History
Chief complaint. How long. Associated problems. Functional deficit. Can the child keep up with peers (run/jump/play).
Sit/sleep in any unusual positions (W position for sitting, knees to chest sleeping)
Past Medical History (birth history)
Any pregnancy problems. # weeks of pregnancy, type of birth (SVD, c-section: emergent, scheduled). Age walked at.
Allergy
Social History
Who lives with
Year in school, does well or poorly in school
Family History
ROS
Physical Exam
Spine curvature. Rib prominence. Shoulders and pelvis level. Neck masses/ROM. Upper extremities ROM, reflexes, NV status, strength, deformity, stability of joints
Feet supple, alignment. Dorsiflexion. Tibial torsion. Popliteal angle. Overall leg alignment (varus/valgus). Reach down to touch toes. Hip internal/external rotation (in extension, best done with patient supine). Reflexes, NV status, strength, deformity, stability of joints.
Gait exam
TTP
x-ray
If fx: describe fx location and if fracture is in anatomic or acceptable alignment vs. displaced (describe displacement). Growth plates open or closed? Involved in fx or not?
Assessment
Plan