The adolescent must be treated with sensitivity, respect, and confidentiality to foster the optimal environment for medical care.
9. Family history: Because many conditions are inherited, the ages and health of siblings, parents, grandparents, and other family members can provide important diagnostic clues. For instance, an obese child with a family history of adult-onset diabetes is at high risk for developing diabetes; early intervention is warranted.
10. Social history: Living arrangements, economic situations, type of insurance, and religious affiliations may provide important clues to a puzzling diagnostic case or suggest important information about the acceptability of therapeutic options.
11. Review of systems: A few questions about each of the major body systems allows the practitioner to ensure that no problems are overlooked and to obtain crucial history about related and unrelated medical conditions.
PHYSICAL EXAMINATION
1. General appearance: Well- versus poorly nourished; evidence of toxemia, including lethargy (defined as poor or absent eye contact and refusal to interact with environment), signs of poor perfusion, hypo- or hyperventilation, and cyanosis; or stigmata of syndromes (such as Down or Turner).
2. Skin: In smaller children, checking the color of the skin for evidence of pallor, plethora, jaundice, or cyanosis is important. Abnormalities such as capillary hemangiomas (eg, “stork bites” in a newborn), café-au-lait spots, pigmented nevi (eg, “Mongolian spots”), erythema toxicum, or pustular melanosis can be identified. In older children, macules, papules, vesicles, pustules, wheals, and petechiae or purpura should be described, and evidence of excoriation, crust formation, desquamation, hyperpigmentation, ulceration, scar formation, or atrophy should be identified.
3. Vital signs: Temperature, blood pressure (generally begin routine measurement after 3 years), heart rate, respiratory rate, height, weight, and head circumference (generally measured until age 3 years). Measurements are plotted and compared to normals for age.
4. Head, eyes, ears, nose, mouth and throat:
a. Head: For the neonate, the size of fontanelles and presence of overriding sutures, caput succedaneum (superficial edema or hematoma that crosses suture lines, usually located over crown), or cephalohematoma (hematoma that does not cross suture lines) should be noted. For the older child, the size and shape of the head as well as abnormalities such as swellings, depressions, or abnormal hair quality or distribution may be identified.
b. Eyes: For infants, abnormalities in the size, shape, and position of the orbits, the color of the sclera (blue sclera, for instance, may indicate osteogenesis imperfecta), conjunctival hemorrhages or abnormalities, or the presence of iris defects (such as coloboma) may be found. The visual acuity of older children should be determined.
c. Ears: For all children, abnormalities in the size, shape, and position of the ears can provide important diagnostic clues. Whereas tympanic membranes are difficult to assess in newborns, their integrity should be assessed in older children. For all children, the quality and character of discharge from the ear canal should be documented.
d. Nose: The size, shape, and position of the nose (in relation to the face and mouth) can provide diagnostic clues for various syndromes, such as a small nose in Down syndrome. Patency of the nostrils, especially in neonates who are obligate nose breathers, is imperative. Abnormalities of the nasal bridge or septum, integrity of the mucosa, and the presence of foreign bodies should be noted. A butterfly rash around the nose can be associated with systemic lupus erythematosus (SLE), and a transverse crease across the anterior portion of the nose is seen with allergic rhinitis.
e. Mouth and throat:
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