregnancy

A. last menstrual period (LMP) B. estimated date of confinement (EDC) C. prenatal care D. weight gain E. medications or drugs including OTC preparations F. illnesses or infections G. alcohol or tobacco use H. blood type/antibody screen I. serology or cultures J. gestational age dating (quickening, ultrasound, fundal height) K. complication (bleeding or spotting, edema, abdominal pain)’

IV. Labor A. onset of uterine activity (spontaneous, induced) B. duration C. intensity of contractions D. membrane status (intact, ruptured spontaneously or artificially) E. amniotic fluid (volume, color, character) F. presentation (vertex, breech, transverse, etc) G. augmentation (oxytocin) H. monitoring (auscultation, electronic) I. analgesia (type, route)

V. Delivery A. mode (vaginal, abdominal) B. assistance (forceps, vacuum extraction) C. position D. anesthesia or analgesia E. complications

VI. Immediate neonatal period A. apgar scores (include breakdown) B. resuscitation provided (ventilation, drugs, etc) C. neonatal course (include procedures, labs)

VII. Family history

VIII. Social history A. Marital status B. Planned pregnancy C. Socioeconomic status

IX. Physical examination A. General appearance B. Vital signs

PR= HC= AC= CC= RR= Length= Wt= T= C. HEENT D. Neck E. Chest and lungs F. Heart G. Abdomen H. Umbilicus I. Genitalia J. Extremities K. Back L. Anus

X. Neurologic examination XI. Gestational age assessment XII. Impression

NEUROLOGIC EXAMINATION OF THE NEWBORN

GENERAL PRESENTATION 1. Initial presentation:

( ) Symmetrical position ( ) Gross abnormalities of skeletal, vascular and skin development

2. Mental status: ( ) Spontaneous activity (alertness) ( ) Response to external stimulation ( ) Drowsiness ( ) Ease of consolability ( ) Orientation to visual and auditory stimuli ( ) Habituation to various stimuli

3. Posture of flexion: ( ) Limbs semi-flexed and legs partially abducted at the hips ( ) Head is slightly flexed and position at the midline or turned to one side ( ) Spontaneous motor activity of flexion and extension alternation between arms and legs ( ) Forearms supinate with flexion at the elbow and pronate with extension ( ) Fingers are flexed with tight fist ( ) Low frequency and high frequency tremors of the arms, legs, and body (vigorous crying or at rest during the 1st 48 hours of life) ( ) Negative flexion (hypotonia) ( ) Head and legs are extended (breech presentation) ( ) Legs abducted and externally rotated (frank breech baby) ( ) Tremors at rest (4 days after birth) ( ) Asymmetrical movement of arms and legs (central/peripheral neurologic deficits, birth injuries or congenital anomalies)

HEAD 1. Inspection/palpation

Anterior fontanels: Size= Tenderness Contour: ( ) Bleeding ( ) Nodules ( ) Vascular lesion ( ) Defect ( ) Irregularities of bone densities of frontal and parietal bone

2. Head circumference: ___________ cm or inches 3. Auscultation 4. Transillumination: __________ cm (< or = to 1cm is abn)

CRANIAL NERVES 1. CN I = not tested 2. CN II =

( ) Fixed at an object placed 10-12 inches from the eyes and can follow it 60° ( ) Pursuit is not enough

3. CN III, IV, VI: ( ) Symmetrical size of globe ( ) Doll’s eye maneuver ( ) Nystagmus ( ) Ptosis

4. CN V: ( ) Sucking reflex 5. CN VII:

( ) Symmetrical face ( ) Ineffective sucking and drooling

6. CN VIII:( ) Moro reflex (loud sound) 7. CN IX, X:

( ) Evaluate baby’s cry ( ) Swallow

8. CN XI: ( ) Good SCM 9. CN XII:

( ) Tongue symmetrical ( ) Tongue atrophy

MOTOR ( ) Spastic ( ) Flaccid ( ) Hypotonic REFLEXES

1. Primitive reflex (infantile automatism): ( ) Moro/startle reflex ( ) Babinski ( )Tonic neck ( ) Stepping ( ) Palmar grasp ( ) Plantar grasp ( ) Placing ( ) Rooting ( ) Galant/truncal incurvation

2. Deep tendon reflexes: ( ) Biceps ( ) Triceps ( ) Knee jerk ( ) Ankle

SENSORY Response to pain: ( ) Awake ( ) Withdraw

( ) Change in facial expression

Department of Pediatrics

History and Physical Examination

History Outline – General

The following outline should be modified as appropriate for the age of the child and the condition for which he is brought to the Physician.

Clinical History

I. Identifying Information

Name, age, sex, residence, date of admission, number of admissions

II. Source of History, Reliability

Good, fair and poor.

