Skip to main content

History and Physical

  Infants < 1 year of age Children

Injury Related History
  • Symptom onset
  • Nature of symptoms
  • Symptom alleviating and exacerbating factors
  • Behavior prior, at the time of, and following injury
  • Events leading up to injury
  • Feeding: Duration, frequency of feeds, intake over the past 24-hour period
  • Presence of fever
  • Nature of injury (time, mechanism, initial symptoms, progression of symptoms)
  • Presence of neurological symptoms
  • Behavior prior, at the time of, and following injury
  • Events leading up to injury
  • Supervision at the time of injury
  • If delay in seeking care, clarify the reason for the delay

Past and Familial Medical History
  • Birth history
  • Prior emergency department visits
  • Prior hospitalizations
  • Primary care physician and date of last visit
  • Immunization status
  • Infant or child temperament, such as excessive crying, challenging, or cautious
  • History of familial genetic disorders or syndromes

Social History

(if not obtained by Social Work)
  • Familial patterns of discipline
  • History of abuse (infant or child, siblings, or parents)
  • Past and/or present Child Protective Services involvement with the family
  • History of substance abuse by caregivers or others living in the home
  • History of mental health concerns of parents
  • History of arrests, incarcerations, or interactions with law enforcement
  • History of domestic violence
  • Social and financial stressors

Development
  • Mobility (rolling, crawling, cruising, walking, running)
  • Normal vs. abnormal
  • Parent's expectations of the infant's or child's development

Review of Systems
  • Does the infant or child have new and/or unexplained symptoms commonly associated with missed abuse, particularly missed abusive head trauma?
    • Neuro: Altered mental status, irritability, lethargy, seizures, abnormal movements, loss of consciousness
    • HEENT: Increased head circumference, subconjunctival hemorrhage, abnormal eye movements, bleeding from nose or mouth, bruising or injury
    • CV/Resp: Brief resolved unexplained event (BRUE), apnea, disordered or abnormal bleeding
    • GI: Vomiting without other ill symptoms
    • Musculoskeletal: Decreased movement of an extremity, not moving all extremities equally
    • Heme: Abnormal bruising or bleeding
    • Skin: Presence of bruising, or other skin injury, history of prior bruising or skin injury

Physical Examination
  • Review of vital signs
  • Measure and plot growth measures, including head circumference
  • Neurological examination
  • HEENT examination
  • Skin examination, document location of skin injuries, particular attention to TEN-FACES regions

References

Christian, C. W., & the Committee on Child Abuse and Neglect, American Academy of Pediatrics. (2015). The evaluation and treatment of suspected child physical abuse. Pediatrics, 135(5), e1337-e1354. https://doi.org/10.1542/peds.2015-0356

Narang, S. K., Fingarson, A., Lukefahr, J., & the Council on Child Abuse and Neglect, American Academy of Pediatrics. (2020). Abusive head trauma in infants and children. Pediatrics, 145(4), e20200203. https://doi.org/10.1542/peds.2020-0203

 

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.

Children's Mercy Kansas City   /    Health Care Providers   /    Evidence Based Practice / Clinical Pathways    /    Clinical Practice Guidelines, Care Process Models, and Enhanced Recovery After Surgery Pathways   /    Child Physical Abuse   /   History and Physical