PEDIATRIC EXAM Gerald Hickson, MD Joe Gigante, MD
THE PEDIATRIC HISTORY
I. General principles Smile. Introduce yourself. Shake hands with parents, child if old enough. Try to help family feel comfortable, establish rapport. II. Identifying information: name of patient, date of birth, gender, date of interview. Identify source of history. III. Chief Complaint: ask the patient or parent, use their own words if possible. IV. History of Present Illness: What are the symptoms? How long have they been present? Who else is sick? (family members, daycare contacts) Has this patient ever had a similar illness? What treatments have been tried for this problem? Include pertinent ROS and past medical history. V.
Past Medical History
A. Perinatal maternal history: mother's age, gravida, para (term, preterm), abortions (spontaneous or elective). pregnancy: LMP, EDC, onset of prenatal care, weight gain, complications (bleeding, preterm labor, infections, medications, gestational diabetes), rubella immunity status, RPR, PPD, hepatitis B, drugs, alcohol, tobacco use. labor and delivery: spontaneous or induced, duration, duration of rupture of membranes prior to delivery, complications, medications or anesthesia, vertex or breech presentation, vaginal or c-section, meconium staining of amniotic fluid. neonatal: birth weight, estimated gestational age, Apgar score, resuscitation in delivery room, problems in nursery ( e . g . jaundice, feeding difficulty, respiratory distress), length of stay, reasons for prolongation of stay. B. Previous hospitalizations age, length of stay, reason, location C. Childhood illnesses or exposures age, complications, treatment recent exposures, date, nature of exposure travel to other locations, animal exposure D. Previous surgery/ transfusions age, reason for procedure, complications E. Trauma/ injuries/ ingestions, burns age, circumstances surrounding event, treatment, complications
The Pediatric History, page 2 Past medical history, continued F. Allergies medications - name of medication, timing of reaction, signs and symptoms, who madethe diagnosis of allergy. other allergies - signs and symptoms, therapy G. Medications current or recent, include OTC meds, dosage, frequency indications andreactions, timingof most recent dose H. Nutrition infants - breast or formula, frequency, amount, problems toddlers -introductionof babyfoodsandcereal,milkintake when did transition from formula/breast to cow's milk occur' problems, peculiar eating habits (pica) older children - good appetite or "picky eater", special diets, milk intake, "junk foods", concerns about weight
'
I. Immunizations and reactions Don't rely on memory; ask to see shot record. hepatitis Bl
Birth 2mo
hepatitis B2
4mo 6mo
hepatitis B3
DTP1
Hibl
OPV1
DTP2
Hib2
OPV2
DTP3
Hib3
15mo
Hib4
MMR1
18mo
DTP4
OPV3
4-6 yr
DTPS
OPV4
14-16 yr
dT
J. Growth weight, height,head circumference, rate ofgrowth, concerns, puberty, menarche K. Development Grossmotormilestones Fine motor milestones Social interactions, behavior Speech and language development School performance Hearing,vision
MMR2* or MMR2
The Pediatric History, page 3 VI. Family history Ask aboutparents, siblings, grandparents and extended family. Focus on Inherited diseases, diseases that "run in the family", miscarriages, infant or childhood deaths, congenital anomalies, developmental delay, mental retardation, seizures, early cardiovascular diseases, sickle cell disease, consanguinity, any family members with similar problems to patient's current complaint. Drawafamilytree. VII. Social History ONE OF THE MOST IMPORTANT COMPONENTS OF THE HISTORY1 Observe interactions between the family and child. Seek information about the home environment which will impact how the child and family cope with illness. Find out what resources are available for support for the child, mother, family. Find out if there are underlying concerns that have not yet been brought out ( e . g . an neighbor died from a brain tumor, and the mother fears that this child's headache is a sign of a tumor.) Typical questions may include: Who lives at home? Who is the primary caregiver or disciplinarian? Does the child attend school, daycare or a babysitter? Who helps the mother? In the outpatient setting, important questions may include: Do you have a way to pay for this prescription? Do you have transportation to return if your child gets worse? VIII. Review of Systems Similar in general to adult patients with a few important differences: A. General: include fever, weight loss, etc. as in adults, but also include patient's activity level, playfulness, appetite, sleep habits, days of school missed. B. HEENT: include recent or past history of ear infections if not already included in PMH. C. GI: diarrhea, vomiting, constipation, etc. Young children willnot complain of nausea. Encopresis. D. GU: change in urinary pattern such as enuresis in previously toilet trained child. E. Hydration status: tears, wet diapers, details of p . o . intake, details of losses (frequency of diarrheal stools, volume, frequency of emesis), activity level.
