SILLIMAN UNIVERSITY MEDICAL SCHOOL

DEPARTMENT OF PEDIATRICS
History and Physical Exam

Patient’s Name Age/Sex Date of Birth

Address Citizenship Religion
Informant % Reliability Admitted for the time
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS
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REVIEW OF SYSTEMS:
GENERAL RESPIRATORY  Discharge  Temper outburst
 Weight change  Chest pain  Enuresis  Hallucinations
 Appetite  Cough  Edema MUSCULOSKELETAL
 Activity level  Dyspnea ENDOCRINE  Bone pain
 Delay in growth CARDIOVASCULAR  Breast asymmetry  Myalgia
CUTANEOUS  Orthopnea  Breast pain  Arthralgia
 Rashes  Cyanosis  Breast discharge  Swelling
 Pigmentation  Fatigue  Cold/ heat intolerance  Limited motion
 Hair loss  Fainting spells  Polyuria  Stiffness
 Acne GIT  Polydipsia  Limping
 Pruritus  Vomiting  Polyphagia HEMATOPOIETIC
HEENT   Diarrhea/constipation NERVOUS/ BEHAVIORAL  Pallor
 Headaches  Encopresis  Tremors  Bleeding
 Dizziness  Passage of worms  Sleep problems  Bruising
 Visual difficulty  Abdominal pain  Convulsions PREPUBERTAL
 Lacrimation  Jaundice  Weakness  Discharge
 Hearing  Food intolerance  Mental deterioration  Itching
 Discharges  Pica  Personality changes PUBERTAL
 Epistaxis GUT  Memory loss  Menstrual period
 Toothache  Color of urine  Eating problem  Onset
 Salivation  Burning  School failures  Frequency
 Sore throat  Frequency  Mood changes

PERSONAL HISTORY:
Gestational: Age of mother OB Score Neonatal:
Prenatal check-up
Maternal illness Feeding(<2yo): Breastfeeding
Medications taken: Milk formula
Birth: Delivered at by Semi solids
☐Full term ☐Preterm BS: BW: _ Food intolerance
Manner of delivery AS: Rank: Supplements
Development/Behavioral History (6-11 y.o: School performance, Tanner)
HEADSS (> 10 yrs old)
Home Education Eating Activities Drugs Sexual Suicidal
Menstrual: Allergies:
Menarche ☐Regular ☐Irregular
Days/cycle pads/day ☐Dysmenorrhea
LMP

Past Illness: (Measles, mumps, chicken pox; hospitalizations; surgeries)

IMMUNIZATION FAMILY HISTORY

BCG (at birth then 7 yrs old) 1 dose Age Occupation State of health
DPT (2, 4 , 6 mos) 3 doses Mother
IPV/OPV (2, 4, 6 mos) 3 doses Father
Hep B (at birth, 6, 10, 14) 3 doses Siblings
Hib (2, 4 6 mos)
Measles (6-9 mos) 1 dose
MMR (15 mos) 1 dose
Heredofamilial
Others Diseases:
SOCIOECONOMIC HISTORY (place and nature of home, # of persons) ENVIRONMENTAL HISTORY (exposure to smoke,
pollutants, water source, garbage disposal, pets)

PHYSICAL EXAMINATION
General Survey: ( ) awake, ( ) Alert ( ) conscious, ( ) coherent, (+)/(-) respiratory distress, febrile/afebrile, ( ) Ambulatory, ( ) Wheelchair Bound
Notes:
Vital Signs: T: CR: RR: BP: SaO2:
Anthropometrics: Wt: Ht/Lt: BMI: HC: CC: AC:
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Skin: ( ) rashes, ( ) discoloration, ( ) jaundice, ( ), good/ poor tone, good/poor turgor, cold/cool/warm to touch
Notes:
HEENT: ( ) normocephalic, flat/bulging fontanels, anicteric/icteric sclerae, pink/pale palpebral conjunctiva, ( ) sunken eyeballs, ( ) nasoaural
discharges, dry/moist oral mucosa, tonsils: Neck ( ) supple, trachea midline/deviated L/R, ( ) LADS

C/L: symmetric/ asymmetric, equal chest expansion, ( ) retractions: subcostal, substernal, intercostal, suprasternal, supraclavicular, ( ) clear
breath sounds, ( ) rales/crackles, ( ) wheezes, ( ) stridor
Notes:

CVS: adynamic/dynamic precordium, apex at the ( )th LICS MCL, normal/fast/slow rate and rhythm, ( ) thrill, ( ) Murmur
Notes:

GIT: flat/ globular/distended, Normo/hyper/hypoactive bowel sounds, soft, non-tender, tender on:____________________, tympanic/highly
tympanitic/ dullness on percussion, ( ) masses, ( ) organomegaly, liver span:
Notes:

GUT: grossly male/female, ( ) discharges, ( ) Tanner Stage:

Notes:
Ext: ( ) gross deformities, ( ) clubbing, ( ) edema, ( ) CRT, strong/weak/thread peripheral pulses
Notes:

CNS: