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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

 

C/S (indication)

Presenting Part

Cephalic

Face

Breech

Transverse

Medications

Eye Prophylaxis

Vit. K

Hep. B

 

III.

POST-NATAL HISTORY

Feeding

Breastmilk

Milk Formula

Mixed

Medical Problems

None

Respiratory

Cyanosis

 

Sepsis

Seizure

Jaundice

IV. IMMUNIZATIONS No Yes at: Center __ Private Both 1 st dose 2 nd dose 3
IV.
IMMUNIZATIONS
No
Yes at:
Center
__
Private
Both
1 st dose
2 nd dose
3 rd dose
1 st booster 2 nd booster
None
BCG
DTP
OPV
Hib
Hep B
Pneumoccocal
Rotavirus
Flu
Varicella
AMV
MMR
Others:
Typhoid
Hep. A
Meningococcal
HPV

1

V.

FEEDING HISTORY

 

0 – 6 months

 

Breastfeed

Milk Formula

Mixed

6 – 12 months

Breastfeed

Milk Formula

Mixed

Age semisolid started

 

Type __________________

Food preference :

Allergies _______________

Food dislikes

:

 

_________________

 

Vitamin Supplements:

Type ____________

When started ____________

Amount _________

Duration

____________

VI. PAST MEDICAL/SURGICAL HISTORY Unremarkable Remarkable If remarkable : ______________________________________________ Date Diagnosis Intervention Hospitalization (including operation)
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

 

a.

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

_____________________________________________

Name of Patient ___________________________________________________

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  • X. 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 child’s 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

fatigue

Temperature sensitivity

  • I. CHIEF COMPLAINTS ( History of Present Illness)

__________________________________________________________

__________________________________________________________

__________________________________________________________

___________________________________________________.

3

PEDIATRIC PHYSICAL EXAMINATION

Name of Patient

_______________________

Date of Birth ____________

1. VITAL SIGNS BP ___ HR ___ RR ___ ___ 2. GENERAL OBSERVATION ___________________________________ _________________________________________________________ _________________________________________________________
1.
VITAL SIGNS
BP ___
HR
___
RR ___
___
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:
Close
Open
Flat
Sunken
Bulging
Posterior
Close
Open
Flat
Sunken
Bulging
5.
EYES
Eyelids
R
L
Eyeballs
R
L
Normal
Normal
Laceration
Sunken
Inflamed
Bulging
Mass
Pupils
Puffy
Reactive
Drooping
Unreactive
Sclerae
Equal
Normal
Unequal
Icteric
Vision
Red
Normal
Discharges
Blurred
Contact Lens
With correctional glasses
Comments : ______________________________________________________

Name of Patient ___________________________________________________

jalim’11

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6. EARS Pinna R L External Canal R L Normal No Problem Anomalies Discharge Symmetrical Pain
6.
EARS
Pinna
R
L External Canal
R
L
Normal
No Problem
Anomalies
Discharge
Symmetrical
Pain
Tympanic Membrane
R
L Hearing
Intact
Normal
Perforated
Deaf
Discharge
With hearing-aid
Mastoid
Tenderness
Swelling
Comments: _______________________________________________________
7. NOSE/NECK/THYROID Nares R L No problem Nasal flaring Discharge Epistaxis Turbinates Normal Inflamed/congested Neck a.
7.
NOSE/NECK/THYROID
Nares
R
L
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
Comments : ______________________________________________________

Name of Patient: ___________________________________________________

jalim’11

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8.

MOUTH/THROAT

 

Lips :

Pink

Red

Pale

Cyanotic

Dry

Moist

Swelling

Thin

Downturning

Fissures

Cleft

Teeth:

Temporary

Permanent

 

No teeth

Complete

Incomplete

Caries

No problem

Braces

Mottling

Discoloration

Notching

Malocclusion/malalignment

 

Gums:

Normal

Inflamed

Number

Tongue:

Pink

Coated

Furrows

Strawberry red

 

Mucosa:

Normal

Thrush

Discharge

Ulcers

Bleeding

Tonsils:

Normal

Inflamed

Exudates

Smell:

Normal

Foul

Not assessed

Voice:

Hoarseness

stridor

Grunting

Type 0f Cry ____________

Type of speech ___________________

 

Comments: _______________________________________________________

 

9.

RESPIRATORY/THORAX

   

Upper Airway:

Normal

Stridor

Hoarseness

Drooling of Secretions

Chest/Upper Trunk:

 
 

Normal

Kyphosis

Scoliosis

Mass

Scars

Abrasions

Rash

Expansion:

Equal

Unequal

Retractions:

Absent

Present

Lungs:

 

Normal

Tenderness

Crepitations

Resonant

Tympanic

Dullness

Flatness

Clear breath sounds

 

Rales

Ronchi

Wheeze

Breast:

 

Normal for age

 

Symmetrical

Assymetrical

Lumps/masses

 

Comments: ______________________________________________________

10. CARDIOVASCULAR

Apical impulse:

Location __________

Precordial Bulging

Heaves

Pulses:

Strong

Regular

Weak

Irregular

Heart Sound:

Normal

Splitting

Murmurs

Rate:

Regular

Irregular

Normal

Bradycardia

Tachycardia

Capillary Refill Time:

______________________________

Comments: _______________________________________________________

Name of Patient : __________________________________________________

jalim’11

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11. GASTROINTESTINAL Abdomen: Inspection: Flat Scaphoid Distended Globular Percussion: Tympanitic Dull Fluid Wave Palpation: Normal Splenomegaly
11.
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
________
Not Applicable
Length of Cycle:
________
Regular
Irregular
Tanner Staging:
Tanner Score:
_____

