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PEDIATRIC HISTORY AND CLINICAL EXAMINATION

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PEDIATRIC HISTORY AND CLINICAL EXAMINATION Powered By Docstoc
					PEDIATRIC HISTORY AND
CLINICAL EXAMINATION
        Faisal Abu-Ekteish
      Professor of Pediatrics
  Jordan University of Science &
           Technology
    Differences between Adult and
              Pediatrics

   History is given by second person.
   The parents may place their own interpretation on
    events(any fever may be called tonsillitis).
   The cooperation of the child cannot be guarantied
   The expression of the disease may be influenced
    by the child’s developmental status(apnea may
    indicates convulsion in newborn)
    Differences between Adult and
              Pediatrics
 The predominant impact of the disease may
  be on growth and development (UTI,
  Chronic illness).
 Physiological norms are more constant in
  adults, variable with age in infants and
  children( HR, RR)
 Clinical signs of the disease may differ from
  those of adults (Liver is palpable in
  infancy).
     Age Groups In pediatrics
 Neonatal period      1st month
 Infancy              1st year
 Childhood            1-15 years
      -Toddler         2 years
      Pre-school child 2-5 years
      school child     5-15 years
      Adolescent       13-19
                Pediatric history
   Introduce yourself to the parents and child.
   A worm greeting and friendly smile to allay
    anxiety and promote confidence.
   Encourage the parents to tell the story with
    minimum of interruption and listen carefully.
   You should not swallow the diagnosis given by
    the parents.
   It is essential to find out what the concern of the
    parents are.
            Pediatric history
 Presenting Complaint.
 History of present illness and important
  related positive & negative symptoms.
 Systems review
 Past history
            Pediatric history
 Maternal history (Pre-natal).
 Birth history (Natal).
 Post-natal history.
 Nutritional history.
 Vaccination
 Growth and development
 Family history
 Social history
              Pediatric history
   Maternal history:
    – Multiparity, any miscarriages, stillbirth or
      congenital malformation.
    – Maternal health during pregnancy, regular
      antenatal care, Rh iso-immunization.
    – History of drugs ingestion during pregnancy,
      oligohydroamnios or polyhydroamnios
                Pediatric history
   Birth history:
    –   Mode of delivery.
    –   Crying immediately or not.
    –   Apgar score
    –   History of asphyxia
    –   Meconium stained amniotic fluid.
              Pediatric history
   Post-natal history:
    – NICU admission
    – How much did the baby stay in the nursery.
    – Did the baby required mechanical ventilation ?
    – Oxygen was given ? Duration of oxygen.
    – Baby had history of jaundice? Exchange
      transfusion done?
    – Any illness during first month of life:
      meningitis, convulsion, fever ..etc.
                Pediatric history
   Nutritional history:
    –   Breast or bottle feeding
    –   Type of formula
    –   How much milk is given , number of feeds/day
    –   How is the milk prepared
    –   When the solid food or cereals is introduced,
        content of food, any allergy to the food.
              Pediatric history
   Vaccination history:
    – Vaccination program in details( National,
      UNRWA)
    – Any special vaccination was given.
    – When the last vaccine was given
    – Any complication of given vaccine
    – Any contraindications for certain vaccine?
             Pediatric history
   Growth and development history:
    – Details of development milestones, smiling ,
      sitting, standing, walking, speech,
    – Bladder and bowel control
    – School performance, behavioral and emotional
      history.
              Pediatric history
   Family history;
    – Father and mother age, consanguinity, level of
      education and they are healthy or not.
    – History of smoking in either parent
    – Siblings: number, sex, and their ages.
    – History of similar disease, unexplained death
      and genetic diseases.
    – Draw family pedigree
              Pediatric history
   Social & Environmental history;
    – It is necessary to build up a picture of the
      child’s social and cultural environment
    – Appreciate fears and stresses at home( parental
      attitudes, separation, divorce, absence of
      parent)
    – Jealously at the arrival of a new baby
    – Unexplained injuries may raise the possibility
      of child abuse.
          Pediatric Examination
   Important points to remember:
    – The examination of infants and children is an
      art, demanding qualities of understanding,
      sympathy and patience.
    – Heart rate, Respiratory rate, BP, liver size, heart
      size varies with age.
    – Keep disturbing or painful procedures to the
      end.
    – It is not necessary to be systemic in your
      examination , but should be complete.
          Pediatric Examination
   General inspection:
    – The first step is ascertain quickly if the baby is
      well, mild or severely ill.
    – Assess state of consciousness, breathing
      pattern, position, reaction to environment.
    – State of nutrition, speech, cry, size relative to
      the age.
    – The child should be as completely undressed as
      possible, but not necessarily all at once.
          Pediatric Examination
   General appearance:
    – If the child is seriously ill ABC and vital signs
      must be taken without delay and necessary
      immediate intervention is undertaken.
    – Describe any dysmorphism, abnormal
      movements, unusual position he assumes, his
      mental status and activity.
            Pediatric Examination
   Measurements: should include
    –   Height (length)
    –   Weight
    –   Head circumference
    –   All given with percentile for age.
