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Pediatric

Pediatric Clinical
Clinical
Diagnosis
Diagnosis
Hartono Gunardi, Sudigdo
Sastroasmoro,
Irawan Mangunatmadja,
Department of Child Health, Medical

Differences Adult and


Pediatrics
A child is not a small
History is givenadult
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 childs developmental status
(hypothermia may indicates severe infection in
newborn)

Differences 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).

Clinical exam in infants


and children:
A child is not a small adult!
Why special attention?
Keywords: growth and
development
Any information about history,
physical, and laboratory /
supporting exams should be

The
diagnostic
paradigm:
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Pediatric
History
(Anamnesis)

Auto-anamnesis: self reporting by the


patient
Allo-anamnesis: any information other
than by patient

Supporting exam:5%
Physical exam 10-20%

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History: 80%
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Lis ing y
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Pediatric history
Introduce yourself to the parents and child.
A warm 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.

Anatomy of history taking


1. Patients identity
2. Chief complaint
3. Clinical course
4. Previous illness
5. History of maternal pregnancy
6. History of delivery
7. Feeding history
8. Immunization status
9. Growth and development
10.Family history
11.Environment

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.
Immunization
Growth and development
Family history
Social and environmental history

Maternal history
Multiparity, any miscarriages, stillbirth or
congenital malformation.
Maternal health during pregnancy
(hypertension, TORCH), regular antenatal
care, Rh iso-immunization.
History of drugs ingestion during pregnancy,
oligohydroamnios or polyhydroamnios

Birth history
Mode of delivery.
Crying immediately or not.
Apgar score
History of asphyxia
Meconium stained amniotic fluid.

Post-natal history
NICU admission?
How long 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.

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.

Immunization history
Vaccination program in details ( National)
Any special vaccination was given.
When the last vaccine was given
Any complication of given vaccine
(Any contraindications for certain vaccine?)

Growth and development


history
Details of development milestones,
smiling , sitting, standing, walking,
speech
Bladder and bowel control
School performance, behavioral and
emotional 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, chronic ds (TB),
unexplained death and genetic diseases.
Draw family pedigree

Social & Environmental


history
It is necessary to build up a picture of
the childs 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.

Should complete history be


obtained in all patients
irrespective of their illness?
1. A 8-year old girl, 30 kg, 130 cm, 3rd grade
of elementary school, repeatedly had good
ranking in class. She was brought to the
clinic due to 3-day high grade fever,
stomach ache, and epistaxis

2.

A 12-year old boy, basketball player,


suspected of suffering from radial fracture.

The My 5 Moments for Hand


Hygiene approach

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.

Physical
examination

In general similar to that in adults, i.e.


to obtain accurate physical status
irrespective of the approach
Needs modification due to nature of
infants & children:
Start with inspection
Followed by auscultation: abdomen &
heart
End with examination using

Steps in
physical exam
General condition
Vital signs
Anthropometric
measurements
Systematic exam

Pre-exam checklist:
WIPE
:Wash your hands [thus warming them].
Introduce yourself to pt, explain what going
to do.
Position pt [+/- on parent's knee].
Expose area as needed [parent should
undress].

Any unusual behavior.


If asleep, do the heart, lungs and
abdomen first.

Pre-exam checklist
Parent-child interaction, reaction to
someone new walking entering the
room (child abuse).
Ask if tenderness anywhere, before
start touching them.

A. General
condition
1. Consciousness
:
somnolent,
comatous
2. Appearance
:
moderate /
severely ill, distressed
3. Color
:
cyanotic
4. Specific facies
:
facies

alert, apathetic,
soporous,
health, mild /
pale, jaundiced,
syndromes,

B. Vital signs
1. Pulse

: rate, regularity,
volume, equality
: rate,

2. Respiration
regularity,
pattern
3. Blood pressure : of 4 extremities
4. Temperature
: oral, axillary,
Note: always describe complete pulse & respir
rectal

C. Anthropometric
measurements
1. Body length / height: sitting,
standing
2. Body weight
3. Head circumference
4. Arm circumference
5. Abdominal circumference
6. Nutritional status:
W/A, H/A, W/H
plot in standard normal curve
(WHO

D. Systematic
examination
Head and neck
Chest
Abdomen
Genitals
Extremities
Skin, hair, lymph
nodes
Neurological

Head
Examine the head for shape
Sutures, Bone defects
Size and tension of fontanelles
Head circumference, rate of growth.
Head asymmetry, microcephaly,
macrocephaly, other visible
abnormalities
The hair and scalp should be
examined

Position

Eye Examination
Look for palpebral edema, ptosis,
exopthalmus
Examine the conjunctivae for anemia and
sclerae for jaundice and the cornea for
haziness and opacities
Pupils size and shape, pupil reflex
Evaluate for strabismus by position of the
light reflex and the cover test. Strabismus is
normal before 4-6 months.
Look for nystagmus
Fundoscopic examination
Visual fields should be tested in all children
old enough to cooperate

Eye abnormality?

