university of warmia and mazury in olsztyn faculty of ... · circulation – heart rate, pulse...
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University of Warmia and Mazury in OlsztynFaculty of Medical Sciences
Department od Clinical Pediatrics
▸ Although some of the principles of examining children are similar to adult examination, there are important differences in both outline and detail.
▸ Children are not just small adults, and the pattern of disease, the approach to the examination and content of the examination are quite different in children.
▸ To complicate things further, the examination changes as children develop and get older.
▸ Eventually it is similar to examination in adults
The aims and objectives are:
▸ H = history
▸ E = examination
▸ L = logical deduction
▸ P = plan of management
▸ Obtaining the child’s cooperations: ◦ Make friends with the child ◦ Be confident but gentle ◦ Avoid dominating the child◦ Short mock examination, e.g. Auscultating a teddy or
the mother’s hand, may allay a young child’s fears◦ When first examining a young child, start at a non-
threatening area, such as hand or knee◦ Explain what you are about to do and what you want
him to do, in language he can understand◦ A smiling, talking doctor appears less threatening but
this should not be overdone as it can interfere with one’s relationship with the parents ◦ Leave unpleasant procedures until last
▸ Adapting to the child’s age: ◦ Adapt the examination to the child’s age◦ Babies in the few month are best examined on an
examination couch with a parent next to them◦ A toddler is best initially examined on his mother’s lap
or occasionally over a parent’s shoulder. Parents are helpful in facilitating the examination if guided as to what to do◦ Pre-school children may initially be examined whilst
they are playing◦ Older children and teenagers are often concerned
about privacy. Teenage girls should normally be examined in the presence of their mother, nurse or suitable chaperone. Be aware of cultural sensitivities in different ethnic groups
Warm smile
Warm hands
▸ Warm stethoscope
▸ Initial observations: Careful observation is usually the key to success in examining children. Look before touching the child. Inspection will provide information on: Severity of illness Is the child ill-appearing?
Growth and nutrition State of activity- increased/ decreased
Behaviour and social responsiveness Way of movement and crying
Level of hygiene and care
▸ Severity of illness:
◦ Airway and Breathing – respiration rate and effort, presence of stridor or wheeze, cyanosis◦ Circulation – heart rate, pulse volume,
peripheral temperature, capillary refill time◦ Disability - level of consciousness
▸ General state estimation◦ Good◦ Quite good◦ Intermediate◦ Quite poor◦ Poor◦ Agonal (terminal, extremely severe)
▸ The level of consciousness:
◦ Quantitative disorders presomnolence-child is apathetic but proper contact
is present somnolence- child is sleepy, difficult contact but still
present precoma-child may be aroused by strong stimuli coma- total loss of consciousness
◦ Qualitative disorders
▸ Measurements:-A variety of measurements can be recorded
and plotted to allow accurate assessment of growth and pubertal development
-As abnormal growth may be the first manifestation of chronic illness in children, always measure and plot growth on centile charts for:
▸ Head circumference routinely in those aged under 2 years▸ Length (under one year) or height.▸ Weight.▸ Plotting of serial measurements to establish pattern and
range of growth.▸ Use of appropriate growth charts.▸ Skin fold thickness where indicated.▸ Assess and plot pubertal development where indicated.
▸ Estimation of the body building and nutritional status
◦ Type of the body building- asthenic, athletic, pycnic
◦ Parameters of the growth- height/ weight
Obesity- >97 centile Eutreptic-+/- 10% of proper body weight Hypotreptic- poor nutritional status Atreptic- lack of >40% of proper body weight
▸ Estimation of psycho-motorical development
◦ Body posture and gross locomotion
◦ Visual-motor coordination
◦ Speech
◦ Social contacts, maturity, independence
▸ General appearance:
The face, head , neck and hands are examined. The general morphological appearance may suggest a chromosomal or dysmorphic syndrome. In infants, palpate the fontanelle and sutures.
