EXAMINATION OF THE PEDIATRIC PATIENT

I. DIAGNOSTIC EVALUATIONS
 HISTORY
 PHYSICAL EXAMINATION
II. STANDARDIZED ASSESSMENT TOOLS

DIAGNOSTIC EVALUATIONS
HISTORY
- Clinical and developmental history is the basis of an accurate medical and rehabilitation diagnosis.
- Typically obtained from the parent (but the children are generally able to participate in the diagnostic
interview by the time they reach school age
- Obtaining a medical history can be facilitated by having the parent fill out a new patient questionnaire before
clinical examination is started
- Should include a determination of the ages at which major developmental milestones were met to assess
deviations from normal (Table of the Developmental Milestones); to know if the disability is confined
primarily to the neuromuscular system or involves deficits in other areas because it can influence the
rehabilitation program, interventional methods and ultimate outcome.
- Maternal hx: a history of maternal disease or acute illnesses, or pregnancy or labor abnormalities can help
guide the examination and diagnostic studies.
- the duration of the pregnancy, description of fetal movements, the ease or difficulty of labor
and delivery should be included.
- Events during newborn period: record of any unusual episodes of cyanosis or respiratory distress, seizures and
other physical sx such as jaundice or anemia.
- APGAR SCORE: an important piece of information about the infant in the immediate perinatal
period; it has 5 key elements: Activity, Pulse, Grimace, Appearance and Respiration.
- Feeding hx: can suggest potential neurological abnormalities. It includes record of any difficulties with sucking
or swallowing, whether the baby is or was breast-fed or bottle-fed, the volume of frequency of feedings.
- Medical hx: include chronic medical problems, hospitalizations, procedures and surgeries; include list of
medications and allergies as well as the status of child’s medications.
- Psychosocial hx: essential to fully understand child’s past and present capabilities.
- identifies the social and psychological aspects of the child or adolescent and the family.
- Family hx: assist in the identification of inherited or congenital diseases.
- frequently helpful to briefly examine a family member if a genetic disorder is suspected.

DEVELOPMENTAL MILESTONES

Age Gross Motor Language Fine Motor Social

3 mo. Good head control in sitting Cries Grasps toy Smiles at face
Rolls back to side Coos Object to mouth
Hands to midline
6 mo. Ability to sit Babbles Thumb opposition emerging Recognizes family
Rolls both ways Makes vowels sounds Reaches with one hand members
9 mo. Crawls Uses gestures Can release voluntarily Plays patty cake
Pulls to stand and cruises Understands “no” Pincer grasp (crude) Plays peek-a-boo
Can point
12 mo. Walks with hand held or Mama/dada specific Bangs two blocs together Waves bye-bye
independently Has at least two other Grossly turns pages book
Can squat (stand to sit) words Puts objects in container
Responds to name Pincer grasp (mature)
18 mo. Can run Four to 20 words Builds tower of two to four Feeds self
Walks stairs Follows simple cubes Takes off simple
instructions Throws ball clothes
One or more body parts Scribbles
24 mo. Kicks ball Two-word sentences Builds tower of 6-7 cubes Can put on some
Runs better Body parts Turns a door knob clothes
Intelligible most of time Can draw a vertical line
(70%)
200 words
3 yr Balances on one foot First and last name Builds tower of 9-10 cubes Dresses
Rides a tricycle Knows age and sex Holds crayon with fingers Potty-trained
Three-word sentences Copies circle Separates easily
Can count 3 objects
4 yr Hops on one foot 4 to 5-word sentences Throws ball overhead Tries to be
Stands on one foot 5 Counts to four Uses scissors independent
seconds Knows colors Draws circle and square Imaginary play
Draws person of 2-4 parts
5 yr Skipping Counts 10 or more Catches a ball Ties shoelaces
Stands on one foot 10 sec. objects Copies triangle Sings and dances
Mature gait 6-8-word sentences Draws person with a body
Walks backward heel-toe Knows coins
Knows address

PHYSICAL EXAMINATION
K