References Algranati, PS. The Pediatric Patient: An Approach to history and PhysicalExamination.Williams &Wilkins, 1 992.
Report of the Committee on Infectious Diseases 22nd ed. American AcademyofPediatrics, 1991.
PEDIATRIC PHYSICAL EXAMINATION
Wash your hands. Introduce yourself. Say something compliment nice, or the child/parents (at the end of the session as w ell). The .order of the exam can be individualized. Start observation, by introduce instruments and let the child check out,them keep invasive or painful parts for the end. Explain everything you will be doing. Use age-appropriate non-threatening terms. Give feedback. In the newborn, observe, auscultate palpate and first. The child has to be undressed for the exam, but this can be done gradually. Exam has to be thorough, even in the child. uncooperative Special focus of the pediatric exam: Grow th and Developm Points ent. of special relevance to the newborn are in boldface. VITAL SIGNS Ax illary- T° is 2° below rectal, oral is 1° below rec tal. BP cuff should cover 1/2 to 2/3 of arm span . Heart rate and repiratory rate. Height and w eight. Head circumference. Chest and abdo minal circumference if indicated. Plot them on charts. Skinfoldthickness. GENERAL APPEARANCE Nutritional status. Cleanliness. Posture. Reluctance to m ove. A lertness, interest in surroundings, p layfulness, cooperati Distress, consolability (paradox ical irritability). Hyd ration status. Developm ent. Cry o r speech. G ross abnorm alities. M include a note about the family.
SKIN Color, pigmentation. Jaundice. Cyanosis (acrocyanosis). Mottling. Pallor. Birthmarks (nevus flammeus, salmon patch). Texture. Scars. Rashes (erythema toxicum). Ecchymosis (color and age). Craddle cap. Capillary refill. Edema. Milia. Vernix caseosa. Desquamation. Mongolian spot. NAILS Cyanosis,clubbing.Pitting.Capillaryrefill. HAIR Lanugo. Alopecia (including occipital alopecia). Lice or nits. Pubic hair and Tanner stage. LYMPH NODES ' HEAD Size and symmetry. Circumference. Sutures. Fontanelles, size (AT perpendicular to sides), bulging or depression, pulsatility. Caput Cephalhematoma. Craniotabes. Transillumination. Sinuses.
• measured succedaneum.
FRONT
metopic suture coronal sagittal
lambdoid
FACE Paralysis. Asymmetry. Anomalies, coarseness of features. Edema. Parotid glands. EYES Vision, visual fields. Scleral color. Strabismus (paralytic, non-paralytic). Nystagmus. Conjunctivitis, discharge. Hemorrhages (subconjunctival hemorrhages). Reaction to light. Iris (absence-). Ophthalmoscopy (red reflex, retinal hemorrhages, macula). EARS Position, shape. Discharge. Tenderness. Auricular pits or tags. Otoscopy (use the bigger speculum). Hearing. NOSE Discharge, obstruction, polyps (use otoscope). Bleeding. Flaring.
MOUTH Drooling. Teeth (map, hygene). Cysts. Palate Gums. Tongue. Palate. Tonsils. Postnasal drip.
(cleft).
Thrush.
VOICE Stridor,hoarseness,cry(weak,high-pitched).Vocalization, speech. NECK Position, motility, webbing. Nodes, masses. Neck stiffness, Brudzinski sign. CHEST Inspection,"palpation, percussion, ausculation. Pectus (carinatum, excavatum). Harrison's groove. Respiratory rate, chest expansion, symmetry, retractions, paradoxical breathing. Grunting. Flaring, use of accessory muscles. Cough (characteristics, frequency). Breast size, milk discharge, symmetry, Tanner stage. HEART Rate and rythm (sinus arrythmia). Inspection, palpation, percussion, ausculation.
