Essentials of the Pediatric Exam

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

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?

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?

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?

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?

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.

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