Exam/Eval

Patient-Client Management Model

Adapted from American Physical Therapy Association. Guide to physical therapist practice (2nd ed). Physical Therapy. 81(1). Copyright 2001 by the American Physical Therapy Association.

History Taking—Relevant Items

Past Medical History/Birth History

• Significant medical history of biological parents

• Mother's history related to pregnancy, labor, delivery

• Child's history related to pregnancy, labor, delivery

• Significant medical history of relatives including siblings

• General health status

• History of major childhood/adolescent illnesses

• History of any surgical or medical procedures

• Known allergies to food, medications, substances, etc.

• Neonatal screening and immunization history

• Diagnostic or medical tests related to past history

Current Medical History

• Current sign and symptoms

• Onset, duration, and severity of presenting problem

• Current health-care practitioners involved with child's care (includes physicians, therapists, psychologists, orthotists, etc.)

• Current medications—purpose, dosage, history of adverse reactions

• Date and, if available, results of recent medical and diagnostic testing

• Current and planned medical and surgical interventions

• Current functional and activity levels

• Use of adaptive equipment or devices

Developmental History

• Infant/child temperament

• Child/caregiver interactions

• Growth and nutrition (including rate of growth in height, weight, head circumference; timing of tooth eruption)

• Feeding—daily routine, preferences, difficulties

• Achievement of major milestones (including sensorimotor, social-emotional, cognitive, language, self-care, etc.)

• Bowel and bladder control/toilet training

Social History

• Parents/caregivers' employment status

• Home layout and environment (including safety issues/childproofing; exposure to lead, tobacco, or other hazards)

• Sleep routine, child's sleeping position

• Use of car seat

• Child care and school history

• Signs of abuse and neglect

Systems Review/Basic Screening

Cardiovascular-Pulmonary System

• Vital signs: Heart rate, respiratory rate, blood pressure, temperature, pain^*

• Observation: Difficulty breathing or crying, excessive crying, cyanosis, retractions, nasal flaring, cough, response to change in position, activity; fatigue, weight loss or gain

• Palpation: Peripheral pulses, tactile fremitus

• Auscultation: Heart and lung sounds

• Percussion: Any areas of dullness over lung fields

Neuromuscular System

• Newborns: APGAR, gestational age, birth weight; suck and swallow; irritability/consolability, state regulation^*

• Observation: General resistance to passive movement; is it velocity-dependent?

• Observation: Ability to make eye contact and track objects

Musculoskeletal System

• Anthropometrics: Height, weight, head circumference^*

• Observation: Size and shape of head, face, skull; any abnormalities of eyes, ears, nose, mouth, palate, teeth; skeletal asymmetry; swelling, bruising

• Complaints: Pain; refusal to bear weight, walk, move; fever; night pain

Integumentary System

• Observation/palpation: Texture, temperature, color ...