CARL NOTES: PEDIATRICS VERSION m

OUTLINE HISTORY TAKING 3. Chronic Illness: Primary infection, tuberculosis, congenital

I. HISTORY TAKING HISTORY OF PRESENT ILLNESS heart disease, and other congenital anomalies
o History of Present Illness 1. Narrate the symptom/problem of the patient starting with 4. Known allergies, specify the allergen
o Birth History the onset, setting at which it developed, manifestation, 5. Co-morbid conditions: asthma, hypertension, diabetes
o Maternal History and intervention (what was done). mellitus, and ESRD, Hyperlipidemia, Obesity, CVD
o Feeding History 2. Characterize and narrate each symptom with the ff:
o Immunization History a. Description of the symptom FAMILY HISTORY
o Past Health History b. Associated Signs and Symptoms *up to the third degree of family lineage
o Family History c. Intervention done/Consult done
o Social/Environmental History d. Effect of the intervention/treatment done upon 1. Present Illness of the child, if congenital
o Developmental History consultation 2. Chronic illness, such as TB exposure – with confirmatory
II. GENERAL SURVEY 3. Make sure to complete symptom analysis thoroughly tests? medication? Family screening done?
before another symptom. 3. Acquired Illness: CVD (e.g. heart attack, stroke)
III. ANTHROPOMETRICS (SOMATIC GROWTH)
4. Summarize the pertinent positives and negatives to 4. Risk Factors: Diabetes, HPN, Hyperlipidemia, Obesity,
o Determine Height, Weight and BMI.
elucidate a presumptive diagnosis. Allergies, Asthma
o Interpretation of z-score
5. Formulate an initial diagnosis from your HPI. 5. Smoking in the household
o Determine the Head & Chest Circumference
IV. VITAL SIGNS SOCIAL-ENVIRONMENTAL HISTORY
BIRTH HISTORY
o Observe for Respiratory Rate 1. Where the patient lives
1. Term or Preterm?
o Check for Temperature a. Community/Neighborhood
2. Manner of Delivery
o Check for Pulse Rate b. House structure
3. Age of the mother with OB Score
o Determine and Interpret the Blood Pressure c. # of persons living in place of habitat
4. Condition at birth (APGAR if available)
V. SEXUAL MATURITY RATING 5. Weight and Length at Birth (if available) d. Drinking water source
VI. DEVELOPMENTAL AND BEHAVIORAL 6. Maternal History (if with maternal events at 1st to 3rd e. Waste and garbage disposal
o Infancy trimester or those surrounding birth) f. Sewage
o Early Childhood (1-4y/o) g. Other factors that may be relevant
o Middle Childhood (5-10y/o) MATERNAL HISORY 2. Family structure – i.e. who takes care of the patient for
o Early Adolescence (10-14y/o) 1. Known problems of the mother prior to pregnancy behavioral or developmental problems
o Middle Adolescence (15-16y/o) 2. Drug intake as maintenance prior to illness 3. Source of income
o Late Adolescence (17-20y/o) 3. Exposure to infection (i.e. fever, rashes, viral infection)
VII. PHYSICAL EXAMINATION 4. Family History DEVELOPMENTAL HISTORY
o Head and Neck 5. Condition surrounding labor/birth *critical for those < 2 years of age (d/t RED FLAGS)
o Eyes
o Ears FEEDING HISTORY GENERAL SURVEY
o Nose 1. Feeding since birth 1. Sensorium
o Mouth and Pharynx 2. When supplemental feeding was initiated 2. Any signs of Cardiorespiratory Distress
o Skin 3. Recall of present diet in the last 24-48 hours 3. Acute or Chronically Ill
o Chest and Lungs 4. Estimated caloric intake 4. Color of lips and skin
o Cardiovascular System 5. Activity
o Abdomen IMMUNIZATION HISTORY 6. Consolabilty
o Musculoskeletal System 1. Ask if immunization was COMPLETE: both for primary 7. Pain/Irritability
o Nervous System and booster immunization
VIII. THE NEW BALLARD SCORE a. # of doses given ANTHROPOMETRICS (SOMATIC GROWTH)
IX. APGAR SCORING b. When last dose was given DETERMINE HEIGHT
X. OTHER TESTS c. If booster doses were given 1. Check the scale if it is adjusted to “0”
o Tourniquet Test d. Adverse Vaccine Reactions a. For Neonates, remove heavy clothing and place the
o Brudzinski Test 2. Tuberculin Test baby in the center of the scale.
o Kernig Test ➢ BCG, DPT (Diphtheria, Tetanus, Pertussis), Polio, b. For children who can stand on the scale, remove
o Skin Pinch Test Measles the shoes and heavy clothing.
2. Determine and record the weight in kg
XI. ESTIMATION OF ANTHROPOMETRICS
PAST HEALTH HISTORY
XII. IMMUNIZATION
1. Previous hospitalization – date of confinement, hospital DETERMINE WEIGHT
XIII. SELECTED CONDITIONS IN PEDIATRICS and diagnosis, procedures done, subsequent admissions 1. Determine the instrument to be used:
for the same illness after the procedure. a. For babies, use a measuring scale/tape measure,
2. Communicable disease/Viral Exanthems: Measles, or a stationary headboard with an adjustable
Chicken pox, Rubella, Typhoid, Dengue Fever footboard.
 b. For children who are able to stand, use a height • The rate is interpreted based on age as follows: Stage I Hypertension 95th to 99th percentile plus
chart. 5mmHg
2. Determine and record the height in cm. Birth – 2 months 40 – 60/min Stage II Hypertension >99th percentile plus 5mmHg
2 – 12 months 30 – 50/min
DETERMINE BMI >1 year 20 – 40/min SEXUAL MATURITY RATING
1. Compute using this formula: Late childhood 20 – 30/min For Girls:
𝑘𝑔 1. Assess and determine the sexual development of the
𝐵𝑀𝐼 = • Interpret. Tachypnea in the following age groups: patient’s breasts.
𝑚2
Birth – 2 months >60/min Stage I Preadolescent: elevation of the nipple only.
INTERPRETATION OF Z-SCORE Stage II Breast bud stage: elevation of the present and
2 – 12 months >50/min
▪ Plot the z-score in the WHO charts to determine the z- nipple as a small mound; enlargement of
