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PEDIATRIC EXAM

Gerald Hickson, MD Joe Gigante, MD

THE PEDIATRIC HISTORY

I. General principles

Smile. Introduce yourself. Shake hands with parents, child if old enough. Try to help family feel comfortable, establish rapport.

II. Identifying information: name of patient, date of birth, gender, date of interview. Identify source of history.

III. Chief Complaint: ask the patient or parent, use their own words if possible.

IV. History of Present Illness:

What are the symptoms? How long have they been present? Who else is sick? (family members, daycare contacts) Has this patient ever had a similar illness? What treatments have been tried for this problem? Include pertinent ROS and past medical history.

V. Past Medical History

A. Perinatal maternal history: mother's age, gravida, para (term, preterm), abortions (spontaneous or elective). pregnancy: LMP, EDC, onset of prenatal care, weight gain, complications (bleeding, preterm labor, infections, medications, gestational diabetes), rubella immunity status, RPR, PPD, hepatitis B, drugs, alcohol, tobacco use.

labor and delivery: spontaneous or induced, duration, duration of rupture of membranes prior to delivery, complications, medications or anesthesia, vertex or breech presentation, vaginal or c-section, meconium staining of amniotic fluid. neonatal: birth weight, estimated gestational age, Apgar score, resuscitation in delivery room, problems in nursery ( e . g . jaundice, feeding difficulty, respiratory distress), length of stay, reasons for prolongation of stay.

B. Previous hospitalizations age, length of stay, reason, location

C. Childhood illnesses or exposures age, complications, treatment recent

exposures, date, nature of exposure travel to other locations, animal exposure

D. Previous surgery/ transfusions age, reason for procedure, complications

E. Trauma/ injuries/ ingestions, burns age, circumstances surrounding event, treatment, complications

ThePediatricHistory,page2Pastmedicalhistory,continued

F. Allergies medications - name of medication, timing of reaction, signs and symptoms, who made the diagnosis of allergy. otherallergies-signsandsymptoms,therapy

G. Medications

current or recent, include OTC meds, dosage, frequency indications and reactions, timing of most recent

 

dose

 

H.

Nutrition

 

infants - breast or formula, frequency, amount, problems toddlers - introduction of baby foods and cereal, milk intake when did transition from formula/breast to cow's milk occur' problems,peculiareatinghabits(pica) older children - good appetite or "picky eater", special diets,milkintake,"junkfoods",concernsaboutweight

 

'

I.

Immunizations and reactions Don't rely on memory; ask to see shot record.

 

Birth

 

hepatitis Bl

       

2mo

 

hepatitis B2

DTP1

Hibl

OPV1

 

4mo

   

DTP2

Hib2

OPV2

 

6mo

 

hepatitis B3

DTP 3

Hib3

   

15mo

     

Hib4

 

MMR1

18

mo

 

DTP4

 

OPV3

 

4-6 yr

   

DTPS

 

OPV4

MMR2*

14-16 yr

   

dT

   

or MMR2

J. Growth weight, height, head circumference, rate of growth, concerns, puberty, menarche

K. Development Grossmotormilestones Finemotormilestones Socialinteractions,behavior Speechandlanguagedevelopment Schoolperformance Hearing,vision

ThePediatricHistory,page3

VI. Family history

Ask about parents, siblings, grandparents and extended family. Focus on Inherited diseases, diseases that "run in the family", miscarriages, infant or childhood deaths, congenital anomalies, developmental delay, mental retardation, seizures, early cardiovascular diseases, sickle cell disease, consanguinity, any family members with similar problems to patient's current complaint.

Drawafamilytree.

VII. Social History ONE OF THE MOST IMPORTANT COMPONENTS OF THE HISTORY1 Observe interactions between the family and child. Seek information aboutthe homeenvironment which will

impact how the child and family cope with illness. Find out what resources are available for support for the child, mother, family. Find out if there are underlying concerns that have not yet been brought out ( e . g . an neighbor died from a brain

tumor, and the mother fears that this child's headache is a sign of a tumor.)

Typical questions may include:

Who lives at home? Who is the primary caregiver or disciplinarian? Does the child attend school, daycare or a babysitter? Who helps the mother? In the outpatient setting, important questions may include:

Do you have a way to pay for this prescription? Do you have transportation to return if your child gets worse?

VIII. Review of Systems Similar in general to adult patients with a few important differences:

A. General: include fever, weight loss, etc. as in adults, but also include patient's activity level, playfulness, appetite,

sleep habits, days of school missed.

