Documente Academic
Documente Profesional
Documente Cultură
PEDIATRICS II
1.1A PEDIATRIC HISTORY & PHYSICAL DIAGNOSIS
If you do not know what is wrong with a patient after you have taken a
history, then take another history.
If you still dont know , take a third history.
If you do not know then, you probably never will.
Clifton K. Meador, M.D.
A Little Book of Doctors Rules
PEDIATRIC DIAGNOSIS
differs from adults in many ways
infancy and preschool children - derived from adequate
information from the parents or guardian
reliability of the informant is of utmost importance
older patient may not require an informant
it would even be in the best interest of the patient that he/she
answers questions from the inquirer so that rapport and trust
between the pediatric patient and doctor can be established early
on
RULE OF THUMB
When dealing with adult or pediatric patients,
well organized
time of manifestation
negative information
living conditions
economic status
Social Condition:
socioeconomic status
home facilities
family problems
Personal History:
prenatal
birth
neonatal
Feeding
Growth and Development
Behavior
Immunization
Past Illnesses
medical illnesses
operations or accidents
drug reactions
System Review
Special senses
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Neuromuscular
Interval History
1.
2.
3.
number of admissions
Chief Complaint
Pediatrics II
urgency of situation
NEWBORN
APGAR SCORE
Appearance color
Respiratory effort
APGAR score
GENERAL SURVEY
Inspect head, face and oral cavity, extremities, perineum, palpating the
abdomen, and auscultating the anterior thorax and abdominal wall
A small tube should be passed through the nose and
esophagus, into the stomach to rule out posterior choanal and
esophageal atresia
Aspirate gastric contents to prevent regurgitation and
aspiration
A more extensive examination of the newborn is
performed at after the 12th-24th hour of life
Gives ample time to recover from the trauma of
delivery or when applicable the effects of anesthesia on the mother
DUBOWITZ SCORING SYSTEM
Used to assess both the physical and neurological characteristics of the
patient
Page 2 of 6
Pediatrics II
Observe the baby lying undisturbed in his bassinet and examine him
right there or place him on an examining table completely undressed
Repeat when the baby is for discharge
ROOMED-IN
Examine the baby with the mother awake
Ask any inquiries regarding her new baby
Answer their queries as best as possible
Observe the neonates breathing color, cry, size, body
proportions, nutritional state and movements of the head and
extremities
Responsiveness is best noted 2-3 hours after feeding
Newborn lies normally in a symmetrical position with
limbs semi-flexed and legs partially abducted at the hip.
The head is slightly flexed and in the midline or turned
to one side
ORTOLANI'S SIGN
Hip abduction maneuver
To find out if a congenital hip dislocation is present
INFANCY
Little difficulty will be encountered when performing physical
examination
Provide some form of distraction:
a game of peek-a-boo
Baby may be examined on the examining table or seated on the
mothers lap
Observe the interaction between mother and infant
This can give you clues on problems in mothering practice and
can be part of your treatment goals later on
PRESCHOOL
Establish rapport with your patient in this age group
When you are able to communicate with your patient ask him
about his activities and how his daily activities are
Attempt to observe the preschool child
If with abdominal pain:
night fears
SCHOOL-AGE CHILDREN
Deal with the child as an increasingly independent individual
Communication is vital and need not be limited to verbal
exchanges
3 developmental levels:
Page 3 of 6
Pediatrics II
Vital signs and body size taken since deviations from the
normal are apt to be the first and often the only indicators of the
presence of disease in infants and children
Weight and height - taken periodically
Pattern of growth over a period of time is more important than a
single measurement
TEMPERATURE
Average temperature
Breathing is abdominal
EARS
Superior border of the ears should align with the eye
External ear and auditory canal should be visualized using
otoscope
Tympanic membrane backward tug on the auricle
Eardrum glistening pearly membrane
Impairment of hearing should be assessed
EYES
Newborn
Page 4 of 6
Pediatrics II
NECK
Newborn infant relatively short neck
Webbings, hygromas, cutaneous hemangiomas
Masses, cervical lymph node
Thyroid gland may be physiologically enlarged in the adolescent
girl
Meningitis pain on flexion of the neck
THE CHEST
Auscultate the chest before the baby starts to cry
Shape barrel-shaped, elliptical
Circumference
nipple line
Rate:
Depth
deep peripheral
Symmetry
Inspiratory, suprasternal, supraclavicular, intercostal, subcostal
retractions
Severe dyspnea alar flaring
Most of the childs activity is effected by abdominal motion until
age 6 or 7, there is very little intercostal motion
Later thoracic motion becomes responsible for air exchange
Vocal Fremitus
Sensation of vibration
Fine vibrations
Axillary Nodes
More resonant chest wall is thinner and muscles are smaller
Posterioriorly: shoulder to 8th-10th rib
Anteriorly: below the clavicle to (R) level of dullness of liver, (L)
heart
Dullness scapulae, diaphragm, liver and heart
Mediastinum
Emphysema
Sign of obstruction
Pediatrics II
Masses
Liver Span
Each clinic visit should be attended to maintain the trust and confidence of
the parents.
This way more vigorous investigation may be avoided.
_______________________________________________________________________________________
END OF TRANX
Be kind whenever possible. It is always possible. - Dalai Lama
THE GENITALIA
Done by inspection
Female
Page 6 of 6