L 5 - Pediatric History & Clinical Examination 08

8/7/2019 L 5 - Pediatric History & Clinical Examination 08

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PEDIATRIC HISTORY ANDPEDIATRIC HISTORY ANDCLINICAL EXAMINATIONCLINICAL EXAMINATION

Faisal AbuFaisal Abu--EkteishEkteish

Professor of PediatricsProfessor of Pediatrics

Jordan University of Science &Jordan University of Science &

TechnologyTechnology



Differences between Adult andDifferences between Adult and

PediatricsPediatrics

History is given by second person.History is given by second person.

The parents may place their own interpretation onThe parents may place their own interpretation onevents(any fever may be called tonsillitis).events(any fever may be called tonsillitis).

The cooperation of the child cannot be guarantiedThe cooperation of the child cannot be guarantied

The expression of the disease may be influencedThe expression of the disease may be influenced

by the child¶s developmental status(apnea may by the child¶s developmental status(apnea mayindicates convulsion in newborn)indicates convulsion in newborn)



Differences between Adult andDifferences between Adult and

PediatricsPediatrics The predominant impact of the disease mayThe predominant impact of the disease may

be on growth and development (UTI, be on growth and development (UTI,Chronic illness).Chronic illness).

Physiological norms are more constant inPhysiological norms are more constant inadults, variable with age in infants andadults, variable with age in infants andchildren( HR, RR)children( HR, RR)

Clinical signs of the disease may differ fromClinical signs of the disease may differ fromthose of adults (Liver is palpable inthose of adults (Liver is palpable ininfancy).infancy).



Age Groups In pediatricsAge Groups In pediatrics

Neonatal period Neonatal period 11stst monthmonth

InfancyInfancy 11stst year year

ChildhoodChildhood 11--15 years15 years--Toddler Toddler 2 years2 years

PrePre--school childschool child 22--5 years5 years

school child 5school child 5--15 years15 years

AdolescentAdolescent 1313--1919



Pediatric historyPediatric history

Introduce yourself to the parents and child.Introduce yourself to the parents and child.

A worm greeting and friendly smile to allayA worm greeting and friendly smile to allay

anxiety and promote confidence.anxiety and promote confidence.

Encourage the parents to tell the story withEncourage the parents to tell the story with

minimum of interruption and listen carefully.minimum of interruption and listen carefully.

You should not swallow the diagnosis given byYou should not swallow the diagnosis given by

the parents.the parents. It is essential to find out what the concern of theIt is essential to find out what the concern of the

parents are. parents are.




Presenting Complaint.Presenting Complaint.

History of present illness and importantHistory of present illness and important

related positive & negative symptoms.related positive & negative symptoms. Systems reviewSystems review

Past historyPast history




Maternal history (PreMaternal history (Pre--natal).natal).

Birth history (Natal).Birth history (Natal).

PostPost--natal history.natal history. Nutritional history. Nutritional history.

VaccinationVaccination

Growth and developmentGrowth and development Family historyFamily history

Social historySocial history




Maternal history:Maternal history:

± ± Multiparity, any miscarriages, stillbirth or Multiparity, any miscarriages, stillbirth or

congenital malformation.congenital malformation. ± ± Maternal health during pregnancy, regular Maternal health during pregnancy, regular

antenatal care, Rh isoantenatal care, Rh iso--immunization.immunization.

± ± History of drugs ingestion during pregnancy,History of drugs ingestion during pregnancy,

oligohydroamnios or polyhydroamniosoligohydroamnios or polyhydroamnios




Birth history:Birth history:

± ± Mode of delivery.Mode of delivery.

± ± Crying immediately or not.Crying immediately or not. ± ± Apgar scoreApgar score

± ± History of asphyxiaHistory of asphyxia

± ± Meconium stained amniotic fluid.Meconium stained amniotic fluid.




PostPost--natal history:natal history:

± ± NICU admission NICU admission

± ± How much did the baby stay in the nursery.How much did the baby stay in the nursery.

± ± Did the baby required mechanical ventilation ?Did the baby required mechanical ventilation ?

± ± Oxygen was given ? Duration of oxygen.Oxygen was given ? Duration of oxygen.

± ± Baby had history of jaundice? ExchangeBaby had history of jaundice? Exchange

transfusion done?transfusion done? ± ± Any illness during first month of life:Any illness during first month of life:

meningitis, convulsion, fever ..etc.meningitis, convulsion, fever ..etc.




