Obtaining an accurate and complete pediatric health history is essential when providing healthcare to children. The accuracy of the physical examination and diagnoses depends on whether the health history is accurate and complete. The pediatric healthcare provider must possess excellent communication skills when working with children and families to elicit the most accurate and complete health history. Communicating well and establishing rapport with the parent or primary caregiver and the child are the crucial first steps when obtaining the health history interview. The emergency pediatric health history is often conducted in urgent care clinics, emergency rooms, or pediatric intensive care units. This history involves the rapid collection of data in emergent, potentially life-threatening situations. Analysis of both subjective and objective data allows the provider to create a problem list, which is a consideration of all the possible diagnoses based on the information gathered through interviewing and examining the child.

Obtaining an accurate health history is the essential first step in the pediatric healthcare visit. The accuracy of the physical examination and diagnoses depends on whether the health history is accurate and complete. This chapter helps the student refine skills in obtaining the pediatric health history. It also helps the student to identify the type of history that needs to be obtained based on the reason for seeking care and how the various components of the health history differ according to age and developmental stage. It then helps the reader to demonstrate age and developmentally appropriate communication and interview skills when obtaining the health history. It presents the essential terminology, and critical thinking exercises in two formats: short answer, and case study. It also presents certification exam-style multiple choice questions (with answers) followed by blank sample documentation to show examples of subjective and objective findings that are necessary to record.

Assessment of the newborn infant requires specialized knowledge and skills. During the transition from intrauterine to extrauterine life, and extending through the neonatal period (first 28 days of life), the infant undergoes numerous physiologic changes. Providers require an understanding of neonatal anatomy and physiology as well as the skills to accomplish a comprehensive infant assessment. This chapter reviews newborn assessment, including a comprehensive history and a detailed physical examination. Assessment of the newborn infant is a critical component of pediatric care. The chapter provides the basic techniques of newborn assessment. Proficiency is attained through practice. The provider must be well prepared, using a systematic yet flexible approach. The experienced provider integrates multiple aspects of assessment; for example, behavior is evaluated during the physical assessment, rather than separately. Parents should be included in the examination, providing an excellent opportunity for education.

Cardiovascular assessment is very important in the assessment of both well and acutely ill children, as well as in children with chronic conditions. The cardiovascular evaluation of a child includes taking a detailed history and conducting a comprehensive physical examination that includes inspection, palpation, and auscultation. Further evaluation is recommended if the history and physical examination findings are suggestive of congenital or acquired heart disease. Taking a comprehensive health history is one of the most important steps in evaluating whether a child is at risk for or already has heart disease. Laboratory tests, electrocardiogram, and chest films are generally abnormal only when the congenital heart disease or acquired heart disease is significant enough to cause hemodynamic changes. However, these diagnostic tests can provide useful information about the progression of the disease as well as the health status of children living with heart disease.

Assessment of the reproductive system can provoke a great deal of anxiety for the child or adolescent, the parent, and the provider. This chapter assists in gaining the skills to facilitate obtaining an accurate and complete pediatric genitourinary assessment in children of all ages. It helps the reader to obtain a thorough and accurate pediatric reproductive and genitourinary history and to demonstrate sensitivity and maintain privacy when conducting the pediatric genitourinary history and physical examination. It also helps the reader to demonstrate the ability to obtain an accurate history and physical examination of the breasts. The chapter presents the essential terminology, and critical thinking exercises in two formats: short answer, and case study. It also presents certification exam-style multiple choice questions (with answers) followed by the blank sample documentation to show examples of subjective and objective findings that are necessary to record.

One of the most critical assessments the pediatric healthcare provider can make is to determine whether a child is being neglected or abused. The healthcare provider must have sharp assessment skills to be able to recognize the various types of child neglect, differentiate between intentional and unintentional injuries, identify the subtle signs of emotional or verbal abuse, and sensitively gather subjective and objective data when sexual abuse is suspected. This chapter helps the reader to discuss the characteristics of the parent, child, and environment that increase the risk for child abuse or neglect and to describe the elements of the pediatric history and physical examination that may indicate abuse or neglect. It presents the expected learning outcomes, essential terminology, and critical thinking exercises followed by certification exam-style multiple choice questions (with answers) and the blank sample documentation to show examples of subjective and objective findings that are necessary to record.

Assessment of the face, nose, and throat is an essential skill for the pediatric healthcare provider. Upper respiratory infections, allergies, oral or facial trauma, dental caries, and pharyngitis are common diagnoses in children. When obtaining the history and physical examination of the face, nose, and throat in children, the healthcare provider can also identify parent and child teaching opportunities, for example, encouraging regular dental care, compliance with antibiotic therapy for streptococcal pharyngitis, and the consistent use of sports safety gear to avoid oral and facial injuries. As part of the assessment of the face, nose, and mouth, the quality of the child's speech is also evaluated. Appropriate referrals to a speech pathologist, otolaryngologist, and pediatric dentist may be necessary. Various diagnostic tests may be necessary to clarify differential diagnoses of abnormal conditions involving the face, nose, and mouth. This chapter summarizes some examples of these diagnostic studies and their indications.

Assessment of the head and neck is an important part of the pediatric health evaluation. Common minor childhood infections often manifest in the head and neck area. Acute infections or injuries to the head and neck can also lead to long-term developmental delays, disabilities, and even death in infants and children. When obtaining the history and physical examination of the head and neck, the healthcare provider can also identify parent and child teaching opportunities, such as encouraging repositioning in young infants with positional plagiocephaly or the consistent use of bicycle helmets. When assessing a child with an illness or injury related to the head or neck, the provider should obtain focused history. This chapter discusses the causes of head and neck lymphadenopathy in children, the diagnostic studies used to evaluate the conditions of the head and neck and the differential diagnosis of head and neck mass in infants and children.

Assessment of the ears is an essential skill for the pediatric healthcare provider to possess. Important skills include obtaining a thorough history; an age-appropriate physical examination of the external ear, external auditory canal, and tympanic membrane; and the ability to perform an efficient and accurate otoscopic examination. Familiarity with age-appropriate receptive and expressive language milestones, and risk factors for and signs and symptoms of hearing loss are necessary for early identification of hearing loss in infants and children. This chapter helps the reader to identify normal anatomic landmarks of the external and middle ear. It presents the essential terminologies related to ear assessment, and critical thinking exercises in two formats: short answer, and case study. It also presents certification exam-style multiple choice questions (with answers) followed by the blank sample documentation to show examples of subjective and objective findings that are necessary to record.

Performing a comprehensive assessment of the female external genitalia requires knowledge of the anatomy, involving the women, and using a systemic approach to carefully observe and palpate the various tissues and anatomic features. Examining the vulvar region provides the opportunity to detect anatomic changes and other abnormal physical examination findings that may provide diagnostic clues about the possible diagnosis of any symptoms described during the interview. This chapter helps the reader to learn how to describe the anatomy of the external genitalia, including key structures and landmarks and how to conduct a systematic assessment of the external genitalia. It describes normal and abnormal external genitalia findings. The chapter then discusses the focus of the visual examination. The systematic approach to examining the external genitalia includes an initial visual examination followed by palpation and separation of skin folds; assessment for tenderness, masses, muscle tension, or any other abnormal findings.