History and Physical Examination Krzysztof Narebski Toruń

Problems to discuss 1)Pediatric population 2)Taking a history 3)Examination

Pediatric populations Newborn < 1 month Infant < 1 year Toddler 1 – 2 years Preschool child 2 – 5 years School child Adolescent

What brought you along today ? 1)Diagnosis of acute illness 2)Diagnosis of chronic illness 3)Developmental screening and assessment (growth, nutrition and immunization, milestones)

Taking history 1 Review by systems – Fever, rashes, oedamas – ENT: sore throat, snoring, stridor – Respi: cough, wheeze, dyspnea – Cardio: cyanosis, exercise tolerance, murmur – Gastro: vomiting, diarrhoea, constipation, pain – Genitourinary: dysuria, wetting, toilet-training – Neuro: headaches, seizures – Musculoskeletal: problems of gait, limb pain

Taking history 2 Presenting complaints (present illness) – One or several – Onset (health before) – Duration (progress of disease) – Character of each symptom – What relieves / aggravates – Previous episodes

Taking history 3 General health (personal details and social history) – Growth – Nutrition – Milestones – Pubertal development – Family, social, environmental history – Consanguinity

Taking history 4 Past medical history (according to age !) – Maternal diseases and obstetric problems – Maternal pyrexia – Prematurity and Perinatal problems – Past illnesses (same / others) – Past injuries, operations – Allergies and drug allergies – Immunisations

Examination 1 Establish your own scheme General appearance Severity of illness – Level of consciousness – Airway and breathing – Circulation Temperature (infections !) Systems (respi, cardio, abdo etc.)

Examination 2 Methods of testing Inspection Palpation Percussion Auscultation

Respiratory system 1 Chest movement Dyspnea – Nasal flaring – Expiratory grunting – Retractions – Difficulty of feeding or speaking Tachypnoea – Neonate 30 – 50 / min – Young children 20 – 30 / min – Older children 15 – 20 / min Percussion (normal, dull, hyperresonant)

Respiratory system 2 Auscultation of breath sounds – Normal, symmetrical and vesicular – Transmissions from upper airways – Stridor (inspiratory – larynx obstruction) – Wheeze (expiratory – bronchioles obstruction) – Rales (discharge in bronchi) – Crackles (moist sounds – opening of bronchioles and pulmonary alveoli)

Lying or sitting position

Cardiovascular system 1 Cyanosis (central, peripheral) Pulse (and femoral pulse) < 1 year 100 – 160 / min 2 – 12 years 70 – 140 / min > 12 years 50 – 100 / min Blood pressure Palpation (cardiac thrill) Hepatomegaly

Cardiovascular system 2 Auscultation Heart sounds – First, second (and third) – Splitting of second heart sound Murmurs – When : Systolic / Diastolic / Continuous – Site of maximal intensity

Cardiovascular system 3 Auscultation of Murmurs cont. Loudness – : soft, difficult to hear – 3 : easily audible – 4 – 5 : loud with thrill – 6 : easily audible over abdomen Radiation – to neck or to back

Abdomen 1 Inspection - size and distention (five „F”) – Fat – Fluid (ascites) – Faeces (constipation) – Flatus (intestinal obstruction) – Fetus Palpation – warm hands, be systematic, watch the child

Abdomen 2 Tenderness – Location Hepato / splenomegaly Abnormal masses Percussion Auscultation

Not the best method to palpate the abdomen.

Genito – urinary system Kidneys – Palpation – Tenderness – Urianalysis Genital area Rectal examination

Neurological examination Watch the infant – posture, movement, muscle tone, head control, reflexes Watch the child – play, manipulation, gait – speech, social interaction Neurological examination in details

Neonatal reflexes – grasp reflex

Neonatal reflexes – Galant reflex

Neonatal reflexes – the Moro reflex 1st stage 2nd stage 3rd stage

Head and Neck Head : skull, sutures, fontanels, ears, eyes (pupils) Lymph nodes !!! – Occipital, submandibular, cervical – Size (< 1 cm) – Tenderness (infection vs malignancy) – Fixed or movable Thyroid (enlargement)

Lymph nodes

Ears, nose and throat Spatula in young children Look tongue, tonsils, pharynx, palate Teeth - deciduous / permanent, caries Nasal discharge, obstruction Drum (tympanum) – Swelling, redness, perforation – Middle ear fluid

Throat

Ear with otoscope

Skin Rash Hives (urticaria) Spots (pustules) Vesicular rash Hair problems Other lymph nodes (axillary and inguinal)

Chickenpox JAMA 2005; 294: 866

Body mass

Body length

Height

Circumferences

Thank you