Name of patient: __________________________________________________

jalim’11

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Females & Males: Pubic Hair

 

Male Genitalia Changes

 

Breast Changes in Females

PH 1

No change

G1

Testes – volume <1.5 Phallus – childlike

B1

Prepubertal breast with areola

PH 2

Some slightly pigmented downy hair along the base of the scrotum and phallus (male) or

G2

Testes – 1.6 cc – 6 cc Scrotum – reddened, thinner, Larger

B2

confined to the general chest line. Breast bud with some amount of glandular tissue, areola widens

PH 3

labia majora (female) Moderate amount of curly, pigmented and coarse hair extending laterally

G3

Phallus – no change Testes – 6 cc – 12 cc Scrotum – more enlargement

B3

Breast is larger and more elevated extending beyond areolar limit; areola continues to enlarge but remains in contour with breasts

PH 4

Resembles adult hair in curliness ad coarseness but does not extend to the medial thigh.

G4

Testes – 12 22 – 20 cc Scrotum – further enlargement, darkened Phallus – longer with increased circumference

B4

Breast is larger, more elevated; areola and papilla form a mound projecting form breast contour.

PH 5

Adult type extending to medial thigh

G5

Testes - > 20 cc. Scrotum & Phallus – adult size

B5

Breast is adult size; areola and breast on the same plane and papilla projecting above areola.

13. NEUROLOGIC A. Pediatric Glasgow Coma Scale (Teasdale & Bennet) Score Eye Opening Opens eyes spontaneously
13. NEUROLOGIC
A. Pediatric Glasgow Coma Scale (Teasdale & Bennet)
Score
Eye Opening
Opens eyes spontaneously
4
Opens eyes in response to speech
3
Opens eyes in response to painful stimuli
2
Does not open eyes
1
Verbal Response
Smiles, oriented to sound, follow object, interacts
5
Confused, consolable crying, inappropriate actions
4
Inappropriate, persistently irritable, vocal sound, moaning
3
Incomprehensible, restless, agitated, cries
2
No verbal response
1
Motor Response
Obeys, infant moves spontaneously or purposefully
6
Localizes pain, oriented, follow, infant withdraws from touch
5
Infant withdraws from pain, consolable crying, interact
4
Abnormal flexion to pain in infants (decorticate response), inconsistently consolable crying
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

Conscious

Drowsy

Stupurous

Coma

Oriented

Disoriented

Name of Patient ___________________________________________________

jalim’11

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II.

Cranial Nerves:

 

CN I (Olfactory)

 

Intact

Anosmia

Hyperosmia

Not done

CN II (Optic)

Intact

Blindness

Scotoma

Diplopia

CN III, IV, XI ( Oculomotor, Trochlear, Abducens)

 

PUPILS:

 

Reactive

Non-reactive

Equal

Non-equal

EOM

:

Full ROM

Palsy

Ptosis

CN V (Trigeminal)

Trismus

Paresthesia

Intact

Corneal Reflex

Present

Absent

Right

Left

CN VII (Facial)

 

Facial Symmetry:

 

Symmetric

Assymetric

 

Tongue (sensory)

Intact

Absent

Facial Muscle

Strong

Weak

CN VIII (Vestibulo-cochlear) Hearing :

 

Normal

Deafness

 

Balance :

Normal

Disequilibrium

CN IX,X (Glossopharyngeal) Gag reflex:

 

Present

Absent

 

Able to

Not done

CN XI ( Spinal Accessory)

Shrug shoulder:

 

Able

Not able

Not done

CN XII (Hypoglossal)

Tongue at rest :

Midline

Deviated

R

L

Protrusion

:

Midline

Deviated

R

L

 

III.

Cerebellar:

 

FTNT:

Well-coordinated

Not coordinated

 

Not done

APST:

Well-coordinated

Not coordinated

Not done

Ataxia

Nystagmus

 

Romberg’s:

Positive

Negative

Not done

IV.

Sensory:

 

Light Touch

Intact

Absent

 

Not done

Pain

Intact

Absent

Not done

Temperature

Intact

Absent

Not done

V.

Motor

R L Manual Scoring Upper Extremity 5 – Normal Proximal 4 – Can raise against slight
R
L
Manual Scoring
Upper Extremity
5 – Normal
Proximal
4 – Can raise against slight resistance
Distal
3 – Can raise against gravity
Lower Extremity
2 – Gross movements but not against gravity
Proximal
1 – Flicker of movement
Distal
0 No movements

Name of Patient ___________________________________________________

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14. REFLEXES Deep Tendon Reflexes + 4 – Very brisk, hyperactive + 3 – Brisker than
14.
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:
None
Nuchal Rigidity
Kernig’s
Brudzinki’s
Priitive Reflex:
NA
Present
Absent
Present
Absent
Moro
_____
_____
Tonic Neck
_____
_____
Rooting
_____
Babinski
_____
_____
Sucking
_____
_____
Ankle Clonus
_____
_____
Grasp
_____
_____
15.
MUSCULOSKELETAL:
Normal
Fractures
Deformities
Tenderness
Swelling
Comments: _______________________________________________________

Student’s Name

_________________

Year & Section ___

Criteria:

Accuracy (20)

_______

Comprehensiveness (20)

_______

Completeness (15)

_______

Documentation (5)

_______

TOTAL (60)

_______

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