Pediatric Clinical Diagnosis Hartono Gunardi, Sudigdo Sastroasmoro, Irawan Mangunatmadja, Department of Child Health, Medical School University of Indonesia,

Pediatric Clinical Diagnosis

Pediatric Clinical Diagnosis

Hartono Gunardi, Sudigdo Sastroasmoro,

Irawan Mangunatmadja, Department of Child Health, Medical

SchoolUniversity of Indonesia, Jakarta

Differences Adult and Pediatrics

• History is given by second person.• The parents may place their own

interpretation on 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 (hypothermia may indicates severe infection in newborn)

A child is not a small adult !

Differences Adult and Pediatrics

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

• Physiological norms are more constant in adults, 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).

Clinical exam in infants and children:

Why special attention?

A child is not a small adult!

Keywords: growth and development

Any information about history, physical, and laboratory /

supporting exams should be judged in relation with the child’s

stage of growth and development.

The diagnostic paradigm:

History

Physical

Routine lab

Special investigations

Pediatric History(Anamnesis)

Auto-anamnesis: self reporting by the patient Allo-anamnesis: any information other

than by patient

History: ≥80%

Supporting exam: 5%

Physical exam 10-20%

Listen to them; they are

telling you the diagnosis!!!

Pediatric history

• Introduce yourself to the parents and child.• A warm greeting and friendly smile to allay

anxiety and promote confidence.• Encourage the parents to tell the story with

minimum of interruption and listen carefully.

• You should not swallow the diagnosis given by the parents.

• It is essential to find out what the concern of the parents are.

1. Patient’s identity 2. Chief complaint 3. Clinical course 4. Previous illness 5. History of maternal pregnancy 6. History of delivery 7. Feeding history 8. Immunization status 9. Growth and development 10.Family history11.Environment

Anatomy of history taking

Pediatric history• Presenting/Chief Complaint. Develop DD/• History of present illness and

important related positive & negative symptoms.

to exclude by anamnesis• Systems review• Past history

Pediatric history

• Maternal history (Pre-natal).• Birth history (Natal).• Post-natal history.• Nutritional history.• Immunization• Growth and development• Family history• Social and environmental history

Maternal history

– Multiparity, any miscarriages, stillbirth or congenital malformation.

– Maternal health during pregnancy (hypertension, TORCH), regular antenatal care, Rh iso-immunization.

– History of drugs ingestion during pregnancy, oligohydroamnios or polyhydroamnios

Birth history

– Mode of delivery.

– Crying immediately or not.

– Apgar score

– History of asphyxia

– Meconium stained amniotic fluid.

Post-natal history

– NICU admission?– How long 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.

Nutritional history– Breast feeding 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.

Immunization history– Vaccination program in details (National)

– Any special vaccination was given.

– When the last vaccine was given

– Any complication of given vaccine

– (Any contraindications for certain vaccine?)

Growth and development history

- Details of weight increment (KMS)

– Details of development milestones: smiling , sitting, standing, walking, speech

– Bladder and bowel control

– School performance, behavioral and emotional 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, chronic ds (TB), unexplained death and genetic diseases.

– Draw family pedigree

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.

1. A 8-year old girl, 30 kg, 130 cm, 3rd grade of elementary school, repeatedly had good ranking in class. She was brought to the clinic due to 3-day high grade fever, stomach ache, and epistaxis

2. A 12-year old boy, basketball player, suspected of suffering from radial fracture.

Should complete history be obtained in all patients

irrespective of their illness?

The “My 5 Moments for Hand Hygiene” approach

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.

In general similar to that in adults, i.e. to obtain accurate physical status irrespective of the approachNeeds modification due to nature of infants & children: Start with inspection Followed by auscultation: abdomen

& heart End with examination using

equipment

Physical examination

Pre-exam checklist: WIPE

• :Wash your hands [thus warming them].Introduce yourself to pt, explain what going

to do.Position pt [+/- on parent's knee].Expose area as needed [parent should

undress].

