Pediatrics/Paediatric Examinations Made Easy for Medical Students, succinate summary with approach to short and long cases for MBBS examination

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PEDIATRICS EXAMINATIONS MADE EASY FOR MEDICAL STUDENTS
By Dr Varsha Atul Shah
Senior Consultant, Neonatal and Developmental Medicine, Singapore General Hospital
Visiting Consultant, Department of Child Development, KK Women's and Children's Hospital

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TABLE OF CONTENTS
1. FORMAT OF CLINICAL EXAMINATION ..............................................................................................................................................ERROR! BOOKMARK NOT DEFINED.
2. GENERAL EXAMINATION IN PEDIATRICS..............................................................................................................................................................................................5
3. NEWBORN SCREENING: ROUTINE EXAMINATION OF THE NEWBORN FOR MEDICAL STUDENTS........................................................................................................ 15
4. DEVELOPMENTAL ASSESSMENT FOR MEDICAL STUDENTS................................................................................................................................................................. 20
5. NEUROLOGICAL EXAMINATION......................................................................................................................................................................................................... 30
6. CARDIOVASCULAR EXAMINATION IN CHILDREN................................................................................................................................................................................ 33
7. PAEDIATRIC RESPIRATORY EXAM ...................................................................................................................................................................................................... 38
8. APPROACH TO LONG CASE, PAEDIATRIC HISTORY & PHYSICAL EXAM ............................................................................................................................................... 44
9. SEIZURES/EPILEPSY: LONG CASE........................................................................................................................................................................................................ 48
10. HEMIPLEGIA: LONG CASE................................................................................................................................................................................................................... 50
11. CEREBRAL PALSY: LONG CASE............................................................................................................................................................................................................ 53
12. BRONCHIAL ASTHMA: LONG CASE..................................................................................................................................................................................................... 55
13. THALASSEMIA: LONG CASE................................................................................................................................................................................................................ 60
14. DIABETES MELLITUS: SHORT AND LONG CASE ................................................................................................................................................................................... 65
15. SPINA BIFIDA: LONG CASE ................................................................................................................................................................................................................. 68
16. APPROACH TO CHILDHOOD OBESITY................................................................................................................................................................................................. 71
17. APPROACH TO CASE OF SYSTEMIC LUPUS ERYTHEMATOSUS: LONG CASE......................................................................................................................................... 73
18. APPROACH TO CASE OF PNEUMONIA: LONG CASE ............................................................................................................................................................................ 75
19. APPROACH TO INFANT WITH JAUNDICE ............................................................................................................................................................................................ 78
20. APPROACH TO MARFAN SYNDROME: INTRODUCTION...................................................................................................................................................................... 80
21. APPROACH TO HEMOPHILIA: LONG CASE .......................................................................................................................................................................................... 81
22. SHORT CASE EXAMINATION: APPROACH TO CHILD WITH SHORT STATURE....................................................................................................................................... 84
23. APPROACH TO SKIN RASH ................................................................................................................................................................................................................. 86

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SHORT CASES:
just 40 minutes of 4 short stations (3 Internal Medicine + 1 Paeds) and 8 APs…
There’s no reading time in between stations, so when the bell rings, you just rush out of the room and straight to the next station.
8 mins are for PE, and the remaining 2 mins are for discussion. Always remember to wash your hands before and after PE, cos if
you don’t you lose 2 marks instantly!
you’ll pass the station as long as you’re able to pick up the signs (with/without prompting), don’t fabricate signs, and show that
you’re professional and take care of your patient/have good bedside manners.
Case Analysis/Long Case

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In every circuit of 5 students, 1 person will get a Paeds long case
 37 minutes
o 15 min history taking
o 10 min to present your history and do PE
o 2 min to organize your thoughts, alone in the room
o 10 min Q&A

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1. GENERAL EXAMINATION IN PEDIATRICS
Pediatric Examination for Medical Students in made easy
Dr. Varsha Atul Shah
Senior Consultant
Neonatal and Developmental Medicine, SGH
General Examination in Pediatrics:
Newborns (birth to 1 month)
Infants (1 month to 12 months
Toddlers (1 year to 2-3 years)
Preschool: (3-4 years)
School Age (5 years to 11/12 years)
Adolescents (12 years to 18/20 years)
Environment: Notice
 Nebulizers, drugs on dresser.
 Special food, including sugar-free (DM).
 Mobility-assisting devices.
 Hospital equipment.
General appearance
 Pre-exam checklist: WIPE:
 Wash your hands or scrub them with alcohol
then rub hands, [warming them].
 Introduce yourself to patient, explain what
going to do.
 Position patient [+/- on parent's knee].
 Expose area as needed [parent should undress]
and Examine, Eyeball. USE EYES, EARS,
ENGAGE,
 (Always do general inspection of significant
followed by system asked).
 Examine from the Right side of the patient.
 Posture, body positions, body shape.
 Skin colors (pale, jaundice (lemon or greenish), blue
(cyanosed), plethoric, bronze)
 Hydration.
 Dress, hygiene.
 Alertness, happiness, eye gaze
 Crying: high-pitched vs. normal.
 Any unusual behavior.
 Parent-child interaction, reaction to someone new
walking entering the room (child abuse).
 Ask if tenderness anywhere, before start touching
them.
 If asleep, do the heart, lungs and abdomen first.
 Arms, vital signs
 Nails:
 Hands:
 Clinical hand signs.
 Color, warmth.
 Radial pulse.
 Femoral pulse.
 BP.
 Temperature.
 Axillary lymph nodes.
Examination tips
 Can establish rapport while checking cyanosis,
dyspnea, and cough.
 Can examine teddy bear first.
 Best examination method by age:
 Neonates, very young infants: on examining
table
 Up through preschool: lying sit on mother's lap
 Adolescent: without family present.
 Parent, not examiner, should undress a small child.

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 Kids are impatient, so a systematic full examination
may get difficult. Examine the most pertinent area
first.
 Record respiratory rate first, before crying starts.
 In child, breath sounds are easier to hear, but harder
to localize.
 ENT exam more likely to induce a cry so these go last.
 Opportunism:
 If child dozes, auscultation heart.
 While parent removes shirt, examine
shoulder/arm movement, head control.
 If child kicks examiner, observe hip range of
motion.
 If cries, the deep breaths between each cry can
reveal rales with stethoscope.
 Perform physical examination from head to toe on a
pediatric patient.
Vital Signs
 Vital signs in pediatrics include temperature, heart
rate, blood pressure, respiratory rate, weight, length,
and head circumference.
Weight
 Gender specific progressive percentile charts for
Height, weight, and head circumference should be
plotted on a growth curve graph.
 Decrease in weight percentile may be due to decreased
intake (malnutrition, central nervous system
abnormality), malabsorption (cystic fibrosis, IBD,
celiac disease, parasitic infestation), or an increased
metabolic rate (hyperthyroidism, congestive heart
failure).
 Increase in weight is most commonly exogenous but
may also be associated with certain genetic syndromes
(Prader- willi).
Height
 A child’s length (lying flat on a table) is measured until
2 to 3 years of age; after that it is measured as height
(standing).
 Decrease height may be familial or may be seen in
conditions affecting weight or independent of weight
(Turner syndrome).
 Increase height may be familiar or associated with
certain genetic and endocrine abnormalities (Cerebral
gigantism).
Head Circumference
 Head circumference is routinely measured until 2 to 3
years of age.
 Microcephaly may be part of a syndrome (Rett
syndrome), congenital infection (CMV), or the result of
abnormal brain growth (schizencephaly).
 Macrocephaly may be familiar or may represent a
pathologic state (Hydrocephalus, Canavaan disease,
AV malformation).
Blood Pressure
 Blood pressure must be measured with a cuff wide
enough to cover at least 1/2 to 2/3 of the extremity
and its bladder should encircle the entire extremity.
 A narrow cuff elevates the pressure, while a wide cuff
lowers it.
 Systolic hypertension is seen with anxiety, renal
disease, coarctation of the aorta, essential
hypertension, and certain endocrine abnormalities.
 Diastolic hypertension occurs with endocrine
abnormalities and coarctation of the aorta.
 Hypotension occurs in hypovolemia and other forms of
shock.
 The level of systolic blood pressure increases gradually
throughout infancy and childhood.

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2 years 96/60 112/78
6 years 98/64 116/80
9 years 106/68 126/84
12 years 114/74 136/88
Pulse
 An elevated heart rate is seen in infections,
hypovolemia, hyperthyroidism, and anxiety.
 A rule of thumb is that the heart rate increases by
10/minute for each 1 degree of temperature
Centigrade.
 Bradycardia is seen in hypertension, increased
intracranial pressure, certain intoxications, or other
hypometabolic states.
 It is best to examine an infant’s heart first during the
exam.
Heart Rate
Birth 140
1 - 6 months 130
6 - 12 months 115
1 - 2 years 110
2 - 6 years 103
6 - 10 years 95
10 - 14 years 85
14 - 18 years 82
Respiration
 Tachypnea is seen with increased activity, hyper
metabolic states, fever, or respiratory distress.
 A decreased respiratory rate is seen with conditions
affecting the central nervous system, including
medications/toxins, congenital malformations, and
other lesions.
 A variable respiratory rate, known as periodic
breathing, is commonly seen in neonates but more
than a 20 second pause is always abnormal.
 Cheyne-Stokes breathing is seen with brainstem
abnormalities.
Respiratory Rate
Newborn 30 - 75
6 - 12 months 22 - 31
1 - 2 years 17 - 23
2 - 4 years 16 - 25
4 - 10 years 13 - 23
10 - 14 years 13 - 19
15 + same as adult
Temperature
 Temperature may be elevated with infections, tumors,
hyperthyroidism, autoimmune disease, environmental
exposures, certain medications, or increased activity.
 Temperature may be decreased with infections
(especially in neonates), hypothyroidism, certain
medications, environmental exposures, shock, or CNS
disease affecting the hypothalamus.
 Control of heat production and heat loss is
maintained by the thermoregulatory center in the
hypothalamus.
Infrared is same as rectal
 For the appropriately clothed child a fever is
considered if temp >38* rectal.
 3 months of age and less always take temperature
rectally.
General Inspection

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 A comment should be made about the patients’
general appearance.
 Activity level and whether the patient is ill, is
interacting with the surroundings, and level of
distress, if any.
 Comment about unusual odors.
Head
 In an infant the size and topography of the anterior
fontanel should be noted.
–Ant. Fontanel is the largest 4 to 6 cm and closes between 4
and 26 months.
–Post. Fontanel is 1 to 2 cm and closes by 2 months.
 Bulging of the fontanel may indicate increased
intracranial pressure found in infections, neoplastic
diseases of the central nervous system, or obstruction
of the ventricular circulation.
 Depression of the fontanel is found in decreased
intracranial pressure and may be a sign of
dehydration.
 Symmetry should be examined from various
perspectives:
1. Plagiocephaly: is characterized by flattening of the
occipital skull.
2. Dolichocephaly/Scaphocephaly: describes an elongated
head with flattening of the bones in the temporoparietal
regions.
3. Cephalhematoma: term applied when there is bleeding
over the outer surface of a skull bone elevating the
periosteum.
4. Caput succedaneum a localized pitting edema in the
scalp that may overlie sutures of the skull, usually
formed during labor because of circular pressure of the
cervix on the fetal occiput.
–Craniosynostosis refers to premature fusion of one or more
of the sutures of the cranial bones and should be considered
in any neonate with an asymmetric cranium.
-Craniotabes is a term for softening of the skull bones, with
pressure the skull may be momentarily indented before
springing out again. The major clinical significance is with
congenital rickets. Rarely, osteogenesis imperfecta or
congenital hypophosphatasia may be causes. Pressure to
skull makes a sound “Crack” like a ping pong ball.
 Macewen’s Sign is characterized by a “Cracked pot”
sound when the cranium is percussed with the
examining finger. A positive Macewen’s sign may be
evident until fontanel closure.
 The shape of the head can reveal much about the
baby’s trip through the birth canal.
 Palpate suture lines for abnormalities.
 Palpate for any bumps or points of tenderness.
 Examine the hair and eyebrows for texture, quantity,
and pattern.
 Abnormalities in hair may be associated with systemic
disease or abnormality. Dry, course and brittle hair
may be associated with congenital hypothyroidism.
Eyes
 The shape and position of the eyes should be noted.
 Any abnormal eye movement and the ability to focus
on the examiner are important to note.
 Hard to examine because of the bright lights.
Nose
 Look for deformities, obstruction of the airway, color
of the mucosa, discharge, and tenderness.
 Check the nose for foreign bodies (beans, carrots,
crayons) younger children often putting foreign objects
into the various orifices of the body and they often get
stuck their.