B. HEENT: include recent or past history of ear infections if not already included in PMH.

C. GI: diarrhea, vomiting, constipation, etc. Young children will not complain of nausea. Encopresis.

D. GU: change in urinary pattern such as enuresis in previously toilet trained child.

E. Hydration status: tears, wet diapers, details of p . o .

intake, details of losses (frequency of diarrheal stools,

volume, frequency of emesis), activity level.

References Algranati, PS. The Pediatric Patient: An Approach to history and Physical Examination. Williams & Wilkins, 1992.

Report of the Committee on Infectious Diseases 22nd ed. American Academy of Pediatrics, 1991.

PEDIATRIC PHYSICAL EXAMINATION

Wash your hands. Introduce yourself. Say somethingcomplimentnice, or

the child/parents (at the end of the session as well).

The .order of the exam can be individualized. Startobservation,by

or painful parts for the end. Explaineverything you will be doing. Use age-appropriate non-threateningterms. Give feedback. In the

newborn, observe, auscultatepalpateand

The child has to be undressed for the exam, but this can be done gradually. Exam has to be thorough, even in thechild.uncooperative

Special focus of the pediatric exam: Growth and Development.Points of special relevance to the newborn are in boldface.

introduce instruments and let the child checkout,themkeep invasive

first.

VITAL SIGNS Axillary- T° is 2° below rectal, oral is 1° below rectal. BP cuff should cover 1/2 to 2/3 of arm span. Heart rate and repiratory rate. Height and weight. Head circumference. Chest and abdominal circumference if indicated. Plot them on charts. Skinfoldthickness.

GENERAL APPEARANCE Nutritional status. Cleanliness. Posture. Reluctance to move. Alertness, interest in surroundings, playfulness, cooperatio Distress, consolability (paradoxical irritability). Hydration status. Development. Cry or speech. Gross abnormalities. M include a note about the family.

SKIN

Color, pigmentation. Jaundice. Cyanosis (acrocyanosis). Mottling. Pallor. Birthmarks (nevus flammeus, salmon patch). Texture. Scars. Rashes (erythema toxicum). Ecchymosis (color and age). Craddle cap. Capillary refill. Edema.

Milia.

Vernix

caseosa.

Desquamation.

Mongolian spot.

NAILS

Cyanosis,clubbing.Pitting.Capillaryrefill.

HAIR Lanugo. Alopecia (including occipital alopecia). Lice or nits. Pubic hair and Tanner stage.

LYMPH NODES '

HEAD Size and symmetry. Circumference. Sutures. Fontanelles, size (AT measured perpendicular to sides), bulging or depression, pulsatility. Caput succedaneum. Cephalhematoma. Craniotabes. Transillumination. Sinuses.

FRONT

metopic suture

FRONT metopic suture coronal sagittal lambdoid FACE Paralysis. Asymmetry. Anomalies, coarseness of features. Edema.

coronal

sagittal

lambdoid

FACE Paralysis. Asymmetry. Anomalies, coarseness of features. Edema. Parotid glands.

EYES Vision, visual fields. Scleral color. Strabismus (paralytic, non-paralytic). Nystagmus. Conjunctivitis, discharge. Hemorrhages (subconjunctival hemorrhages). Reaction to light. Iris (absence-). Ophthalmoscopy (red reflex, retinal hemorrhages, macula).

EARS

Position,

shape. Discharge. Tenderness. Auricular pits or tags.

Otoscopy (use the bigger speculum). Hearing.

NOSE

Discharge,

obstruction, polyps

(use otoscope). Bleeding. Flaring.

MOUTH Drooling. Teeth (map, hygene). Cysts. Palate Gums. Tongue. Palate. Tonsils. Postnasal drip.

VOICE

Stridor,hoarseness,cry(weak,high-pitched).Vocalization,

speech.

(cleft).

Thrush.

NECK Position, motility, webbing. Nodes, masses. Neck stiffness, Brudzinski sign.

CHEST Inspection,"palpation, percussion, ausculation. Pectus (carinatum, excavatum). Harrison's groove. Respiratory rate, chest expansion, symmetry, retractions, paradoxical breathing. Grunting. Flaring, use of accessory muscles. Cough (characteristics, frequency). Breast size, milk discharge, symmetry, Tanner stage.

HEART Rate and rythm (sinus arrythmia). Inspection, palpation, percussion, ausculation.

ABDOMEN Inspection, palpation, percussion, ausculation. Shape (scaphoid, pot-belly). Circumference. Umbilicus (cord stump), umbilical hernia. Diastesis recti. Gastric waves. Liver,

spleen, masses. Unimanual palpation of the kidneys. Bladder.

Superficial reflexes. Inguinal areas,

femoral pulses,

lymph

nodes.