• Any unusual behavior.• If asleep, do the heart, lungs and

abdomen first.

Pre-exam checklist

• Parent-child interaction, reaction to someone new walking entering the room (child abuse).

• Ask if tenderness anywhere, before start touching them.

Steps in physical exam

General condition Vital signs Anthropometric

measurements Systematic exam

A. General condition

1. Consciousness : alert, apathetic, somnolent, soporous, comatous2. Appearance : health, mild / moderate / severely ill, distressed3. Color : pale, jaundiced, cyanotic4. Specific facies : syndromes, facies cholerica, fish-mouth, facies

leonina, Cooley’s facies

B. Vital signs

1. Pulse : rate, regularity, volume, equality

2. Respiration : rate, regularity, pattern3. Blood pressure : of 4 extremities4. Temperature : oral, axillary, rectal Note: always describe complete pulse & respiration!

C. Anthropometric measurements

1. Body length / height: sitting, standing2. Body weight3. Head circumference4. Arm circumference5. Abdominal circumference6. Nutritional status:

W/A, H/A, W/Hplot in standard normal curve

(WHO or NCHS)

Age (Completed weeks or months)

Le

ng

th (

cm

)Length-for-age GIRLSBirth to 6 months (z-scores)

-3

-2

-1

0

1

2

3

0 1 2 3 4 5 6 7 8 9 10 11 12 133 4 5 6

WeeksMonths

45

50

55

60

65

70

45

50

55

60

65

70

Age (Completed weeks or months)

We

igh

t (k

g)

Weight-for-age GIRLSBirth to 6 months (z-scores)

-3

-2

-1

0

1

2

3

0 1 2 3 4 5 6 7 8 9 10 11 12 133 4 5 6

WeeksMonths

2

3

4

5

6

7

8

9

10

2

3

4

5

6

7

8

9

10

We

igh

t (k

g)

Weight-for-length GIRLSBirth to 6 months (z-scores)

Length (cm)

-3-2

-1

0

1

2

3

45 50 55 60 65 70 75 80

2

3

4

5

6

7

8

9

10

11

12

13

14

2

3

4

5

6

7

8

9

10

11

12

13

14

Age (Completed weeks or months)

BM

I (k

g/m

²)BMI-for-age GIRLS

Birth to 6 months (z-scores)

-3

-2

-1

0

1

2

3

0 1 2 3 4 5 6 7 8 9 10 11 12 133 4 5 6

WeeksMonths

10

11

12

13

14

15

16

17

18

19

20

21

22

10

11

12

13

14

15

16

17

18

19

20

21

22

D. Systematic examination

Head and neck Chest Abdomen Genitals Extremities Skin, hair, lymph

nodes Neurological

Head

Examine the head for shape, asymetrySutures, Bone defectsSize and tension of fontanelles

Head circumference, rate of growth. microcephaly, macrocephaly other visible abnormalities The hair and scalp should be examined

Position

Eye Examination– Look for palpebral edema, ptosis,

exopthalmus– Examine the conjunctivae for anemia and

sclerae for jaundice and the cornea for haziness and opacities

– Pupils size and shape, pupil reflex– Evaluate for strabismus by position of the

light reflex and the cover test. Strabismus is normal before 4-6 months.

– Look for nystagmus– Fundoscopic examination– Visual fields should be tested in all

children old enough to cooperate

Eye abnormality?

Ears Examination

• Exam position: same as eye, but child faces the side.

• Check for position (low set ) and shape of both ears.

• Discharge, canals, external ear tenderness.

