The document provides guidelines for performing a pediatric clinical diagnosis, including taking a thorough patient history, conducting a full physical examination involving multiple body systems, and documenting findings. The physical exam section details how to assess things like vital signs, growth measurements, skin appearance, and examination of specific organ systems like heart, lungs, abdomen, and musculoskeletal system.

1. Pediatrics clinical diagnosis
ZEGEYE G.(MD)
General practioner,GUH
February 2017

2. History taking
1.Identification:
Name,age,sex,address,ward,bed number date of
admission
Parents name, age & occupation
2.Historians:mother ,father or caretaker
3.Chief complaint: the main reason for parents or
care taker to seek medical advice
can be more than one; write with chronological
order

3. Cont….
4. History of present illness:
Elaborates the chief complaint with emphasis on the genesis
of the illness and associated symptoms.
Elaborate symptoms based on
anatomic location
quantity and quality of symptoms
aggravating relieving factors
variation over time
chronological order
associated symptoms
absent symptoms
response to intervention if any

4. Cont…
5.Past medical history:
a) past childhood illness e.g.
measles,mumps,chicken pox
b)major chronic illness e.g TB, cardiac disease ,
DM etc
c)Hospital admisions with clear description of
time ,reason and outcome
d)surgical procedure major or minor including
circumcision and uvulectomy
e)accidents

5. Cont…
f) Perinatal history:
Antenatal hx-general maternal health or specific
diseases ,medications ,nutritional status radiation
exposure and antenatal care
Natal hx- duration of pregnancy, labor initiation
and duration ,time of ROM,place of
delivery,mode of delivery, presentation
complication
Postnatal hx-APGAR score ,time of onset of cry ,
feeding ,fever,convusion etc.

6. Cont…
6.Nutritional Hx:
From time birth till the present age
Prelacteal feeding
Time of breast feeding initiation , total duration
breast feeding, Age of complementary diet.
Hx of bottle feeding
Present diet-type, amount and frequency

7. 7. Developmental HX:
Assess from birth to present age since
development is dynamic.
Ask certain milestones unless detailed
developmental assessment needed.
• 8 .Immunization Hx:
A )Type of vaccine, age administered, frequency
of administrations, boosters, complications of
vaccines.
B )If not immunized or incomplete ask for
reasons. see next table the EPI schedule

8. Expanded program of Immunization
No Age Type of vaccine
1st birth BCG,OPV0
2nd 6wks Pentavalnt 1(DPT-
hib ,he-
b),OPV1,PCV1
3rd 10 wks Pentavalant2,OPV2,
PCV2
4th 14wks Pentaavalant3,PCV
3
5th 9 month measles

9. Cont…
9) Family HX:
a) family size ,number of siblings and health
status
b) If any death in the family, ask for cause and time
death
c)Familial diseases
DM, HTN ,Epilepsy and communicable diseases
like TB etc.

10. Cont…
10. Personal &social Hx:
a) School adjustments, habit of sleeping,
eating , swimming and playing
b)parental occupation ,education, marital
status and monthly income
c) Housing condition
d) waste disposal and water source

11. Cont…
11. REVIEW OF SYSTEMS:
explores other organ system problems that
have been unaddressed or over looked in the
HPI
a) General constitutional symptoms
fever, chills, malaise, fatigue night sweating,
weight loss or gain

12. Cont…
a)HEENT
Head-headache,diziness,syncope and head injury
Eye-visual
problems(bluring,diplopia,photophobia)
Ear-hearing loss, ear pain ,ear discharge
Nose- sense of smell,epistaxis
Throat-sore throat, hoarseness of voice, gum
bleeding and taste disturbance

