Download - 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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