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 A green, foul smelling, purulent discharge from only
one side of the nose is common with a foreign object
being left in the nose.
 Purulent discharge bilaterally indicates infection.
 Delivery can give nasal obstruction due to
displacement of the septal cartilage.
 Flaring of the nostril almost always shows respiratory
distress.
 Mucosal Assessment:
–Red: Acute infection, Blue and Boggy: Allergy
–Gray and Swollen: Rhinitis, Maxillary and ethmoid are
developed in infancy.
 Frontal sinus developed by 5 years of age.
 The size, shape and symmetry of the nose should be
noted.
 A horizontal crease may be seen in the skin on the
surface of the nose, this signifies repetitive wiping of
the nose commonly seen in allergic rhinitis.
Ears
 The size and any aberration in shape of the external
ear (Pinna) should be noted.
 A low position (below the level of the eyes) or small
deformed auricles may be an indication of a brain
defect or congenital kidney abnormality, especially
renal agenesis.
 Inspection of the auricle and periauricular tissues can
be done by checking the 4 D’s:
–Discharge, Discoloration, Deformity, Displacement
 Discharge: from the ear canal can be a result of otitis
external or chronic untreated otitis media.
 Discharge may be thick and white; it may accompany
a bright pink or red canal.
 To differentiate between otitis externa and otitis
media, pull on the pinna, if this elicits pain, it is most
likely otitis externa.
 Prolonged moisture in the ear canal promotes bacteria
and fungal growth which predisposes the child to
otitis externa (swimmers’ ear).
 Equal mixture of alcohol and vinegar used as a rinse
will keep the ears dry and keep bacteria from growing.
 If the discharge is accompanied with perforation of the
tympanic membrane, otitis media is suspected.
 The presence of a foreign body in the ear is common
and if left in the ear for a period may cause an
inflammatory response which may produce a foul-
smelling purulent discharge.
 Discoloration in the form of ecchymosis over the
mastoid area is called “Battle Sign” and is associated
with trauma and should be considered an emergency.
 Deformity of the ears may develop from intrauterine
positioning or could be the results of hereditary
factors.
 These deformities are of minor concern unless gross
deformities are present.
 Gross deformities of the external ear are often
associated with anomalies of the middle and inner ear
structures.
 Displacement of the auricle away from the skull is a
distressing sign associated with mastoiditis; other
signs of mastoiditis are erythema and tenderness over
the mastoid and pinna, fever, and purulent discharge.
 Other conditions associated with displacement of the
auricle are parotitis, primary cellulitis, contact
dermatitis, and edema.
Mouth

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 Examine the external mouth for symmetry, such as
drooping of the corner of the mouth.
 The lips and mucous membrane should be examined
for evidence of cyanosis.
 The tongue should be palpated for movement and
strength of suck, this evaluates the function of the
glossopharyngeal, vagus, and hypoglossal nerves
 The soft palate should be examined for presence of the
gag reflex, evaluates the vagus nerve.
 The hard palate should be evaluated for structure,
absence of clefts, and alignment of the arch. A high
arched palate may possibly indicate future dental
problems associated with insufficient space for teeth
(high arched palate may indicate syndromes like
Marfan syndrome).
Mumps
 The color of the oropharynx should be noted, the size
of the tonsils and tonsillar pillars and any discharge
should be noted.
 Cobble stoning of the posterior pharyngeal wall is a
sign of chronic allergic disease.
 The quality of the patient’s voice should also be noted.
 The tongue should be examined for size, shape, color,
and coating.
 A coated tongue is nonspecific, a smooth tongue is
found in avitaminosis
 A strawberry or raspberry tongue is seen in specific
stages of Scarlet Fever.
 A geographic tongue is a common finding.
 Thrush on the Tongue
 Acute Tonsillitis, Diphtheria Bull Neck
 Diphtheria Pseudomembrane
 Stomatitis of the Tongue
 Mastoiditis, Mumps
Throat
 Examine the oral mucosa may have creamy white
reticular plaques commonly seen with thrush caused
by Candida Albicans.
 A gray/white, sand grain sized dots on the buccal
mucosa opposite the lower molars, called Koplik Spots
are seen with Rubeola.
 Examine the teeth for dental caries, color of the teeth,
number of teeth and for dental occlusion.
 Examine the neck for masses, enlarged glands,
tracheal tugging, carotid bruits, mobility, and webbed
neck.
 Klippel Feil
 Congenital Muscular Torticollis
Thorax and Heart
 Note the symmetry of the chest, asymmetric
expansion may be seen with pneumothorax or
diaphragmatic paralysis. Also note any abnormal
shapes (Pectus Excavatum or Pectus carinatum.
 Barrel-shaped chest are sometimes seen in patients
with chronic obstructive pulmonary disease (chronic
asthma or cystic fibrosis).
 A rachitic rosary may be seen or palpated in rickets.
 Widely spaced nipples may be a sign of Turner
Syndrome.
 Note the pubertal development of the breast (Tanner
staging) in females.
 Note any masses, tenderness, or discharge of the
breast and describe in detail.
 Breast buds are commonly seen in neonates.
 The integrity of the clavicles should be noted in
newborns
 Males sometimes develop unilateral or bilateral breast
hypertrophy during puberty, called gynecomastia,

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with milk production may or may not be present.
Approximately 40% of all males between the ages of
10 and 16.
 Pectus Excavatum or Carinatum
 Pigeon Breast, Gynecomastia
 Female breast usually develops asymmetrically.
 Inspect the thorax for color, respiration, type of
breathing.
 Auscultate breath sounds (rate, ease, depth, rhythm).
 Palpate thorax (tenderness, respiratory excursion,
vocal or tactile fremitus, and areas of abnormality)
 Measure chest circumference at nipple line.
 Auscultate the heart (murmurs, rubs, clicks, or
gallops) should be noted.
 The point of maximum impulse is at the fourth
intercostal space until about age 7.
 A history of excessive perspiration and difficulties
in feeding are two of the most common complaints
of early congestive heart failure.
 Important questions to ask the parent:
 How has the infant been feeding?
 Does he or she get out of breath or appear exhausted?
 Has the child’s growth pattern changed recently?
 Does the child tire easily, with eating or with playing?
 Does the child perspire excessively, especially with efforts
such as feeding?
 Does the infant breathe rapidly, even at rest?
Upper Extremity
 Examination of the upper extremities should include
inspection for normal anatomy and limb position,
palpation for structural integrity, and joint range of
motion.
 The extremities should be examined for clubbing,
cyanosis, and edema.
 Acrocyanosis is a common finding in neonates,
characterized by cyanotic discoloration, coldness, and
sweating of the extremities, especially the hands.
 Any deformities or extra digits should be noted.
 Range of motion, swelling, erythema, and warmth
should be noted of any joint.
 Check for signs of contusions, abrasions, and edema
which are common signs of trauma.
 Polydactyl
 Check for muscle tone and strength of the upper
extremity.
 Evaluate all range of motion of each joint.
Abdomen
 Inspection is the most important first step.
 The order of examination has been changed slightly in
that palpation is done last.
 It is a good idea, before performing abdominal
examination, to ask the child if they need to use the
restroom.
 For the examination of the infant or toddler the knees
may be bent in order to relax the abdomen and the
child’s arms down at their sides.
 Inspect for rashes, scars, lesions, or discoloration.
 Observe overall contour and symmetry.
 Inspect the umbilicus for shape, signs of inflammation
or hernia
 Auscultation of the abdomen should be done before
palpation or percussion since the latter may alter the
frequency and quality of bowel sounds.
 Listen to the 4 quadrants noting the frequency and
quality of the bowel sounds.
 Abnormal sounds: gurgles, clicks, growls
 Frequency of sounds is from 5 to 34 times per minute.

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 An increase in frequency or pitch of bowel sounds may
be associated with intestinal obstruction or diarrhea.
 Decreased or absent sounds may be associated with
paralytic ileus or peritonitis.
 To be certain that bowel sounds are absent listen for 2
minutes in the area just inferior and to the right of the
umbilicus.
 Percussion in the pediatric patient is the same as the
adult patient.
 Because children tend to swallow a lot of air when
eating or crying the stomach and intestines has a
great amount of air in them.
 A distended abdomen may signify an obstruction,
infection, celiac disease, ascites, or an abdominal
mass.
 Palpation will reveal masses (note size and location)
hepatosplenomegaly, and any sources of pain.
 If the liver is felt below the costal margin (it commonly
is 1 cm below the margin) its span in the
midclavicular line should be percussed.
Rectum
 A chaperone may be necessary.
 The anus should be inspected for position (an
imperforated anus is associated with a host of other
anomalies; an abnormally places anus can also be
associated with constipation or encopresis, depending
on the position of the orifice with respect to the
sphincter).
 Any fissures, trauma, or parasites should be noted.
 A rectal prolapse may be seen with many conditions
including malnutrition, constipation, and cystic
fibrosis.
 The rectal exam is mandatory for any child
complaining of abdominal pain, encopresis,
constipation, hematochezia, or melena.
 A lubricated small finger is used to palpate for any
masses, tone of the sphincter, and any focal pain, as may
be seen with appendicitis.
 The stool should be tested for occult blood.
 Rectal examination on infants and young children should
be performed in the supine position.
Genitalia
 Patients should always be examined is the presence of
a parent or a caretaker or in the case of a pre-teen or
teenager with a staff member present.
 Tanner Staging is the measurement for sexual
maturation.
Lower Extremity
 Visually inspect the lower extremity for abrasions,
contusions, rashes, edema, cyanosis, clubbing, and
discoloration.
 Visually inspect for any abnormalities or deformities
(any extra digits should be noted).
 Measure the extremity as to circumferential
measurements, actual leg length (ASIS to Medial
malleolus) and apparent leg length (Umbilicus to
Medial Malleolus).
A way to determine true leg length is to take a Scanogram
(this is a x-ray procedure where three views are taken of the
extremities the first is through the head of the femurs, the
second is through the knees, and the third is through the
ankles) using a Bell
 Range of motion should be performed, and any joint
swelling, erythema, and warmth should be noted.
 Hips are routinely examined in infants (see orthopedic
sect.)

