1. Pediatric
Physical diagnosis

2. After this lecture the students should understand:
The philosophy of clinical examination
The place of history taking and physical exam in the perspective of professionalism
The characteristics of clinical examination in infants and children
The systematic of clinical examination in infants and children

3. What is the philosophy? Doctor as a professional must
be aware that patients are looking for
attention and help
Patients primarily want to be examined by a respected doctor, NOT
to be subjected as
an object of technology

4. Dean, The University of California, San Francisco
Professionalism should be taught in medical schools and during residencies. Currently, we do suboptimal jobs in medical schools and a poor job in residencies.
We are, I believe, witnessing an improvement in public esteem and trust in the medical profession. Restoration of full trust will require consistent professional conduct in medical students, residents, and practitioners of medicine…….
Dr. Haile Debas (2000)
Dean, The University of California, San Francisco
President of The American Surgical Association

5. The core clinical competencies
Patient care
Medical knowledge
Interpersonal and communication skills
Professionalism
Practice-based learning & improvement
Systems-based practice

6. What do patients usually want?
Patients usually want to be
respected as an individual;
they are not numbers or even
a member of a group of numbers

7. So what? Personal and humane approach!!
Medicine is the science of uncertainties
and the art of probabilities

8. 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.

9. The diagnostic paradigm:
History
Physical
Routine lab
Special investigations

10. History (Anamnesis) Auto-anamnesis: self reporting by the patient
Allo-anamnesis: any information other than by patient (parents, caregiver, referring doctor, previous medical record, previous lab results, etc)

11. Advances in medical knowledge & technology do not exclude the importance of clinical assessment
Appropriate use of medical technology is based on thorough history & physical exam
No laboratory or other exams are performed without appropriate clinical information
No laboratory or other exams are interpreted without aligning with clinical condition
Mastering clinical examination is a must for all doctors caring for patients, from GP to sub-specialist

12. Listen to them; they are telling you the diagnosis!!!
History: ≥80%
Supporting exam: 5%
Physical exam 10-20%
Listen to them; they are
telling you the diagnosis!!!

13. Anatomy of history taking
Patient’s identity
Chief complaint
Clinical course
Previous illness
History of maternal pregnancy
History of delivery
Feeding history
Immunization status
Growth and development
Family history
Environment

14. Nutrition, immunization, growth & development3 2 1 1 1
Birth
Past history
Present
Clinical course
Prenatal 4
Birth
Nutrition, immunization, growth & development
5, 6, etc

15. Points to remember Who provides the patient’s history?
(determines your confidence to the information provided)
Be patient, create a conducive atmosphere
Use ordinary expression instead of medical terms
Be sure that the history-giver understands your points
Use history taking as a method for health education
ALWAYS: make footnotes /remarks at the end of
history taking

16. Should complete history be obtained in all patients irrespective of their illness?
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.

17. It is the patient that should be treated; not the disease
Remember
It is the patient that should be treated; not the disease

18. Physical examination
In general similar to that in adults, i.e. to obtain accurate physical status irrespective of the approach
Needs modification due to nature of infants & children:
Start with inspection
Followed by auscultation: abdomen & heart
End with examination using equipment

19. Steps in physical exam General condition Vital signs
Anthropometric measurements
Systematic exam

20. General condition
1. Consciousness : alert, apathetic, somnolent, soporous, comatous
2. Appearance : health, mild / moderate / severely ill, distressed
3. Color : pale, jaundiced, cyanotic
4. Specific facies : syndromes, facies cholerica, fish-mouth, facies leonina, Cooley’s facies

21. B. Vital signs 1. Pulse : rate, regularity, volume, equality
2. Respiration : rate, regularity, pattern
3. Blood pressure : of 4 extremities
4. Temperature : oral, axillary, rectal
Note: always describe complete pulse & respiration!

22. C. Anthropometric measurements
1. Body length / height: sitting, standing
2. Body weight
3. Head circumference
4. Arm circumference span
5. Abdominal circumference
6. Nutritional status:
W/A, H/A, W/H
(plot in standard
normal curve NCHS)

23. D. Systematic examination
Head and neck
Chest
Abdomen
Genitals
Extremities
Skin, hair, lymph nodes
Neurological

24. 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

25. performing examination
Common mistakes in
performing examination
History
Fail to identify the patient first
Make an incomplete history
Provide a disorganized history
Physical exam:
Fail to describe general condition & vital signs first
Incomplete description of features, e.g. pulse rate only or respiratory rate only without further characteristics

26. Developmental Approach to Physical Exam in Infants
Perform uncomfortable parts of the exam last
Complete the exam with the infant in the parents arm
Keep the infants warm and covered
Observe general appearance, respiratory rate and effort, overall color

27. Developmental Approach to Physical Exam in Toddlers
Approach quietly, calmly and slow
Complete the assessment wherever the child is comfortable
Allow the child to play with your stethoscope
Have a toy or something to distract the child
Consider listening to parent or child’s toy to promote comfort

28. Developmental Approach to Physical Exam in School Age
Clearly explain the plan and expectations before the examination
Answers the child’s questions honestly
Talk about topics of interest during the examination
They may be modest, allow them to keep a gown on
Include them in your history taking

29. Developmental Approach in Adolescents
Questions should be directed at the adolescent and parent
Be honest
Ensure privacy during the examination and in sharing information
Provide the adolescent with the opportunity to have the parent step out for history and/or examination
Provide reassurance

30. Concluding
remarks
History taking and physical exam skills require good background knowledge and a sound human relation;
as a part of medical practice, they are science and art
The art of history taking and physical exam are by no
means inferior to your scientific knowledge of the
disease under investigation
Respect the patient and the family if you want to be
respected by them; by and large, respecting each
other is the key for success in medical practice

31. How can you be a good examiner?
THINK,
PRACTICE,
PRACTICE
!!!

32. Thank
you