History and Physical Examination Krzysztof Narebski Toruń

Problems to discuss Pediatric population Taking a history Examination 2

Pediatric populations Newborn < 1 month Infant < 1 year Toddler 1 – 2 years Preschool child 2 – 5 years School child Adolescent

What brought you along today ? Diagnosis of acute illness Diagnosis of chronic illness Developmental screening and assessment (growth, nutrition and immunization, milestones)

Taking history 1 Review by systems Fever, rashes, oedamas ENT: sore throat, snoring, stridor Respi: cough, wheeze, dyspnea Cardio: cyanosis, exercise tolerance, murmur Gastro: vomiting, diarrhoea, constipation, pain Genitourinary: dysuria, wetting, toilet-training Neuro: headaches, seizures Musculoskeletal: problems of gait, limb pain 5

Taking history 2 Presenting complaints (present illness) One or several Onset (health before) Duration (progress of disease) Character of each symptom What relieves / aggravates Previous episodes

Taking history 3 General health (personal details and social history) Growth Nutrition Milestones Pubertal development Family, social, environmental history Consanguinity 8

Taking history 4 Past medical history (according to age !) Maternal diseases and obstetric problems Maternal pyrexia Prematurity and Perinatal problems Past illnesses (same / others) Past injuries, operations Allergies and drug allergies Immunisations 9

Examination 1 Establish your own scheme General appearance Severity of illness Level of consciousness Airway and breathing Circulation Temperature (infections !) Systems (respi, cardio, abdo etc.) 10

Examination 2 Methods of testing Inspection Palpation Percussion Auscultation 11

Respiratory system 1 Chest movement Dyspnea Tachypnoea Nasal flaring Expiratory grunting Retractions Difficulty of feeding or speaking Tachypnoea Neonate 30 – 50 / min Young children 20 – 30 / min Older children 15 – 20 / min Percussion (normal, dull, hyperresonant) 12

Respiratory system 2 Auscultation of breath sounds Normal, symmetrical and vesicular Transmissions from upper airways Stridor (inspiratory – larynx obstruction) Wheeze (expiratory – bronchioles obstruction) Rales (discharge in bronchi) Crackles (moist sounds – opening of bronchioles and pulmonary alveoli) 13

Lying or sitting position 14

Cardiovascular system 1 Cyanosis (central, peripheral) Pulse (and femoral pulse) < 1 year 100 – 160 / min 2 – 12 years 70 – 140 / min > 12 years 50 – 100 / min Blood pressure Palpation (cardiac thrill) Hepatomegaly 15

Cardiovascular system 2 Auscultation Heart sounds First, second (and third) Splitting of second heart sound Murmurs When : Systolic / Diastolic / Continuous Site of maximal intensity 16

Cardiovascular system 3 Auscultation of Murmurs cont. Loudness 1 - 2 : soft, difficult to hear 3 : easily audible 4 – 5 : loud with thrill 6 : easily audible over abdomen Radiation to neck or to back 17

Abdomen 1 Inspection - size and distention (five „F”) Palpation Fat Fluid (ascites) Faeces (constipation) Flatus (intestinal obstruction) Fetus Palpation warm hands, be systematic, watch the child 18

Abdomen 2 Tenderness Hepato / splenomegaly Abnormal masses Percussion Location Hepato / splenomegaly Abnormal masses Percussion Auscultation 19

Not the best method to palpate the abdomen. 20

Genito – urinary system Kidneys Palpation Tenderness Urianalysis Genital area Rectal examination 21

Neurological examination Watch the infant posture, movement, muscle tone, head control, reflexes Watch the child play, manipulation, gait speech, social interaction Neurological examination in details 22

Neonatal reflexes – grasp reflex 23

Neonatal reflexes – Galant reflex 24

Neonatal reflexes – the Moro reflex 2nd stage 1st stage 3rd stage 25

Head and Neck Head : skull, sutures, fontanels, ears, eyes (pupils) Lymph nodes !!! Occipital, submandibular, cervical Size (< 1 cm) Tenderness (infection vs malignancy) Fixed or movable Thyroid (enlargement) 26

Lymph nodes 27

Ears, nose and throat Spatula in young children Look tongue, tonsils, pharynx, palate Teeth - deciduous / permanent, caries Nasal discharge, obstruction Drum (tympanum) Swelling, redness, perforation Middle ear fluid 28

Throat 29

Ear with otoscope 30

Skin Rash Hives (urticaria) Spots (pustules) Vesicular rash Hair problems Other lymph nodes (axillary and inguinal) 31

Chickenpox JAMA 2005; 294: 866 32

Body mass 33

Body length 34

Height 35

Circumferences 36

Thank you 37