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 Foot abnormalities are common in infancy but not in
later life.
 The peripheral pulses, especially the femoral pulses.
Orthopedic Testing
 Infant orthopedic testing should include all range of
motion testing, static and motion palpation.
 Ortolani’s Test is a common test performed on the
infant.
–It is a reduction test.
–With the baby relaxed in the supine position, the hips and
knees are flexed to 90*, the examiner grasp the baby’s thigh
with middle finger over the greater trochanter and lifts the
thigh and simultaneously gently abducting the thigh, thus
reducing the dislocation and a “clunk” will be observed
 Barlow’s Test is a provocative test (dislocation) also
called Reverse Ortolani’s test.
 Barlow’s Test is performed to discover any hip
instability.
 The baby’s thigh is grasped with the middle finger
along the baby’s thigh adducted and with a gentle
downward pressure.
 Dislocation is palpable as the femoral head slips out of
the acetabulum.
 Trendelenburg’s Test with the child standing with
weight on the affected side the normal hip drops
down, indicating weakness of the abductor muscles of
the affected side.
Neurological Testing
 Much of the neurologic exam comes from observation
of the child.
 Any limitation in the use of the hands, legs, or
pupillary light response.
 Babinski reflex the baby’s foot is stroked from heel
toward the toes. The big toe should lift, while the other
toes fan out: absence of the reflex may suggest
immaturity of the CNS, defective spinal cord, or other
problems. This reflex may be seen up to age 12 to 24
months. Then it will reverse with toes curling
downward.
 Doll’s Eye while manually turning baby’s head, his
eyes will stay fixed, instead of moving with the head.
While normally vanishing around one month of age, if
it reappears later, there may be damage to the CNS.
Legs, feet
 Infants: hip abduction in infants with knees flexed.
 Feet abnormalities, such as rocker-bottom feet.
 Similar signs as seen in hands nail.
Nervous
 Abnormalities during play.
 Limbs: movement, tone, limp, Gower's sign.
 Head control.
 Reflexes:
 Moro and tonic neck reflexes <3months.
 Babinski's sign positive <12-15 months.
 Hypertonicity commonly is normal infants, but
hypotonicity is abnormal.
 Other reflexes: grasp, suck, root, stepping and
placing.
 Meningitis signs if indicated: Kernig, Brudzinski.
Integumental
 Rashes, using proper terminology.
Head and neck
 Head circumference, rate of growth.
 Head asymmetry, microcephaly, macrocephaly, and
other visible abnormalities.
 Fontanelle, if <18 months:
 Full vs. flat vs. depressed.
 Thyroid enlargement, other lumps.

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 Neck stiffness.
 Neck lymph nodes: location, size in cm, tenderness,
consistency.
Eyes
 Exam position: mother holds child on lap facing
forward, one arm encircling child's arms, the other
hand on child's forehead.
 Pupils: reaction to light, accommodation.
 Strabismus [aka squint].
o Strabismus is normal before 4-6 months.
 Photophobia, proptosis, sclera, conjunctivae, ptosis,
congenital cataracts.
 Fundoscopy.
Ears
 Exam position: same as eye, but child faces the side.
 Discharge, canals, external ear tenderness.
 Test hearing.
 Otoscope to examine ear drums.
Nose
 Nares patency, septum, nasal flaring.
 Discharge, mucous membranes, sinus tenderness.
Height, weight
 Measure and plot on appropriate centile chart.

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2. NEWBORN SCREENING: ROUTINE EXAMINATION OF
THE NEWBORN FOR MEDICAL STUDENTS
Strictly speaking, a neonate is any baby <4 weeks old. Then
up to 1 year old, the child is an ‘infant’.
Usually, within minutes after birth, a midwife or doctor will
conduct a very brief overview examination, e.g., checking
gender, checking gross abnormalities (e.g., breathing, cleft lip
& palate). Then, within 48 hours of birth a doctor will
perform a more thorough routine examination of the
newborn.
- Some doctors suggest the optimum time for neonatal
exam is between 24-48 hours. This allows the foramen ovale
time to close (and thus eliminates this physiological murmur)
and allows time for neonatal jaundice to present.
- However, usually in practice, the exam in performed
<24h after birth.
This is not only important as it can identify any medical
problems, but also it is an opportunity to meet with the
parents and discuss their concerns. Ideally you should
perform the examination with both parents’ present. It may
also provide an opportunity to counsel the parents in the
case of any congenital defects.
- The routine examination of the newborn has a poor
sensitivity for picking up congenital abnormalities.
- There is no proven benefit of having two doctors perform
the examination to spot abnormalities
Serious Congenital abnormalities (in order of prevalence)
1) Congenital heart disease
2) Developmental dysplasia of the hip
3) Talipes
4) Down’s Syndrome
5) Cleft lip and palate
6) Urogenital abnormalities
7) Spina bifida / anencephaly
Congenital abnormalities that spontaneously resolve
Most apparent abnormalities at birth will resolve with no
treatment. Examples of these include:
 Peripheral cyanosis – particularly hands and feet
– will usually resolve within 24 hours
 Traumatic cyanosis –can result from the
umbilical cord around the baby’s neck, or a
face/brow presentation. Typically causes a blue
face, and there may also be petechiae on the head
and neck.
 If there are any signs of cyanosis, you should perform
pulse oximetry.
- Distorted head shape / swollen eye lids –normal side
effects of delivery
 Subconjunctival hemorrhage
 Cysts – in the gums and floor of the mouth
 Breast enlargement / milk production –can
occur in either sex or is completely normal
 Vaginal discharge / blood –a small prolapse is
also normal
 Capillary Haemangioma (“stork bites”) – pink
macules on upper eyelid, forehead, and neck, due
to capillary distension. Should fade within first
year of life. Those on the neck will become covered
with hair. May persist into adulthood on the neck
but are not visible due to hair.
 Urticaria (“hives”) – rash – dark red raised area,
with white papules at the center. Can be at any
site, but most common on the trunk.
 Epstein’s Pearls –harmless small white cysts
along the midline of the palate. Resolve within
weeks.
 Milia –small white pimples on the face

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 Mongolian Blue Spots –look a bit like bruises.
Dark/blue patches, usually around the base of the
spine. Typically, in Asian and African babies. Will
fades over the first few years of life.
 Umbilical Hernia –particularly common in African
babies. Will resolve by age 2-3.
 Positional talipes –the foot (or feet) remains
internally rotated as if in the fetal position but can
be passively externally rotated and have a full
range of movement.
 True talipes equinovarus (club foot)– more serious.
Again, can involve one foot or both (50% of cases
bilateral). Quite common (1 in 1000), and 2x as common
in boys. Can usually be treated with physiotherapy, or in
more serious cases, casts, and splints. Surgery is rarely
needed. It is generally caused by short/tight tendons, and
thus in casts/splints, the tendons are gradually
stretched, usually over a period of weeks or months.
 Differentiating – in turn talipes equinovarus, it is now
possible to dorsiflex the foot such that the dorsal surface
of the foot touches the shin. In positional talipes, this is
possible.
Other Abnormalities
 Strawberry Naevus – not present at birth usually
but develops in the first few weeks of life. They are
more common in premature babies. Looks a bit
like a red strawberry. They tend to grow for 3-9
months, and then gradually recede. No treatment
is needed, except for some rare instances, where it
may obstruct vision or with the airway.
Thrombocytopenia can be present with large
lesions.
 Naevus flammeus – aka Port wine stain – this is
usually present at birth and grows as the child
grows. Caused by abnormal capillaries in the skin
(dermis layer). If it is particularly disfiguring laser
treatment is available.
Before the examination, check:
 Name
 DOB
 Gestational age
 Birthweight
 Including birthweight centile
 Delivery type
 Feeding / urinating / bowel movements
(meconium passed?)
 Any parental concerns?
As with all examinations, it is important to have a
system! This exact system itself isn’t particularly important
– it is just useful as a method not to forget what you are
doing!
In this case we will go from head to foot.
Examination
General Inspection
- Completely undress the baby!
- Have a general inspection, particularly looking at the
baby’s appearance, posture, and movements. Also note the
general muscle tone, and the colour of the baby (pink,
dusky, jaundiced)
o If there is apparent cyanosis check the tongue as the
most accurate indicator of central cyanosis. If present,
central cyanosis requires immediate action!
o If pale, check hematocrit for polycythaemia or anaemia
o Hypotonia may be due to Down’s
- Is the baby responsive?
Head

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- Measure head circumference – using a paper tape
measure. This provides a rough estimate of brain size. You
should plot your recordings on the growth chart.
- Palpate the fontanel and sutures
 Fontanel size is extremely variable.AF 4-6 cm
- Raised fontanel in crying is normal
- If fontanel is raised when baby is not crying, raised ICP may be
the cause. Cranial ultrasound is recommended in this
instance.
- A tense fontanel is also a late sign of meningitis, raised ICT
 Sagittal suture is often separated
 Coronal suture may be ‘over-riding’
 It is normal for the skull bones to have been moved
during birth
 Should NOT be fused
o Face
 Check symmetry, e.g., of eyes, ears, nose
 an unusual looking face could be the result of a
congenital syndrome. There are hundreds! Seek expert
help. Particularly common is:
Down’s syndrome:
· Oblique eye fissures with epicanthic skin folds
· Flat nasal bridge
· Light colored spot in peripheral iris Brush field spots
· Protruding tongue (due to small oral cavity)
· Short neck
- Eyes
Check Red reflex with ophthalmoscope:
 Retinoblastoma (white reflex)
 Cataracts
 50% of cases are identified in this manner. Congenital
cataracts can affect development of normal vision.
 Corneal Opacity
- Ears – tops of the eras should be level with the
eyes. If the ears are lower down (‘low set’) then
this is a possible sign of Down’s syndrome.
 Palate –use your finger and a torch! A tongue
depressor may damage to baby’s palate.
 Make sure you check posteriorly to exclude posterior
cleft lip and palate. Also, at the back of the palate
there may be an indentation from a submucous cleft.
 Natal teeth are sometimes present. If they are loose,
they should be removed to avoid aspiration.
 Chest
o Breathing and chest wall movement – have a
general inspection, looking for signs of
respiratory distress
 RR – 30-60 is normal
o Auscultate the heart
 HR – 110-160 is normal. May drop to 85 during sleep.
 Congenital heart disease
 50% of all murmurs in newborns will be ‘innocent’. An
innocent murmur is usually:
· Mid systolic
· Radiates to the back/axilla
 Difficult to detect if it is innocent or not in many cases
 If in doubt, get an echo
 Communicate with parents. Tell them if the baby has
an unusual feeding or other difficulties to bring them
back straight away
Abdomen
 Liver – usually 1-2 fingers below the costal margin
 Spleen – usually palpable
 Kidneys – may be palpable – particularly on the
left
 Bladder – palpable bladder could be a sign of
urinary outflow obstruction. This is particularly

