Welcome toWelcome toCourseCourse
473 Peds 473 Peds
Dr Mohamad-Hani Ali TemsahDr Mohamad-Hani Ali TemsahAsst Professor of PediatricsAsst Professor of Pediatrics
Pediatric IntensivistPediatric IntensivistKKUH ndash King Saud UniversityKKUH ndash King Saud University
Riyadh ndash Saudi ArabiaRiyadh ndash Saudi Arabia
GoalsGoals
bull By completing this course each student is expected to
Have general knowledge about pediatrics
Master the basic principles and skills of pediatrics that will allow him to work as an efficient and safe intern
Keys to Success in this course
bull Punctualitybull Motivationbull Lots of clinical exposurebull Critical thinkingbull Make good use of your teachersbull Reading hellip Practicing hellip
Feedback
Recommended ReadingsRecommended Readings
httpwwwgeocitiescomkkuh_pedia
Student s Guide Studentrsquo
Distribution
10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups
1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7
Activities
1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp
participateparticipate
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
GoalsGoals
bull By completing this course each student is expected to
Have general knowledge about pediatrics
Master the basic principles and skills of pediatrics that will allow him to work as an efficient and safe intern
Keys to Success in this course
bull Punctualitybull Motivationbull Lots of clinical exposurebull Critical thinkingbull Make good use of your teachersbull Reading hellip Practicing hellip
Feedback
Recommended ReadingsRecommended Readings
httpwwwgeocitiescomkkuh_pedia
Student s Guide Studentrsquo
Distribution
10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups
1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7
Activities
1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp
participateparticipate
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Keys to Success in this course
bull Punctualitybull Motivationbull Lots of clinical exposurebull Critical thinkingbull Make good use of your teachersbull Reading hellip Practicing hellip
Feedback
Recommended ReadingsRecommended Readings
httpwwwgeocitiescomkkuh_pedia
Student s Guide Studentrsquo
Distribution
10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups
1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7
Activities
1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp
participateparticipate
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Recommended ReadingsRecommended Readings
httpwwwgeocitiescomkkuh_pedia
Student s Guide Studentrsquo
Distribution
10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups
1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7
Activities
1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp
participateparticipate
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Student s Guide Studentrsquo
Distribution
10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups
1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7
Activities
1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp
participateparticipate
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Distribution
10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups
1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7
Activities
1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp
participateparticipate
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Activities
1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp
participateparticipate
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Activities
bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different
systems
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Exams
bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format
bull OSCE week 125 stations including history taking
physical examination and oral
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Extra Notes
bull Extra sessions arranged for the whole group should only be on Thursdays
bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull Remember We are here for you
bull WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
History Taking in Pediatrics
Similar to adults Plus
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Historybull Patient ID
bull Present Complaint(s) ( CO)
bull History of Present Complaint(s) (HPI)
bull Past Medical History (PMHX)
bull Pregnancy and delivery
bull Neonatal History
bull Systemic Review
bull Family History (FHX)
bull Social History
bull Vaccination History
bull Nutritional History
bull Developmental History
bull Drugs
bull Allergy
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Identifying DataIdentifying Data
bull Patients name age sexPatients name age sex
Informant (parent) ReliabilityInformant (parent) Reliability
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Chief Compliant (CC)Chief Compliant (CC)
bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
History of Present Illness History of Present Illness (HPI)(HPI)
bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Past Medical History Past Medical History (PMH)(PMH)
bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Perinatal HistoryPerinatal History
bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of
delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection
jaundice) jaundice) bull length of hospital staylength of hospital stay
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
NutritionNutrition
Breast feeding vs bottle
Amount and frequency
Quality of food
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
MedicationsMedications
bull Names and dosagesNames and dosages
bull Allergies to Rx or FoodAllergies to Rx or Food
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Developmental History
1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two
words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance
behavioral problemsbehavioral problems
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Immunizations
bull Know the local schedulebull Type of vaccine killed or live-
attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Family History
bull More detailed
bull Learn to draw family pedigree
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Family HistoryFamily History
bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies
cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Social HistorySocial History
bull School level and gradesbull Relationship with parents and
siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke
detectors bicycle helmetsdetectors bicycle helmets
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Review of Systems (ROS)Review of Systems (ROS)
bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue
bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes
bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of
colds pharyngitis otitis mediacolds pharyngitis otitis media
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Cont ROSCont ROS
bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing
bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope
bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Cont ROSCont ROS
bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge
bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis
bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay
polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
TIPS
bull Some parents may exaggerate or mislead you so ask specific questions
bull Avoid leading questionsbull Show appreciation and empathy
with parents anxiety and worrybull Be aware of the sensitivity of some
issues in the family lifebull Take note of the parents behavior
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
QuestionsQuestions
bull Contact e-mailContact e-mail
kkuh_pediayahoocomkkuh_pediayahoocom
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Pediatric Physical Pediatric Physical Examination Examination
Video DemosVideo Demos
(45 minutes)(45 minutes)
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
ObservationObservation
bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures
bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting
position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched
cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Does the child appear to Does the child appear to bebe
(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished
(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued
(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated
(4) Unusual body odors(4) Unusual body odors
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
Vital SignsVital Signs
bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature
bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)
bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes
bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry
bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing
bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency
bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate
bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor
bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions
bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia
bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi
bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses
bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes
bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet
bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence
emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to
5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis
triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar
reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting
suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age
on developmental screening teston developmental screening test
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes
bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)
bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses
bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations
Work HardWork HardBecome ExcellentBecome Excellent
Best WishesBest Wishes