Presentation on theme: "Pediatric Clinical Diagnosis"— Presentation transcript:
1Pediatric Clinical Diagnosis Hartono Gunardi, Sudigdo Sastroasmoro,Irawan Mangunatmadja,Department of Child Health, Medical SchoolUniversity of Indonesia, Jakarta
2Differences 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 guarantiedThe expression of the disease may be influenced by the child’s developmental status (hypothermia may indicates severe infection in newborn)
3Differences 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).
4Clinical exam in infants and children: Why special attention? A child is not a small adult!Keywords: growth and developmentAny information about history, physical, and laboratory / supporting exams should be judged in relation with the child’s stage of growth and development.
6Pediatric History (Anamnesis) Auto-anamnesis: self reporting by the patientAllo-anamnesis: any information other than by patient
7Listen to them; they are telling you the diagnosis!!! History: ≥80%Supporting exam: 5%Physical exam 10-20%Listen to them; they aretelling you the diagnosis!!!
8Pediatric 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.
9Anatomy of history taking Patient’s identityChief complaintClinical coursePrevious illnessHistory of maternal pregnancyHistory of deliveryFeeding historyImmunization statusGrowth and developmentFamily historyEnvironment
10Pediatric history Presenting/Chief Complaint. Develop DD/ History of present illness and important related positive & negative symptoms.to exclude by anamnesisSystems reviewPast history
11Pediatric history Maternal history (Pre-natal). Birth history (Natal). Post-natal history.Nutritional history.ImmunizationGrowth and developmentFamily historySocial and environmental history
12Maternal historyMultiparity, 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
13Birth history Mode of delivery. Crying immediately or not. Apgar score History of asphyxiaMeconium stained amniotic fluid.
14Post-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.
15Nutritional history Breast feeding or bottle feeding Type of formula How much milk is given , number of feeds/dayHow is the milk preparedWhen the solid food or cereals is introduced, content of food, any allergy to the food.
16Immunization history Vaccination program in details (National) Any special vaccination was given.When the last vaccine was givenAny complication of given vaccine(Any contraindications for certain vaccine?)
17Growth and development history - Details of weight increment (KMS)Details of development milestones: smiling , sitting, standing, walking, speechBladder and bowel controlSchool performance, behavioral and emotional history.
18Family historyFather and mother age, consanguinity, level of education and they are healthy or not.History of smoking in either parentSiblings: number, sex, and their ages.History of similar disease, chronic ds (TB), unexplained death and genetic diseases.Draw family pedigree
21Social & Environmental history It is necessary to build up a picture of the child’s social and cultural environmentAppreciate fears and stresses at home( parental attitudes, separation, divorce, absence of parent)Jealously at the arrival of a new babyUnexplained injuries may raise the possibility of child abuse.
22Should 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 epistaxis2. A 12-year old boy, basketball player, suspected of suffering from radial fracture.
25Pediatric 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.
26Physical examinationIn 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 inspectionFollowed by auscultation: abdomen & heartEnd with examination using equipment
27Pre-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.
28Pre-exam checklistParent-child interaction, reaction to someone new walking entering the room (child abuse).Ask if tenderness anywhere, before start touching them.
29Steps in physical exam General condition Vital signs Anthropometric measurementsSystematic exam
32C. 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 (WHOor NCHS)
39D. Systematic examination Head and neckChestAbdomenGenitalsExtremitiesSkin, hair, lymph nodesNeurological
40Head Examine the head for shape, asymetry Sutures, Bone defects Size and tension of fontanellesHead circumference, rate of growth.microcephaly, macrocephalyother visible abnormalitiesThe hair and scalp should be examined
42Eye Examination Look for palpebral edema, ptosis, exopthalmus Examine the conjunctivae for anemia and sclerae for jaundice and the cornea for haziness and opacitiesPupils size and shape, pupil reflexEvaluate for strabismus by position of the light reflex and the cover test. Strabismus is normal before 4-6 months.Look for nystagmusFundoscopic examinationVisual fields should be tested in all children old enough to cooperate
44Ears 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
48Mouth and throat Breath odor The color of lips and mucosa The condition of teeth, gums (hypertrophy in phenytoin) and buccal mucosaLook for tongue (geographic tounge), palate, tonsils and pharynxListen to the voice and the quality of cry and the presence of stridor
51Neck Examine for nuchal rigidity Swelling Webbing Lymph node : location, consistency, size, tendernessThyroid glandThe position of trachea
52ChestInspectionThe general shape (pectus excavatum or pectus carinatum)Abnormal signs : beading (rosary), asymmetry of expansionAsess rate,pattern and effort of breathingIdentify variations of respiration and signs of respiratory distressRecognize grunting, stridor
54Chest Palpation Percussion Auscultation: breath sounds in children are usually bronchovesicular. Recognize : wheezing, crackles and asymmetric breath sounds
55Cardiovascular 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 ?PercussionAuscultation: heart sound, murmurNote the effect of changing of position and exercise on the murmur. Splitting of the 2nd heart sound is common in normal children
58Abdomen (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.
60GenitaliaRecognize genital abnormalities in a boy : cryptorchidism, hypospadias, phymosis, hydrocelePalpate the testesRecognize genital abnormalities in a girl: signs of virilization, labial adhesions and signs of injury
61Back Inspection and palpation: Posture : lordosis, kyphosis, scoliosis MassesTendernessLimitation of motionSpina bifida
62Anus Patency (imperforated anus) Presence of fissure, fisulae or hemorrhoidsRectal examination if indicated
63Musclo-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
70Neurologic (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.
73Neurologic (3)Meningitis signs if indicated: Kernig, Brudzinski.
74Use of stethoscope Use binaural stethoscope Bell-shaped side: for low & medium pitched soundsMembrane (diaphragm): for medium to high pitched soundsFor heart examuse bell-shaped side firststart without pressure, then with pressureEnd with diaphragm side
75performing examination Common mistakes inperforming examinationHistoryFail to identify the patient firstMake an incomplete historyProvide a disorganized historyPhysical exam:Fail to describe general condition & vital signs firstIncomplete description of features, e.g. pulse rate only or respiratory rate only without further characteristics
76How can you be a good examiner? THINK,PRACTICE,PRACTICE!!!