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true in boys, in whom it is possible to have a
congenital urethral valve. This requires urgent
ultrasound. If the valve is the cause, this can
cause urinary retention and subsequent
pyelonephritis and serious kidney damage (reflux
nephropathy).
 Any other masses – are often renal, but still need
investigation!
 Umbilicus – check for hernia (usually benign) and
infection
 Usually, abdomen is soft
Genitalia and Anus
 Testes – confirm they are present!
 Vagina – a small prolapse is normal
 Doubt over the sex? – if there are ambiguous
genitalia – DON’T GUESS THE SEX! – discuss this
with the parents and inform them you will need to
conduct some tests.
- Anus – present? Patent?
Limbs
- Femoral pulses – check on both sides that they are
present. Pulse pressure may be:
 Increased – patent ductus arteriosus
 Reduced –co-arctation of the aorta
o Digits – check the baby has the correct number of
digits on all limbs
 Also check the palmar creases. A single palmar crease is
a sign of Down’s syndrome
o Muscle Tone – if you haven’t look at it already.
You can move the limbs gently, as you might in a
neuro exam. As well as observing normal limb
movements.
 You should sit the baby up and observe head control. In a
normal neonate, they should be able to support their
head very briefly when vertical.
- Palmar crease – a single crease may be a sign of Down’s
syndrome
- Grip –check that the baby is able to grip one of your
fingers with their hand. Check both hands.
Spine
- Have a good look at the whole of the spine, looking for
any midline deformities. Also feel down the spine briefly.
DDH – Developmental dysplasia of the Hip
Leave this until last, as it often upsets the child. The baby
needs to be relaxed – as crying often results in constriction of
the muscles around the hips.
- Barlow Test:
 with one hand, stabilize the pelvis
 with the other hand, place your middle finger on the
greater trochanter of the femur, and your thumb on the
medial aspect of the femur. Then, with the hip flexed, try
to adduct the hip, and press the hip down onto the
mattress. In a normal hip, there will be no dislocation. In
DDH you will feel posterior displacement of the greater
trochanter.
o Ortolani Maneuver
 This is the test to try and replace the dislocated femur in
the case of a positive Barlow test.
 Abduct the effected hip, and you should feel (and
sometimes here) the femur click back into place.
 You can often get ‘clicks’ without displacement of the
head of femur, and these are not significant.
DDH is:
 6x more common in girls
 Seen in children with a family history (20% of
cases have FH)

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 More common in breech birth (30% are due to
breech)
 More common in neuromuscular disorders
 Early recognition reduces morbidity. The affected
limb can be splinted.
 If unsure of the diagnosis, you can do USS.
 Normally performed in the examination of the
newborn, and again at 6 weeks of age. Some cases
are monitored until the child can walk.
 More accurately spotted with USS of the hip joint.
This is being used increasingly in hospitals in the UK,
mainly to confirm the diagnosis after a positive
Barlow/Ortolani test. In some instances, it is also
used ot screen for the condition, but this is expensive
and time consuming,
 Reflexes
 Morrow Reflex - Support the child with your hand
and forearm. Then gently but swiftly, tilt the child
backwards. In normal circumstances, the child should
outstretch their arms (and legs). This is a positive
morrow reflex.
 Rooting reflex – when you gently touch next to the
baby’s mouth, the baby will turn their head and try to
suckle.
 Grasp reflex – place your finger in the baby’s palm.
The baby should grasp with a firm grip
 Stepping reflex – holding upright above the bed, and
then gently brush the bed against the baby’s feet /
shins. The baby should step. They may also be able to
support some of their own weight.

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3. DEVELOPMENTAL ASSESSMENT FOR MEDICAL
STUDENTS
SHORT CASE:
Dr Varsha Atul shah, Senior Consultant, Neonatal and
Dev Medicine SGH
Do watch video at link:
http://www.martindalecenter.com/MedicalClinical_Exams.h
tml
http://library.med.utah.edu/pedineurologicexam/html/hom
e_exam.html
TOOLS NEEDED:
1. Red yarn pom pom (4 cm diameter) with string and
dangling,
2. Bright color 12 cubes 2.5 cm,
3. Rattle with narrow handle
4. Raisins or cheerios or honey stars or m and ms
5. Cup, spoon
6. A 4 size paper
7. Big size color pencils
7. Picture cards, multiple picture books (like bird, fish, dog,
bus etc., fruits etc.) on same page,
8. Tennis ball
9. Small doll
10. Bell
11. Stickers, sweets for rewards
Usual lead in is ‘Would you please perform a developmental
assessment’?
Once you know 18 months of development ‘backwards’,
including time of appearance and incorporation of primary
reflexes, then you can fairly interpret the findings.
WIPE approach: Wash/Hand rub, Introduce, ask for
Permission, Position and Play, Examine
Begin by introducing yourself to parents, hand rub etc. 1st
only look see, play…and examine.
1. Inspect for growth parameters e.g., FTT, syndromes,
under nutrition can have Developmental delay
2. Dysmorphic features e.g., Down’s
3. Appearance of Ex premature infants correct the age.
Obvious neurological anomalies like floppy infants,
posturing, hemiplegic posturing, and involuntary
movements.
If child is on mum’s lap can do vision and hearing,
language and personal social, FM, GM examination. Do
not separate for GM assessment. Bigger kids can examine
on chair. Infants lie in bed.
Vision:
Always do vision before hearing. Fixing and following pom
pom ball. Distance 21 cm away. Check ability to pick up
hundreds and thousands are important.
Hearing:
Use initial distraction with non-noise making stimulus in
front of child. Bell is brought towards ear from behind out
of range from visual fields 20 cm away from ears.
Changes noted are facial expression, vocalizing sounds,
head turns.
Personal social:

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Focus on faces (4 weeks), social smile (6 weeks), excited
with toys (4 mths), castrate (5 mths), stranger anxiety, (6
mths), responds to No, imitates, (8 mths), clapping, bye
bye, (10 mths), peek boo (11 mths), picture books (12
mths), kiss mirror (13 mths), points (15 mths), Body parts
(21 mths)
Language:
Cooing ( 2mths), responds to human voice (4 mths),
Babbling (6mths), Mamma,dada (9mths), 2 words plus
mama,dada(12 mths), Jargon, points (15mths), 10 words
and says his name, points to 3 body parts, one picture
(18mths), 2-3 word phrase, name 3 objects, 4 body parts,
says no(2 years), know name, age sex (2.5yrs),
preposition, count 1-10, 2 colors(3 years), name 3 colors,
converses (4 years)
FM:
Holds rattles (3 mths), hand regards (4 mths), palmer
grasp objects (5 mths), transfer cubes (7 mths), Raisins
for pincer grip (9 mths), 2.5 cm blocks for stacking, 2
cubes 15 mths, 3 cubes (18 mths) 6 cubes (21 mths). 6
cubes turn pages (2 years), 8 cubes (2.5 years), 9 cubes (3
years), beads, thread, putting on biro, plastic knife, and
fork. Comment on personal social interaction, language.
Smiling, waving
GM:
HH (16 weeks), Roll over, Tripod (6 mths), Bear weight,
bounces, lifts head (7 months), sit well (8 mths) pull to sit
and stand, crawl (10mths), Creep 11 months, walk with
support (1year), climb stairs with rail, throw ball(18mths),
walk upstairs (21 mths) up and down (2 years). 180-
degree flip examination in infant < 8 mths and gait for > 1
year.
Supine: Note posture, abnormal ATNR, involuntary
movements with CP. paucity of movements for
hemiplegia.
Pull to sit head lag. Sitting: Head and trunk control.
Back is straight or rounded.
Weight bearing scissoring, hypotonia, advanced weight
bearing (CP)
Ventral suspension: Describe posture, low tone, increase
extensor tone.
Prone: Observe ability to raise head, trunk above
horizontal.
Primitive reflexes:
1. Sucking/Rooting :( 0-4,6mths),
2. Palmer grasp; (0-3 months).
3. Placing, stepping: (0-6weeks)
4. ATNR: 2-6 Months.
5. Landau: on ventral suspension, normally extend head,
trunk, and hip. Flex head and neck, response is
flexion of hip, trunk.0-6 month).
6. Neck righting reflex: rotation of trunk 6mths-2 years.
7. Moro: 0-4 months.
8. Parachute: 6-12 months persist. Prone position, move
rapidly, face down. Will extend both upper limbs.
Present the case as:

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On general inspection of this cute little
Newborn/infant/toddler, who is well thrived, but would
like to chart gender specific progressive percentiles for
OFC, l and weight, he is not dysmorphic, (no expremmie
look), not floppy has good muscle tone moving all limbs
equally. No involuntary movements seen.
On examination of vision, he fixed followed, approached
to toys, eye gaze, picked up raisins etc. On examination of
hearing…, On personal social., On language. On fine
motor…On gross motor...
In summary: this infant has DA of….GM … FM…. SL etc
I would like to complete by charting age and gender
specific progressive percentile charts for head
circumference, length and weight
Developmental Milestones
6 weeks
 Gross motor: Lifts chin occasionally when prone.
 Social: Social smile.
2 months
 Gross motor: Arms extend forward when prone.
 Fine motor: Pulls at clothes.
 Speech: Cooing sounds.
3 months
 Gross motor: Moro’s reflex gone.
4 months
 Gross motor: Rolls from front to back.
 Fine motor: Reaches, pulls objects to mouth.
 Speech: Responds to human voice.
6 months
 Gross motor: When prone, can put weight on hands.
 Fine motor: Ulnar grasping.
 Speech: Responds to name. Babbling starts.
 Social: Stranger anxiety.
9 months
 Gross motor: Pulls to stand.
 Fine motor: Finger-thumb grasping.
 Speech: 'Mamma, Dadda'.
 Social: Separation anxiety.
12 months
 Gross motor: Walks under support.
 Fine motor: Pincer grasp. Throws. Babinski begins to
disappear.
 Speech: 2 words beyond 'Mama, Dadda'.
 Social: Drinks with cup.
15 months
 Gross motor: Walks without support.
 Fine motor: Draws line.
 Speech: Jargon
 Social: Points to needed items.
18 months
 Gross motor: Climbs steps with support
 Fine motor: Scribbling.
 Speech: Says own name. 10 words.
 Social: Uses spoon.
2 years
 Gross motor: Runs. Kick ball. Climb 2 steps.

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 Fine motor: Undresses.
 Speech: Combine 2-word sentences, with pronouns.
Favorite word is 'No'.
 Social: Parallel play.
3 years
 Gross motor: Ride tricycle.
 Fine motor: Copies a circle.
 Speech: Prepositions.
 Social: All dress/undress except buttons.
4 years
 Gross motor: Hop on 1 foot.
 Fine motor: Copies a cross.
 Speech: Tells story.
 Social: Cooperative play. Toilet trained. Buttons
clothes.
5 years
 Gross motor: Skip. Catch ball.
 Fine motor: Copies a square, Prints own name. Ties
shoelaces.
 Speech: Alphabet. Future tense.
 Social: Oedipus complex.
6 years
 Gross motor: Rides bicycle.
 Fine motor: Copies a triangle.
 Speech: Begins reading.
 Social: Develops right vs. wrong sense.
Mnemonics
By year:
 1 year:
 Single words.
 2 years:
 Climb 2 steps.
 2-word sentences.
 "Parallel" requires 2 things.
3 years:
 Tricycle. Repeats 3 digits.
4 years:
 Copies a square [4 sides].
Shape copying:
 Shapes are in alphabetical order: Circle (3yr),
Cross(4yr), Square(5yr), Triangle(6yr).
Gesell figures are shapes that your kids can draw, and which
can help you assess their development.

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.

