PEDIATRIC HISTORY AND CLINICAL EXAMINATION Jordan University of Science & Technology

There is a nation out there of small people And They are NOT like us

Children do not Act Think Emote Play Respond As Adults

Age Groups In pediatrics Neonatal period 1st month Infancy 1st year Childhood 1-15 years Toddle 2 years Pre-school child 2-5 years School child 5-15 years Adolescent 13-18

“The most important attribute of any good doctor is to be a good listener” – Denis Gill & Niall O’Brien, Paediatric Clinical Examination, 1997.

Differences between Adult and Pediatrics History is given by second person.

What You Don’t Know Can Hurt You The parents may place their own interpretation on the 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

Differences between Adult and Pediatrics Clinical signs of the disease may differ from those of adults Children are not little adults

Physiological norms are more constant in adults, variable with age in infants and children( HR, RR)

The predominant impact of the disease may be on growth and development (UTI, Chronic illness).

Pediatric history Introduce yourself to the parents and child.

A warm greeting and friendly smile to allay anxiety and promote confidence.

It is essential to find out what the concern of the parents are. Encourage the parents to tell the story with minimum interruption and listen carefully. It is essential to find out what the concern of the parents are. You should not swallow the diagnosis given by the parents. Understand open ended and directed questions

Differences of a Pediatric History Compared to an Adult History I. Content Differences A. Prenatal and birth history B. Developmental history C. Immunization history D. Nutritional history E. Social history of family - environmental risks

Differences of a Pediatric History Compared to an Adult History II. Parent as Historian Parent’s interpretation of signs, symptoms Observation of parent-child interactions Parental behaviors/emotions are important A. Children above the age of 4 may be able to provide some of their own history Reliability of parents’ observations varies Adjust wording of questions B. Distraction to parents may interfere with history taking C. Parental guilt , non judgmental , reassurance, irate parent

Pediatric history Chief Complaint History of present illness and important related positive & negative symptoms Systems review Past history

Pediatric history Maternal history (Pre-natal) Birth history (Natal) Post-natal history Nutritional history Vaccination Growth and development Family history Social history

Pediatric history Past Medical History Major medical illnesses Major surgical illnesses-list operations and dates Trauma-fractures, lacerations Previous hospital admissions with dates and diagnoses Current medications Known allergies (not just drugs)

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 Maternal health during pregnancy: bleeding, trauma, hypertension, fevers, infectious illnesses, medications, drugs, alcohol, smoking, rupture of membranes B. Gestational age at delivery C. Labor and delivery - length of labor, fetal distress, type of delivery (vaginal, cesarean section), use of forceps, anesthesia, breech delivery D. Neonatal period - Apgar scores, breathing problems, use of oxygen, need for intensive care, hyperbilirubinemia, birth injuries, feeding problems, length of stay, birth weight

Pediatric history Birth history: Mode of delivery. Gestational age (37-42wk) Birth weight 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. When the last vaccine was given Any complication of given vaccine Any contraindications for certain vaccine?

Pediatric history Growth and development history (Related to the age of the patient): 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. 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 Vital signs Temperature (rectal, oral ,axillary) Respiration HR, Blood pressure Growth parameters Height (length) Weight Head circumference All given with percentile for age.

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 Size and tension of fontanelles The hair and scalp should be examined Bone defects

Pediatric Examination Eyes: make a gross test of vision. 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 Visual fields should be tested in all children old enough to cooperate 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: 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 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 posture, lordosis, kyphosis, scoliosis) Masses Tenderness Limitation of motion Defect (Spina bifida)

Pediatric Examination Genitalia: Undesent of testes Hydrocele Hypospedius Ambiguous genitalia

Pediatric Examination Anus: Patency(imperforated anus) Presence of fissure, fisulae or hemorrhoids Anal sphincter (Patulous anus ) Rectal examination if indicated

Pediatric Examination Musclo-skeletal system: Asymmetry Anomalies of extremities Pain and tenderness of the joint or limbs Always 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, deep and superficial reflexes.

Pediatric Examination Developmental assessment Gross motor Vision and fine motor Hearing and language Social and adaptive

Pediatric physical exams are better left to real doctors !!