1. PEDIATRIC HISTORY AND CLINICAL EXAMINATION
Prof. Hala Al-Rimawi
Jordan University of Science & Technology

2. Differences between Adult and Pediatrics General information
History is given by second person.
The cooperation of the child cannot be guarantied
The expression of the disease may be influenced by the child’s developmental status (apnea may indicates convulsion in newborn)
The predominant impact of the disease may be on growth and development (UTI, Chronic illness).
Physiological norms are more constant in adults and variable with age in infants and children( HR, RR)
Clinical signs of the disease may differ from those of adults (Liver is palpable in infancy).

3. Pediatric history Important points to remember
Introduce yourself to the parents and child.
A worm greeting and friendly smile to allay anxiety and promote confidence.
Encourage the parents to tell the story with minimum of interruption and listen carefully.
It is essential to find out what the concern of the parents are.
The parents may place their own interpretation on events (any fever may be called tonsillitis).You should not swallow the diagnosis

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

5. Pediatric history Common with adults
Presenting Complaint.
History of present illness and important related positive & negative symptoms.
Systems review
Past history

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

7. Pediatric history Specific
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

8. Pediatric history Specific
Birth history:
Mode of delivery.
Crying immediately or not.
Apgar score
History of asphyxia
Meconium stained amniotic fluid.

9. Pediatric history Specific
Post-natal history:
NICU admission
How much did the baby stay in the nursery.
Did the baby required mechanical ventilation ?
Oxygen given ? Duration of oxygen.
Is there history of jaundice? Exchange transfusion ?
Any illness during first month of life: meningitis, convulsion, fever ..etc.

10. Pediatric history Specific
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.

11. Pediatric history Specific
Vaccination history:
Vaccination program in details( National, UNRWA, privet Dr.)
Any special vaccination given.
When the last vaccine given?
Any complication of given vaccine?
Any contraindications for certain vaccine?

12. Pediatric history Specific
Growth and development history (Related to the age of the patient):
History related to the 4 developmental domains
Details of development milestones, smiling , sitting, standing, walking, speech,
Bladder and bowel control
School performance, behavioral and emotional history.

13. Pediatric history Specific
Family history:
Father and mother age, consanguinity, level of education and they are healthy or not.
History of smocking in either parent
Siblings: number, sex, and their ages.
History of similar disease, unexplained death and genetic diseases.
Draw family pedigree

16. Pediatric history Specific
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.

17. 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.

18. 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.

19. Pediatric Examination
General appearance:
Describe any dysmorphism, abnormal movements, unusual position, his mental status and activity.
Measurements: should include
Vital signs : Temp. (rectal, oral ,axillary), RR, HR, BP
Growth parameters:
Height (length), Weight, Head circumference
All given with percentile for age.

23. Pediatric Examination
Skin:
Include color,
Discolored patches
Jaundice (NN periods)
Rash
Edema
Skin turgor
Amount of subcutaneous tissue

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

25. 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?

26. 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

27. 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

28. Pediatric Examination
Neck examination:
Examine for neck rigidity
Swelling
Webbing
Lymph node
Thyroid gland

29. Pediatric Examination
Nose and sinuses:
The nasal examination is performed to detect deformities.
Presence of foreign body
Examine the sinuses for tenderness, nasal discharge color

30. Pediatric Examination
Chest examination: bilateral
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 broncho-vesicular.

31. Pediatric Examination
Cardiovascular system:
Inspection
Palpation: the apex beat is normally felt in the 4th intercostal space just to the left of the mid- clavicular line in children under 7 years of age. After that it is felt in the 5th intercostal space in the mid-clavicular 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

32. Pediatric Examination
Abdomen:
Inspection : Distension, Scaphoid abdomen
Palpation : -
The lower border of the liver is normally felt 1 cm below costal margin in infants & children, and liver span is 4 -8 cm (depending in age)
An enlarged spleen is extending into the left iliac fossa in infancy and the right in older
Percussion
Auscultation

33. Pediatric Examination
Musclo-skeletal system:
Asymmetry
Anomalies of extremities
Pain and tenderness of the joint or limbs
Always s examine for congenital dislocation of the hip in infants

34. Pediatric Examination
Genitalia:
Indecent of testes
Hydrocele
Hypospedius
Ambiguous genitalia
Anus:
Patency(imperforated anus)
Presence of fissure, fisulae or hemorrhoids
Anal sphincter (Patulous anus )
Rectal examination if indicated

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

36. Pediatric Examination
Developmental assessment

37. Thank you

38. Developmental assessment
Gross motor:
Head and neck control in prone position(6-8 weeks)
Able raise head and chest (3months)
Pull from lying or no head lag (4 months)
Sit without support back straight (8-9 months)
Stand without support (10-12 months)

39. Developmental assessment
Vision and fine motor
Follows moving person with eyes (6-8 weeks)
Follows small ball at 10 feet distance(9months)
Pincer grasp (between index finger and thumb using small object (11-12 months)
Copies a circle (with pencil, build a bridge of 3 cubes when shown (3years)

40. Developmental assessment
Hearing and language:
Turns eyes to sound-rattle 12 inches (2-4 months)
Says Mama, Baba (7-9 months)
Says simple sentences 3-4 words(2-2.5 years)
Says first name, knows own sex (3 years)

41. Developmental assessment
Social and adaptive
Smiles when spoken, vocalizes (6-8 weeks)
Reaches for and shakes rattle, puts objects to mouth (5- month)
Fear of strangers (7-8 months)
Drinks from cup without spilling (18 months)
Wash hands, pull pants up and down (3 years)