>1 year >40/min
score. Once identified, use the following table to areolar diameter.
interpret – Late childhood >30/min
Stage III Further enlargement of elevation of the breast
CHECK FOR TEMPERATURE and areola, with no separation of their
For 0 to 5 years old: contours.
1. Take auditory canal temperature recording (this is
preferable because they can be obtained quickly with Stage IV Projection of the areola and the nipple to form
essentially no discomfort). a secondary mound above the level of the
• Interpret: breast.
Stage V Mature Stage: projection of the nipple only.
Fever >38.2oC Areola has receded to general contour of the
Normal 36.8 – 37.2oC breast (although in some normal individuals,
the areola continues to form a secondary
mound)
CHECK FOR PULSE RATE
1. For infants, palpate the femoral arteries in the inguinal
area to palpate HR or the brachial arteries in the 2. Assess and determine the sexual development of the
antecubital fossa. patient’s pubic hair.
2. ALTERNATIVE: Auscultate the heart in most patients.
3. The rate is interpreted based on age as follows: Stage I/II Preadolescent – no pubic hair except for the
fine body hair (vellus hair) similar to that on
Birth – 2 months 140 (90-190) the abdomen
For 5 to 19 years old: 0-6 months 130 (80-180) Stage III Darker, coarser, curlier hair, spreading
6-12 months 115 (75-155) sparsely over the pubic symphysis.
1-2 years 110 (70-150) Stage IV Course and curly hair as in adults; area
2-6 years 103 (68-138) covered greater than in stage 3 but not as
6-10 years 95 (65-125) great as in the adult and not yet including the
thighs.
DETERMINE AND INTERPRET BLOOD PRESSURE Stage V Hair adult in quantity and quality, spread on
1. Make sure you are using the appropriate cuff (should the medial surface of the thighs but not up
cover 2/3 of the child’s arm length). over the abdomen.
2. Inflate the cuff while checking for pulse until the pulse rate
disappears. For Boys:
3. Inflate the pulse until 20-30mmHg mercury more when the 1. Assess and determine the sexual development of the
pulse rate disappears. patient’s pubic hair.
4. Release/deflate the cuff slowly and until the first pulse is
auscultated (1st Korotkoff sound). Stage I Preadolescent: no pubic hair except for the
DETERMINE HEAD AND CHEST CIRCUMFERENCE 5. The cuff is continuously released until the pulse fades (2nd fine body hair (vellus hair) similar to that on
1. Use a measuring tape. Korotkoff sound) and disappears (3rd Korotkoff sound). the abdomen.
2. Wrap it around the forehead with the upper edge of the 6. Verbalize and record the blood pressure. Stage II Sparse growth of long, slightly pirmented,
ears 7. Chart height and determine percentile for age. downy hair, straight or only slightly curled,
8. Classify BP as follows based on sex and heigh percentile chiefly at the base of the penis.
VITAL SIGNS using the chart for BP. Stage III Darker, coarser, curlier hair spreading
OBSERVE FOR RESPIRATORY RATE sparsely over the pubic symphysis.
1. Observe for respiratory rate for 60 seconds from a Normal th
<90 percentile Stage IV Coarse and curly hair, as in the adult; area
distance. Pre-Hypertensive 90 to <95th percentile or BP covered greater than in stage 3 but not as
• In infants and early childhood, diaphragmatic breathing is exceeds 120/80mmHg even if great as in the adult and not yet including the
predominant; thoracic excursion is minimal. below the 90th to 95th percentile thighs.
Stage V Hair adult in quantity and quality, spread over 12 months Drinking from a cup Exhibiting echolalia (excessive echoing or
the medial surface of the thighs but not up 15 months Scribbling for the first time simply repeating what others say);
over the abdomen. 18 – 24 months Circular Strokes Does not respond to request to point to body
3 years old Making a circle parts
2. Assess and determine the sexual development of the 4 years old Copy cross, copy triangle Is not talking in 2-word phrases
patient’s penis 5 years old Copy square 3 years Is not talking in simple sentences
6 years old Copy diamond Not being able to ask simple questions
Stage I Preadolescent: same size and proportions as 9 years old Copy cylinder 3.5 years Consistently fails to produce the final
in childhood consonants of words (ex. Instead of “cat”,
Stage II Slight or no enlargement 4. RED FLAGS IN FINE MOTORS SKILLS the child will say “ca”)
Stage III Larger, especially in length 3 months Persistent fisting Intelligibility to unfamiliar adult at <50%
Stage IV Further enlarged in length and breadth, with Below 18 months Hand preference 4 years Child is still stuttering (dysfluent)
development of the glans 4.5 years Not able to tell or retell a familiar story
Stage V Adult in size and shape 5. ESSENTIAL MILESTONES IN LANGUAGE SKILLS 5 years Not fully intelligible to an unfamiliar adult
Birth Responsive to Sound (“baby startles”); 7 years Has any speech sound errors
3. Assess and determine the sexual development of the Note: Sense of hearing is the first to
patient’s testes and scrotum be most developed 7. ESSENTIAL MILESTONES IN SOCIAL SKILLS
3 months Voices and coos 2 months Social smile
Stage I Preadolescent, same size and proportions as 4 – 6 months Locates sounds 6 months Imitates actions
in childhood 6 – 7 months Response to name 9 months Plays peek-a-boo
Stage II Testes larger, scrotum larger, somewhat 8 months Baby first utters “Mama” and “Dada” 1 year Comes when called by name
reddened and altered in texture 18 months Follows directions related to routines
12 months Utter 3 words with meaning
Stage III Further enlarged 2 years Parallel play is achieved