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4. NEUROLOGICAL EXAMINATION
INTRODUCTION
Neurological examination in pediatrics varies according to
age e.g.: the approach to neonates will vary from that of
children. Observation is key to diagnosis since physical signs
are usually less obvious than in adults. Become familiar with
normal ranges to be confident about the abnormal.
Talk to the parents.
Allow older children play as you observe. This may require
that you have some toys.
Communicate with the children.
Always carry out a detailed neurological examination in a
child with a history of seizures, headaches, an abnormal or
unsteady gait, any weakness and any increase or decrease in
gait. The examination should be directed and focused by the
presenting complaint.
MENTAL STATUS EXAM
It includes the following.
 State of consciousness
 Orientation
 Mood
 Thought process and form
 Memory
 Abstract and judgment
 Insight
Use the mental state exam where applicable. It’s easier to
use in older children.
MOTOR FUNCTIONING
FOR THE VERY YOUNG
If the infant is not yet mobile, use the 180-degree test:
 Look for head lag when you pull the hands to a sitting
position with the baby supine.
 Can the baby sit unsupported?
 Does the baby roll from front to back and from back to
front?
 Note whether the baby can take his weight with the
feet on the table.
 Can the baby support his head when facing down?
 Test the parachute reflex seen from 6-9 months.
A child usually starts walking between 12-18 months. From
then on, observe children running, walking, jumping and
hopping. Watch them play to assess fine motor development.
Assess senses and social skills. Observe how children
interact with their parents.
FOR OLDER CHILDREN
Do the neurological exam as that of an adult.
Assess muscle bulk. This is subjective so it needs practice-
an experienced eye!
Assess muscle tone. Do this by assessing muscles in groups
Assess gait and coordination by observing them walk across
the room.
Reflexes
Moro reflex: hold infant semi-upright and suddenly and
transiently release support of head.
 normal: bilateral arm abduction and extension, hand
opening, and then flexion and adduction of arms
 absence suggests CNS injury; asymmetry suggests
peripheral injury
 disappears by three months
 Galant reflex: hold infant and stroke one side of back
 normal: pelvis moves towards side of stimulation
Extensor plantar response.
Grasp reflex: finger flexion with tester's finger in the palm
Primitive walking: infant places foot down when in contact
with surface

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Rooting reflex: infant turns face towards stimulation near
mouth
Babinski is upgoing until 4 months
DEEP TENDON REFLEXES
- Upper Extremity:
1) Bicep’s reflex: Elbow flexion.
2) Triceps reflex: Foramen extension
3) Brachioradialis reflex: Tap distal radius, flexion and
partial supination of the forearm.
- Lower Extremity:
1) Patellar reflex; Contraction of Quadriceps and extension of
leg.
2) Suprapatellar reflex; above the knee, same response.
3) Achilles Reflex: Causes plantarflexion of foot.
Grading reflexes
0: Complete absence
1: Diminished
2: Normal reflex
3: Hyperactive reflex
4: Clonus
SUPERFICIAL REFLEXES:
1) Upper abdomen: Ipsilateral contraction of abdominal
muscles on the stroked side.
2) Lower abdominal: Ipsilateral contraction of abdominal
muscles on stroked side.
3) Cremasteric: stroke inner thigh – elevation of testes.
BRAIN REFLEXES:
1) Corneal reflex
2) Pupillary light reflex
3) Gag reflex
ABNORMAL REFLEXES:
1) Babinski sign: Stroke bottom o foot- fanning of the big toe
2) Hoffman’s sign: Flexion of the terminal phalanx of the
thumb and of the second and third phalanges of one or more
of the fingers when the volar surface of the terminal phalanx
of the fingers is flicked. Its significant for pyramidal tract
disease when it is unilateral. If its bilateral then the meaning
is uncertain.
3) Oppenheim’s sign: Scratch inner side of leg- extension of
toes. Sign of cerebral irritation.
4) Gordon’s sign: squeeze the calf muscles and note the
response of the great toe. Fanning or extension is considered
abnormal.
5) Chaddock’s reflex: When the external malleolar skin area
is irritated, extension of the great toe occurs in case of
organic disease of the corticospinal reflex paths.
PRIMITIVE REFLEXES:
Primitive reflexes are present during the early stages in life,
but they later disappear. Presence of these reflexes in older
children is a sign of frontal lobe lesions.
1) Suck reflex: Gently tap or rub the upper lift- elicit a
reflexive sucking or puckering response.
2) Grasp reflex: Stroke the patient’s palm, causing him to
grasp your fingers. A positive test occurs when the patient
does not let go of your fingers.
3) Palmomental sign: Rub the thenar eminence- elicit
reflexive contraction of the muscles of the chin.
ASSESSMENT OF MUSCLE POWER
Grade muscle power on a scale of 0-5 using the medical
research council criteria.
0: No contraction; paralysis
1: Trace of contraction.
2: Moves if gravity is eliminated.
3: Moves against gravity.

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4: Moves against gravity and against some resistance.
5: Normal strength.
SENSORY ASSESMENT
 Assess pain using a prick with a sharp and dull
object.
 Assess temperature sensation using a warm and cold
object.
 Assess light touch using cotton wool applied to
different parts of the body.
 Assess vibration using a tuning fork.
CRANIAL NERVES
Assess the cranial nerves like in an adult.
ASSESS DEVELOPMENT
This is important to have a complete neurological exam in
some cases.

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5. CARDIOVASCULAR EXAMINATION IN CHILDREN
Dr Varsha Atul Shah
The first question on general inspection should be: is there
evidence of dysmorphology? Several dysmorphic syndromes
are closely associated with specific heart lesions, and their
presence lends a strong clue.
Any FTT?
Any SOB?
From here the hands are inspected:
is there clubbing - first seen in the thumbs
cyanosis may be apparent from the nail beds, as may
anaemia
Inspection of face:
central cyanosis may be seen in the lips, or more
convincingly the tongue
the teeth should be inspected for caries, which are a risk
factor for infective endocarditis
Conjunctiva for cyanosis, plethora, pallor
Inspection of the neck is only useful in the older child - for
example in teenagers for JVP. Features are like the adult
cardiovascular examination.
Inspection of the chest:
a careful examination should be made for scars:
lateral thoracotomy scars might imply Blalock Taussig
shunting in tetralogy of Fallot, or on the left might imply
pulmonary artery banding, PDA ligation
midline scars are usually associated with intracardiac
surgery
Harrison's sulcus is rarely a cardio logical sign but may be
seen in chronic pulmonary hypertension with reduced lung
compliance.
Palpation
The pulses should be felt as follows:
Radial pulses, except in an infant where it may be easier to
feel the brachial pulses. From this rate, rhythm and
character should be noted.
Although they should never be forgotten, the femoral pulses
are usually best left until the end of the examination, as
palpation will make most infants cry.
Pulse, respiratory rate, BP
In the older child the carotid pulse may be felt; a thrill may
be noted.
Palpation of the apex beat is next. To avoid missing the
examiner's favorite - dextrocardia - a two handed approach
may be used. The apex beat can usually be felt in the 5th,
left intercostal space in the mid-clavicular line; the character
of the beat should be noted.
Right ventricular heave should be examined for with the
hand on the sternum. During palpation of the chest any
palpable heart sounds or thrills should be noted. Palpation of
the cardiovascular system is completed by examining for the
liver.
Auscultation
The examination of infants and toddlers should take place
with the patient on the mother's knee, only later moving the
child on to the couch. An initial attempt at auscultation
through the clothing enables the child to get used to the
stethoscope, and a count of the resting heart rate to be
obtained. Giving the child a toy to hold may help. Timing of
systole by palpation of the carotid pulse, it is wise to begin
auscultation in the second left intercostal space where the
two components of the normal second sound are best heard.
A split first sound is often heard and is normal at the lower
left sternal border. Physiological splitting of the second
sound (P2 after A2) is most significant on inspiration. A2 is
louder than P2 in pulmonary stenosis (P2 is soft and
delayed), but P2 is as loud as or louder than A2 in a

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secundum ASD or pulmonary hypertension. Splitting of A2
and P2 excludes truncus arteriosus or pulmonary atresia,
but a single sound may be heard in a VSD with pulmonary
hypertension, or tetralogy of Fallot.
A venous hum increases on inspiration and disappears in
the head down posture and is thereby differentiated from the
continuous murmur of a ductus. The child should not only
be listened to in the prone position but rolled onto his left
side for the appreciation of a mid-diastolic murmur at the
apex and sat up and leaned forward for the blowing early
murmur of aortic incompetence.
The blood pressure
BP is usually recorded at the end of the examination in the
hope that the patient will be more relaxed and lying
comfortably. Errors in cuff selection can be minimized by
selecting the longest cuff that will fit snugly around the
child's arm or leg. It is important to record the width of the
cuff used. In smaller children the 'flush' method may be
used. In this method a cuff of suitable size is applied round
the forearm or upper leg and attached to a
sphygmomanometer. The hand or foot is firmly clenched by
the examiner's hand. The cuff is pumped up before
compression is released, leaving the extremity blanched. The
pressure is then slowly reduced while a watch is kept on the
pale skin. The point at which the colour suddenly returns to
the skin is the 'flush' pressure, which is approximately equal
to the mean blood pressure.
S/S of CCF in infant and child:
A history of excessive perspiration and difficulties in feeding
are two of the most common complaints of early congestive
heart failure.
Important questions to ask the parent:
How has the infant been feeding?
Does he or she get out of breath or appear exhausted?
Has the child’s growth pattern changed recently?
Does the child tire easily, with eating or with playing?
Does the child perspire excessively, especially with efforts
such as feeding?
Does the infant breathe rapidly, even at rest?
Heart
Inspection:
Scars, DO NOT MISS THE SCARS,
Precordial bulge, Apical heave, apical impulse, pulsation
Respiration
Type of breathing
Palpation:
Apex beat location (on both side for dextrocardia)
Palpable P2 (Diastolic shock),
Carotid, suprasternal thrills
Thrills, parasternal heaves.
The point of maximum impulse (AB) is at the fourth
intercostal space until about age 7.
Auscultation:
Auscultate the heart in all 4 areas, suprasternal, carotids,
axilla, back. (Murmurs, rubs, clicks, or gallops) should be
noted.
Site, radiation.
Pitch, quality, character.
Intensity, rhythm, duration.
Changes with respiration, posture.
Carotid bruits.
Causes of acyanotic heart disease that present with CCF:
Anemia
Aortic atresia
Aortic stenosis (AS)

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Arteriovenous malformation
Coarctation of the Aorta (COA)
Complete arteriovenous canal
Cor pulmonale caused by bronchopulmonary dysplasia
Endocardial cushion defect (ECD)
Hypoplastic left heart (HLHS)
Interrupted aortic arch
Mitral valve atresia
Patent ductus arteriosus (PDA)
Truncus arteriosus (TA)
Ventricular septal defect (VSD)
Causes of cyanotic heart disease: the five “terrible Ts”
(one “S”)
1. Transposition of the great vessels (TGA)
2. Total anomalous pulmonary venous return (TAPVR)
3. Tetralogy of Fallot (TOF)
4. Truncus arteriosus (TA)
5. Tricuspid atresia (TrA)
6. Severe pulmonic stenosis
Causes of CCF in neonates:
At birth:
Hypoplastic left heart syndrome
Severe tricuspid or pulmonary regurgitation
Large systemic AV fistula
Week 1
Large PDA in preterm
TGA
TAPVR below diaphragm
Weeks 1-4
Critical AS or PS
Preductal COA
Non-Cardiac causes:
Birth asphyxia
Metabolic hypoglycemia, hypocalcemia
Severe anaemia
Sepsis
Over hydration
Myocardia diseases
Myocarditis,
cardiomyopathy
Arrhythmias
SVT,
CHB,
AF
Thoracotomy Scars on chest:
Horizontal:
Left Thoracotomy scar:
PDA ligation
PA banding
Pulmonary valvotomy
Left BT shunt
COA repair, repair of interrupted aortic arch
Diaphragmatic hernia repair
Esophageal atresia repair
Hiatus hernia repair
Lung Biopsy
Horizontal Right Thoracotomy scar:
Right Blalock Taussig shunt
PA banding
Lung surgery
Mid-sternotomy scar
Complete repair— any major bypass surgery, for example
valvular repair or one of the more
Complicated cardiac repairs.
Waterson shunt (caval shunt bet ascend Ao and rt PA)
PA banding
Thymectomy for MG

