Comprehensive Pediatric History and Physical Examination Template
A structured pediatric encounter should systematically capture demographic data, detailed prenatal/perinatal history, developmental milestones, immunization status, feeding patterns, and age-appropriate physical examination findings, with the order of examination adapted to the child's cooperation level.
History Components
Demographic and Administrative Data
- Patient identifiers: Name, date of birth, sex/gender identity 1
- Historian information: Identity, relationship to child, language barriers 1
- Other healthcare providers: Primary care physician, specialists involved 1
Chief Complaint and Present Illness
Document the specific reason for the visit and detailed chronology of current symptoms. For nonverbal children, obtain witness accounts with specifics about the child's position before and after any injury 2. The history of present illness drives the remainder of the examination and assessment 3.
Prenatal and Birth History
- Gestational age and birth weight (critical for assessing fracture risk in preterm infants) 2
- Maternal infections or substance/drug exposure during pregnancy 1
- Complications during pregnancy or delivery 1
- Total parenteral nutrition history (affects bone mineral content) 2
Past Medical History
- Prior hospitalizations and surgeries 1
- Chronic diseases: renal insufficiency, metabolic acidosis, malabsorption, cerebral palsy, neuromuscular disorders 2
- Hepatobiliary disease, diuretic therapy, corticosteroid use 2
- General health status and overall development 1
Developmental History
Document age-appropriate milestones and any developmental delays. Screen for the "4 Ds": Defects at birth, Deficiencies, Diseases, and Developmental Delay including Disability 4.
Immunization History
Complete record of vaccines received and those due 4.
Feeding and Nutritional History
- Detailed dietary intake 2
- Feeding intolerance, diaphoresis with feeding 5
- Growth patterns and nutritional status 4
Medications and Allergies
Current medications (including those affecting bone health) and documented allergies 1, 2.
Family History
- Genetic conditions affecting skeletal development 2
- Ocular conditions: amblyopia, strabismus, retinoblastoma, congenital cataracts, congenital glaucoma 1
- Cardiac conditions and sudden cardiac death risk 5
- Relevant systemic diseases 1
Social History
- Racial/ethnic heritage 1
- Living situation and caregivers
- School performance and learning disabilities 1
- For adolescents: psychosocial assessment 4
Review of Systems
Comprehensive organ system review appropriate to age 1.
Physical Examination Approach
General Principles
Adapt examination order based on child's cooperation level 1. Perform least invasive procedures first. Make the child comfortable with pleasant surroundings and playful behavior 4. Document the child's cooperation level, as this aids interpretation of results 1.
Vital Signs
- Blood pressure (upper and lower extremities when indicated) 5
- Heart rate, respiratory rate, temperature
- Growth parameters: weight, length/height, head circumference, BMI
Nutritional Assessment
Identify malnutrition status using appropriate growth charts 4.
General Appearance
- Level of alertness and interaction
- Signs of distress or discomfort
- Dysmorphic features
Skin
- Color, perfusion, capillary refill 5
- Rashes, bruising, burns (document location, size, pattern for abuse screening) 2
- Birthmarks or lesions
Head, Eyes, Ears, Nose, Throat (HEENT)
- Head: shape, fontanelles (if applicable), trauma
- Eyes: visual assessment, red reflex symmetry 4
- Ears: hearing screening 4
- Nose and throat: patency, lesions
Cardiovascular
- Precordial impulse and thrills 5
- Heart sounds: rate, rhythm, murmurs (document frequency/pitch, duration, quality, location, radiation) 5
- Femoral pulses quality 5
- Perfusion status 5
Respiratory
- Respiratory effort and pattern 5
- Breath sounds, wheezing, crackles
- Work of breathing indicators
Abdomen
- Inspection, auscultation, palpation
- Organomegaly, masses, tenderness
Musculoskeletal
- Range of motion, deformities
- Fracture assessment: mechanism consistency, multiple fractures, fractures of different ages (high suspicion for abuse) 2
- Gait (if ambulatory)
Neurological
- Mental status, cranial nerves
- Motor strength, tone, reflexes
- Developmental assessment appropriate to age 4
- Coordination and balance
Genitourinary
Special Considerations for Adolescents
- Conduct portions of interview and examination privately (without parents present when appropriate) 6
- Psychosocial assessment (HEADSS: Home, Education, Activities, Drugs, Sexuality, Suicide/depression) 4
- Tanner staging 4
Critical Screening Elements
Abuse Detection
High suspicion indicators 2:
- No history of injury or implausible mechanism
- Inconsistent or changing histories
- Fracture in nonambulatory child
- High-specificity fractures (rib fractures)
- Multiple or different-aged fractures
- Delay in seeking care