Ears Examination
Exam position: same as eye, but child
faces the side.
Check for position (low set ) and
shape of both ears.
Discharge, canals, external ear
tenderness.
Otoscope to examine ear drums.
Evaluate hearing.
The mastoid also need to be checked

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

Mouth and throat


Breath odor
The color of lips and mucosa
The condition of teeth, gums (hypertrophy in
phenytoin) and buccal mucosa
Look for tongue (geographic tounge), palate,
tonsils and pharynx
Listen to the voice and the quality of cry and
the presence of stridor

Tonsils

Neck
Examine for nuchal rigidity
Swelling
Webbing
Lymph node : location,
consistency, size, tenderness
Thyroid gland
The position of trachea

Chest
Inspection
The general shape (pectus excavatum or
pectus carinatum)
Abnormal signs : beading (rosary),
asymmetry of expansion
Asess rate,pattern and effort of breathing
Identify variations of respiration and signs of
respiratory distress
Recognize grunting, stridor

Chest
Palpation
Percussion
Auscultation: breath sounds in
children are usually bronchovesicular.
Recognize : wheezing, crackles and
asymmetric breath sounds

Cardiovascular system:

Inspection : Precordial bulge, apical


heave.
Palpation: apex beat : in the 4th
intercostals space in the midclavicular
line in children < 7 years ; after that apex :
the 5th ics. Thrill ?
Percussion
Auscultation: heart sound, murmur
Note the effect of changing of position and
exercise on the murmur. Splitting of the 2nd
heart sound is common in normal children

Heart Sounds

Abdomen (1)
Inspection:
Shape: Distension, Scaphoid
abdomen,
Visible swellings, hernias.
Umbilicus, veins.
Visible peristalsis.
Auscultation:
Bowel sounds.

Abdomen (2)
Palpation:
Masses.
Areas of ternderness, rebound,
guarding.
Liver, spleen: <6 years may palpate up
to 2cm below costal margin.
Kidneys, bladder.
Percussion :
Fluid wave, shifting dullness.
Liver, spleen.

Genitalia
Recognize genital abnormalities in
a boy : cryptorchidism,
hypospadias, phymosis, hydrocele
Palpate the testes
Recognize genital abnormalities in
a girl: signs of virilization, labial
adhesions and signs of injury

Back
Inspection and palpation:
Posture : lordosis, kyphosis,
scoliosis
Masses
Tenderness
Limitation of motion
Spina bifida

Anus
Patency (imperforated anus)
Presence of fissure, fisulae or
hemorrhoids
Rectal examination if indicated

Musclo-skeletal system
Assess symmetry of length and size.
Observe shape of bones, temp, and color.
Observe for bowlegs: space b/t the knee more
than 5 CM. should disappear after 2-3Y.
Inspect for knock-knee: from 2-7Y, and distance
between two ankle should not exceed 3 CM.
Palpate for presence on edema.
Assess muscle strength and muscle tone
estimation.

Always s examine for congenital dislocation


of the hip in infants

Extremities (1)
Examine the hips of a newborn for
congenital dysplasia using Ortolani
maneuvers

Extremities (2)
Identify age-related changes in
gait
Identify age- related variations
,tibial torsion,genu valgus,flat feet

Neurological Examination

Observation
Mental status
Cranial nerves
Cerebellar function
Motor system
Sensory system
Reflexes-primitive (neonatal reflexes,
deep and superficial reflexes.

Neurologic (1)
Abnormalities during play.
Limbs: movement, tone, limp, Gower's
sign.
Head control.

Neurologic (2)
Reflexes:
Moro and tonic neck reflexes <3months.
Babinski's sign positive <12-15 months.
Hypertonicity commonly is normal
infants, but hypotonicity is abnormal.
Other reflexes: grasp, suck, root,
stepping and placing.

Moro reflex

Neurologic (3)
Meningitis signs if indicated:
Kernig, Brudzinski.

Use of
stethoscope
Use binaural stethoscope
Bell-shaped side: for low &
medium
pitched sounds
Membrane (diaphragm): for
medium to
high pitched sounds
For heart exam
use bell-shaped side first
start without pressure, then with
pressure
End with diaphragm side

Common mistakes in
performing examination
History
Fail to identify the patient first
Make an incomplete history
Provide a disorganized history
Physical exam:
Fail to describe general condition &
vital signs
first
Incomplete description of features,
e.g. pulse rate only or respiratory rate
only without
further characteristics

How can you be a good


examiner?

THINK,
PRACTICE,

PRACTICE,

PRACTICE
!!!

Thank you