III. Chief Complaint

Preferably in parent’s or information’s words

IV. History of Present Illness

Chronologic evaluation, if possible, with dates, of the patient’s illness, including initial symptoms and date of onset, subsequent symptoms chronologically, pertinent negative data, appetite and activity, medications given during present illness and effect. If neonate, start history of present illness from birth.

V. Past History A. Hospitalizations: Record dates and reasons (accidents, poisoning, other

emergencies, tests, etc.) for hospitalizations. B. Infections: Note the child’s age at onset, type of infection, number and severity of

episodes. C. Contagious Diseases: Record the child’s age at exposure to the following infectious

diseases, measles, rubella, chickenpox, mumps, pertussis, diphtheria, and scarlet fever. Note the presence and severity of complications.

D. Other Serious Noninfectious Illness: Obtain information about such illnesses as neoplastic diseases and genetic disorders.

VI. Family History Any similar illness in the family, familial illnesses like PTB, diabetes, cancer, epilepsy, hypertension, allergy, blood dyscrasias, mental or nervous diseases, cardiovascular diseases, rheumatic fever, congenital abnormalities, and other heredofamilial disorders.

VII. Birth History

A. Antenatal: Obtain basic information regarding the mother’s health during pregnancy, including prenatal care, diet infections (e.g. rubella) and other illnesses, vomiting, bleeding, preeclampsia-eclampsia and other complaints. Ask about serologic tests, pelvimetry medications, x-ray procedures, and amniocentesis.

B. Natal: Note the duration of pregnancy, kind and duration of labor, type of delivery, sedation and anesthesia (if known), birth weight, state of infant at birth, resuscitation required, onset of respirations, first cry, special procedures.

C. Neonatal: Ask about the child’s Apgar score, color (cyanosis, pallor, jaundice) and cry; and about any twitching, excessive mucus, paralysis, convulsions, fever, hemorrhage, congenital abnormalities, or birth injuries. Record length of hospital stay and the child’s discharge weight.

VIII. Nutrition

A. Breast or Formula Feeding: Record the type of feeding, duration, major formula changes, time of weaning, difficulties.

B. Supplements: Note the addition of vitamins (type, amount duration). C. Solid Foods: Ask when solid foods were introduced, how taken types, unusual family

dietary habits (e.g. Vegetarian) D. Appetite: Child’s food likes and dislikes, idiosyncrasies, allergies, and general attitude

to eating. IX. Developmental Milestones

Record the child’s age when he or she first raised head, rolled over, sat alone, pulled up, walked with help, walked alone, talked (meaningful words, sentences). Ask about urinary continence during day and night, control of defecation; compare development with that of sibling, record school grade, and quality of work.

X. Personal-Social History

Parents and Grandparents: age, occupation, state of physical and emotional health, living or dead, if dead – cause and nature of death.

Siblings: ages, state of health and where living. If dead, age of death, cause and nature of death.

Patient: age, school, activities, school status, living circumstances, sleeping arrangements, number of persons living in home, members of the family who work, general level of economic independence, caregiver (mother, yaya, etc.)

XI. Immunizations and Tests

Indicate child’s age at immunization, type and number of immunizations, boosters, reactions if any. Record any tests done (e.g. PPD), medications given, long-term or maintenance medications and indications.

XII. Environmental History

A. Indoor Air Pollution: Note whether the child’s health appears to be affected by house dust, mold, animal dander, fumes from disinfectants or other chemicals, ventilation problems, ‘sick building syndrome’.

B. Pesticides, and Lawn Care Products: Ask parents about accessibility of these products and security of household storage, proper washing of fresh fruits and vegetables.

C. Playground Hazards: For older children, note locations of play areas, local traffic conditions, adult supervision, and sturdiness of play equipment.

Review of Systems

A. General Review: Record any unusual weight gains or losses, fatigue, fevers, growth patterns, recent behavioral changes.

B. Skin: Check for rashes, lumps, itching, dryness, color changes, changes in hair or nails, easy bruising.

C. Eyes: Record vision, date of last eye examination, use of glasses or contact lenses, pain redness, excessive tearing, double vision, lazy eye.

D. Ears, Nose & Throat: Note the presence of frequent colds, sore throats, sneezing, stuffy nose, nasal discharge or postnasal drip, mouth breathing, snoring, otitis, adenitis, allergies, note hearing acumen.

E. Dental: Record child’s age at eruption of deciduous and permanent teeth; note presence of bleeding gums, pyorrhea, condition of teeth, etc.

F. Cardiorespiratory System: Record the frequency and nature of any disturbances; note the presence of dyspnea, chest pain, cough, sputum, wheezing, history of pneumonia, cyanosis, syncope, tachycardia.

