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Pediatric History Taking (OLDCAARTS) & Complete Physical Examination

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PART 1: COMPLETE PEDIATRIC HISTORY

1. Identifying Data

• Patient's full name, age/date of birth, sex, weight
• Informant (mother, father, guardian, child) and reliability of historian
• Date and place of consultation
• Referral source (if applicable)

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2. Chief Complaint (CC)

"Why did you bring your child in today?"

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3. History of Present Illness (HPI) — Using OLDCAARTS

Pediatric Tip: In children <3 years, all OLDCAARTS data comes from the parent/caregiver. In children 6–12 years, address BOTH child and parent. In adolescents, interview the child separately (with parental consent) for confidential issues.

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4. Past Medical History (PMH)

• Birth history: gestational age, mode of delivery (NVD/LSCS), birth weight, APGAR scores, complications (e.g., neonatal jaundice, respiratory distress, NICU admission)
• Neonatal history: feeding difficulties, cyanosis, seizures, metabolic screening results
• Previous illnesses: hospitalizations, surgeries, significant illnesses (e.g., febrile seizures, pneumonia)
• Accidents/injuries/poisonings
• Chronic conditions: asthma, diabetes, epilepsy, congenital heart disease
• Growth history: any concerns about height/weight gain

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5. Immunization History

• Review vaccination records (BCG, OPV, DPT, HepB, Hib, PCV, MMR, Varicella, etc.)
• Note any missed doses or reactions
• Compare with national immunization schedule

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6. Developmental History

Key screening tools: Denver Developmental Screening Test (DDST), Ages & Stages Questionnaires (ASQ)

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7. Feeding/Nutritional History

• Infants: Breastfed or formula? Frequency, duration, last feed; introduction of solids (when, what)
• Older children: Typical diet, meal frequency, appetite changes, food aversions
• Adolescents: Dietary habits, any disordered eating

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8. Medications & Allergies

• Current medications (dose, frequency, route, duration)
• Recent/past medications related to the chief complaint
• Allergies: drug, food, environmental — type of reaction (rash, anaphylaxis, GI)

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9. Family History (FH)

• Illnesses in parents, siblings, grandparents (especially: heart disease, diabetes, asthma, epilepsy, mental illness, genetic disorders, malignancy)
• Consanguinity (especially relevant in pediatrics)
• Similar illness in family members (infectious or hereditary clues)
• Infant/child deaths in the family (sudden infant death, metabolic disorders)

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10. Social History (SH)

• Household: Who lives at home? Single-parent family? Main caregiver?
• Socioeconomic status: Employment, housing, food security
• School: Grade, academic performance, behavior, attendance
• Childcare/daycare: Exposure to sick contacts
• Travel history: Recent domestic/international travel
• Exposures: Tobacco smoke (passive), pets, pesticides, lead paint
• Adolescent-specific (HEADSS screen):
  • Home, Education, Activities, Drugs, Sexuality, Suicide/depression

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11. Review of Systems (ROS)

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PART 2: COMPLETE PEDIATRIC PHYSICAL EXAMINATION

General Principles

• Build rapport before examination — greet child by name, explain each step
• Observe first — much information is gathered by observation before touching
• Sequence flexibility: In young children, examine less threatening systems first (cardiac when quiet) and save oropharynx for last (often causes crying)
• In infants, the examination is best done with the child in the parent's arms/lap
• Warm hands and stethoscope before contact

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1. General Appearance

• Level of consciousness and alertness (AVPU: Alert, Voice, Pain, Unresponsive)
• Toxic vs. non-toxic appearance
• Nutritional status: well-nourished, malnourished, obese
• Hydration status
• Dysmorphic features (unusual facies, body proportions)
• Distress level: comfortable, in mild/moderate/severe distress
• Interaction with parents and examiner
• Does the child resemble the parent(s)?