ABDOMEN Inspection, palpation, percussion, ausculation. Shape (scaphoid, pot-belly). Circumference. Umbilicus (cord stump), Diastesis recti. umbilical hernia. Gastric waves. Liver,
spleen, masses. Unimanual palpation of the kidneys. Superficial reflexes. Inguinal areas, femoral pulses,
Bladder. lymph nodes.
GENITALIA Penis size, meatus location, circum cision, testicles (Tdescen ded), hydroc oele, r^rnia, cremasteric reflex. In girls, labia prominent in the newbo rn. Discharge, adhesions. Diaper Tanner rash. stage. RECTAL An us (patency), anal w ink, fissures, fistula, prolapse, hem orrhoids, masses, stools, Guaiac. Diaper rash. EXTREMITIES AND MUSCULOSKELETAL. Posture, asymmetry, extra digits, clubbing, temperature,Hand swelling. s and dermatoglyphics. Nails. Feet (clubbing). Genu valgum,gait, hips (dislocation). Sp ine, scoliosis, sacral pit tuft. or Pulses. hair Joints range of motion, arthralgias, arthritis. Kernig's sign. NEUROLOGICAL State of consciousness. Spontaneous m ovem ents, abnormal m ovem ents. Tone and strength. Superficial reflexes, d Suck, root, grasp, Moro, tonic neck, Babinski, stepping, placing,Landau, parachute reflexes.Sensations. reflexes. Coordination, cerebellar signs. Cranial nerves. Gait. Developm ent Screening (Denver T e s t ) .Meningeal signs. JAUNDICE
Includes hands and feet
Head alone Head and chest To knees Includes arms and lower legs
B I L I L E V E L ( m g / d l) 5-8
6-128-161018 ' 15-20+
APPEARS
DISAPPEARS REFLEX ECCHYMOSES COLOR
Birth Birth Birth Birth Birth Birth Birth 3 mo 7-9mo
Infancy3 -4 mo Suck Root Moro 3-7 mo Tonic neck Babinski 3-5 mo Stepping Placing 1-2 yrs Landau Parachute early 1 y r 1-2 yr Remains
AGE (days) Fresh Purple-Red 1-4 Dark blue-brown Greenish-yellow5-7 >7 Yellow
Reference; M a n u a l o f P e d i a t r ic P h y s ic a l D i a g n o s i s. L. A. B arness. Sixth ed. Mosby Yearbook, 1991.
STAGES OF PUBERTY (TANNER STAGES) Female breast. I. Preadolescent. The breast has an elevated papilla (nipple) and a small flatareola. II. Breast bud. The papilla and areola elevate as a small mound, and the diameter ofthe areolaincreases. III. The breast bud further enlarges. The areola continues to enlarge. No separation of breast contours is noted. IV. The areola and papilla separate from the contour of the breast to form a secondary mound. V. Mature. The areolar mound recedes into the general contour of the breast. The papilla continues to project. Pubic hair. Male Female I. Preadolescent. No pubic hair. Preadolescent. No pubic hair. Sparse distibution of long, II. Sparse distibution of long, slightly pigmented straight hair appear bilaterally along slightly pigm ented hair at the base of the penis the medial border of the labia majora. The pubic hair pigmentation increases; it begins to curl and spread III. The pubic hair pigmentation sparsely over the mons pubis. increases; it begins to curl and spread laterally in a scantydistribution. The pubic hair continues to curl and become coarse in IV. The pubic hair continues toand curlbecom e coarse in texture. The number of hairs continues to increase. texture. An adult type o f distribution attained, is but Mature. The pubic hair attains an adult feminine triangular with fewer h airs. pattern, with spread to the surface of the medial thigh. V. M ature. The pubic hair attains an adu lt distribution, spreading to the surface of the medial thigh. Pubic hair grows along the linea alba in 80% of m ales.
Male
genital development.
I. Preadolescent. I I. The testes enlarge. The scrotum enlarges, developing a reddishaltering hue andin skin texture. The penis enlarges slightly. III. The testes and scrotum co ntinue to grow. The length of the increases. penis IV. The testes and scrotum continue to grow; the scrotal skin darkens. penis grows The in width, and the glans penis develops. V. M ature. The testes, scrotum, and penis are adult in size and shape. Reference; TannerJM: Growthatadolescence. Oxford, Blackwell, 1962.
