CONSIDERATIONS FOR PEDIATRICS 2021

CONSIDERATIONS FOR PEDIATRICS RECORDING THE HISTORY AND PE  Organizational structure for recording the history and physical examination of newborns and infants is the same as for adults  Recorded information varies from the adult’s primarily because of the developmental status of the infant  In newborns, the focus is on the transition to extrauterine life and the detection of any congenital anomalies Additional HISTORY for INFANTS  Present problem o Newborns include the details of the mother’s pregnancy and any untoward events occurring since birth  Details of pregnancy o Mother’s health during pregnancy o Prenatal care o Labor and delivery  Infant’s status at birth o Birth weight, respiratory status, color, Apgar scores if known, nutrition, congenital anomalies, meconium staining, bilirubin phototherapy, bleeding, convulsions, prescriptions  Breast-fed infants o Frequency; use of supplemental formula and vitamin D supplementation o Mother’s diet, fluid intake, concern with milk supply; any problems with nipple soreness, cracking, or infections; age weaned  Formula-fed infants o Specific formula and preparation method, concentration, and amount of water added; frequency of feeding; amount per feeding; total ounces per day; and whether juice, water, or vitamins are given  Solid foods o Age at which cereal and other foods were introduced; feeding methods, amount, food preparation; the response of infant to foods Additional to PHYSICAL EXAM for INFANTs General o Age in hours, days, weeks, or months; gender; race o Gestational age o Length, weight, and head circumference with percentiles; for newborns, percentiles for gestational age Mental status o Infant state during examination (irritable, crying, sleeping, alert, quiet) Skin o Color, texture, presence of lanugo or vernix, Mongolian spot, nails o Presence of hemangiomas, nevi, telangiectasia, milia Lymphatics o Visible or palpable lymph nodes Head o Shape, molding, forceps or electrode marks o Fontanel size, dysmorphic facial features, swelling Eyes o Red reflex, corneal light reflex, follows object with eyes o Swelling of lids, discharge Ears o Shape and alignment of auricles, presence of skin tags or pits o Startle to noise or response to voice Nose o Patency of nares, nasal flaring, discharge Mouth o Palate and lip integrity o Presence and number of teeth o Strength of sucking, coordinated sucking and swallowing Neck o Head position, neck control o Presence of masses, webbing, excess skinfolds Chest and lungs o Symmetry of shape, circumference o Breast swelling or discharge o Abdominal or thoracic breathing o Presence of retractions (intercostal, supraclavicular, substernal), presence of grunting or stridor o Quality of cry Heart and blood vessels o Recording as for adults, but with peripheral vascular findings integrated in this section