From the Guidelines
For pediatric patients, the best concise history and physical exam guidelines are to obtain a thorough health history, including allergies, medication history, and relevant diseases, and to perform a physical examination with a focused evaluation of the airway, vital signs, and a review of systems, as outlined in the most recent and highest quality study 1.
History
- Chief complaint and duration
- Past medical history, including birth history and immunizations
- Family history
- Social history, including home environment and school performance
- Review of systems, focusing on age-appropriate milestones
Physical Exam
- Vital signs (temperature, heart rate, respiratory rate, blood pressure)
- Growth parameters (height, weight, head circumference for infants)
- General appearance and behavior
- Head-to-toe examination, with emphasis on:
- Skin
- Head and neck
- Chest and lungs
- Heart
- Abdomen
- Genitalia
- Extremities
- Neurological assessment
Age-specific considerations
- Newborns: fontanelles, primitive reflexes
- Infants: developmental milestones
- Toddlers: language development, social interaction
- School-age: school performance, peer relationships
- Adolescents: puberty assessment, risk behaviors As supported by 1 and 1, a thorough history and physical examination are crucial in pediatric care, and the approach should be tailored to the child's age and developmental stage, using age-appropriate language and techniques to engage the child and put them at ease, and involving parents or caregivers in the history-taking process, especially for younger children.
From the Research
Guidelines for Obtaining a Thorough History and Physical Examination in Pediatric Patients
- A head-to-toe approach is recommended for assessing pediatric patients, taking into account the unique differences between children, adolescents, and adults 2.
- The Pediatric History and Physical Exam Evaluation (P-HAPEE) rubric is a validated tool for evaluating written histories and physical examinations in pediatric patients 3, 4.
- The P-HAPEE rubric consists of 10 items and has been shown to have adequate inter-rater reliability and internal consistency 3.
- Observation, history, and physical examination are all important components of assessing febrile children, with observational assessment using the Acute Illness Observation Scales (AIOS) adding to the efficacy of traditional history and physical examination 5.
- A comprehensive physical examination in pediatric patients should include assessment of the lower extremities, taking into account unique findings such as weight-bearing examination, gait evaluation, and non-weight-bearing examination 6.
- Self-directed rater training materials are available for the P-HAPEE rubric, which can be implemented in a pediatric clerkship or other educational setting 4.