15 – 18 months Knows how to point to at least one
Stage IV Further enlarged, and scrotal skin darkened body part 3 years Interactive play is achieved
Stage V Adult size and shape 18 months Utter 10 words with meaning 4 years Responds to instructions, imitates tasks
2 years Short phrases such as “Mommy eat”, 5 years Plays games with simple rules (hide-and-
DEVELOPMENTAL AND BEHAVIORAL “Mommy look”, “Let’s go” seek, tag)
1. ESSENTIAL MILESTONES IN GROSS MOTOR SKILLS 6 years Plays board games
3 years Talk in complete sentences
3 – 6 months Head Control in prone position
4 – 5 months Start of rolling over 6. RED FLAGS IN LANGUAGE SKILLS 8. RED FLAGS IN SOCIAL SKILLS
6 months Sit with support 2 months Does not alert or quiet to sound 3 months No social smile
8 – 9 months Sitting Alone 6 Months The baby is not turning his/her head towards 6 months Not laughing in playful situations
9 months Pulls to stand holding on the source of sound (one should suspect a Lack of smiles or other joyful expressions
11 – 12 months Standing Up Independently hearing problem) 9 months Lack of reciprocal (back –and-forth sharing
13 months Mean age for Independent Walking Does not coo of vocalizations, smiles, or other facial
24 months Climb up and down the stairs alone 10 months The baby is not babbling and not responding expressions
36 months Ride a trike to his/her name when being called 1 year Hard to consult, stiffens when approached
48 months Hop on one foot 12 months Does not follow verbal routines/ games Failure to respond to name when called;
14 months Absence of pointing absence of babbling; lack of reciprocal
2. RED FLAGS IN GROSS MOTOR SKILLS 15 months Does not understand simple questions gestures (showing, reaching, waving)
4 - 6 months Lack of steady control when sitting (head Does not understand at least three words 15 months Lack of proto-declarative pointing or other
lag) *Critical period for head control is 6 Is not understanding and responding to the showing gestures
months words, “NO”, and “BYE BYE” 18 months Lack of simple pretend play
9 months Inability to sit 16 months Does not say 3 different spontaneous words 3 years Constant motion, resists discipline, and does
18 months Inability to walk independently 18 months Does not point to 3 body parts not play interactively with other children
Persistent toe walking, tip toeing Does not follow simple commands Any age Loss of previously acquired babbling,
Persistent scissoring of the feet Not being able to say up to 10 words speech, or social skills
Stands when pulled to sit 21 months Not responding to directions like “Sit down”,
Difficult diapering “Come here”, “Stand up”
30 months Does not follow 2 part commands 9. ESSENTIAL MILESTONES IN COGNITIVE DEV’T
3. ESSENTIAL MILESTONES IN FINE MOTOR SKILLS The child has his/her speech built but is not Newborn Identify mother’s voice and smell
3 months Hands open intelligible to family members 3 months Reach for dangling ring
4 months Midline play 36 months Does not answer simple questions 6 months Responds playfully to mirror
4 - 5 months Reaching and grasping for objects 2 years Child is talking a lot in jargons 9 months Object permanence
6 months Holding the bottle (unrecognizable words) 12 months Understand spatial relationshps
9 months Pincer grasp
15 months Make tower of 3 cubes; insert 1 shape in a. Keep the child calm by sitting on the parent’s
form board puzzle lap.
24 months Tower of 7 cubes; 3 shapes in form board b. Pull the auricle upward, outward and backward
puzzle (older children); downward, outward,
36 months Imitate bridge; tower of 10 cubes backward (infants).
48 months Imitate gate; answers how many c. Hold the otoscope with your other hand using
the widest possible speculum.
10. RED FLAGS IN COGNITIVE DEV’T
2 months Not alert to mother NOSE
6 months Not searching for dropped object* 1. Check for asymmetry or deformities of the nose.
2. Check for patency – look for the nasal vestibule, and test
12 months No concept of object permanence
for nasal obstruction.
18 months No interest in cause-&-effect games
3. Check the mucosa – color, swelling, or exudate.
2 years Does not categorize similarities
4. Nasal septum – deviation, inflammation or perforation.
3 years Does not know full name 5. Note for any discharge or abnormalities (e.g. polyps,
4 ½ years Cannot count sequentially ulcers).
5 years Does not know letters or colors 6. Sinus tenderness – frontal and maxillary sinuses
EYES
5 ½ years Does not know own birthday or address
1. Eyelids – note the position of the lids in relation to the
School Slow to remember facts eyeballs. Inspect for the following: width of the palpebral MOUTH AND PHARYNX
aged Slow to learn new skills, relies heavily on fissures, edema of the lids, color of the lids (e.g. redness), 1. Look at the upper lip and staining of the teeth
children memorization lesions, condition and direction of the eyelashes, a. Any teeth missing
Poor coordination, unaware of physical adequacy with which the eyelids close. b. Discoloration
surrounding and prone to accidents 2. Conjunctiva – pink or pale c. Abnormally positioned
May be awkward and clumsy, and has 3. Sclera – usually colored white. Note for icteresia, which is 2. Ask the child to open the mouth and examine the upper
trouble with fine motor skills a sign of jaundice. and lower lips.
4. Pupils – size (normal 3-5mm), reactivity to light, direct 3. Color, moisture; observe for lumps, ulcers, cracking.
11. PERSONAL MILESTONES and consensual reflex, convergence and accommodation. 4. Examine the tongue (symmetry, color, and texture).
