pediatric clinical examintion

7/30/2019 Pediatric Clinical Examintion

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Pediatric clinical examintion


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Pediatric age group is further divided into

various subgroups:

Neonatal period first months of life

Infancy first year of life

Pre-school child 1- 5 years

School child 5-15 years


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pediatric diagnosis relies heavily on history,

partly on examination and partly on

investigation.

Obtain the history from the mother, whenever

possible, other family members may be more

vocal or dominant, but they should be

discouraged.


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Supplementary questions are often needed

during history taking as parents tend to

emphasize their effort s more at seeking the

treatment than describing the child`s

symptoms. Terms used by then may also need

to be further elaborated


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Many times parents volunteer their own

interpretation of child symptom which may

not true. E.g. mother often attributes undue

crying of the baby to abdominal pain while

actual problem may be somewhere else.


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The older child may give an accurate and

detailed acout of their illness and should be

questioned directly. It may be sometimes

important to talk to a grown up child and his

parents in the absence of the other part.


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The pattern of writing the history is the same

as in adults with additional information about

birth history, developmental history, feeding

history and immunization.


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PRESENTING COMPAINTS

These should be recorded in chronological

order.


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HISTORY OF PRESENT ILLNESS

Ask details of all the symptoms listed under

presenting complaints, one by one.

Remember that the young child`s ability to

express himself is every limited and similar

symptoms like crying, poor feeding, lethargy,

vomiting, fever etc may signal many different

illnesses.


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A worried anxious mother may forget or

ignore a symptom or detail of it. To avoid

missing significant information about the

child`s illness


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Ask questions about all the important

symptoms in the form of systemic inquiry,

after the mother has finished has narration.


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SYMPTOMATOLOGY

Same questions are useful in older children in

most of the situation. Some presentation of

the disease are peculiar to the pediatric age

group. These are briefly described below.


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FEVER

Fever is perhaps the most common symptom

of disease in childhood and infection- localized

or generalized- the most common cause. Ask

about duration of fever, its pattern, and anyassociated symptom. In the absence of

localizing features malaria and enteric fever

are the likely possibilities.


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In child with fever throat examination is the

single most important examination and urine

examination is the single most important

investigation.


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FEEDING

Refusal to feed is an important symptom in

children and indicates the severity of illness.

Ask about any change in milk intake( in case of

young child) or food and water intake ( incases of older child since illness started


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VOMITING

It is very common in sick children. Vomiting

and diarrhea together due to gastroenteritis

are one of the most common pediatric

problems in third world countries. Vomitingmay be an associated symptom in high grade

fever or cough


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Persistent vomiting accompanied by

distension or abdomen suggests intestinal

obstruction. Ask about following details:

Colour and contents of vomitus

Force and frequency of vomiting

Relationship of vomiting with feeding


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Remember that effortless regurgitation of milk

is common in normal infants and should not

be confused with true vomiting.


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BOWEL HABITS

Normal bowel habits of an infant may vary

from 5 or 6 times a day to once in a couple of

days. Diarrhea is very common in infancy.

Often there is associated vomiting of fever.Infections of gastrointestinal tract are the

most common cause of diarrhea.


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Other causes include anywhere else in the

body, overfeeding or underfeeding, drugs etc.

ask questions about:

Duration of diarrhea

Frequency, quantity, consistency, color contents of

stool particularly the presence of blood or mucus

in the stool


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CRYING

Young children generally cry when sick; they

also cry when hungry, thirsty, wet, warm, cold

or lonely. (Mother usually can distinguish

these physiological cries of their infants fromabnormal cries due to disease).


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On the other hand, a severely ill infant may

be too weak to cy. Similarly, a child mental

handicap and developmental delay may be

very quiet and placid.


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COUGH

Respiratory tract infections are very common

in children and cough is an important

presenting symptom. Long spasm of cough

associated with a whoop and vomiting arecharacteristics ofwhooping cough.


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Ask the following questions about cough:

Is it dry or wet ( children usually swallow the

sputum)?

Is it worse at a particular time of the day ( late

nigh or early morning cough may be due to

asthma)?

Is there any relation with feeding (cough duringfeeding may indicated aspiration of mild)?