G. Gastrointestinal System: Note the existence of any swallowing problems, spitting, vomiting, diarrhea, constipation, type of stool, abdominal pain, or discomfort, jaundice, changes in bowel movements, blood in stool.

H. Genitourinary System: Note the presence of enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of urine stream, vaginal itching, or discharge; note

menstrual history, bladder control, abnormalities of genitalia, bruising or evidence of trauma.

I. Neuromuscular System: Inquire about headache, nervousness, dizziness, tingling, convulsions, habit spasm, ataxia, muscle or joint pains, postural deformities, exercise tolerance, gait. Screen the child for scoliosis.

J. Endocrine System: Check for disturbances in growth, excessive fluid intake, polyphagia, thyroid disease, goiter, age at onset of pubertal changes.

Physical Examination

Vital Signs:

T: HR: RR: BP: Ht: Wt:

General Survey: Development, nutrition, sensorium, presence or absence of distress, gait, posture, orientation, type of cry or voice.

Skin: Color, texture, turgor, pigmentation, eruptions, hydration, edema, hemorrhagic manifestations, scards, dilated vessels, and direction of blood flow, hemangiomas, café-au-lait areas and nevi, Mongolian spots, elasticity, subcutaneous nodules, sensitivity, hair distribution, character, desquamation.

Lymph Nodes: Examiner should note the location, size, sensitivity, mobility, and consistency of the lymph nodes. Try to routinely palpate the suboccipital, preauricular, anterior cervical, posterior cervical, submaxillary, sublingual, epitrochlear and inguinal nodes.

HEENT:

Head: Note size, shape, circumference, asymmetry, cephalhematoma, bossae, craniotabes, molding, bruits, fontanelles (size, tension, number, abnormality), sutures, dilated veins, scalp hair (texture, distribution, parasites), face, and transillumination.

Face: Check for asymmetry, paralysis, note the distance between the nose and mouth, the depth of the nasolabial folds, bridge of the nose, distribution of hair, size of mandible, swellings, hypertelorism, Chvostek’s sign, and tenderness over the sinuses.

Eyes: Note if there is a photophobia, check visual acuity, muscular control and conjugate gaze; check for nystagmus; Mongolian slant, Brushfield’s spots, epicanthic folds; lacrimation; discharge; lids; exopthalmos or enophthalmos; condition of the conjunctivae; papillary size, shape, reaction to light and accommodation; check for corneal opacities, cataracts (congenital or acquired); fundi; visual fields (in older children).

Ears: Check the pinnas (position and size), canals, tympanic membranes (landmarks, mobility, perforation, inflammation, discharge), mastoid tenderness and swelling, hearing.

Nose: Patency of the nares, flaring of the alae nasi; discharge; obstruction; septum.

Mouth and Throat: Note configuration of the lips (thinness, downturning, fissures, color, cleft); teeth (number, position, caries, mottling, discoloration, notching, malocclusion or misalighment); mucosa (color, enanthems, Bohn’s nodules, Epstein’s pearls); also the gums, palate, tongue, uvula, mouth breathing, geographic tongue.

Throat: Observe the tonsils (size, inflammation, exudates, crypts, inflammation of the anterior pillars) epiglottis, mucosa, hypertrophic lymphoid tissue, postnasal drip, voice (hoarsenesss, stridor, grunting, type of cry, speech)

Neck: Flexibility, swelling, thyroid enlargement, trachea in midline, size, consistency, tenderness and mobility of lymph nodes, sternocleidomastoid (swelling and shortening), webbing, edema, auscultation, movement, tonic neck reflex.

Chest and Lungs: Observe thoracic shape and symmetry, veins, retractions and pulsations, beading; presence of Harrison’s groove, flaring of ribs, pigeon breast, funnel shape; the size and position of the nipples, breasts, intercostals or subcostal retraction, asymmetry, scapulae, clavicles; the presence of scoliosis; check for type of breathing, dyspnea, cough, femitus, flatness or dullness to percussion, rales, wheezing; check expansion, resonance, quality of breath and voice sounds.

Heart: Inspection: Precordial heave or bulge Palpation: PMI – diffuse or circumscribed, thrills, apex beat Percussion: heart broders Auscultation: Rate, rhythm, sounds (i.e. M1, M2, etc.), murmurs (timing, duration, intensity, quality, transmission)

Abdomen: Check with regard to size and contour, visible peristalsis, respiratory movements, veins (distension, direction of flow, umbilibus, hernia, musculature, tenderness and rigidity, rebound tenderness, tympany, shifting dullness, pulsation, palpable organs or masses (size, shape, position, mobility), fluid wave, reflexes, femoral pulsations, bowel sounds.