3 months Open mouth expectantly 5. Visual fields – entire area seen by an eye when it looks 5. Ask the child to open his/her mouth wider to inspect the
6 months Holds bottle; finger feeds; feeds self with at a central point. oral pharynx.
crackers 6. Extraocular movements – the movement of each eye is 6. Use light and tongue depressor to inspect the oral
12 months Drinks well from cup; begins to hold spoon controlled by the coordinated action of 6 muscles: the 4 mucosa, tonsils, posterior pharynx, or post-nasal drip.
18 months Feeds self with spoon recti (superior, lateral, inferior, and medial rectus) and 2 7. Note the quality of the child’s voice.
2 years Expresses need to go to bathroom; oblique (superior and inferior oblique) muscles.
cooperates in dressing 7. Visual Acuity – use of the Snellen (far) or Jaeger (near) SKIN
3 years Puts on shirt, shorts; dry by night; use fork to chart. 1. Assess for:
pierce 8. Fundoscopy – note for the red-orange reflex, posterior a. Appearance/color
4 years Dresses without supervision; brush teeth part of the eye that is seen through an ophthalmoscope is b. Texture
with assistance known as the fundus (including the retina, choroid, fovea, c. Notable lesions
5 years Tie shoes macula, optic disc, and retinal vessels). The optic nerve d. Birthmarks
with its retinal vessels enters the eyeballs posteriorly. e. Skin turgor
PHYSICAL EXAMINATION
HEAD AND NECK EARS CHEST AND LUNGS
1. Examine the face: look for symmetry and presence of 1. Auricle – inspect for deformities, lumps or skin lesions. INSPECTION
facies. 2. Ear canal and ear drum – note for ear pain (which is 1. General Appearance
2. Palpate the scalp: inspect the hair and texture. present in otitis external and not in otitis media) a. Inability to feed
3. Palpate the neck: check for – a. Ear canal – note for discharge, foreign bodies, b. Lack of consolability
a. Swelling and abnormal posture redness of the skin or swelling. Cerumen may 2. Respiratory rate
b. Enlargement of the gland obstruct the view. a. Note for tachypnea
c. Lymph nodes (including pre-auricular, posterior b. Eardrum – look for the cone of light, color and b. Compare to normal rate per age
auricular, occipital, tonsillar, submandibular, contour, and also look for any perforations. 3. Color
submental, superficial cervical, posterior cervical, 3. Auditory acuity – estimate hearing by testing one ear at a. Observe for any pallor or cyanosis.
deep cervical chain, and supraclavicular) a time. b. Take note of lips, tongue and extremities.
d. Suppleness of the neck 4. Air and Bone Conduction – if hearing is diminished 4. Nasal flaring
4. Palpate the clavicles: intact or not. between conductive and sensorineural hearing loss; test 5. Audible breath sounds at rest.
for lateralization (Webber test); and compare air and a. Grunting – repetitive, short expiratory sound
bone conduction (Rinne test). b. Wheezing – musical expiratory sound
5. Otoscopic Examination: c. Stridor – high-pitched, inspiratory sound
 d. Decreased/absent breath sounds – probably due
to obstruction
6. Note the characteristic of cough or if there is frequent
throat clearing.
7. Take note of the shape and size of the thoracic cavity.
a. Evidence of deformities
i. Pectus excavatum
ii. Pectus carinatum
8. Determine work of breathing.
a. Presence of nasal flaring
b. Presence of retractions/chest indrawing
i. Subcostal
ii. Intercostal
iii. Supraclavicular
PALPATION
1. Perform Tactile Fremitus: place your hand or fingertips
over each side of the chest and feel for symmetry in the
transmitted vibrations.
2. Check for presence of rattly or gurgly chest (halak) –
this is produced by turbulent airflow through obstructed
airways.
PERCUSSION
1. Perform percussion.
a. Hyperextend the middle finger. Press its distal
interphalangeal joint firmly on the surface to be
percussed.
b. Position forearm quite close to the surface
c. With a quick sharp but relaxed wrist motion, strike
the middle finger. Aim at your distal interphalangeal
joint.
d. Withdraw your striking finger quickly to avoid
damping the vibrations you have created.
2. Observe in older children
a. Hyper resonant lungs – indicates hyperinflation
b. Dullness – indicates the presence of atelectasis,
consolidation, or pleural effusion.
3. This is not helpful in infants since an infant’s chest is hyper
resonant throughout.
AUSCULTATION
1. Position the diaphragm of your stethoscope at the
patient’s back while removing any obstructing materials
like clothes or hair.
2. Instruct the patient to breathe deeply through an open
mouth.
3. Move the diaphragm from one side to the other and
compare symmetric areas of the lungs.
4. If you hear/suspect any abnormal sounds, auscultate
adjacent areas to fully assess the extent of the
abnormality.
5. Listen to at least one full breath in each location/
6. Distinguish sounds originating from the upper and lower
airways.
a. Upper airway sounds tend to be loud, transmitted
symmetrically throughout the chest loudest toward
the neck, usually inspiratory, course sounds.
b. Lower airway sounds are loudest over the site of along the lower border of the thorax corresponding
pathology, often asymmetric and occur during to the costal insertion of the diaphragm; seen in
expiration. advanced rickets)
7. Listen for any adventitious lung sounds. g. Chest deformities – pectus carinatum; pectus
a. Wheezes – reflect narrowing of smaller airways or excavatum is not usually associated with cardiac
bronchioles. structural disease.
b. Rhonchi – reflect obstruction of larger airways or 9. Jugular Venous Pressure (JVP)