Is it accompanied by wheeze or fever?


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BREATHLESSNESS (Dyspnea)

Chest infection (eg. Pneumonia), asthma andheart disease congenital as well asrheumatic are the usually causes of

breathlessness in children. It may also be dueto metabolic acidosis ask about:

Age of onset

Relation with activity

Relation with feeding in young infant

Present of cough, wheeze or cyanosis


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RASHES

These are frequent in children. Common

causes are viral infections ( measles,

chickenpox, rubella) eczema, scabies allergy

and drug reactions. Find out:

Duration

Site

Changes in color and size

Presence of itching


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CYANOSIS

It is bluish discoloration of skin and mucous

membrane due to excess of reduced

hemoglobin. In children it is either due to

congenital heart disease or respiratorydisorder. As about:

Age of onset

Variation in color

Relation with recent illness


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JAUNDICE

Jaundice occurs in more than 50 percent of

newborns. In case of neonatal jaundice the

time of onset after the birth is very important.

Jaundice developing of the first day after birthmay be due to hemolytic disease of the

newborn while that appearing on the second

or third days is usually physiological.


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If jaundice persists beyond 2nd week of age,

consider the possibility of biliary obstruction.


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LETHARGY AND UNCONSCIOUSNESS

Lethargy is a sign of disease, particularly in

acute illness. Unconsciousness is usually due

to neurologic or metabolic disorders like

meningitis, encephalitis renal failure orhepatic failure.


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POSTURE AND GAIT

Rickets, polio, cerebral palsy, muscular

dystrophies, hemiplegia and congenital

abnormalities can affect the children`s gait

and posture ask about any difficulty in: Walking

Running

Getting up from lying or sitting position

Going upstairs


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INVOLUNTARY MOVEMENTS

Get full description of involuntary movements

from parents or patient if he is old enough

obtain information about:

Age of onset

Any relation with febrile illness

Progress since onset


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CONVULSIONS ( FITS OR SEIZURES)

If doctor himself has not observed the

convulsion ( or fits) detailed description by an

obser is the main information on which the

diagnosis is based. True convulsion should bedifferentiated from restlessness, jerkiness,

volunatary or involuntary movements or

breath-holding attacks.


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Febrile convulsions- associated with high

grade fever- are common in children between

six months and five years of age; there may be

previous history of such convulsion


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HEARING

Hearing defects are frequent in children. Ask

whether child responds normally to any voice

out of his field vision, and whether he has

difficulty in understanding words.


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HISOTRY OF BIRTH

It is particularly important in youn children

and in children with neurological disorders. It

is divided into three periods:


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Antenatal

Inquire about health of mother during pregnancy;

ask about history of :

Diabetes mellitus

Hypertension

Swelling of feet

Fits

Infection ( Tuberculosis, rubella) Drug intake ( dose, duration, and time of gestation)

x-rays


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Natal

Ask about:

Duration of gestation

Place of delivery ( in the hospital or at home;

carried out by traditional birth assistant (TBA)midwife, or doctor

Duration of labor

Mode of delivery ( spontaneous, assisted,cesarean section)

Complications during delivery


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Postnatal ( newborn)

Information should be obtain about:

First cry immediately or delayed

Time of onset of respiration after delivery, any

resuscitation required

Birth weight

Birth injury

Feeding difficulty in neonatal period

Jaundice, cyanosis, fits, fever, or any other

symptom during neonatal period


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FEEDING HISTORY

It is particularly significant in malnutrition andother nutritional disorders. Find out:

Time between the birth and the first feed

Type of feeding ( breast feeding or formula feeding

type of milk)

Frequency of feeding; quantity and dilution of bottlefeeds

Progress in feeding Age at which solids were started and their nature,

amount and frequency


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Supplements (vitamins, iron)

Current feeding practices before present illness

Any change in food intake during illness


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IMMUNIZATION

Check the vaccination card if available;

otherwise ask about:

Type of vaccination

Dates

Complete or incomplete

Boosters


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DEVELOPMENTAL HISTORY

Mother should be asked when did the child

first:

Smile

Hold his neck

Roll over

Start responding to voices

Sit up with support and without support

Crawl


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Start to walk with and without support

Talk; single words, sentences

Run

Start feeding with hands

Indicate toilet needs, became dry by day/by night


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PAST HISTORY

Details of birth, feeding, development and

vaccination are also a part of past history. In

addition, inquire about any significant illness

in the past, particularly infectious diseases,rheumatic fever or tuberculosis.


