1. History and Physical Examination
Krzysztof Narebski
Toruń

2. Problems to discuss Pediatric population Taking a history Examination2

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

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

5. 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 5

7. 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

8. Taking history 3 General health (personal details and social history)
Growth
Nutrition
Milestones
Pubertal development
Family, social, environmental history
Consanguinity 8

9. 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 9

10. 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.) 10

11. Examination 2 Methods of testing Inspection Palpation Percussion
Auscultation 11

12. Respiratory system 1 Chest movement Dyspnea Tachypnoea
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) 12

13. 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) 13

14. Lying or sitting position14

15. 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 15

16. Cardiovascular system 2
Auscultation
Heart sounds
First, second (and third)
Splitting of second heart sound
Murmurs
When : Systolic / Diastolic / Continuous
Site of maximal intensity 16

17. Cardiovascular system 3
Auscultation of Murmurs cont.
Loudness
1 - 2 : soft, difficult to hear
3 : easily audible
4 – 5 : loud with thrill
6 : easily audible over abdomen
Radiation
to neck or to back 17

18. Abdomen 1 Inspection - size and distention (five „F”) Palpation Fat
Fluid (ascites)
Faeces (constipation)
Flatus (intestinal obstruction)
Fetus
Palpation
warm hands, be systematic, watch the child 18

19. Abdomen 2 Tenderness Hepato / splenomegaly Abnormal masses Percussion
Location
Hepato / splenomegaly
Abnormal masses
Percussion
Auscultation 19

20. Not the best method to palpate the abdomen.20

21. Genito – urinary system
Kidneys
Palpation
Tenderness
Urianalysis
Genital area
Rectal examination 21

22. 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 22

23. Neonatal reflexes – grasp reflex23

24. Neonatal reflexes – Galant reflex24

25. Neonatal reflexes – the Moro reflex
2nd stage
1st stage
3rd stage 25

26. 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) 26

27. Lymph nodes 27

28. 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 28

29. Throat 29

30. Ear with otoscope 30

31. Skin Rash Hives (urticaria) Spots (pustules) Vesicular rash
Hair problems
Other lymph nodes (axillary and inguinal) 31

32. Chickenpox
JAMA 2005; 294: 866 32

33. Body mass 33

34. Body length 34

35. Height 35

36. Circumferences 36

37. Thank you 37