bronchi. h. Provides valuable information about the patient’s
c. Crackles/Rales – discontinuous sounds neat the volume status and cardiac function
end of inspiration. i. Reflects pressure in the RA or CVP and is best
assessed from the pulsations in the right internal
CARDIOVASCULAR SYSTEM jugular vein.
INSPECTION j. Difficulty to see in children <12 years old
1. General appearance/built k. Liver character and size – a more reliable indicator
a. Malnutrition may be seen in CHF of systemic congestion in infants and children.
2. Position of comfort
a. Sitting upright – HF PALPATION
b. Leaning forward – Pericarditis 1. Precordium – to confirm the characteristics of the apical
3. Body shakes with each heartbeat – may be seen in impulse:
aortic insufficiency. a. Ask the patient to assume a left lateral decubitus
4. Look for features: position.
a. Associated with a genetic syndrome b. The entire palm and hand should be warmed and
b. Suggestive of specific structural cardiac then fully applied to the chest wall to maximize the
abnormalities ability to detect thrills and heaves.
5. Skin Color c. Palpate for impulses using the finger pads. If not
a. Peripheral Cyanosis assessed, ask the patient to exhale fully and stop
➢ Most prominent in cool exposed areas that breathing for a few seconds.
may not be well perfused. d. Once you have found the apical impulse, make finer
➢ Normal arterial saturation. assessment with your fingers and then with one
b. Central Cyanosis finger, assess the following:
➢ Due to intracardiac or intrapulmonary R  L ▪ Location – using the 4 auscultatory areas
shunting involving the entire body. ▪ Diameter – is there radiation?
➢ Includes warm, well-perfused sites such as ▪ Amplitude
the conjunctivae and the mucous membrane ▪ Duration: timing with systole/diastole while
of the oral cavity; arterial desaturation. palpating for pulses
➢ Look at the tongue 2. Apical Impulse and PMI
c. Pallor a. Apical impulse represents the brief early pulsation
➢ Vasoconstriction from CHF or Circulatory of the LV as it moves anteriorly during contraction
shock. and touches the chest wall
d. Jaundice b. Point of Maximal Impulse (PMI)
➢ Patients with congenital hyperthyroidism ▪ Helps in determining whether the RV or the LV
(common heart lesions are PDA and PS); is dominant
chronic CHF. ▪ RV  left lower sternal border
6. Clubbing ▪ LV  apex is >4th ICS LMCL in less than 4
a. Characterized by widening and thickening ends of years old; >5th ICS LMCL in older children and
the fingers and toes; the fingernails are convex and adolescents.
there is loss of angle between the nail and nailbed. 3. Ventricular Impulse – may heave or lift the fingers
b. Due to the long-standing desaturation (usually >6 a. Heave – impulse is more diffuse and slow-rising
months) (indicative of volume overload)
7. Respiration: Pattern of breathing ▪ At the apex  Left ventricular heave
c. Note the rate, depth, and effort respiration ▪ At the area of the sternum  RV Heave
d. Tachypnea + tachycardia  early sign of LHF b. Tap – well-localized and sharp-rising (indicative of
8. Chest pressure overload)
e. Precordial activity – hyperactive if with volume c. Thrill – vibratory sensation that represent palpable
overload manifestation of loud, harsh murmurs; it is elicited
f. Precordial bulge – chronic cardiac enlargement or by pressing the ball of the hand firmly on the chest
long-standing RV volume overload; Harrison’s or the tips of the fingers on the suprasternal notch
groove (Harrison's groove a horizontal groove and over the carotid arteries.
 4. Peripheral Pulses INSPECTION Smile
a. Brachial, radial, femoral, dorsalis pedis ▪ Dynamic/Adynamic Precordium Corneal reflex
b. Note for any irregularities in the rate, rhythm, ▪ PMI – location (4th or 5th) Facial sensation
volume and character of the pulses. 7 Muscles of facial movement and expression
c. Compare the volume of the pulse between the right PALPATION 8 Hearing and vestibular function
and left arm; and between an arm and a leg. ▪ Heaves – location (apex or area of the sternum) 9,10 Sensory and motor functions of the palate,
d. The dynamic character of the pulse may provide pharynx and larynx; ask the child to stick out her
information about the cardiac output, such as: AUSCULTATION whole tongue and move it back and forth
▪ Bounding pulse ▪ Describe S1 & S2 (Split? Timing with respiration? 11 Innervates SCM and upper trapezius muscle; ask
▪ Weak and thread pulses Murmur? What auscultatory area?) the child to push your hand away using the head
▪ Unequal pulses o Grade/intensity 12 Mediates motor functions of the tongue, affecting
o Timing - systolic/diastolic/continuous articulation of words; observe the child speaking
PERCUSSION o Where best heard
Palpation has replaced percussion in the estimation of cardiac size. o Radiation 5. Motor strength – ask the child to push or pull you with
their hands or legs.
AUSCULTATION
6. Sensory system – ask the child to close eyes and ask
1. Using both the bell and diaphragm, the examiner should ABDOMEN whether they feel the tickling
develop a routine of listening systematically to all 1. Inspect the abdomen with the patient lying supine and 7. Deep tendon reflexes (See General OSCE Notes)
components of the cardiac cycle and auscultatory areas. knees flexed. a. Biceps: C5, C6
2. Stethoscope Use 2. Auscultate for bowl sounds (hold the legs flexed at the b. Brachioradialis: C6
a. Diaphragm knees and hips). c. Triceps: C7
▪ For high-pitched sounds 3. Palpate d. Patellar: L4