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TREATMENT HISOTRY

Record the details of treatment given

including the doses of drugs which usually are,

either more or less than needed. Inquire

about traditional treatment as well.


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FAMILY HISTORY

Ask about the following:

Age of mother and father

Parent`s health( present and past)

Stillbirths, miscarriages

Siblings


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Grand parent`s health (particularly if living with

the familya0

If an inherited disorder is suspected, obtain

information about health of uncles, aunts andtheir children. Also find out whether inter-cousin

marriages are common in the family and whether

parents are closely related to each other.


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SOCIAL HISTORY

Find out:

Parent`s education

Persons living in the house

Parent`s relation with each other

Parent`s attitude toward children

Financial status of the family


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PERSONAL HISTORY

Inquire about:

Particular habits of the child

Behavior of the child at school and relationship

with other children


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ENVIRONMENTAL HISTORY

Inquire about:

Size of the house and number of occupants

Home surrounding

Cleanliness and general hygiene conditions

Source of drinking water


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EXAMINATION

Before examining the children it is important

to know normal values of various indices in

children of various ages. Students are advised

to examine and larges number of normalchildren of all ages before starting to gain an

understanding of the disease children.


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Examination of children demands patience

and a friendly and kindly attitude.

Unfortunately, the unnecessary and

deplorable practice of giving injections to thechildren have created in them fear of doctor`s

clinics.


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So be patient and try to remove child`s fear by

talking to him and parents in understandable

terms and by offering the child toys suitable

for his age. ( toys suitable for children of allages should be available in the examination

room).


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Observation (inspection) constitutes the most

important method of examination in children.

It should start during history taking and

should be supplemented by few minutes ofkeen observation just before actually touching

the child.


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The principles in the technique of examination

of children is STOP.LOOKTOUCH.

Children, generally don`t like their clothes to

be removed; so exposure should be limited tominimum necessary.


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Posture of examination varies with age.

Children between the ages of one year and

three years are better examination on the

mother`s lap because they are too afraid toleave her. Those below this age can be

examined on the couch and those above this

age can be examined while standing.


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Older children can be requested to lie of the

couch if they agree. Sequence of examination

should be regional rather than systemic. You

should be ready to change your routine andorder of examination according to the

circumstances and child`s response.

Frightening and painful procedures likeexamining the throat should be postponed till

the end.


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MEASUREMENTS

Measure weight, height, and head

circumference routinely during general

examination of child and compare with

standard values for his age. Charts givingstandard values for these measurement at all

ages are available and can be used but you

should try to remember them as well. Up to 7years of age, there is little difference between

both sexes.


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WEIGHT

It is an important parameter of growth andshould be measured regularly. Below 5 yearsof age weight for age is a very good screening

test for nutritional status. Regular growthmonitoring of children below 5 years of ageby measuring their weight and plotting on agrowth chart is recommended by WHO.

Sometimes weight for height is used to detectcurrent (acute) malnutrition which is alsocalled wasting.


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Causes of inability to attain adequate height in

order children include chronic disease and

endocrine disorders. While considering

adequacy of height in any child, height ofparents should also be taken into account.

Height velocity is increased in height per years

it is maximum in early years and increasesagain at puberty.


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HEAD SIZE

Abnormal head size usually indicates some

disease. Occipito-frontal circumference of the

head is measured and is compared with

standard tables of head circumference atdifferent ages.


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Small head size ( microcephaly) may be due to

inadequate brain growth ( mostly associated

with mental handicap) or premature closure

of the sutures while large size is usually due tohydrocephalus.


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TEMPERATURE

In infants and children usually skin

temperature is taken. In infants groin is the

best site with thights flexed to the abdomen.

Some prefer rectal temperature which is 0.25C higher in order children axilla is suitable


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pediatric clinical examintion

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