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2. Vital Signs & Anthropometrics

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3. Skin

• Color: pallor, cyanosis (central vs. peripheral), jaundice, erythema
• Birthmarks: hemangiomas, café-au-lait spots (≥6 → NF1), port-wine stain (Sturge-Weber), Mongolian spots
• Rashes: morphology (macule, papule, vesicle, pustule), distribution, blanching
• Turgor: tent sign (dehydration)
• Petechiae/purpura: non-blanching — serious sign (meningococcemia, ITP)
• Bruising: unusual sites/patterns → consider non-accidental injury
• Jaundice: assess skin and sclerae

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4. Head, Eyes, Ears, Nose, Throat (HEENT)

• Shape and symmetry: normocephalic, microcephaly, macrocephaly, plagiocephaly
• Fontanelles (infants): anterior (closes 9–18 mo) and posterior (closes 6–8 wk)
  • Bulging (↑ ICP), sunken (dehydration), tense
• Sutures: craniosynostosis
• Hair: texture, distribution, fragility

• Red reflex (Brückner test) — bilateral; absent → cataract/retinoblastoma
• Pupil size, symmetry, and reaction to light
• Extra-ocular movements (strabismus, nystagmus)
• Epicanthal folds, hypertelorism
• Conjunctivae: pallor (anemia), icterus
• Visual acuity (Snellen, Tumbling E, Allen cards age-appropriate)

• Pinna: shape, position (low-set → chromosomal abnormalities), pre-auricular pits/tags
• External ear canal: cerumen, discharge
• Tympanic membrane: landmarks (light reflex, handle of malleus), color, mobility (pneumatic otoscopy), perforations

• Shape, symmetry
• Nasal mucosa: pale/boggy (allergy), erythematous (viral)
• Septal deviation, nasal flaring (respiratory distress sign)
• Discharge: color, consistency

• Examine last in children <7 years
• Lips: color (cyanosis, pallor, cracking), angular cheilitis
• Oral mucosa: hydration, aphthous ulcers, Koplik spots
• Teeth: number, caries, enamel defects
• Tongue: macroglossia, geographic tongue, frenulum (tongue-tie)
• Palate: high-arched, cleft
• Tonsils: size (graded 1–4), color, exudates
• Uvula: midline, bifid

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5. Neck

• Lymph nodes: size (<1 cm mobile cervical = normal in children), tenderness, consistency, matting
• Thyroid: size, consistency, nodules
• Range of motion: nuchal rigidity (meningitis), torticollis
• Tracheal position
• Webbing (Turner syndrome), redundant skin
• Clavicles: fractures (birth injury)

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6. Chest & Respiratory Examination

• Chest shape: barrel chest, pectus excavatum/carinatum, Harrison's sulci
• Work of breathing: nasal flaring, subcostal/intercostal/suprasternal retractions, grunting, use of accessory muscles
• Symmetry of expansion
• Respiratory rate and rhythm

• Expansion (symmetric?)
• Tactile fremitus

• Resonance, dullness (consolidation/effusion), hyperresonance (air-trapping)

• Breath sounds: vesicular, bronchial, bronchovesicular
• Added sounds: wheeze (obstructive), crackles (fine = alveolar, coarse = secretions), stridor (upper airway)
• If child is crying: adequate airway/lung aeration is demonstrated

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7. Cardiovascular Examination

Perform while the child is quiet — auscultate early if child is settled

• Central cyanosis vs. acrocyanosis (normal in neonates)
• Visible precordial pulsations
• Peripheral perfusion: capillary refill time (<2 seconds normal)
• Clubbing: fingers and toes (chronic hypoxia, cyanotic CHD)
• Edema: periorbital (infants), peripheral

• Apex beat: location (normal: 4th ICS MCL <7yr; 5th ICS MCL ≥7yr)
• Heaves and thrills
• Peripheral pulses: rate, rhythm, volume — compare upper vs. lower limb pulses (coarctation of aorta)
• Liver size (↑ in right heart failure)

• S1 and S2: normal splitting of S2 with respiration
• Murmurs: timing (systolic/diastolic), location, grade (I–VI), radiation, quality, effect of position
  • Innocent murmurs: soft, systolic, short, no radiation, no thrill, varies with position
• S3 (normal in children), S4 (always abnormal)
• Rub (pericarditis)

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8. Abdominal Examination

• Shape: distended, scaphoid, protuberant (normal in toddlers)
• Umbilicus: hernias, discharge (neonates)
• Visible peristalsis (pyloric stenosis)
• Skin: caput medusae, spider nevi, visible veins

• Light palpation all four quadrants first
• Deep palpation for organomegaly
  • Liver: normally palpable 1–2 cm below RCM in infants/children
  • Spleen: normally palpable in infants/neonates
  • Kidneys: ballotable (bimanual)
• Guarding, rigidity, rebound tenderness
• Masses
• Inguinal area: hernias, lymph nodes, undescended testes