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CCF presentation in infants/newborn
poor feeding
poor weight gain
sweating over forehead, cold sweat
dyspnea/breathlessness
puffy eyelids
tachycardia
tachypnea
cyanosis
crackles, Ronchi
hepatomegaly
gallop rhythm
cardiomegaly on CXR
increased pulmonary marking, pulmonary edema on CXR
Common CHD with common syndromes:
1. Down syndrome: ECD/CAVSD, VSD
2. Turner syndrome: COA, AS, ASD
3. Noonan syndrome: PS
4. Marfan syndrome: MVP, AR, MR
5. William syndrome; Supravalvular AS, PA stenosis
6. Kartageners syndrome: Dextrocardia
7. Tuberous Sclerosis: Rhabdomyoma
8. VATER: VSD
9. Trisomy 18: VSD, PDA, PS
10.Trisomy 13: VSD, PDA, Dextrocardia
11.Holt Oram syndrome: ASD, VSD
12.Ellis-Van Crevald syndrome: Single atrium
Congenital Heart Disease: Surgical Corrective Procedures
AORTICOPULMONARY WINDOW SHUNT
= side-to-side anastomosis between ascending aorta and left
pulmonary artery (reversible procedure) – used in Tetralogy
of Fallot
BLALOCK-HANLON PROCEDURE
= surgical creation of ASD: Complete transposition
BLALOCK-TAUSSIG SHUNT
= end-to-side anastomosis of subclavian artery to pulmonary
artery, performed ipsilateral to innominate artery/opposite to
aortic arch: Tetralogy of Fallot, tricuspid atresia c pulmonic
stenosis
FONTAN PROCEDURE
= (1) external conduit from R atrium to pulmonary trunk (=
venous return enters pulmonary artery directly) (2) closure of
ASD: floor constructed from flap of atrial wall and roof from
piece of prosthetic material: Tricuspid atresia
GLENN SHUNT
= end-to-side shunts between distal end of right pulmonary
artery and IVC; reserved for patients with cardiac defects in
which total correction is not anticipated: Tricuspid atresia
POTT SHUNT
= side-to-side anastomosis between descending aorta + left
pulmonary artery: Tetralogy of Fallot
MUSTARD PROCEDURE: Removal of atrial septum (b)
pericardial baffle placed into common atrium such that
systemic venous blood is rerouted into left ventricle and
pulmonary venous return into right ventricle and aorta:
Complete Transposition
RASHKIND PROCEDURE
= balloon atrial septostomy: Complete transposition
RASTELLI PROCEDURE
= external conduit (Dacron) with porcine valve connecting RV
to pulmonary trunk: Transposition
WATERSON-COOLEY SHUNT = side-to-side anastomosis
between ascending aorta and right pulmonary artery (a) extra
pericardial (WATERSON) and (b) intrapericardial (COOLEY):
Tetralogy of Fallot

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Example of presentation.
ABC is _ years old C/I/M boy, not syndromic, not in any
respiratory distress, seems not under nourished, would like
to chart gender specific progressive percentile charts for
OFC, HT and wt, is not tachypneic, not centrally cyanosed.
Not pale, not clubbed. Afebrile, Pulse: 90 per minute,
regular, good volume with good upstroke and down stroke,
all peripheral pulses are well felt. No water hammer pulse,
there is no radio femoral or radio radial delay. I would like to
take 4 limbs BP. No peripheral signs of SBE.
There is no conjunctival pallor/congestion/jaundice, tongue
no cyanosis, teeth no caries. On inspection of chest RR is no
sign of RD, no surgical scars seen, no asymmetry. No visible
pulsation. Palpation, AB is heaving in character, in 6th LICS
in MCL. There are no thrills felt on precordium or carotid or
left parasternal heave or palpable pulmonary sound o felt.
On auscultation grade 3/6, ESM, high low pitched, heard
best over LUSE, not radiated. No fixed split. No
hepatomegaly, splenomegaly, lung no crept. In summary:
This child has congenital noncyanotic heart disease, with DD
of PS/ASD, not in cardiac failure

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6. PAEDIATRIC RESPIRATORY EXAM
General Inspection
How old is the child? You will probably have to adapt the
exam accordingly! Generally, you could put the children into
three categories depending on their age: 0-6months, 6-24
months and 2 years+
- Is the child awake and alert? Are they running around?
Do they seem generally ill or distressed? Who is with them?
Are they sat on their parents’ knee?
Signs of respiratory distress are tachypnea, grunting, head
bobbling and ala nasi flare in infants plus use of accessory
muscles of respirations like SCR, ICR, supra sternal
retractions, use of sternocleidomastoid muscles, tachypnea,
Audible wheeze, inspiratory stridor’s,
- Are there any medications around?
 Oxygen – if so, check at the wall how much, and by what
method is it being administer (e.g., mask, nasal specs)
 Fluids – what fluids?
 Inhalers?
 Cannula
 Central line (e.g., in F to provide IV antibiotics)
 Saturation monitors
 BIPAP
- Any audible cough, wheeze, breathing difficulties,
Stridor, wheeze, snoring, mouth breathing, nose block.
Clothes – next it is best to take the child’s clothes off. Be
sensible. If they child is under 2, then ask the parents to
help. If the child is a bit older, then they are probably able to
take their own clothes off. Obviously, with older and
adolescent children, you will be able to take a more focused
approach and be more wary of privacy.
General appearance:
 Fat/skinny
 Rashes, scars?
Hands
 Clubbing – sign of CF
 Tremor – from B2 agonists
 Check capillary refill
 Feel temperature of hands / cyanosis
 Check radial/brachial pulse
 Radial is often difficult to feel in children#
 Check the respiratory rate at the same time
Face
It is often a good idea to leave ears and throat until last, as
these might upset the child, and then you will have trouble
doing the rest of the exam!
Nose
 Snotty / red
 Nasal polyps (CF)
Ears
 TAKE TEMPERATURE
 Always look inside! In an infected ear, it is likely to be red
and tender. Check the tympanic membranes. S their a
fluid level? Is it damaged? In infection Wax is less likely,
as the high temperature often melts it, so if your view is
obstructed by wax, it might not be a bad sign
- Mouth and Throat
 Look at the lips and under the tongue for signs of
cyanosis
 Using a torch, look at the back of the throat for signs of
infection
 Using a tongue depressor is down to personal preference.
Some practitioners do not recommend it as you could

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injure the child, particularly the soft palate, and many
children don’t like it.
 Tonsillitis may cause white pus to exude from the tonsils
 Infections in the larynx and below will generally not have
any throat signs. Some textbooks even advise not to look
in the throat in croup – as the presence of the tongue
depressor can exaggerate the condition.
Neck
- Lymph nodes – examine the lymph nodes of the neck in
the same way as in an adult, from behind examining all
triangles.
- Trachea
 Is it central? – in OSCE just say you would check –
unpleasant and will upset the child!
 Tracheal Tug – This is where the trachea is pulled
posteriorly and superiorly during inspiration, and
results from recruitment of accessory muscles in
labored breathing
Chest
Inspection
 Any scars – surgery –e.g., Meconium Ileus in CF
 Rahses
 Hickman line
Recession
 Subcostal
 Intercostal
 Suprasternal, supraclavicular
 Harrison’s Sulcus – two symmetrical sulci, horizontal, at
the lower margin of the anterior thorax, at the attachment
of the diaphragm. A sign of prolonged respiratory
distress in children. Most commonly present in children
with asthma that have required an increased respiratory
effort over several months.
· Also present in Rickets where there is insufficient
calcium to allow for bone mineralization, and the
soft ribs are distorted by the pull of the diaphragm.
 Does it look like there is hyper expansion? localized
bulging
 Check the respiratory rate, rhythm, type of
respiration, prolonged expiration
 Diaphragmatic movements
 Spinal or chest deformity
Look for chest expansion from end of bed.
Palpation
 Chest Expansion – in young children, only need to check
one, usually on the front. In older children, with a larger
thorax, you should check 4 times – twice on the front,
and twice on the back – at the top, right under the axilla,
and at the bottom of the thorax.
 Measure chest expansion with tape measure – measure
at full inspiration and full expiration. (Not often
performed in practice – but say you would do it)
 Heart – feel the location of the apex beat, checking for
displacement
 Palpate for tracheal shifts
 Check Tactile vocal fremitus with hand
Percussion
 Difficult and will probably not yield great results in
very small children (under 2). Should be performed in
older children. Same technique as adult
Vesicular, hyper resonant, impaired dull or stony dull
Auscultation
 Same technique as adult – just make sure you
compare sides and listen to all lobes, including under
the axilla and to the apices above the clavicle for air

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entry, crepitations/crackles, Ronchi/wheeze,
bronchial breathing, vocal fremitus
Air entry: absent, diminished, or increased or equal
Finishing off
 Feel for the liver. If the liver is lower than expected, it
may be displaced by hyper expanded lungs. Normal
liver position:
 Age 0-6 months – 1-2 fingers below rib cage
 Age 6-24 months – 0-1 finger below rib cage
 Age 2+ - usually not palpable (but remember, palpable
liver is often still normal)
 Do a peak flow test
 Check O2 sats
 If not already done, you might want to strip off the
child to check for rashes (meningitis / septicemia)
 Remember to look in the ears and throat if you
missed it out earlier!
7. PAEDIATRIC ABDOMINAL EXAMINATION:
General inspection
- Get the child to take their top off
- Look around the bed for:
 Medications
 Drip
 Special dietary requirements
 Stool sample pot, colour
o Look at the patient for:
 Obvious signs of illness
 Abdomen: The 5 ‘Fs’ (only 4 apply in children!
 Fat, Faeces, flatus, fluid (+ fetus)
§ Scars
§ Bruising
§ Stoma
§ Mass / discoloration
· More for big kids, Pancreatitis
o Grey-Turner’s sign – discoloration in the flank
o Cullen’s sign – discoloration around the umbilicus
§ Obvious movements?
· Pyloric stenosis – sometimes you can see a peristaltic
movement from left to right, particularly after a feed
Hands
Palmer erythema
- Leukonychia – white nails – hypoalbuminemia (liver
failure)
- Koilonychia – spoon shaped nails – iron deficiency
anaemia
- Polished nails – sign of scratching – rash (e.g. jaundice)
- Clubbing – Crohn’s, UC, Coeliac’s
- Beau’s lines – horizontal white lines – caused by any
acute severe illness – grow out in 12 weeks
- Asterixis – high levels of urea – liver failure
- Dupytrens contracture – idiopathic / liver failure
- Bruising – liver failure / vitamin K deficiency (in
neonates)
Face
- Mouth
 Ulceration – Crohn’s
 Angular stomatitis – iron deficiency anaemia
 Gum hypertrophy – leukemia, scurvy, anti-epileptics
(phenytoin)
 Glossitis – big red smooth tongue – iron deficiency
anaemia / B12 deficiency
 Candida – immunodeficiency (AIDs, leukaemia)
Bronchial breathing
Normal
Breathing