▪ S1, S2, murmurs of AI, MR, friction rubs a. For tenderness, observe the child’s reaction to your e. Achilles Tendon: S1
▪ Includes the: palpation. 8. Cerebellar exam – ask the child to touch her fingers and
➢ 2nd right ICS (aortic area) b. Palpate the liver edge her nose; and do rapid alternating movements
➢ 2nd left ICS (pulmonic area) c. Spleen may be palpable
➢ Left lower sternal border (right d. Palpate for the kidneys on both sides.
ventricular area) OTHER TESTS
➢ Apex (left ventricular area) TORNIQUET TEST
MUSCULOSKELETAL SYSTEM 1. Greet the patient and introduces himself / herself.
b. Bell Compared to adults, the normal child has increased lumbar
▪ For low-pitched sounds Maintains good eye contact, display professionalism and
concavity, decreased thoracic convexity, and often a protuberant courtesy.
▪ S3, S4, murmur of MS abdomen.
2. When listening for a murmur, note the following: 2. Apply the appropriately sized BP cuff
a. Timing – i.e., systolic, diastolic, continuous 3. Inflate to correct pressure by computing for Mean Pulse
1. Examine the feet. Pressure
b. Grading of Intensity 2. Observe the child rising from a sitting position, standing
▪ Grade 1 – very faint, may not be heard in all 4. Formula: (SBP+DBP)/2
and walking barefoot. 5. Inflate the BP cuff for 5 minutes
positions 3. Ask the child to touch her toes, pick up objects, hop and
▪ Grade 2 – quiet, but heard immediately after 6. Refer to 1cm below the antecubital fossa for reading
run short distances. 7. Count the petechia in a 1-square inch area, and interpret
placing the stethoscope on the chest 4. To check for scoliosis, have the child stand with her bare
▪ Grade 3 – moderately loud the result:
feet together and bend forward with her knees straight,
▪ Grade 4 – loud, with palpable thrill and her hands hanging straight down. <10 petechia Normal
▪ Grade 5 – very loud with thrill; may be heard 5. Check for leg length discrepancy 10-<20 petechia Equivocal
when the stethoscope is partly off the chest ≥20 petechia Positive
▪ Grade 6 – audible with the stethoscope NERVOUS SYSTEM
entirely off the chest 1. Gross motor development BRUDZINSKI TEST
c. Location of Maximum Intensity – describe where a. Balance on 1 foot and hop (by 3-4 years old) 1. Greet the patient and introduces himself / herself.
you hear it best inters of the intercostal space and b. Walk on heels (older children) Maintains good eye contact, display professionalism and
its relation to the auscultatory areas 2. Fine motor development courtesy.
d. Radiation or Transmission – reflects not only the a. Copy a circle or a square 2. Confidently demonstrate the steps completely and in
site of origin but also the intensity of the murmur 3. Language development (See Milestones) order:
▪ Aortic  Carotid, Neck 4. CRANIAL NERVES 3. Ask the patient lie down in supine position
▪ Pulmonic  Back, Interscapular
4. Flex patient’s head and neck toward chest.
▪ Tricuspid  Subxiphoid Cranial Nerves
▪ Mitral  Axilla 1 Mediates sense of smell Positive result Resistance or pain
2 Mediates vision Significance: Eliciting for meningeal irritation or
2,3 Control response to light meningeal signs
3, 4, 6 Mediate extraocular movements
5 Muscles of mastication
 fingertips because this will cause pain. The fold of the 4. Withdraw the needle and apply light pressure to the
skin should be in a line up and down the child’s body. injection site for several seconds with dry cotton ball or
4. HOLD the pinch for one second. Then release it. gauze.
5. Interprets the results:
INTRADERMAL ROUTE PROCEDURE
If the skin goes back: 1. Follow standard medication administration guidelines for
very slowly more than 2 seconds site assessment/selection and site preparation.
slowly less than 2 seconds, but not immediately 2. Sterilize the injection site using cotton with 70% isopropyl
immediately alcohol or alcohol swab in an outward circular motion.
Significance: Testing or assessing presence of 3. Insert the needle perpendicular to the skin 15° angle or
dehydration less into the deltoid region of the upper arm.
4. Push on the plunger without aspirating and a wheal is
IMMUNIZATION formed after the delivery of the vaccine.
THE “RIGHTS” OF MEDICAL ADMINISTRATION 5. Skin may also be stretch to ensure that the vaccine will
1. the right PATIENT; be delivered just under the skin into the dermal layer.
2. the right VACCINE or DILUENT; 6. This vaccine should NOT be administered into the volar
KERNIG TEST 3. the right TIME (includes CORRECT AGE, INTERVAL, aspect of the forearm, which is done for tuberculin skin
1. Greet the patient and introduces himself / herself. BEFORE EXPIRATION DATE); testing.
Maintains good eye contact, display professionalism and 4. the right DOSAGE;
courtesy. 5. the right ROUTE, NEEDLE LENGTH, and TECHNIQUE;
Demonstrate the steps completely and in order 6. the right SITE; and, *See the manual for selected pediatric illnesses
2. Ask the patient lie down in supine position. 7. the right DOCUMENTATION. Focus on diagnosis and treatment for each:
3. Flex one of patient’s legs at hip and knee, then straighten ✓ Asthma
the knee. SAFETY MEASURES ✓ Acute Gastroenteritis
1. Use sterile injection equipment and sharps ✓ Dengue
2. Prepare and give injections without contamination or ✓ Febrile Seizures
Positive result Resistance or pain AND flexion of needle-sticks ✓ Pneumonia
hips and knees a. Do not recap needles. Recapping commonly leads ✓ Urinary tract infection
Significance Eliciting for meningeal irritation or to needle-sticks. If recapping is necessary, use a
meningeal signs one-hand technique
3. Dispose of sharps to prevent reuse and harmful waste