    –   Temperature (rectal, oral ,axillary)
    –   Respiration
    –   Blood pressure
            Pediatric Examination
   Skin:
    –   Include color
    –   The presence of cyanosis
    –   Discolored patches
    –   Jaundice
    –   Rash
    –   Edema
    –   Skin turgor
    –   Amount of subcutaneous tissue
           Pediatric Examination
   Head:
    –   Examine the head for shape
    –   Sutures
    –   Bone defects
    –   Size and tension of fontanelles
    –   The hair and scalp should be examined
           Pediatric Examination
   Eyes: make a gross test of vision.
    – Visual fields should be tested in all children old enough
      to cooperate
    – Evaluate for strabismus by position of the light reflex
      and the cover test
    – Look for nystagmus
    – Examine the conjunctivae for anemia and sclerae for
      jaundice and the cornea for haziness and opacities
    – Pupils size and shape
    – Fundoscopic examination
            Pediatric Examination
   Ears:
    – Check for position(low set ) and shape of both
      ears.
    – Examine the tympanic membrane for injection,
      bulging or perforation
    – Evaluate hearing
    – The mastoid also need to be checked
          Pediatric Examination
   Mouth and throat:
    – The color of lips and mucosa
    – The condition of teeth, gums and buccal
      mucosa
    – Look for tongue, palate, tonsils and pharynx
    – Listen to the voice and the quality of cry and
      the presence of stridor
           Pediatric Examination
   Neck examination:
    –   Examine for neck rigidity
    –   Swelling
    –   Webbing
    –   Lymph node
    –   Thyroid gland
    –   The position of trachea
         Pediatric Examination
   Nose and sinuses:
    – The nasal examination is performed to detect
      deformities.
    – Deviation of the septum
    – Color and state of the mucosa and turbinates
    – Presence of foreign body
    – Examine the sinuses for tenderness and
      swelling
          Pediatric Examination
   Chest: Inspection
    – The general shape of the chest (pectus excavatum or
      pectus carinatum)
    – Abnormal signs to look for are beading (rosary),
      asymmetry of expansion
    – In infants respiration is diaphragmatic and abdominal
    – Palpation
    – Percussion
    – Auscultation: breath sounds in children are usually
      bronchovesicular.
           Pediatric Examination
   Cardiovascular system:
    – Inspection
    – Palpation: the apex beat is normally felt in the 4th
      intercostals space just to the left of the midclavicular
      line in children under 7 years of age. After that it is felt
      in the 5th intercostals space in the midclavicular line.
    – Percussion
    – Auscultation: Note the effect of changing of position
      and exercise on the murmur. Splitting of the 2nd heart
      sound is common in normal children
          Pediatric Examination
   Abdomen:
    – Inspection –Distension, Scaphoid abdomen,
    – Palpation – The lower border of the liver is
      normally 1 cm below the costal margin in
      infants and children. Liver span 8 ± 1.8 cm
    An enlarged spleen is extending into the left iliac
      fossa in infancy and the right in older children
    – Percussion
    – auscultation
            Pediatric Examination
   Back:
    – By employing both observation and palpation,
      the spinal shape and posture9lordosis, kyphosis,
      scoliosis)
    – Masses
    – Tenderness
    – Limitation of motion
    – Spina bifida
           Pediatric Examination
   Genitalia:
    –   Undesent of testes
    –   Hydrocele
    –   Hypospedius
    –   Ambiguous genitalia
         Pediatric Examination
   Anus:
    – Patency(imperforated anus)
    – Presence of fissure, fisulae or hemorrhoids
    – Rectal examination if indicated
           Pediatric Examination
   Musclo-skeletal system:
    –   Asymmetry
    –   Anomalies of extremities
    –   Pain and tenderness of the joint or limbs
    –   Always s examine for congenital dislocation of
        the hip in infants
           Pediatric Examination
   Neurological Examination
    –   Observation
    –   Mental status
    –   Cranial nerves
    –   Cerebellar function
    –   Motor system
    –   Sensory system
    –   Reflexes-primitive (neonatal reflexes, deep and
        superficial reflexes.
           Pediatric Examination
   Developmental assessment
    –   Gross motor
    –   Vision and fine motor
    –   Hearing and language
    –   Social and adaptive
      Developmental assessment
   Gross motor:
    – Head and neck control in prone position(6-8
      weeks)
    – Able raise head and chest (3months)
    – Pull from lying or no head lag (4 months)
    – Sit without support back straight (8-9 months)
    – Stand without support (10-12 months)
      Developmental assessment
   Vision and fine motor
    – Follows moving person with eyes (6-8 weeks)
    – Follows small ball at 10 feet distance(9months)
    – Pincer grasp (between index finger and thumb
      using small object (11-12 months)
    – Copies a circle (with pencil, build a bridge of 3
      cubes when shown (3years)
      Developmental assessment
   Hearing and language:
    – Turns eyes to sound-rattle 12 inches(2-4
      months)
    – Says Mama, Baba (7-9 months)
    – Says simple sentences 3-4 words(2-2.5 years)
    – Says first name, knows own sex (3 years)
      Developmental assessment
   Social and adaptive
    – Smiles when spoken, vocalizes (6-8 weeks)
    – Reaches for and shakes rattle, puts objects to
      mouth(5-s month)
    – Drinks from cup without spilling (18 months)
    – Wash hands, pull pants up and down (3 years)