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 Freckling around the mouth – Putz-Jehger’s syndrome
– associated with polyps in the bowel. High risk of cancer
/ obstruction
Eyes
 Yellow sclera – jaundice
 Pale conjunctiva – anaemia
 Keyser-Fleischer rings – Wilson’s disease (mean age of
presentation 6-20)
 Xanthelasma – Hyperlipidemia (can be inherited in an
autosomal dominant fashion but unlikely to present in
children)
 Corneal arcus – cholesterol deposits
Abdomen
- Inspect if you didn’t earlier
Distension, scars-Post kasaii (Rt hypochondriac horizontal
scars, or Mercedes Benz scar (post liver transplant),
umbilicus position pushed down if upper Abd mass, bulging
in flanks, dilated veins, caput medusa, umbilical hernia
- Palpation
 Palpate all 9 areas
 Look at the patients face for signs of pain as you palpate
§ Abdo pain in children
· Many causes!
· Classical signs of appendicitis may / may not be present
if there is appendicitis.
· Pain tends to be less localized than in adults
 Superficial palpation first
 Then deep palpation
 Faeces? Pale like tahu/clay in BA, dark urine etc.
 Other masses?
Size / placement of the liver
 In children it is likely to be up to 2 fingers palpable. This
is normal, and prevalence of this decreases with age
Technique same as adult. May use finger in infants, let liver
come and touch your index finger. Describe in centimeters
not finger size, size, right/left lobe separately, consistency,
tender non tender, smooth, rough surface, sharp or rounded
margin, pulsatile, hepatojugular reflux, upper border ( to
differentiate pushed down liver in hyper inflated chest) ,
span.GB palpable etc., moves well with respiration, bruit,
Normal Liver span- 2 months is 5 cm, 1 year is 6 cm, 3
years is 7 cm, 5 years is 8 cm, 12 years is 9 cm. use ruler
not measuring tape.
Size / placement of the spleen: Start from Rif and proceed
to left hypochondrium, feel for notch, and describe all 8
features size in cm, consistency, surface, non-tender,
edge/margin, movement with respiration, notch, bruit
Same technique as adult
Tipping for the spleen – asks the patient to lie on their right-
hand side and bring their left knee towards their chest. Put
their left hand on your left shoulder, and ask them to take a
deep breath in, as you feel under the costal margin. You
might just feel the edge of the spleen.
Traube’s note – percussion at the 9th intercostals space at the
mid-axillary line – normally resonant, but in splenic
enlargement, becomes dull
Ballot for the kidneys
Must know difference between spleen and liver.
Gallbladder – not usually palpable. If painful and palpable, then
not gallstones!
- Percussion
Size of the liver, spleen
Shifting dullness
- Auscultation
 Listen 2cm above the umbilicus
 Should be able to hear any renal artery bruits if present
 Should be able to hear bowel sounds

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 Normal bowel sounds – aka borborygmi occur at least
every 2-3 minutes
 High pitched, tinkling bowel sounds - obstruction
 Absent bowel sounds - peritonitis
Causes of Hepatomegaly in children
- Herpes infection including
 CMV, EBV
- Leukemia, Lymphoma
- Congestive cardiac failure – possibly due to congenital
heart defects
- Infection –toxins / sepsis
- Drugs –e.g. Anti-tuberculosis drugs
- Hepatitis
- Metabolic disorders
- TORCH infections – these are usually referred to as
infections of the pregnant mother which can cause
congenital defects: Toxoplasmosis, Other (syphilis,
Hepatitis B, HIV), Rubella, Cytomegalovirus, Herpes
Causes of splenomegaly in children
10% of neonates will have a palpable spleen normally
- TORCH Infections
- Sepsis
- Hemolytic anaemia (rare)
- Juvenile Rheumatoid arthritis (rare)
Finishing off
- Check external genitalia / hernia orifices– e.g.,
testicular atrophy in liver disease, hernias
- Do a PR – lumps, constipation, bleeding, and lesions
Rarely performed in children, but may be indicated in some
cases
- Ankle edema – liver failure
- Urine dipstick – renal failure, diabetes, infection
- COVER UP THE PATIENT AND THANK THEM!
Abdomen
 Inspection is the most important first step.
 The order of examination has been changed slightly in
that palpation is done last.
 It is a good idea, before performing abdominal
examination, to ask the child if they need to use the
restroom.
 For the examination of the infant or toddler the knees
may be bent in order to relax the abdomen and the
child’s arms down at their sides.
 Inspect for rashes, scars, lesions, or discoloration.
 Observe overall contour and symmetry.
 Inspect the umbilicus for shape, signs of inflammation
or hernia
Abdomen
 Listen to the 4 quadrants noting the frequency and
quality of the bowel sounds.
Abnormal sounds:
–Gurgles, clicks, growls
 Frequency of sounds is from 5 to 34 times per minute.
Abdomen
 An increase in frequency or pitch of bowel sounds may
be associated with intestinal obstruction or diarrhea.
 Decreased or absent sounds may be associated with
paralytic ileus or peritonitis.
 To be certain that bowel sounds are absent listen for 2
minutes in the area just inferior and to the right of the
umbilicus.
 Percussion in the pediatric patient is the same as the
adult patient.
 Because children tend to swallow a lot of air when
eating or crying the stomach and intestines has a
great amount of air in them.

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Abdomen
 A distended abdomen may signify an obstruction,
infection, celiac disease, ascites, or an abdominal
mass.
 Palpation will reveal masses (note size and location)
hepatosplenomegaly, and any sources of pain.
 If the liver is felt below the costal margin (it commonly
is 1 cm below the margin) its span in the
midclavicular line should be percussed.
Abdomen (summary)
 Inspection:
o Shape.
o Visible swellings, hernias.
o Umbilicus, veins.
o Visible peristalsis.
 Palpation:
o Masses.
o Areas of tenderness, rebound, guarding.
o Liver, spleen: <6 years may palpate up to 2cm
below costal margin.
o Kidneys, bladder.
 Percussion [often optional]:
o Fluid wave, shifting dullness.
o Liver, spleen.
 Auscultation:
o Bowel sounds, bruit
Hernial Sites

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7. APPROACH TO LONG CASE, PAEDIATRIC HISTORY &
PHYSICAL EXAM
(CHILDREN ARE NOT JUST LITTLE ADULTS, BUT MAY
BE LIKE INNOCENT ANIMALS IF < 4years)
-HISTORY-
Learning Objectives:
1. To understand the content differences in obtaining a
medical history on a pediatric patient compared to an adult.
a. To understand how the age of the child has an impact on
obtaining an appropriate medical history.
2. To understand all the ramifications of the parent as
historian in obtaining a medical history in a pediatric
patient.
3. To understand the appropriate wording of open-ended and
directed questions, and appropriate use of each type of
question.
4. To develop an awareness of which clinical settings it is
appropriate to obtain a complete medical history compared
to a more limited, focused history.
Competencies:
1. To obtain an accurate and complete history of a pediatric
patient in different age groups (<1 year; 1-5 years; > 5 years).
Differences of a Pediatric History Compared to an Adult
History:
I. Content Differences
A. Prenatal and birth history
B. Developmental history
C. Social history of family – environmental risks
D. Immunization history
II. Parent as Historian
A. Parent’s interpretation of signs, symptoms
1. Children above the age of 4 may be able to provide some of
their own history
2. Reliability of parents’ observations varies
3. Adjust wording of questions – “When did you first notice
Johnny was limping”? Instead of “When did Johnny’s hip
pain start”?
B. Observation of parent-child interactions
1. Distractions to parents may interfere with history taking
2. Quality of relationship
C. Parental behaviors/emotions are important
1. Parental guilt – nonjudgmental/reassurance
2. The irate parent: causes
Outline of the Pediatric History:
I. Chief Complaint
A. Brief statement of primary problem (including duration)
that caused family to seek medical attention
II. History of Present Illness
A. Initial statement identifying the historian, that person’s
relationship to patient and their reliability
B. Age, sex, race, and other important identifying
information about patient
C. Concise chronological account of the illness, including any
previous treatment with full description of symptoms
(pertinent positives) and pertinent negatives. It belongs here
if it is relating to the differential diagnosis for the chief
complaint. Focus on chronic related major problem, then
acute symptoms in long case.
III. Past Medical History
A. Major medical illnesses
B. Major surgical illnesses-list operations and dates
C. Trauma-fractures, lacerations
D. Previous hospital admissions with dates and diagnoses
E. Current medications
F. Known allergies (not just drugs)
G. Immunization status -–be specific, not just up to date
IV. Pregnancy and Birth History

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A. Maternal health during pregnancy: bleeding, trauma,
hypertension, fevers, infectious illnesses, medications, drugs,
alcohol, smoking, rupture of membranes
B. Gestational age at delivery
C. Labor and delivery -–length of labor, fetal distress, type of
delivery (vaginal, cesarean section), use of forceps,
anesthesia, breech delivery
D. Neonatal period -–Apgar scores, breathing problems, use
of oxygen, need for intensive care, hyperbilirubinemia, birth
injuries, feeding problems, length of stay, birth weight
V. Developmental History
A. Ages at which milestones were achieved and current
developmental abilities -–smiling, rolling, sitting alone,
crawling, walking, running, 1st word, toilet training, riding
tricycle, etc (see developmental charts)
B. School-present grade, specific problems, interaction with
peers
C. Behavior -–enuresis, temper tantrums, thumb sucking,
pica, nightmares etc.
VI. Feeding History
A. Breast or bottle fed, types of formula, frequency and
amount, reasons for any changes in formula
B. Solids -–when introduced, problems created by specific
types
C. Fluoride use
VII. Review of Systems: (usually very abbreviated for
infants and younger children)
A. Weight -–recent changes, weight at birth
B. Skin and Lymph -–rashes, adenopathy, lumps, bruising
and bleeding, pigmentation changes
C. HEENT -–headaches, concussions, unusual head shape,
strabismus, conjunctivitis, visual problems, hearing, ear
infections, draining ears, cold and sore throats, tonsillitis,
mouth breathing, snoring, apnea, oral thrush, epistaxis,
caries
D. Cardiac -–cyanosis and dyspnea, heart murmurs, exercise
tolerance, squatting, chest pain, palpitations
E. Respiratory -–pneumonia, bronchiolitis, wheezing, chronic
cough, sputum, hemoptysis, TB
F. GI -–stool color and character, diarrhea, constipation,
vomiting, hematemesis, jaundice, abdominal pain, colic,
appetite
G. GU -–frequency, dysuria, hematuria, discharge,
abdominal pains, quality of urinary stream, polyuria,
previous infections, facial edema
H. Musculoskeletal -–joint pains or swelling, fevers, scoliosis,
myalgia or weakness, injuries, gait changes
I. Pubertal -–secondary sexual characteristics, menses and
menstrual problems, pregnancies, sexual activity
J. Allergy -–urticaria, hay fever, allergic rhinitis, asthma,
eczema, drug reactions
VIII. Family History
A. Illnesses -–cardiac disease, hypertension, stroke, diabetes,
cancer, abnormal bleeding, allergy and asthma, epilepsy
B. Mental retardation, congenital anomalies, chromosomal
problems, growth problems, consanguinity, ethnic
background
IX. Social -–financial
A. Living situation and conditions -–daycare, safety issues
B. Composition of family
C. Occupation of parents
D. Insurance, medifund, Disability allowance, MSW helping
etc.
E. Support Group
PHYSICAL EXAMINATION- MAY BE REQUESTED IN LONG
CASES
Objectives

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1. To understand how the general approach to the physical
examination of the child will be different compared to that of
an adult patient and will vary according to the age of the
patient.
2. To observe and demonstrate physical findings unique to
the pediatric population, and to understand how these
findings may change depending upon the age of the child.
Competencies
1. To obtain accurate vital signs (Temperature, HR, RR, BP)
in a pediatric patient in different age groups and to be able to
evaluate these vital signs compared to
age-adjusted normal. To understand the normal variation in
temperature, depending on the route of measurement. 2. To
complete a thorough physical examination on a pediatric
patient in different age groups.
INTRODUCTION (START OF THE PRESENTATION OF
LONG CASE: SASPOP)
Sex
Age
Social statement (the most important, relevant social
factoid)
Past history (of relevance only)
Onset
Presentation
Summarize problem list: 1. Jones is a 12-year-old
overweight boy with a known history steroid resistant
Nephrotic syndrome, who presents with the diagnostic
problem of the sudden onset of abdominal pain with fever
and sore throat