Nutritional history: Nutritional history:

± ± Breast or bottle feedingBreast or bottle feeding

± ± Type of formulaType of formula ± ± How much milk is given , number of feeds/dayHow much milk is given , number of feeds/day

± ± How is the milk preparedHow is the milk prepared

± ± When the solid food or cereals is introduced,When the solid food or cereals is introduced,

content of food, any allergy to the food.content of food, any allergy to the food.




Vaccination history:Vaccination history:

± ± Vaccination program in details( National,Vaccination program in details( National,

UNRWA)UNRWA)

± ± Any special vaccination was given.Any special vaccination was given.

± ± When the last vaccine was givenWhen the last vaccine was given

± ± Any complication of given vaccineAny complication of given vaccine

± ± Any contraindications for certain vaccine?Any contraindications for certain vaccine?




Growth and development history:Growth and development history:

± ± Details of development milestones, smiling ,Details of development milestones, smiling ,

sitting, standing, walking, speech,sitting, standing, walking, speech,

± ± Bladder and bowel controlBladder and bowel control

± ± School performance, behavioral and emotionalSchool performance, behavioral and emotional

history.history.




Family history;Family history;

± ± Father and mother age, consanguinity, level of Father and mother age, consanguinity, level of

education and they are healthy or not.education and they are healthy or not.

± ± History of smoking in either parentHistory of smoking in either parent

± ± Siblings: number, sex, and their ages.Siblings: number, sex, and their ages.

± ± History of similar disease, unexplained deathHistory of similar disease, unexplained death

and genetic diseases.and genetic diseases.

± ± Draw family pedigreeDraw family pedigree








Social & Environmental history;Social & Environmental history;

± ± It is necessary to build up a picture of theIt is necessary to build up a picture of the

child¶s social and cultural environmentchild¶s social and cultural environment

± ± Appreciate fears and stresses at home( parentalAppreciate fears and stresses at home( parental

attitudes, separation, divorce, absence of attitudes, separation, divorce, absence of

parent) parent)

± ± Jealously at the arrival of a new babyJealously at the arrival of a new baby ± ± Unexplained injuries may raise the possibilityUnexplained injuries may raise the possibility

of child abuse.of child abuse.



Pediatric ExaminationPediatric Examination

Important points to remember:Important points to remember:

± ± The examination of infants and children is anThe examination of infants and children is anart, demanding qualities of understanding,art, demanding qualities of understanding,

sympathy and patience.sympathy and patience. ± ± Heart rate, Respiratory rate, BP, liver size, heartHeart rate, Respiratory rate, BP, liver size, heart

size varies with age.size varies with age.

± ± Keep disturbing or painful procedures to theKeep disturbing or painful procedures to the

end.end. ± ± It is not necessary to be systemic in your It is not necessary to be systemic in your

examination , but should be complete.examination , but should be complete.




General inspection:General inspection:

± ± The first step is ascertain quickly if the baby isThe first step is ascertain quickly if the baby is

well, mild or severely ill.well, mild or severely ill.

± ± Assess state of consciousness, breathingAssess state of consciousness, breathing

pattern, position, reaction to environment. pattern, position, reaction to environment.

± ± State of nutrition, speech, cry, size relative toState of nutrition, speech, cry, size relative to

the age.the age. ± ± The child should be as completely undressed asThe child should be as completely undressed as

possible, but not necessarily all at once. possible, but not necessarily all at once.




General appearance:General appearance:

± ± If the child is seriously ill ABC and vital signsIf the child is seriously ill ABC and vital signs

must be taken without delay and necessarymust be taken without delay and necessary

immediate intervention is undertaken.immediate intervention is undertaken.

± ± Describe any dysmorphism, abnormalDescribe any dysmorphism, abnormal

movements, unusual position he assumes, hismovements, unusual position he assumes, his

mental status and activity.mental status and activity.




Measurements: should includeMeasurements: should include

± ± Height (length)Height (length)

± ± WeightWeight ± ± Head circumferenceHead circumference

± ± All given with percentile for age.All given with percentile for age.

