History and physical examination in pediatrics; illustrated book of pediatrics

1. History and physical examination
1. What are the 5 things the doctor should notice in any child?
1. Acute illness
2. Chronic illness  FTT
3. Congenital malformations  syndrome or DDH
4. Delay in development  walking,talking,skills
5. Behavioral problems  tempers, ADHD, eating disorders
Note: always observeobserve and observe! Observation gives you clues to diagnosis.
History taking:
1. General enquiry:
a. General health
b. Feeding, drinkingand appetite
c. Growth and development
d. Any recent change in behavior or personality
2. System review:
a. General  Rash or fever
b. Respiratory  Cough, wheeze, breathing problems
c. ENT  Throat infections,snoring,stridor
d. CVS  Exercisetolerance, cyanosis,murmurs
e. GIT  Vomiting, bowel habits,abdominal pain
f. GUT  Dysuria,frequency, wetting, toilet-trained
g. CNS  Headache, abnormal movements, seizures
h. Musculoskeletal  Gait,pain,swelling
3. Past medical history:
a. Pregnancy  ante/intra/postpartum problems.
b. GBS
c. Birth weight
d. Pastillnesses and admissions
4. Medications
5. Family history
a. Consanguinity
b. Family tree
c. Any death in neonate/handicap
d. Genetic diseases
6. Social history:
a. Parental occupation
b. Economic status
c. Relationships

2. d. Smoking and alcohol etc…
e. Marital stress
f. Housing
g. Is the child happy athome and at nursery/school
7. Development:
a. Parental concerns aboutvision,hearing,development
b. Milestones  a good overview can be taken whilewatchinghim play
c. Bladder and bowel control
d. Child temper and behavior
e. Sleeping problems
f. Cognitive development
Physical examination:
1. Level of hygiene and care
2. Severity of illness  ABCD
3. Growth and nutrition  weight/length/HC.
4. Behavoir and social responsiveness
5. Vital signs
6. General appearance chromosomal and dysmorphic syndrome
Respiratory system:
1. Tachypnea  age-dependent
2. Dyspnea  increasework of breathing
a. Nasal flaring
b. Grunting  PEEP breathingagainsta partially closed glottis
c. Subcostal and suprasternal retractions  upper airway obstruction
d. Use of accessory muscles
e. Difficulty feedingor speaking
3. Cyanosis
4. Clubbing
5. Chest inspection,palpation,percussion,and auscultation asin adults
6. Note any harsh breath sounds,stridors, hoarsevoice
Note: infants with pneumonia may have a normal physical exam
Note: children don’t produce sputum unless it’s cystic fibrosis in general
Note: bronchiolitisVs Asthma have labored breathing and hyperinflation. Both have hyper-
resonance on exam. And both have wheezes. Bronchiolitishavefine crackles all over.
 What are bronchial breathing?
High pitched sound,equal length of inspiration and expiration
 What are wheezes?
High-pitched sound due to obstruction of distal airway

3.  What are crackles?
Moistsounds due to opening of bronchioles
Cardiovascular system:
1. HR  rate, rhythm, volume
2. BP
3. Cyanosis
4. Clubbing
5. Respiratory distress
6. Precordial pulge
7. Ventricular pulse visibleif thin,hyperdynamic circulation, LVH
8. Operative scars
9. Palpation and auscultation
10. Hepatomegaly
11. Femoral pulses
 What is the character of pulse in the following?
1. Aortic stenosis  Small volume
2. Aortic regurge  collapsing
3. PDA  collapsing
4. High output state  largevolume
 What are the features of heart failure in infants?
1. Failureto thrive
2. Sweating
3. Tachycardia
4. Tachypnea
5. Cardiomegaly
6. Hepatomegaly
 What is the features of a significant murmur?
1. All over the precordium
2. Loud
3. Thrill
4. Diastolic
5. Symptomatic  other symptoms of heart failure
Abdominal exam:
1. Look at the eyes, tongue, fingers
2. Inspection  the abdomen is protuberent in toddlers and young children.
3. Inspectthe buttocks for wastingin celiac diseaseor malnutrition.
4. Palpation  note: psuedohepatomegaly in lung hyperinflation.
5. Genitalia for inguinal hernia and perineal rash

4.  What abnormal masses can be felt on abdominal exam?
1. Wilm’s tumor  kidney mass,not cross midline
2. Neuroblastoma  kid is unwell,cross midline
3. Fecal mass  mobile, indentable, not tender
4. Intussuseption  kid unwell, mass in RUQ
 What are the causes of hepatomegaly?
1. Inborn error of metabolism
2. Hematological causes
3. Infections  hepatits,EBV, parasite
4. Liver tumor
5. Heart failure
6. Pseudohepatomegaly
7. Liver disease--> polycyctic disease,portal hypertension,chronic activehepatitis
 What are the causes of splenomegaly?
1. Metabolic diseases
2. Infections
3. Hematological diseases
4. Tumors
5. Congestion
6. Still’s disease
Neurological exam:
1. Walking patterns: ask them to walk on heels, then outsideof their feet, then inside
a. Normal gait  heel to toe
b. Toe to heel gait idiopathic,pyramidal,footdrop, tight tendo-achilles (muscledx)
c. Broad-based  toddler’s gait, cerebellar disorder
d. Waddlinggait proximal hip muscleweakness
e. Hemiplegic gait  corticospinal tractdysfunction (induced by unusual walkingpatterns)
f. Difficulty initiatingmovement or involuntary movements  extra-pyramidal tract
g. Gower sign  normal til 3 years,after that muscleweakness, or central cause
2. Coordination:
a. Build bricks on each other, draw, undo buttons
b. Hold his arms out  drift
c. Cerebellar tests
3. Inspection of limbs
a. Musclebulk  wastingdue to cerebral palsy,meningomyelocele, polio,or muscle
disorder.Bulkingdue to to DMD or myotonic dx.
b. Muscletone  spasticity vs rigidity
c. Posture  hyper vs hypotonia vs dystonis

5. 1. Scissoring& pronated UL & extended LL & fisting  hypertonia
2. Forg-likeposition  hypotonia
3. Abnormal posture & extension  dystonia
4. Truncal tone
Pyramidal  trunk and head arch backwards
Floppy child  floppy truck
5. Head lag
Pull the child up from supineposition
6. Power
7. Reflexes
a. Brisk reflexes  pyramidal dx
b. Abscent reflexes  neuromuscular or spinal dx
c. Note: plantar responses areunreliablebelow1 years
8. Sensation
a. Loss of sensation  spinal lesion
b. Palpablebladder & absentperineal sensation  spinal lesion
9. Cranial nerves
Note: extreme lateral gaze can inducenystagmus in a normal child
Bone and joint exam:
pGALS  pediatric gait,arms,legs,spine.
If an abnormality is noted  examine the jointin detail and the joints aboveand below.
Neck exam:
1. Thyroid
2. LN  variablesizeand shape infections,kawasaki,catscratch,cancer
Blood pressure:
Use blood pressure– age charts
Eyes exam:
1. Inspection
2. Extraocular musles movement
3. Pupils
4. Red reflex  distance20-30 cm  causes of lostred reflex: cataracts, retinoblastoma,
galactosemia,corneal clouding
5. Fundoscope
 Where do you find retinal hemorrhage?
Head trauma and shaken baby syndrome
ENT exam