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Commonest short cases in Pediatrics: By Dr Varsha Atul Shah
Cardiology VSD, ASD, Post BT shunt, TOF, AR/AS, PS, PDA, Dextrocardia, Post cardiac op complex heart,
Neurology CP, Floppy infant, DMD, Myopathy, SMA, Hemiplegia, Developmental Assessment, Spina bifida,
large head, Hydrocephalous post shunt, small head, Cerebellar signs, Facial weakness, NF1, Gait
examination, Tuberous sclerosis, Sturge Weber syndrome
Nephrology Nephrotic syndrome, CRF, HT, Nephritic syndrome, HSP
Hematology Thalassemia, Hemophilia, leukemia, ITP
Gastroenterology Biliary atresia, post kasaii, post liver transplant, Chronic liver disease, Jaundice in infant, child,
failure to thrive, Glycogen storage disorder, IMS
Endocrinology Diabetes Mellitus, Short stature, Ambiguous genitalia, tall stature, Obesity, Cushing syndrome,
Thyroid disorder,
Genetics Down’s syndrome, Turner syndrome, Noonan syndrome, Marfan syndrome
Respiratory Asthma, Bronchiectasis, Pneumonia, Exprem with BPD, stridor
Rheumatology JRA, SLE, Dermatomyositis
Skin Café au lait spots, Haemangioma, Kasabach Merritt Syndrome
Commonest Paediatric long cases
Cardiology Complex Heart disease with complications, SBE, FTT, hemiplegia
Neurology Epilepsy, DMD, Myopathy, Spina Bifida, CP, Hydrocephalous
Nephrology Steroid resistant Nephrotic Syndrome, CRF, Post renal transplant, Hypertension,
Hematology Thalassemia, Chronic ITP, Leukemia, Aplastic Anaemia, any oncology patient, hemophilia
Gastroenterology EHBA, post kasaii, Post liver transplant, GSD, Crohn’s disease, IBD
Endocrinology Insulin dependent DM, CAH
Genetics Down’s syndrome, Trisomy, Turner,
Respiratory Chronic asthma, Bronchiectasis, CLD
Rheumatology SLE with CRF,
Neonatology IUI, Expremature with/without BPD, dev delay/cp

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8. SEIZURES/EPILEPSY: LONG CASE
1. While greeting and introduction: eyeball patient (and
parent) and decide if child looks normal or not
2. Presenting complaint: A seizure!
3. History of presenting complaint:
a. 1st question: Is this the first time this
happened? If yes, then can’t say its epilepsy -
Who witnessed it?
b. Describe the seizure:
i. Prodrome: Any aura? Change in
behavior?
ii. Seizure:
 Tonic clonic? (Tensing, then
shaking, LOC)
 Atonic? (Drop attack)
 Absence? (Just staring, not
responding when called, +
blinking)
 Partial? Child may be fully
conscious, only ½ limbs
shaking/jerking.
 If temporal lobe – Automations,
strange behavior, altered
conscious level
 How many?
 How long did it last? (>20mins 
status epilepticus)
 Any loss of consciousness? Any
tongue biting?
 What did you do for the child?
(Appropriate vs. Inappropriate first
aid measures)
iii. Post ictal: Drowsy? Sleeping? Vomiting?
Temporary paralysis (Todd’s paralysis)?
c. Did the child have a fever?
Do seizures occur only when child has fever?
Tmax of fever, associated symptoms (e.g., cough, sore throat
etc.), exclude meningitis, encephalitis as a cause.
d. Any head injury just before the seizure?
Now establish: Is it a febrile fit? OR epilepsy? OR 1st time
seizure with no defined cause? OR seizure, probable cause
_______? e.g., poisoning, hypoglycemia OR is it a pseudo
seizure Rigors, breathe holding attack?
e. Past history: Seizures: Frequency of seizures,
Time, occurrence of seizures, Date of last
seizure
f. Epilepsy:
i. Age at 1st seizure, describe seizure,
A/W fever?
ii. H/o febrile seizures when young?
iii. When and how diagnosed. Any event
preceding seizure?
iv. Treatment:
anticonvulsant medications: How many?
Any ↑/↓/∆ in drug dosage & types?
Compliance, how often is a dose missed & what to do if it is
missed?
For how long, any attempt to stop medications?
Side effects of medications?
outpatient review: Frequency, Test done @ f/u
Other Inxs e.g., EEG to date, blood levels
I. Hospitalizations: How many? Reasons?
j. Any identifiable triggers for seizures, e.g., fever, emotion,
lack of sleep, bright lights?
k. Any identified medical problem/cause associated with
seizures? Diagnosis given? e.g.:

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 Neurocutaneous syndromes (NF-1,
TS, S-W)
 Cerebral palsy
 Neurodégénératives syndromes
(Rett’s, Lennox-Gastaut)
 Past h/o brain tumor, head
trauma,
meningitis/encephalitis/brain
abscess
 Inborn errors of metabolism
How are these problems managed?
v. Any other past medical history?
vi. FAMILY HISTORY?
4. Developmental history
a. Antenatal history development in infancy –
milestones
b. Interaction with friends, children his age, family
c. If schooling: keeping pace with classmates?
d. Any regression e.g., loss of walking/talking
ability
5. Social history
i. Impact on child: Schooling, Athletic
participation, Self-esteem, peer
relationships, does teacher know of
condition?
b. On family: Financial burden
c. CONTINGENCY PLAN: What to do in the event
of a seizure?
6. Summary
a. Type of seizure  Classify
b. Associated problems/possible cause
c. Treatment and complications

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9. HEMIPLEGIA: LONG CASE
Dr Varsha Atul Shah
1. HISTORY
Most importance should be given for a proper and
accurate history taking, since it gives the clue for a correct
diagnosis, in CNS cases, unlike other systems where a
proper diagnosis may be made even by clinical findings
alone.
Following points must be stressed in the presenting
complaints: Was the onset acute, sub-acute or gradual? Was
it associated or preceded with fever and/or a seizure? Any
severe headache, vomiting or change in consciousness,
preceding the onset of hemiplegia. .If so, sudden or gradual?
Is the condition deteriorating, static or improving?
Past history: Any history suggestive of vasculitis,
rheumatic fever, trauma or thrombosis or bleeding disorders.
Review of developmental history, antenatal, perinatal,
and post-natal should always be recorded. Family history
and consanguinity must be noted.
2. CLINICAL EXAMINATION
A detailed general examination, including
temperature, pulse, BP, and anthropometric measurements
should be noted. Any facial dysmorphism, cutaneous lesions
like I au lait spots, angiomas or depigmentation and
condition of teeth must be noted.
Look for any midline defect. Examination of chest,
abdomen and palpation of femoral pulse must always be a
part of general physical examination. Note for unusual body
order. Palpation of anterior fontanel, and auscultation for
bruits done in erect posture- over both globes, temporal
fossae, and mastoid region (six sites)
CNS examination:
Higher function assessment according to the age of
the patient.
Cranial nerves.
Olfactory (I) rarely assessed, Optic nerve (II): Elicit he
blink reflex, (in a child> 3-month-old) Fundi examination:
optic disc, retinal hemorrhage, chorioretinitis,
Look for visual acuity, and field of vision depending on
the age, and sensorium of the child.
III, IV, VI Cranial nerves: Enophthalmos, ptosis,
meiosis, lack of sweating, on the ipsilateral side of face. See
the pupillary reflex, if ptosis is present, look for ‘Marcus
Gunn sign,’ Test the movements of all extra ocular muscles.
If the child is unconscious see the ‘doll’s eye movement.
Examine for internuclear ophthalmoplegia by looking for
defective adduction of the medial rectus and nystagmus of
the abducting eye. See for nystagmus, and if present stage it
(stage 1, 2, 3)
V Nerve: Look for deviation of jaw. corneal and
conjunctival reflexes. Test sensation of face.
VII Nerve: Is the facial nerve affected. If so, ipsilateral,
or contralateral to the side of hemiplegia. Look for ‘emotional
‘facial weakness. Confirm whether UMN or LMN type of
involvement. Look at the nasal labial fold and wrinkling of
forehead. Is the taste, salivation and/or tear production
affected?
Look for the strength of orbicularis oculi. Elicit
‘McCarthy reflex’
VIII (Cochlear and Vestibular).
Rinne’s test for defective hearing. Test for vertigo

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Xi’an X: Any nasal regurgitation or change in voice?
Movement of palate.
XI Nerve: Test the sternomastoid .and trapezius
muscles
XII Nerve: Look for deviation of tongue when
protruded, fasciculations when the tongue is inside the
mouth, and lor atrophy.
Motor system: Look for abnormal movements
Muscle power (0-5- MRC scale). Tone, pronator sign
for upper extremities. And Barre sign. For lower limbs,
depending on the age of the child. Look for coordination by
applying specific tests for cerebellar function: Finger nose
test,’ tapping in a circle (one cm. diameter) test’, look for
rebound phenomenon.
Sensory system in older child: Temperature, light
touch, crude touch, based on a dermatomal distribution.
Examine for position and vibration sense and elicit
Romberg’s sign.
Reflexes: Elicit superficial and major tendon reflexes,
knowing its root value, and cutaneous nerve involved. Elicit
plantar reflex and ankle clonus
Infants: Posture and muscle tone, primitive reflexes:
Moro reflex, Tonic neck reflex, Righting – reflex, palmer and
plantar grasp reflexes, Vertical suspension, and Landau
reflex
3. INVESTIGATIONS
Besides, routine CBC, Monteux and X ray chest, the
following investigations should be done:
CSF examination.
Electrolyte estimation (Na +, K+, Cl -)
PT, APTT.
Antiphospholipid antibodies (in SLE) 1 A. NA
Estimation of antithrombin III level, protein C, S, and
factor V Leiden.
ECG, ECHO, EEG, EMG, NCV, and CT brain
Cerebral angiogram, or MR angiography (MRA) /
Functional MRl,
Evoked potentials VERs /BAERs and, SSEPs)
Radiography of Spine and Myelography
Diffusion –Weighted Magnetic Resonance Imaging in
acute stroke conditions Magnetic Resonance Spectroscopy
(MRS) when cerebral metabolites are of significance.
Positron –emission tomography (PET), esp. in children
for surgical programmes. Single –photon –emission
computerized tomography (SPECT) for conditions where
regional blood flow study is important.
4. DIFFERENTIAL DIAGNOSIS
The following conditions should be kept in mind to
arrive at a provisional diagnosis. Of the following, only 3
most probable conditions judged by history and clinical
signs must be discussed in differential diagnosis.
I. Hemiplegic cerebral palsy
II. Infantile hemiplegia (to be considered only in a child
up to 6 years)
III. Vascular causes, including IEM (hemorrhage,
thrombosis, vacuities, trauma, hemiplegic migraine)
IV. Infective causes: bacterial, viral, fungal (Meningitis,
encephalitis, TBM)
V. Demyelinating: Acute Disseminated Encephalo-
Myelitis (ADEM)

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VI. Todd’s paralysis also may be considered if hemiplegia
follows a prolonged seizure.
VII. Space occupying lesions
5. MANAGEMENT:
N on-surgical management
Depends on etiology. Measures to reduce cerebral
edema, correction of fluid and
Electrolyte’s imbalance if any has to be done.
Long term management like physiotherapy, speech
therapy, and rehabilitative measures may be required in
some cases. Referral to a child DCD (Dept of Child
development) is advisable for selective patients.
Surgical management
Surgical management will be required in space
occupying lesions .and selective cases of spastic cerebral
palsy.
a. Any other Site of the lesion, (Localization) must
be discussed before considering the differential
diagnosis.