• Otoscope to examine ear drums.• Evaluate hearing.• The mastoid also need to be checked

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

Mouth and throat

– Breath odor– The color of lips and mucosa– The condition of teeth, gums (hypertrophy in

phenytoin) and buccal mucosa– Look for tongue (geographic tounge), palate,

tonsils and pharynx– Listen to the voice and the quality of cry and

the presence of stridor

Tonsils

Neck

– Examine for nuchal rigidity– Swelling– Webbing– Lymph node : location,

consistency, size, tenderness– Thyroid gland– The position of trachea

Chest

Inspection– The general shape (pectus excavatum or

pectus carinatum)– Abnormal signs : beading (rosary),

asymmetry of expansion•Asess rate,pattern and effort of breathing•Identify variations of respiration and signs of respiratory distress•Recognize grunting, stridor

Chest

• Palpation• Percussion • Auscultation: breath sounds in

children are usually bronchovesicular. Recognize : wheezing, crackles and asymmetric breath sounds

Cardiovascular system:• Inspection : Precordial bulge, apical

heave.– Palpation: apex beat : in the 4th

intercostals space in the midclavicular line in children < 7 years ; after that apex : the 5th ics. Thrill ?

– Percussion– Auscultation: heart sound, murmur – Note the effect of changing of position and

exercise on the murmur. Splitting of the 2nd heart sound is common in normal children

Heart Sounds

Abdomen (1)

• Inspection: – Shape: Distension, Scaphoid

abdomen, – Visible swellings, hernias.– Umbilicus, veins.– Visible peristalsis.

• Auscultation:– Bowel sounds.

Abdomen (2)• Palpation:

– Masses.– Areas of ternderness, rebound,

guarding.– Liver, spleen: <6 years may palpate

up to 2cm below costal margin.– Kidneys, bladder.

• Percussion :– Fluid wave, shifting dullness.– Liver, spleen.

Genitalia

• Recognize genital abnormalities in a boy : cryptorchidism, hypospadias, phymosis, hydrocele

• Palpate the testes

• Recognize genital abnormalities in a girl: signs of virilization, labial adhesions and signs of injury

BackInspection and palpation:

Posture : lordosis, kyphosis, scoliosis–Masses–Tenderness–Limitation of motion–Spina bifida

Anus– Patency (imperforated anus)

– Presence of fissure, fisulae or hemorrhoids

– Rectal examination if indicated

Musclo-skeletal system

• Assess symmetry of length and size.• Observe shape of bones, temp, and color.• Observe for bowlegs: space b/t the knee more

than 5 CM. should disappear after 2-3Y.• Inspect for knock-knee: from 2-7Y, and distance

between two ankle should not exceed 3 CM.• Palpate for presence on edema.• Assess muscle strength and muscle tone

estimation.

• Always s examine for congenital dislocation of the hip in infants

Extremities (1)

• Examine the hips of a newborn for congenital dysplasia using Ortolani maneuvers

Extremities (2)

• Identify age-related changes in gait

• Identify age- related variations ,tibial torsion,genu valgus,flat feet

Neurological Examination

– Observation– Mental status– Cranial nerves– Cerebellar function– Motor system– Sensory system– Reflexes-primitive (neonatal reflexes,

deep and superficial reflexes.

Neurologic (1)• Abnormalities during play.• Limbs: movement, tone, limp, Gower's

sign.• Head control.

Neurologic (2)

• Reflexes:– Moro and tonic neck reflexes

<3months.– Babinski's sign positive <12-15

months.– Hypertonicity commonly is normal

infants, but hypotonicity is abnormal.– Other reflexes: grasp, suck, root,

stepping and placing.

Moro reflex

Neurologic (3)

• Meningitis signs if indicated: Kernig, Brudzinski.

Use of stethoscope

Use binaural stethoscope Bell-shaped side: for low & medium pitched sounds Membrane (diaphragm): for medium to high pitched sounds

For heart exam use bell-shaped side first start without pressure, then with pressure End with diaphragm side

Common mistakes in performing examination

HistoryFail to identify the patient firstMake an incomplete historyProvide a disorganized history

Physical exam: Fail to describe general condition &

vital signs firstIncomplete description of features,

e.g. pulse rate only or respiratory rate only without further characteristics

How can you be a good examiner?

THINK, PRACTICE,

PRACTICE,

PRACTICE!!!

Thank you