± ± Temperature (rectal, oral ,axillary)Temperature (rectal, oral ,axillary)

± ± RespirationRespiration

± ± Blood pressureBlood pressure










Skin:Skin:

± ± Include color Include color

± ± The presence of cyanosisThe presence of cyanosis

± ± Discolored patchesDiscolored patches

± ± JaundiceJaundice

± ± RashRash

± ± EdemaEdema ± ± Skin turgor Skin turgor

± ± Amount of subcutaneous tissueAmount of subcutaneous tissue




Head:Head:

± ± Examine the head for shapeExamine the head for shape

± ± SuturesSutures ± ± Bone defectsBone defects

± ± Size and tension of fontanellesSize and tension of fontanelles

± ± The hair and scalp should be examinedThe hair and scalp should be examined




Eyes: make a gross test of vision.Eyes: make a gross test of vision.

± ± Visual fields should be tested in all children old enoughVisual fields should be tested in all children old enough

to cooperateto cooperate

± ± Evaluate for strabismus by position of the light reflexEvaluate for strabismus by position of the light reflexand the cover testand the cover test

± ± Look for nystagmusLook for nystagmus

± ± Examine the conjunctivae for anemia and sclerae for Examine the conjunctivae for anemia and sclerae for

jaundice and the cornea for haziness and opacities jaundice and the cornea for haziness and opacities ± ± Pupils size and shapePupils size and shape

± ± Fundoscopic examinationFundoscopic examination




Ears:Ears:

± ± Check for position(low set ) and shape of bothCheck for position(low set ) and shape of both

ears.ears.

± ± Examine the tympanic membrane for injection,Examine the tympanic membrane for injection,

bulging or perforation bulging or perforation

± ± Evaluate hearingEvaluate hearing

± ± The mastoid also need to be checkedThe mastoid also need to be checked




Mouth and throat:Mouth and throat:

± ± The color of lips and mucosaThe color of lips and mucosa

± ± The condition of teeth, gums and buccalThe condition of teeth, gums and buccalmucosamucosa

± ± Look for tongue, palate, tonsils and pharynxLook for tongue, palate, tonsils and pharynx

± ± Listen to the voice and the quality of cry andListen to the voice and the quality of cry and

the presence of stridor the presence of stridor




Neck examination: Neck examination:

± ± Examine for neck rigidityExamine for neck rigidity

± ± SwellingSwelling ± ± WebbingWebbing

± ± Lymph nodeLymph node

± ± Thyroid glandThyroid gland

± ± The position of tracheaThe position of trachea




Nose and sinuses: Nose and sinuses:

± ± The nasal examination is performed to detectThe nasal examination is performed to detect

deformities.deformities.

± ± Deviation of the septumDeviation of the septum

± ± Color and state of the mucosa and turbinatesColor and state of the mucosa and turbinates

± ± Presence of foreign bodyPresence of foreign body

± ± Examine the sinuses for tenderness andExamine the sinuses for tenderness and

swellingswelling




ChestChest: Inspection: Inspection

± ± The general shape of the chest (pectus excavatum or The general shape of the chest (pectus excavatum or

pectus carinatum) pectus carinatum)

± ± Abnormal signs to look for are beading (rosary),Abnormal signs to look for are beading (rosary),asymmetry of expansionasymmetry of expansion

± ± In infants respiration is diaphragmatic and abdominalIn infants respiration is diaphragmatic and abdominal

± ± PalpationPalpation

± ± PercussionPercussion

± ± Auscultation:Auscultation: breath sounds in children are usually breath sounds in children are usually

bronchovesicular. bronchovesicular.




Cardiovascular system:Cardiovascular system:

± ± InspectionInspection

± ± Palpation:Palpation: the apex beat is normally felt in the 4the apex beat is normally felt in the 4thth

intercostals spaceintercostals space just to the left of the midclavicular just to the left of the midclavicular line in children under 7 years of age. After that it is feltline in children under 7 years of age. After that it is felt

in the 5in the 5thth intercostals space in the midclavicular line.intercostals space in the midclavicular line.