▸ Skin
◦ Colour
◦ Temperature
◦ Characteristics: rough/smooth, dry/wet, elasticity, flexibility
◦ Anomalies of blood vessels
◦ Pathological rash- papules, purpura, scars, bruises
▸ Subcutaneous tissue
◦ Thickness: poor, moderate, excessive
Check under the scapula,on the posterior part of armon abdomen
Oedema
▸ Lymph nodes
◦ Size
◦ Consistence: soft, tough, cohesive, splashing
◦ Tenderness, pain
◦ Fixed or movable
◦ Skin over lymph nodes- normal, reddish, hot, ulcerous
▸ Bones and joints
◦ Skull shape, symmetry, fontanelle
◦ Chest-types of chest, symptoms of vit D deficiency
◦ Vertebral column
◦ Symmetry of hips
◦ Upper and lower limbs
◦ Joints- flexibility (passive, active) pain symmetry
▸ Detailed examination
◦ Head and neck
◦ Chest
◦ Abdomen
◦ Genito-urinary tract
◦ Neurological assessment
▸ Head and neck ◦ Observe the size and the shape of the skull
◦ Amount, colour and consistency of the hair
◦ Fontanelles- size, tension (increased/decreased) , bulging
◦ Sutures
◦ Cranial bones- craniotabes
▸ Ears
▸ Face- Eyes- position, palpebral fisure, oedema
Squint, colouring of the conjunctival mucousiris
Nose- check for nasal passage Mouth- lips colour, state of the mucosa, teeth
(primary/secoundary dentition), palate, tongue- size, tonsils
Neck-
▸ Respiratory system:◦ Cyanosis ( central cyanosis is best observed on the
tongue)
◦ Clubbing of the fingers and/ or toes (chronic lung disease e.g. cystic fibrosis, congenital heart disease, occasionally in inflammatory bowel disease or cirrhosis)
◦ Tachypnoe (rate of respiration is age-dependent) Age Normal Tachypnoe
Neonate 30-50 >60breaths/min
Infants 20-30 >50Young children 20-30 >40Older children 15-20 >30
▸ Respiratory system:◦ Dyspnoe ( laboured breathing. Increased work of
breathing)* nasal flaring* expiratory grunting * use of accessory muscles* retraction of the chest wall (from use of suprasternal,
intercostal and subcostal muscles)* difficulty speaking, or feeding
- Chest shape- Hyperexpansion or barrel shape (asthma)- Pectus excavatum (hollow chest) or pectus carinatum (pigeon
chest)- Harrison’s sulcus (from diaphragmatic tug) poorly controlled
asthma- Asymmtery of chest movements
▸ Respiratory system:◦ Palpation – chest expansion – this is 3-5cm in school-age
children. Measure maximal chest expansion with tape measure.
Palpable rhonchi or local tenderness crepitant sensation of subcutaneous emphysema
◦ Percussion Needs to be done gently, comparing like with like, using
middle fingers Seldom informative in infants Localised dullnes –collapse, consolidation,fluid
▸ Respiratory system:◦ Auscultation
Note quality and symmetry of breath sounds and any added sounds
Harsh breath sounds from upper airways are readily transmitted to the upper chest in infants
Hoarse voice – abnormality of vocal cord Stridor – harsh, low-pitched, mainly inspiratory sound from
upper airways obstruction Breath sounds – normal are vesicular; bronchial breathing is
higher --pitched and the lengths of inspiration and expiration are equal
Wheeze – high-pitched, expiratory sound from distal airway obstruction
Crackles – discontinuous ‘moist’ sounds from the opening of bronchioles
▸ Cardiovascular system: Cyanosis Clubbing of fingers or toes Pulse - rate
- rythm (sinus arrhythmia)- volume (small – circulatory insufficiency,
aortic stenosis increased in high-output states)
- collapsing (in PDA, aortic regurgitation)
Inspection:* respiratory distress* precordial bulge – caused by cardiac enlargement* operative scars – mostly sternotomy or left lateral thoracotomy
▸ Cardiovascular system:PalpationThrill= palpable murmurApex (4th-5th intercostal space, mid-clavicular line)
Not palpable in some normal infants, plump children or dextrocardia
Heave from left ventricular hypertrophy
PercussionCardiac border percussion is rarely helpful in children
▸ Cardiovascular system:AuscultationListen for heart sounds and murmurs
Heart sounds Splitting of second sound is usually easily heard and is
normal Fixed splitting of second heart sound in atrial septal
defects Third heart sound in mitrial area is normal in young
children
Murmurs Timing – systolic/diastolic/continuous Duration – mid-systolic (ejection)/ pansystolic Loudness
▸ Cardiovascular system:
Murmurs Timing – systolic/diastolic/continuous Duration – mid-systolic (ejection)/ pansystolic Site of maximal intensity –
mitral/pulmonary/aortic/tricuspidareas
Radiation: To neck in aortic stenosis To back in coarctation of the aorta or pulmonary
stenosis Loudness – systolic murmurs graded:
1-2 soft, difficult to hear3 easily audible, no thrill4-6 loud with thrill
▸ Cardiovascular system:
Features of heart failure in infants: Poor feeding/ failure to thrive Sweating Tachypnoe Tachycardia Gallop rhythm Cardiomegaly Hepatomegaly
▸ Cardiovascular system:
Normal resting pulse rate in children:
Age Beats/ min<1 110-1602-5 95-1405-12 80-120>12 60-100
▸ Cardiovascular system:
Check femoral pulses !