• Liver span, splenic dullness
• Shifting dullness (ascites)

• Bowel sounds: present, hyperactive, absent

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9. Genitourinary Examination

• Males: testes (descended bilaterally?), hydrocele, hypospadias/epispadias, phimosis, penile length
• Females: labial adhesions, clitoral size, vaginal discharge, ambiguous genitalia
• Tanner staging (pubic hair and genital development)
• Perform sensitively with a chaperone

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10. Musculoskeletal Examination

• Spine: scoliosis (Adam's forward bend test), kyphosis, lordosis, sacral dimples/hairy patches
• Limbs: symmetry, muscle bulk, tone
• Joints: swelling, warmth, tenderness, range of motion
• Hips (infants): Barlow's and Ortolani's tests for DDH (developmental dysplasia of the hip)
• Feet: talipes equinovarus (club foot), flat feet, pes cavus
• Gait (walking children): limping, in-toeing, out-toeing, toe-walking

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11. Neurological Examination

• Consciousness level, alertness, orientation (age-appropriate)
• Behavior, affect, speech quality

• CN II: visual acuity, visual fields, fundoscopy, red reflex
• CN III/IV/VI: extra-ocular movements, pupillary reflexes
• CN VII: facial symmetry (smile, close eyes)
• CN IX/X: gag reflex, swallowing
• CN XII: tongue movements

• Tone: hypotonia (floppy infant) vs. hypertonia (spastic)
  • Ventral suspension and vertical suspension assessment in infants
• Power: against resistance in cooperative children
• Primitive reflexes (infants): Moro, grasp, rooting, stepping, sucking
• Deep tendon reflexes: biceps, triceps, knee (patellar), ankle; Babinski (normal until 18 months)

• Finger-nose test, heel-shin test, rapid alternating movements
• Gait: ataxia, wide-based gait
• Romberg test (older children)

• Light touch, pain (pin-prick) — may be difficult in young children

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12. Lymph Nodes

• Systematically assess: cervical (anterior/posterior), axillary, inguinal, epitrochlear
• Note: size, consistency, mobility, tenderness, overlying skin changes
• Small (<1 cm), mobile, non-tender cervical nodes are normal in children

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Documentation Template Summary

CC: [Chief complaint in parent/child's words]
HPI: [Age]-year-old [sex] presented with [symptom]:
  - Onset: [date/time, sudden/gradual]
  - Location: [site]
  - Duration: [hours/days/weeks]
  - Character: [quality]
  - Aggravating factors: [...]
  - Alleviating factors: [...]
  - Radiation: [yes/no, where]
  - Timing: [constant/intermittent, pattern]
  - Severity: [scale/impact on daily activities]
PMH: [Birth hx, prior illnesses, hospitalizations]
Immunizations: [Up to date/incomplete/unknown]
Development: [Appropriate/delayed for age]
Feeding: [Breastfed/formula/solids/diet]
Medications: [List]
Allergies: [List with reactions]
FH: [Relevant familial illnesses]
SH: [Caregivers, school, exposures]
ROS: [Pertinent positives and negatives]

PHYSICAL EXAM:
VS: T__ HR__ RR__ BP__ SpO2__
Anthropometrics: Wt__kg (__%ile) Ht__cm (__%ile) HC__cm (__%ile) BMI__
General: [Appearance, distress level]
HEENT: [Findings]
Neck: [Findings]
Chest/Resp: [Findings]
CVS: [Findings]
Abdomen: [Findings]
GU: [Findings if examined]
MSK: [Findings]
Neuro: [Findings]
Skin: [Findings]
Lymph: [Findings]

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Key Pediatric-Specific Reminders

1. Age-appropriate communication: talk to the child directly, not just the parent
2. Pain assessment: use FLACC scale (<3 yr), Wong-Baker FACES (3–7 yr), Numeric scale (>7 yr)
3. Growth charts are mandatory — always plot and interpret
4. Developmental surveillance at every well-child visit
5. Child abuse awareness: unexplained bruises, multiple fractures at different stages of healing, inconsistent history
6. Confidentiality for adolescents: HEADSS screening done privately
7. Order of examination: cardiac → respiratory → abdominal → HEENT (oropharynx last)
8. Innocent vs. pathological murmurs: innocent murmurs are very common in children; don't over-investigate
9. Primitive reflexes: presence beyond expected age = abnormal; absence before expected age = abnormal