Genitalia:

Male: Note circumcision if present, meatal opening, hypospadias, phimosis, adherent foreskin, size of testes, cryptprchidism, scrotum, hydrocele, hernia, pubertal changes. Tanner stage should be noted.

Female: Observe the vagina (imperforate, discharge, adhesions), size of vaginal opening (in prepubertal children), clitoral hypertrophy, pubertal changes. Tanner stage should be noted.

Rectum and Anus: Check for the presence of irritation, fissures, prolapsed, imperforate anus. Note muscle tone, character of stool, masses, tenderness, sensation. (Perform rectal examinations with your finger inserted slowly. Examine stool on gloved finger.

Extremities: A. General: note the presence of deformities, hemiatrophy, bowleg (common in infancy), knock-knee (common at age 2-3 years), paralysis, asymmetry, edema; note temperature, posture, gait and stance. B. Joints: Check for swelling, redness, pain, limitations, tenderness, motion, rheumatic nodules, carrying angle of elbows tibial torsion. C. Hands and Feet: Note the Presence of extra digits, clubbing, simian lines, curvature of little fingers, nail deformities, splinter hemorrhages, flatfeet (feet commonly appear flat during the first 2 years of life); abnormalities of feet; dermatoglyphics; width of thumbs and big toes; syndactyly, length of various segments; dimpling of dorsa; temperature. D. Peripheral Pulses: Observe the presence, absence, or diminution of arterial pulses.

Spine and Back: Check the child’s overall posture, curvatures, rigidity, webbed neck; spina bifida; pilonidal dimple or cyst; tufts of hair, mobility, Mongolian spots; tenderness over spine, pelvis, and kidneys.

Neurologic Examination

A. Mental Status: Note level of consciousness (alert, drowsy, stuporous, comatose), intelligence, memory, orientation, ability to understand and communicate, auditory-verbal and visual0verbal comprehension, visual recognition of objects, speech, ability to write, performance of skilled motor skills. B. Cranial Nerves: I. Olfactory – identification of odors; disorders of smell II. Optic – visual acuity, visual fields, ophthalmoscopic examination III. Oculomotor – elevation of upper lids, EOM – superior, inferior, medial recti, inferior oblique, motor arc of papillary constriction (dilation if via cervical sympathetics) IV. Trochlear – EOM - superior oblique V. Trigeminal – facial sensations, corneal reflex, masseter and temporal muscle reflexes, maxillary reflex (jaw jerk) VI. Abducens – external rectus VII. Facial – wrinkling forehead, frowning, smiling, raising eyebrows, asymmetry of face, strength of eyelid muscles, test on anterior portion of the tongue. VIII. Vestibulocochlear a. Cochlear – hearing, lateralization, air and bone conduction, tinnitus; b. Vestibular – caloric tests IX. Glossopharyngeal – test on posterior 1/3 of the tongue; elevation of palate, sensory arc of gag reflex X. Vagus – swallowing, elevation of epiglottis, movements of vocal chords. a. Cranial – deviation of epiglottis, movements of vocal chords; b. Spinal – innervates sternomastoid and trapezius; atrophy, drooping and inability to shrug shoulders XI. Accessory – strength of trapezius and sternocleidomastoid muscles

XII. Hypoglossal – protrusion of tongue, tremor, strength of tongue C. Cerebellar Function: Examiner should ask the child to perform the following maneuvers: touch finger to nose and finger to examiner’s finger, rapidly alternate pronation and supination of hands; run one heel down the other shin and make a requested motion with foot; stand with eyes closed, walk normally, then walk heel to toe. Also check for tremor, ataxia, general posture; arm swing when walking, nystagmus, abnormalities of muscle tone and speech. D. Motor System: Muscle size, consistency and tone; muscle contours and outlines; muscle strength; myotonic contraction; slow relaxation; symmetry of posture, fasciculations; tremor, resistance to passive movement; involuntary movement. E. Reflexes: Check for the presence of the following reflexes: 1. Deep – biceps, brachioradialis, triceps, patellar, and Achilles; rapidity and strength of contraction and relaxation 2. Superficial – abdominal, cremasteric, plantar and gluteal 3. Neonatal – Babinski, Landau, Moro, rooting, sucking, grasping, and tonic neck F. Sensory Examination: Pain, temperature and light touch, vibration and position sense G. Meningeal Signs: Neck rigidity, Kernig’s sign, Brudzinksy sign H. Autonomic Function: Urinary, bowel incontinence or retention, sweat patterns

Diagnosis and/or Impression: List in order of importance

Basis for Impression: a brief summary of pertinent history and physical findings and discussion of the different diagnoses and of the problem as presented by the patient

Plan of Management: all diagnostic studies and rationale, diet, therapeutic regimen