PEDIATRIC HISTORY AND CLINICAL EXAMINATION

‫الدكتور عبد المهدي عبد الرضا حسن الشحماني‬

PhD,Pediatric & Mental Health Nursing

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

1
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.

2
– 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.

3
– 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

4
– 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:
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

5
– 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

6
 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)

7
– 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)