INTRAMUSCULAR ROUTE PROCEDURE

1. Follow standard medication administration guidelines for
site assessment/selection and site preparation.
2. Sterilize the injection site using cotton with 70% isopropyl
alcohol or alcohol swab in an outward circular motion.
3. To avoid injection into subcutaneous tissue, spread the
skin of the selected vaccine administration site taut
between the thumb and forefinger, isolating the muscle.
4. Another technique, acceptable mostly for pediatric and
geriatric patients, is to grasp the tissue and "bunch up"
the muscle.
5. Insert the needle fully into the muscle at a 90° angle and
SKIN PINCH TEST inject the vaccine into the tissue.
1. Greet the patient and introduces himself / herself. 6. Withdraw the needle and apply light pressure to the
Maintains good eye contact, display professionalism and injection site for several seconds with a dry cotton ball or
courtesy. gauze.

Demonstrates the steps completely and in order: SUBCUTANOUSE ROUTE PROCEDURE

2. Ask the mother to place the child on the examining table
so that the child is flat on his back with his arms at his
sides (not over his head) and his legs straight. Or, ask
the mother to hold the child so he is lying flat on her lap.
3. USE THE THUMB AND FIRST FINGER to locate the
area on the child’s abdomen halfway between the
umbilicus and the side of the abdomen. Do not use the
1. Follow standard medication administration guidelines for
site assessment/selection and site preparation.
2. Sterilize the injection site using cotton with 70% isopropyl
alcohol or alcohol swab in an outward circular motion.
3. To avoid reaching the muscle, pinch up the fatty tissue,
insert the needle at a 45° angle and inject the vaccine
into the tissue.
 THE RIGHT ROUTE AND NEEDLE LENGTH
INDICATION
INTRAMUSCULAR ROUTE
Toddlers, 12 mos. to 2 years
NEEDLE TO USE SITE PRECAUTION
22-25 gauge; 5/8- to 1-inch VASTUS LATERALIS MUSCLE Preferred because provides a large
(ANTERO-LATERAL THIGH) muscle mass.
If the subcutaneous and muscle
tissue are bunched to minimize the
chance of striking bone, a 1-inch
needle is required to ensure
intramuscular administration in
infants aged 1 month and older.