In coarctation of the aorta:- decreased volume or may be impalpable in infants- Brachiofemoral delay in older children
Heart disease is more common in children with other congenital abnormalities or syndromes
▸ Abdomen:
Abdominal examination is performed in three major clinical settings:
Routine examination An ‘acute abdomen’ Abdominal distension/ mass
Associated signs:- the eyes for signs of jaundice and anemia- The tongue for coating and colour- The fingers for clubbing
▸ Abdomen:
Abdominal examination includes: observation auscultation percussion palpation
Abdomen is divided into right upper, right lower quadrant left upper, left lower quadrant
▸ Abdomen:ObservationThe abdomen is protuberant in normal toddlers and
young children. The abdominal wall muscels must be relaxed for palpation
Generalised abdominal distension is most often explained by the five ‘F’s:
Fat Fluid Faeces (constipation) Flatus (malabsorption, intestinal obstruction) Fetus (not to be forgotten after puberty)
Occasionally it is caused by a grossly enlarged liver and/or spleen or muscle hypotonia
▸ Abdomen:
The abdomen is protuberant in normal toddlers and young children. The abdominal wall muscels must be relaxed for palpation
Generalised abdominal distension is most often explained by the five ‘F’s:
Fat Fluid Faeces (constipation) Flatus (malabsorption, intestinal obstruction) Fetus (not to be forgotten after puberty)
Occasionally it is caused by a grossly enlarged liver and/or spleen or muscle hypotonia
▸ Abdomen:
Causes of localised abdominal distension are: Upper abdomen- gastric dilatation from pyloric
stenosis, hepato/ splenomegaly Lower abdomen – distended bladder, masses
Other signs: Dilated veins, abdominal striae Operative scars Peristalsis – from pyloric stenosis, intestinal obstruction
▸ Abdomen:
Auscultation
perform before percussion or paplation
Are the bowel sounds present? Are they frequent or sparse
quiet abdomen hyperactive bowel sounds
▸ Abdomen:
Percussion
Tympanitic (drum-like) sounds- over air filled structures
Dull sounds- over a solid structure or fluid
To determine the size of the liver or spleen
Assessment of the cause of abdominal distention (fluid or gas)
▸ Abdomen:
Palpation: Use warm hands, explain, relax the child and keep the
parent close at hand
Palpate in systemic fashion- liver, spleen, kidney’s, bladder, through four abdominal quadrants
Watch the child’s face for grimacing as you palpate. A young child may become more cooperative if you palpate first with his hand or by putting your hand on top of his
▸ Abdomen:
Palpation:
superficial deep
Begin in an area that is certain to be normal
▸ Abdomen:
Tenderness: Location – localised in appendicitis, hepatitis,
pyelonephritis, generalised in mesenteric adenitis, peritonitis
Guarding – often unimpressive on direct palpation in children. Pain on coughing, on moving about/walking/bumps during car journey suggests peritoneal irritation. Back bent on walking may be from psoas inflammation in appendicitis
▸ Abdomen:
In case of peritonitis check for:
Rovsing sign–pain in the right lower quadrant in response to left-sided palpation or percussion
Blumberg sign- after gradually pressure over the area of tenderness, sudden release produces pain
▸ Abdomen:
Deep palpation:
LiverSpleenKidneyUrinary BladderStool massesPregnency
▸ Abdomen:
Hepatomegaly: Palpate from right iliac fossa Locate edge with tips or side of finger Edge may be soft or firm Unable to get above it Moves with respiration Measure (in cm) extension below costal margin in mid-
clavicular lineLiver tenderness is likely to be due to inflammation from
hepatitis
▸ Abdomen:
Hepatomegaly: Infection (congenital infections, mononucleosis,
hepatitis, malaria, parasitic infection) Heamatological (sickle cell anaemia, thalassaemia) Liver disease (chronic hepatitis, portal hypertension,
polycystic disease) Malignancy (leukemia, lymphoma, neuroblastoma,
Wilms’ tumor, hepatocellular carcinoma Metabolic (glycogen and lipid storage disorders,
mucopolysaccharidoses) Cardiovascular (heart failure) Apparent (chest hyperexpansion from bronchiolitis or
asthma)
▸ Abdomen:
Splenomegaly: Palpate from left iliac fossa Edge is ussually soft Unable to get above it Notch occassionally palpable if markedly enlarged Moves on respiration Measure size below costal marigin (in cm)
▸ Abdomen:
Splenomegaly:
Infection (congenital infections, mononucleosis, hepatitis, malaria, parasitic infection, infective endocarditis)
Heamatological (haemolityc anaemia) Malignancy (leukemia, lymphoma) Metabolic (glycogen and lipid storage disorders,
mucopolysaccharidoses) Other (portal hypertension)
▸ Neurological examination:
Signs of meningism:
Neck stiffness- flex the patient’s neck passively
Kernig’s sign- try to strighten the knee while keeping the patient’s hip flexed
Brudzinski’s sign- on flexing the head the tights and knees also flex
▸ Neurological examination:
Signs of tetany (hypocalcaemia):
Trousseau’s sign- blood pressure cuff is placed on the arm with the preassure raised above patient’s systolic preasure. The thumb becomes adducted, fingers are extended- main d’accoucheur
Chvostek’s sign-tapp over the facial cranial nerve under the ear- brisk muscular twitch occurs on the same side of the face
▸ Neurological examination:
Cranial Nerves
Motor system muscle tone- passive movements of the limbs-
hypotonia, hypertonia motor power- flexion or extension against resistance coordination
Sensory systemReflexes
▸ Newborn babiesThe assessment and examination of the
newborn and neonates (under 4 weeks) often require a specific and detailed series of checks, observations and measurements supplemented with detailed history from the parents. Babies are routinely checked and examined at birth and at between 6 and 8 weeks. This is covered in the separate article
▸ Important aspects of the examination:◦ Ill babies can be assessed according to the baby check
system.◦ The examination is similar to that for newborn babies.◦ Progress with feeding should be discussed.
▸ Growth:◦ Weight, length and head circumference should be plotted.◦ Deviation from centiles should be discussed and followed
up.▸ Development:◦ Milestones should be briefly reviewed in all babies.
▸ General examination:◦ The parameters and methods are as for those outlined in
young and newborn babies .◦ Hips may be examined again.
▸ This age group is frequently seen by doctors.▸ From the age of about 3 months viral illnesses are very common.▸ It is a period of rapid growth and development.▸ Routine checks are no longer normally performed in this age group.▸ Assessment of growth and development is usually done opportunistically.▸ Growth: is very rapid (with a doubling on average of birth weight by 5 months).▸ Length and weight should be plotted and compared with previous readings.▸ It can be very difficult to obtain an accurate length in this age group.▸ Development: Parents will often present with children when there are concerns
over developmental progress.▸ It is a period of rapid developmental progress.▸ Developmental milestones should be reviewed opportunistically. For example:◦ Social smile should have appeared by 8 weeks.◦ Children should be sitting unsupported by 8 months.◦ Children should be babbling by 8 months.
▸ General examination:Rashes are common and may be due to viral infections, as well as skin conditions such as eczema.
▸ Doctors should be familiar with important rashes (such as the purpuric rashes of meningococcal septicaemia, idiopathic thrombocytopenic purpura and Henoch-Schönlein purpura).
▸ Cardiovascular examination:Cardiac output is regulated mostly by changes in heart rate (as with newborn and younger babies). Tachycardia is an important sign which needs explanation.
▸ Respiratory examination:This is frequently performed in this age group.▸ Observation is again very important.▸ It is important to distinguish wheeze from stridor.▸ Gastrointestinal examination:Observation is again important. For
example, with peritonitis, the child lies very still with flexed knees and shallow breaths.
▸ Inspect the anogenital area if appropriate. This is an increasingly difficult examination as children get older and requires sensitive handling.
▸ Warm hands and reassurance are needed to palpate the abdomen of an ill child.
▸ Neurological and developmental examination:Formal examination is very difficult. Improvisation is often required.