GENITALIA Penis size, meatus location, circumcision, testicles (Tdescended), hydrocoele, r^rnia, cremasteric reflex. In girls, labia prominent in the newborn. Discharge, adhesions. DTanneriaper rash.stage.

RECTAL Anus (patency), anal wink, fissures, fistula, prolapse, hemorrhoids, masses, stools, Guaiac. Diaper rash.

EXTREMITIES AND MUSCULOSKELETAL. Posture, asymmetry, extra digits, clubbing, temperature,Handsswelling.and dermatoglyphics. Nails. Feet (clubbing). Genu

valgum,gait, hips (dislocation). Spine, scoliosis, sacral pittuft.orPulses.hair Kernig's sign.

Joints range of motion, arthralgias, arthritis.

NEUROLOGICAL State of consciousness. Spontaneous movements, abnormal movements. Tone and strength. Superficial reflexes, d reflexes.Suck,root,grasp,Moro,tonicneck,Babinski,stepping, placing,Landau, parachute reflexes.Sensations. Coordination,cerebellar signs. Cranial nerves. Gait. DevelopmentScreening(DenverT e s t).Meningeal signs.

JAUNDICE

Includes hands and feet

Head alone

BILI LEVEL (mg/dl)

Head and chest To knees

5-8

Includes arms and lower legs

6-128-1610-

18 '15-20+

arms and lower legs 6-128-1610- 18 '15-20+ APPEARS Birth Birth Birth Birth Birth Birth Birth DISAPPEARS
arms and lower legs 6-128-1610- 18 '15-20+ APPEARS Birth Birth Birth Birth Birth Birth Birth DISAPPEARS
arms and lower legs 6-128-1610- 18 '15-20+ APPEARS Birth Birth Birth Birth Birth Birth Birth DISAPPEARS
arms and lower legs 6-128-1610- 18 '15-20+ APPEARS Birth Birth Birth Birth Birth Birth Birth DISAPPEARS
arms and lower legs 6-128-1610- 18 '15-20+ APPEARS Birth Birth Birth Birth Birth Birth Birth DISAPPEARS

APPEARS

Birth

Birth

Birth

Birth

Birth

Birth

Birth

DISAPPEARS

Infancy3-4 mo

3-7 mo

3-5 mo

3 mo

7-9mo

1-2 yrs

early

REFLEX

Suck

Root

Moro

Tonic neck

Babinski

Babinski

Stepping

Placing

Landau

Parachute

ECCHYMOSES COLOR

AGE (days)

Purple-Red

Fresh

Dark blue-brown 1-4

Greenish-yellow 5-7

> 7

Yellow

1 yr

1-2 yr

Reference; L. A. BarneMss.anual of Pediatric Physical Diagnosis. Sixth ed. Mosby Yearbook,1 9 9 1 .

Remains

STAGES OF PUBERTY (TANNER STAGES)

Female breast.

I. Preadolescent. The breast has an elevated papilla (nipple) and a small flat areola.

II. Breast bud. The papilla and areola elevate as a small mound, and the diameter of the areola increases.

III. The breast bud further enlarges. The areola continues to enlarge. No separation of breast contours is noted.

IV. The areola and papilla separate from the contour of the breast to form a secondary mound.

V. Mature. The areolar mound recedes into the general contour of the breast. The papilla continues to project.

Pubic hair.

Male

Female

I. Preadolescent. No pubic hair.

II. Sparse distibution of long, slightly pigmented hair at the base of the penis

III. The pubic hair pigmentation

Preadolescent. No pubic hair. Sparse distibution of long, slightlypigmented straighthairappearbilaterallyalong the medial border of the labia majora. The pubic hair pigmentation increases; it begins to curl and spread sparselyoverthemonspubis.

increases; it begins to curl and spread laterally in a

scantydistribution.

The pubic hair continues to curl and become coarse in texture. The number of hairs continues to increase. Mature. The pubic hair attains an adult feminine triangular pattern, with spread to the surface of the medial thigh.

IV. The pubic hair continues toandcurlbecome coarse in

texture. An adult type of distributionattained,is

with fewer hairs.

but

V. Mature. The pubic hair attains an adult distribution, spreadingto the surface of the medial thigh.Pubic hair grows along the lineaalba in 80% of males.

Male genital development.

I. Preadolescent.

II. The testes enlarge. The scrotum enlarges, developing a reddishalteringhue andin skin texture. The penis enlarges slightly.

III. The testes and scrotum continue to grow. The length of theincreases.penis

IV. The testes and scrotum continue to grow; the scrotal skin darkens.penis Thegrows in width, and the glans penis develops.

V. Mature. The testes, scrotum, and penis are adult in size and shape.

Reference; Tanner JM: Growth at adolescence. Oxford, Blackwell, 1962.