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

2. Differences Adult and Pediatrics
A child is not a small adult !
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)

3. 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).

4. 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.

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

6. Pediatric History (Anamnesis)
Auto-anamnesis: self reporting by the patient
Allo-anamnesis: any information other than by patient

7. 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!!!

8. 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.

9. 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

10. 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

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

12. 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

13. Birth history Mode of delivery. Crying immediately or not. Apgar score
History of asphyxia
Meconium stained amniotic fluid.

14. 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.

15. 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.

16. 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?)

17. 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.

18. 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

21. 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.

22. 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.

23. The “My 5 Moments for Hand Hygiene” approach

25. 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.

26. 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

27. 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.

28. Pre-exam checklist
Parent-child interaction, reaction to someone new walking entering the room (child abuse).
Ask if tenderness anywhere, before start touching them.

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

30. 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

31. 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!

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

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

40. Head Examine the head for shape, asymetry Sutures, Bone defects
Size and tension of fontanelles
Head circumference, rate of growth.
microcephaly, macrocephaly
other visible abnormalities
The hair and scalp should be examined

41. Position

42. 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

43. Eye abnormality?

44. 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

46. 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

48. 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

49. Tonsils

51. Neck Examine for nuchal rigidity Swelling Webbing
Lymph node : location, consistency, size, tenderness
Thyroid gland
The position of trachea

52. 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

54. Chest Palpation Percussion
Auscultation: breath sounds in children are usually bronchovesicular. Recognize : wheezing, crackles and asymmetric breath sounds

55. 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

56. Heart Sounds

57. Abdomen (1) Inspection: Shape: Distension, Scaphoid abdomen,
Visible swellings, hernias.
Umbilicus, veins.
Visible peristalsis.
Auscultation:
Bowel sounds.

58. 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.

60. 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

61. Back Inspection and palpation: Posture : lordosis, kyphosis, scoliosis
Masses
Tenderness
Limitation of motion
Spina bifida

62. Anus Patency (imperforated anus)
Presence of fissure, fisulae or hemorrhoids
Rectal examination if indicated

63. 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

65. Extremities (1)
Examine the hips of a newborn for congenital dysplasia using Ortolani maneuvers

66. Extremities (2) Identify age-related changes in gait
Identify age- related variations ,tibial torsion,genu valgus,flat feet

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

69. Neurologic (1) Abnormalities during play.
Limbs: movement, tone, limp, Gower's sign.
Head control.

70. 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.

71. Moro reflex

73. Neurologic (3)
Meningitis signs if indicated: Kernig, Brudzinski.

74. 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

75. 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

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

77. Thank you