1. Essentials of the Pediatric Exam

2. Essentials of the Pediatric Exam Interviewing
Interviews occur in different clinical settings
hospital admission
outpatient clinic
Preventive care
Acute illness
Follow-up
Type of history should be according to setting

3. Essentials of the Pediatric Exam Interviewing
Frequently the history is obtained from a second party ( Parent)
In older children, usually two sources of information ( Patient and parent)
Confidentiality becomes an issue in adolescents

4. Essentials of the Pediatric Exam Additional History
Past history should include
Neonatal history, including birth weight, gestational age, maternal complications, alcohol or drug exposure, and problems in the newborn period
Immunization status
Development
Diet

5. Essentials of the Pediatric Exam Additional History
Family History should include:
Number and ages of siblings, consanguinity, known genetic disorders, early childhood deaths, cardiovascular disease, depression and alcohol abuse

6. Essentials of the Pediatric Exam Additional History
Social History should include:
Assessment of the home environment-type of dwelling, water source, pets, resources
School and peer relations important in school-aged children and adolescents

7. Essentials of the Pediatric Exam Additional History
Adolescent History should include:
Sex
Drugs ( Tobacco and ETOH as well)
Rock and Roll ( Peer relationships)
Family
School performance

8. Essentials of the Pediatric Exam Physical Exam
Establish rapport in an age appropriate manner
Order of exam changes with age
Observation of the child gives additional information

9. Essentials of the Pediatric Exam Physical Exam
General Appearance
Recognize signs of acute illness by looking at skin color, hydration status, respirations, mental status, cry, social interaction
Important to look at behavior, development, body habitus, relationship to parent and examiner

10. Essentials of the Pediatric Exam Physical Exam
Vital signs
Heart rate, Respiratory rate, Blood pressure and temperature
Understand that normal values change with age

11. Essentials of the Pediatric Exam Physical Exam
Measurements
Height, weight, head circumference (particularly in first two years)
Plot data
Note relationships between measurements
Use of longitudinal data

12. Essentials of the Pediatric Exam Physical Exam
HEENT
Fontanelles
Head size, shape, hair whorls, etc. dysmorphic features
Eye exam
Tympanic membranes- use of pneumatic otoscopy- In toddlers, should be examined last!
Oropharynx- look at teeth as well

13. Essentials of the Pediatric Exam Physical Exam
Neck
Lymph nodes
Know that nodes are more prominent in childhood
Test for nuchal rigidity and when they are reliable
Pits, clefts, tags, cysts

14. Essentials of the Pediatric Exam Physical Exam
Chest
Know that normal respiratory rate changes with age
Abdominal breathing is normal in infants
Look at rate and effort of breathing
Distinguish stridor, wheezing, rales
Distinguish transmitted upper airway sounds

15. Essentials of the Pediatric Exam Physical Exam
Cardiovascular
Pulses
Heart rate, rhythm, quality of heart sounds
Murmurs- very common
Rate changes with age

16. Essentials of the Pediatric Exam Physical Exam
Abdomen
Should be able to feel liver edge, kidneys in newborn
Umbilical cord in newborn
Be able to evaluate for distention, tenderness, rebound, masses
Rectal exam- when indicated

17. Essentials of the Pediatric Exam Physical Exam
Genital exam- Inspection should be part of every well child exam
Recognize normal appearance of male and female
Tanner staging
Need chaperone ( other than parent) present in adolescents
Parents may chaperone for younger children and infants

18. Essentials of the Pediatric Exam Physical Exam
Extremities
Importance of hip exam in newborns ( up to 6 months of age)
Evaluate gait
Recognize arthritis

19. Essentials of the Pediatric Exam Physical Exam
Spine/Back
Be able to evaluate for scoliosis
Look at back of every patient

20. Essentials of the Pediatric Exam Physical Exam
Neurologic exam
Primitive reflexes
Tone, strength, reflexes, importance of symmetry
developmental assessment helpful
Much of Pediatric neuro exam can be by observation

21. Essentials of the Pediatric Exam Physical Exam
Skin
Recognize jaundice
Be able to describe a rash- macular, vesicular, papular, petechial, etc.
Skin turgor- difficult to assess in young infants

22. Case Studies
You are examining a 15-month-old female who presents for a well child examination. You have been talking with her mother and are preparing to examine the child. As your approach the patient with your stethoscope, she starts to scream.
What do you do next?

23. Case Studies
You are seeing a 6-month-old male who was brought to clinic by his mother because of fever. He is afebrile on arrival to clinic. His history is significant for a 3 day history of clear runny nose with the onset of fever earlier today. His mother is concerned because he has been pulling on his ears. During the physical examination, the child is crying. The examination is unremarkable except for translucent but erythematous tympanic membranes with normal appearing bony landmarks. What diagnoses should you consider?

24. Case Studies
A 4-year-old male is brought to clinic for a preschool check-up. He has been healthy and has no complaints presently. His physical examination is normal but you are unable to see the tympanic membranes secondary to cerumen in the canals. You are unable to remove the cerumen with a curette.
What should you do at this point?

25. Case Studies
A 16-year-old female is brought to clinic by her mother because of poor school performance. She has been your patient since the age of 3 years and has had no significant health problems or previous problems in school. Her mother expresses concerns about her choice of friends and her lack of interest in school. She rolls her eyes and denies that there are any problems at school. However, she refuses to answer other questions and does not make eye contact with you.
What would you do at this point?

26. Case Studies
A 1-year-old boy is brought to clinic by his mother who is concerned because he has been “lethargic” and “irritable” for the last two days. He has a temperature of 102 F. on arrival to clinic. When you enter the room, he is lying in his mother’s lap but sits up when you walk into the room.
What observations may help you determine the severity of this child’s illness?

27. Advice to the Novice
Never show the fear in your eyes. They can sense it.
Try to spend time playing or interacting with children before interacting with them clinically.
Don’t come on too strong. Spend some time in the room with a toddler before addressing or touching them.
If they cry, don’t take it personally.

28. Advice to the Novice
Wash your hands.
Wash your hands again.