For neonates (first 28 days of life)

Infants < 12 mos. old
BELOW TWO YEARS OLD!
and preterm infants, a 5/8-inch
needle usually is adequate if the skin
is stretched flat between thumb and
forefinger and the needle inserted at
a 90-degree angle to the skin.
Can be used instead as an
alternative for older children and
adolescents, but use a 1 to 1 ¼-
inch needle

Gauge - 22- to 25-gauge needle
If the subcutaneous and muscle
tissue are bunched to minimize the
chance of striking bone, a 1-inch
needle is required to ensure
intramuscular administration in
infants aged 1 month and older.
For neonates (first 28 days of life)
and preterm infants, a 5/8-inch
needle usually is adequate if the skin
is stretched flat between thumb and
forefinger and the needle inserted at
a 90-degree angle to the skin.
GLUTEAL MUSCLE buttocks are not used for
administration of vaccines in infants
If the gluteal muscle must be used, and children because of concern about
care should be taken to define the potential injury to the sciatic nerve
anatomic landmarks. Injection should
be administered (1) lateral and
superior to a line between the
posterior superior iliac spine and
the greater trochanter or in (2) the
ventrogluteal site, the center of a
triangle bounded by the anterior
superior iliac spine, the tubercle of
the iliac crest, and the upper border
of the greater trochanter.

22-25 gauge; 5/8- to 1-inch

Children/Adolescents Use 1-inch needle for older

(3-18 years) children and adolescents

Use 1 ½-inch needle for obese

SUBCUTANEOUS ROUTE
 for persons 12 months of age 5/8-inch, 23- to 25-gauge needle the upper outer triceps of the arm
and older

for infants, younger than 12 5/8-inch, 23- to 25-gauge needle the thigh
months of age

INTRADERMAL ROUTE (BCG is the only vaccine with this route of administration)
Gauge 26 deltoid region of the upper arm Watch out for the vessels

The patient should be seated with the

arm bent at the elbow and the hand
on the hip to ensure that the site of
administration is prominent.
 RIGHT ROUTE RIGHT VACCINE RIGHT AGE RIGHT INTERVAL RIGHT DOSE OTHER NOTES
INTRADERMAL BCG AT BIRTH GIVEN ONLY ONCE 0.05mL (<12mos) PPD = (+) if >5mm
0.1 (>12mos) Do PPD before if suspected of having TB
SUBCUTANEOUS MEASLES VACCINE 9 MONTHS / GIVEN ONLY ONCE 0.5 mL Use MMR if need booster
6 MONTHS (outbreak)
INFLUENZA VACCINE (can be 6 MONTHS YEARLY AFTER 0.25mL (6-35 months) If unimmunized by 6 month to 8 years old,
IM/SC) 0.5mL (36 months – 18 years) give 2-doses 4 weeks apart, and yearly after.
MEASLES, MUMPS, RUBELLA 12 MONTHS at 12-14 mos. Old (1st) 0.5 mL 2 doses
VACCINE (MMR) at 4-6 years old (2nd)
VARICELLA VACCINE 12 MONTHS at 12-14 mos. old (1st) 0.5 mL
at 4-6 years old (2nd)
MEASLES, MUMPS, RUBELLA, 12 MONTHS 3 months’ interval 0.5 mL
VARICELLA VACCINE (MMRV)
JAPANESE ENCEPHALITIS 9 MONTHS At 9 months to 17 0.5 mL Booster dose 12 – 24 months after 1st dose
years of age
INTRAMUSCULAR HEPATITIS B VACCINE (HBV) WITHIN 12 HOURS 0, 6, 10, 14 weeks 0.5 mL Give .5mL HBIG if (+) HBV mother; or if <2kg
OF LIFE weight and HBV status of mother is unknown
DIPHTHERIA, TETANUS TOXOID, 6 WEEKS At 6, 10, 14 weeks 0.5 mL 5th dose is not given if 4th dose was given at
PERTUSSIS (DTP) (4th) after 4-6 mos. age 4 or older

HAEMOPHILUS INFLUENZAE 6 WEEKS 6, 10, 14 weeks 0.5 mL Booster at 12-15 months with an interval of 6
CONJUGATE VACCINE (Hib) months from 3rd dose
INACTIVATED POLIOVIRUS 6 WEEKS 6, 10, 14 weeks 0.5 mL Booster on or after 4th birthday, with 6 months
VACCINE (IPV) interval from last dose

INFLUENZA VACCINE (can be YEARLY AFTER 0.5 mL

IM/SC)

PNEUMOCOCCAL VACCINES 6 WEEKS (PCV) 4 weeks’ interval 0.5 mL 3 doses

(PCV/PPV)
HEPATITIS A VACCINE
TETANUS AND DIPHTHERIA
TOXOID (Td) / TETANUS AND
DIPHTHERIA TOXOID AND
ACELLULAR PERTUSSIS VACCINE
HUMAN PAPILLOMAVIRUS (HPV)
ORAL POLIOVIRUS VACCINE (OPV)
ROTAVIRUS VACCINE (RV)
2 YEARS (PPV) (6, 10, 14 weeks) Booster given 6 months after 3rd dose
12 MONTHS 2nd dose 6 months after 0.5 mL 2 doses
For fully immunized: 0.5 mL Fully immunized: 5 doses of DTP, or 4
Given every 10 years doses of DTP if 4th dose was given on or after
4th birthday
Fully-immunized Pregnant: 1 dose after 20
weeks’ age of gestation; Unimmunized
Pregnant: 3 doses at 0-1-6 months
9 YEARS Bivalent: 0, 1, 6 mos. 0.5 mL
Quadri: 0, 2, 6 mos.
6 WEEKS 4 weeks’ interval
(6, 10, 14 weeks)
6 WEEKS 4 weeks’ interval 2 doses if RVI (from human); 3 doses if RVS
(6, 10, 14 weeks) (from bovine); last dose not later than 32wks