± ± PercussionPercussion

± ± Auscultation:Auscultation: Note the effect of changing of position Note the effect of changing of positionand exercise on the murmur. Splitting of the 2and exercise on the murmur. Splitting of the 2ndnd heartheart

sound is common in normal childrensound is common in normal children




Abdomen:Abdomen:

± ± InspectionInspection ± ±Distension, Scaphoid abdomen,Distension, Scaphoid abdomen,

± ± PalpationPalpation ± ± The lower border of the liver isThe lower border of the liver isnormally 1 cm below the costal margin innormally 1 cm below the costal margin in

infants and children. Liver span 8infants and children. Liver span 8 ± ± 1.8 cm1.8 cm

An enlarged spleen is extending into the left iliacAn enlarged spleen is extending into the left iliac

fossa in infancy and the right in older childrenfossa in infancy and the right in older children ± ± PercussionPercussion

± ± auscultationauscultation




Back:Back:

± ± By employing both observation and palpation,By employing both observation and palpation,

the spinal shape and posture9lordosis, kyphosis,the spinal shape and posture9lordosis, kyphosis,

scoliosis)scoliosis)

± ± MassesMasses

± ± TendernessTenderness

± ± Limitation of motionLimitation of motion

± ± Spina bifidaSpina bifida




Genitalia:Genitalia:

± ± Undesent of testesUndesent of testes

± ± HydroceleHydrocele ± ± HypospediusHypospedius

± ± Ambiguous genitaliaAmbiguous genitalia




Anus:Anus:

± ± Patency(imperforated anus)Patency(imperforated anus)

± ± Presence of fissure, fisulae or hemorrhoidsPresence of fissure, fisulae or hemorrhoids ± ± Rectal examination if indicatedRectal examination if indicated




MuscloMusclo--skeletal system:skeletal system:

± ± AsymmetryAsymmetry

± ± Anomalies of extremitiesAnomalies of extremities ± ± Pain and tenderness of the joint or limbsPain and tenderness of the joint or limbs

± ± Always s examine for congenital dislocation of Always s examine for congenital dislocation of

the hip in infantsthe hip in infants




Neurological Examination Neurological Examination

± ± ObservationObservation

± ± Mental statusMental status

± ± Cranial nervesCranial nerves

± ± Cerebellar functionCerebellar function

± ± Motor systemMotor system

± ± Sensory systemSensory system ± ± ReflexesReflexes--primitive (neonatal reflexes, deep and primitive (neonatal reflexes, deep and

superficial reflexes.superficial reflexes.




Developmental assessmentDevelopmental assessment

± ± Gross motor Gross motor

± ± Vision and fine motor Vision and fine motor ± ± Hearing and languageHearing and language

± ± Social and adaptiveSocial and adaptive




Gross motor:Gross motor:

± ± Head and neck control in prone position(6Head and neck control in prone position(6--88

weeks)weeks)

± ± Able raise head and chest (3months)Able raise head and chest (3months)

± ± Pull from lying or no head lag (4 months)Pull from lying or no head lag (4 months)

± ± Sit without support back straight (8Sit without support back straight (8--9 months)9 months)

± ± Stand without support (10Stand without support (10--12 months)12 months)




Vision and fine motor Vision and fine motor

± ± Follows moving person with eyes (6Follows moving person with eyes (6--8 weeks)8 weeks)

± ± Follows small ball at 10 feet distance(9months)Follows small ball at 10 feet distance(9months) ± ± Pincer grasp (between index finger and thumbPincer grasp (between index finger and thumb

using small object (11using small object (11--12 months)12 months)

± ± Copies a circle (with pencil, build a bridge of 3Copies a circle (with pencil, build a bridge of 3

cubes when shown (3years)cubes when shown (3years)




Hearing and language:Hearing and language:

± ± Turns eyes to soundTurns eyes to sound--rattle 12 inches(2rattle 12 inches(2--44

months)months)

± ± Says Mama, Baba (7Says Mama, Baba (7--9 months)9 months)

± ± Says simple sentences 3Says simple sentences 3--4 words(24 words(2--2.5 years)2.5 years)

± ± Says first name, knows own sex (3 years)Says first name, knows own sex (3 years)




Social and adaptiveSocial and adaptive

± ± Smiles when spoken, vocalizes (6Smiles when spoken, vocalizes (6--8 weeks)8 weeks)

± ± Reaches for and shakes rattle, puts objects toReaches for and shakes rattle, puts objects tomouth(5mouth(5--s month)s month)

± ± Drinks from cup without spilling (18 months)Drinks from cup without spilling (18 months)

± ± Wash hands, pull pants up and down (3 years)Wash hands, pull pants up and down (3 years)

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L 5 - Pediatric History & Clinical Examination 08