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Examining The Pediatric Patient

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  • 1. EXAMINING THE PEDIATRIC PATIENT
  • 2. Guidelines on examining pediatric patients
    A keen observation of the child from the beginning to the end of the consultation
    Wash hands before and after examining the patient
    Spend a little time winning the child’s confidence by starting on friendly terms
    Examine the child on the examining table or on a position that suits the child
    In an infant remove all clothing but in adolescents a thorough examination should be conducted with due respect to the patient’s privacy and sensitivities
  • 3. Examining patients: 4 developmental levels
    Infancy- (0-2 yrs- newborn)
    Preschool-(2-5 yrs)
    School-age-(5-10 yrs)
    Adolescent-(10 yrs >)
  • 4. Newborn
    APGAR score immoreextensivemediately after birth
    Do a general survey ; insert tube passing thru nose,aspirate gastric content
    Extensive examination at 12th-24h hour of life- Dubowitz scoring
    Observe baby’s breathing, color,cry,size,body proportion and nutritional state and movements of the head and extremities.Responsiveness is bet noted 2-3 hours after feeding
    Auscultation and palpation should be done when the baby is quiet
  • 5. Preschool
    Mobile patients
    Communicate with patients at their own level;observe speech
    During communication process observe the child
    Get anthropometric measurements
    Observe the child for behavioral features
  • 6. School Age
    Deal with the child as an increasingly independent individual
    Communication is vital
    Antrhpometric measurements, screen for auditory and visual problems
    Check for vaccinations
    Dental and discipline concerns
  • 7. Adolescents
    There should be respect for privacy
    Examination done privately and make sure that they are covered properly
    Examine for changes and appropriateness of secondary sexual characteristics; emphasis on body concerns
    Confidentiality- ethical right to health care
    Information and explanation on what needs to be done should be given in a straightforward fashion
    Transition to care to a non- pediatrician can be facilitated
  • 8. Physical Examination-GeneralSurvey
    Gen survey-wt,hght-temp-rectal,PR-pulsations of carotidmoral or brachial,RR-greater range,BP
    Head
    Shape,headcircumference,sutures,
    anterior fontanel,bruits,transillumination
    Ears-position and shape,tympanicmembrane,impairment of hearing
    Eyes-doll’s eye maneuver,uprightposition,redreflex,pupils,cornea,funduscopy
    Nose-patency, alarflaring,nasal septum deviation,nasal speculum examination
    Mouth, tongue and throat-color of lips,teeth,oralsigns;tongue-shape, thickness,lesions;throat-tonsils,epiglottis
  • 9. Physical Examination-Head
    Head
    • Shape,headcircumference,sutures,
    • 10. anterior fontanel,bruits,transillumination
    • 11. Ears-position and shape,tympanicmembrane,impairment of hearing
    • 12. Eyes-doll’s eye maneuver,uprightposition,redreflex,pupils,cornea,funduscopy
    • 13. Nose-patency, alarflaring,nasal septum deviation,nasal speculum examination
    • 14. Mouth, tongue and throat-color of lips,teeth,oralsigns;tongue-shape, thickness,lesions;throat-tonsils,epiglottis
  • Physical Examination-Chest
    Chest-examined ahead of other regions-inspect,auscultate,palpate and percuss;
    shape and circumference-barrel shaped in infancy then becomes elliptical, relationship of head and chest circumference;
    RESPIRATORY SYSTEM
    rate and depth of respiration-30-60/min-NB and infancy;6yrs and> 20-25/min;deep and shallow breathing;irregularity
    Palpation-vocal fremitus,pericardial or pleural friction rub
  • 15. Physical Examination-Chest
    Percussion –child’s chest more resonant-chest wall thinner and muscles smaller;
    Posteriorly- change in percussion note from 8th-10th ribs
    Anteriorly-decreased percussion note over diaphragm, liver and heart; top of libver dullness-6th rib from midaxillary line to the sternum; lower edge of lung or top of the diaphragm is percussed to the level of the 8th-10th ribs
  • 16. Physical Examination-Chest
    Mediastinum-cardiac dullness-2nd-5th rib extending on the right sternalborder;from left sternal border-2nd rib to midclavicular line at the 5th rib
    Impaired resonance over a fixed area indicates consolidation, collapse or massive atelectasis
    Shifting dullness- hydothorax
    Hyperresonance-emphysema
    Auscultation-decreased breath sounds, rales,wheezing
  • 17. Physical Examination-Chest
    CARDIOVASCULAR SYSTEM
    Femoral pulses and BP
    Inspection-precordialbulging,signs of RVH,cardiac impulse-4thinterspace
    Auscultation-quality of the heart sounds-clear and sharp, gallop rhythm, pericardial friction rub, murmurs
  • 18. Physical Examination-Abdomen
    Inspection-flat when in supine,potbelly,distention-gas, fluids, mass, peristalsis
    Palpation-inspiration and expiration, soft or hard, tenderness, masses, spleen- 1 cm below the left costal margin, liver-1-2 cm below the right costal margin, congenital renal anomalies, bimanual deep palpation for deeper masses
    Percussion-tympanitic-gas,fixed dullness-masses,
    shifting dullness-fluid
    Ausculation-decrease or absence of peristaltic sounds- paralytic ileus
  • 19. Physical Examination-Genitalia
    Inspection
    Female-vaginal discharge,imperforatehymen,size of clitoris, fusion of labia, ambiguous genitalia
    Male-position of urethral orifice,size of penis, undescendedtestes,hernia or hydrocoele
  • 20. Physical Examination-Anus and Rectum
    Anal fissures- bleeding and constipation
    Prolapse of the rectal mucosa
    Rectal examination
  • 21. Physical Examination-Musculoskeletal System
    Range of motion of all joints is greatest in infancy
    Position of feet at birth-fetal position
    Hips examine for dislocation