1. PEDIATRIC HISTORY AND CLINICAL EXAMINATION
Jordan University of Science & Technology

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

3. Children do not
Act
Think
Emote
Play
Respond
As Adults

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

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

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

7. What You Don’t Know Can Hurt You
The parents may place their own interpretation on the events (any fever may be called tonsillitis).

8. The cooperation of the child cannot be guarantied

9. The expression of the disease may be influenced by the child’s developmental status

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

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

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

13. Pediatric history
Introduce yourself to the parents and child.

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

15. 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

16. 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

17. 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

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

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

20. 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)

21. 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

22. 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.

23. 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.

24. 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.

25. 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?

26. 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.

27. 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

30. 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.

31. 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.

32. 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.

33. 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.

36. 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.

40. Pediatric Examination
Skin:
Include color
The presence of cyanosis
Discolored patches
Jaundice
Rash
Edema
Skin turgor
Amount of subcutaneous tissue

41. Pediatric Examination
Head:
Examine the head for shape
Sutures
Size and tension of fontanelles
The hair and scalp should be examined
Bone defects

42. 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

43. 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

44. 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

45. Pediatric Examination
Neck examination:
Examine for neck rigidity
Swelling
Webbing
Lymph node
Thyroid gland
The position of trachea

46. 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

47. 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.

49. 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

50. 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

53. 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)

54. Pediatric Examination
Genitalia:
Undesent of testes
Hydrocele
Hypospedius
Ambiguous genitalia

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

56. 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

57. Pediatric Examination
Neurological Examination
Observation
Mental status
Cranial nerves
Cerebellar function
Motor system
Sensory system
Reflexes-primitive, deep and superficial reflexes.

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

61. Pediatric physical exams are better left to real doctors !!