▸ Cranial nerves are examined by observation - for example, of behavioural and facial movements. Cranial nerve abnormalities in this age group include:◦ Bell's palsy.◦ Eighth cranial nerve impairment (sensorineural deafness).◦ Sixth cranial nerve deficit (convergent squint) with raised intracranial pressure.
▸ Important aspects of the examination:Toddlers are infants who are walking (usually over 1 year) but under 2 years of age.
▸ Again this group consults often.▸ Attendance is likely to be distributed between different settings (for
example, hospital, primary care, clinics, walk-in centres).▸ Good communication between these different agencies is important.▸ Growth and development is rapid.▸ Checks of growth and development will often have to be done
opportunistically.▸ Genu varus is physiological in this age group.▸ Growth:Growth decelerates from the end of the first year.▸ Head growth is rapid as the brain grows with myelination in cortical
areas.▸ Development:Important milestones should be identified. Briefly:◦ Hand dexterity improves along with visual acuity from palmar grasp to pincer grip in
the first year. By the second year a tower of six bricks can be constructed.◦ Speech develops from babbling to six or more words at 18 months and short
phrases during the second year.◦ Comprehension allows simple instructions to be followed by about a year.◦ Babies progress from crawling to cruising and then walking by about 1 year (before
18 months).
▸ General examination:It is usually best to examine babies on a parent's lap and establish relaxed rapport.
▸ Engage in play to facilitate the examination.▸ It may be necessary to be quite selective and examine
important or relevant systems first.▸ Leave more intrusive or unpleasant examinations
until the end (for example, throat examination).▸ Cardiovascular examination:Refer to normal values.▸ Identify innocent murmurs (often heard).▸ Respiratory examination:Observe and identify normal
rate, breathing sounds and pattern.▸ Gastrointestinal examination as above.Neurological
and developmental examination as above.
▸ Important aspects of the examination:This age group also frequently attends for medical care and advice.
▸ Illness and, increasingly, accidents will prompt attendance.▸ Again, rapport and confidence have to be established and maintained for
easier examination. Trust can be built for future examinations.▸ Genu valgus is physiological in this age group.▸ Growth:Growth is decelerating at this stage.▸ Centile charts should be used and checked.▸ Development:The most marked advances are in communication skills
and use of language.▸ A brief assessment of language skills should be made in all children.▸ General examination:Again, most often achieved on a parent's lap or
standing close to the parent.▸ Explain and commentate on procedures as they progress. Answer
questions - they are usually very inquisitive at this age.▸ Cardiovascular examination:Examination is easier in this age group.▸ Again, innocent murmurs are common.▸ Heart sounds are more easily identified with slower heart rates.
▸ Respiratory examination:Observation is again most important.▸ Peak flow measurement is not reliable until about age 5 years▸ Gastrointestinal examination:It is often best to examine kneeling
down alongside the patient.▸ Children may prefer palpation to be done with their hand
underneath the examiner's.▸ Hip and knee examination:Irritable hip and other hip conditions
can occur at this age and require assessment.▸ Normal genu varus (physiological in the toddler) and valgus
(physiological in the pre-school child) often require reassurance at this age.
▸ Neurological and developmental examination:This increasingly approaches what is possible in adults.
▸ Vision can be checked by shape or letter matching at 3 years of age.
▸ A circle will be copied by 3 years, a cross by 4 years, a square by 4.5 years and triangles by about 5 years.
▸ Important aspects of the examination:◦ This age group is examined less often by doctors.◦ Psychological factors begin to play more of a part in how
problems present.▸ Growth:◦ Growth will be steady leading up to the pubertal growth
spurt.◦ Concerns may begin to be expressed about growth and
development in relation to puberty.▸ Development:◦ Social and behavioural aspects of development become
more important.◦ Other aspects of development approach those of adults.
▸ Examination:◦ There are now few differences from adult examination.
▸ Important aspects of the examination:◦ Adolescents attend for medical advice infrequently.◦ Rapport and good communication may be difficult to
establish.◦ Psychological factors are likely to be very important.[4]
◦ Most adolescents are very self-conscious and this can impede adequate examination.◦ It is recommended to have a chaperone.◦ Confidentiality and consent become more important
issues.▸ Growth:◦ Puberty initiates a period of rapid growth.◦ Normal and abnormal puberty should be recognised.
▸ Examination:◦ Examination is very similar to that undertaken in adults.