13. Cont…
c) Respiratory system: cough, sputum production with amount.
chest pain ,dyspnea
d) Cardiovascular system:
Dyspnea ,orthopnea, PND ,palpitation and leg swelling
e)Gastrointestinal system: nausea, vomiting, diarrhea and abdominal
pain
f) Genitourinary system:dysuria, frequency,urgency,urine color and
amount,flank pain
g) Musculoskeletal system:
Extremity pain , joint pain ,swelling, restriction of movement
h) Central nervous system : consciousness,seizure,weakness, sensory
loss

14. Physical examination
Examination of a child is a very difficult task
requiring great patience and is time consuming
especially for the untrained person. Examination
should begin from the very outset by inspecting
the patient without touching or getting nearer
until one is familiar. While asking the history
from the historian one should be able to make
him/her self familiar to the patient especially
young children. Smiling faces and colorful objects
soothe the child.

15. Cont….
• While inspecting the child one should look into
the different parts of the body of the child, the
way he acts and responds to his environment &
strangers, his skin color, signs of distress,
behavior, his body status in relation to the stated
age. It is wise that the attendant undress the
patient without the examiners approach to avoid
discomfort and refusal of examination by the
patient. After that systematic examination
should proceed. For infants and young children
the lap of the mother is the preferred site for
examination.

16. cont….
• General appearance:
level of consciousness
cardiorespirayory distress
nutritional status
health status(acute sick looking ,chronic sick looking
and acute on chronic sick looking)
• Vital signs:
pulse –rate, rhythm and character
respiration-rate,regularity and pattern

17. Cont…
Blood pressure:
use appropriate cuff size
approximately 2/3rd of the upper arm or thigh
should be covered by the cuff width.
a cuff too wide underestimates blood pressure
while narrow cuff over estimate it.
measure on both right and left arms.
>15mmhg is abnormal

18. Cont…
• Temperature:
Rectal is better in neonates ,infants and young
children than oral or maxillary measurement.

19. ANTHROPOMETRIC MEASUREMENTS
• This includes the measurements of height or
length, weight, head circumference, mid
upper arm circumference & chest
circumference. The height, weight, and head
circumference should always be checked for
age using a reference data.

20. Cont…
• LENGTH
Is taken for those less than 2 years of age and
height is taken for those greater or equal to 2
years. Length is measured using infant measuring
board on which measuring tape is attached that
has a rigid foot board and movable head board.
The measuring board is placed on the table so
that the head and footboards are perpendicular
to the table. The infant lies supine on the
measuring board with the head against foot
board with straightened knees.

21. Cont…
• HEIGHT
• The measuring board is fixed upright where
the ground is level. The child stands, upright in
the middle, against the measuring board. The
child’s head, shoulders, buttocks, knees, heels
are held against the board by the assistant,
while the measurer positions the head and
the cursor. The height is read to the nearest
0.1 .

22. Cont…
WEIGHT
• Measurement is done by different types of
scales. Calibrate the scale to zero before the
patient mounts the platform.
HEAD CIRCUMFERENCE
• Use non-stretchable measuring tape. The
landmarks are anteriorly the glabella,
posteriorly the occipital protuberance,
laterally just above the pinna

23. Cont…
HEENT
Head-appearance or shape,size(head
circumference),mass,scar,hair
distribution,texture,plukability,color and fontanel
Eyes-conjuctival appearance,ictres
Ear-deformity,trageus and mastoid tenderness
Nose-shape,septum,discharge,mass
Mouth and Throat-oral lesions,hydration
status,tooth caries,tonsillar erythema,swelling

24. Cont…
Lymphoglandular system :
thyroid elargment
testicular exam
lymph node exam
breast exam

25. Respiratory system exam
Inspection
count respiratory rate
look pattern of breathing(e.g apnea,periodic
breathing,kussmaul breathing)
listen to abnormal sounds such as stridor,
wheez,whooping cough,barking cough, hoarse
voice,grunting,cyanosis ,clubing,flaring of ala nasi
,intercostal and subcostal retraction
Chest deformity
symetry of chest wall movement

26. Cont…
Palpation
Tenderness,crepitation,tactile fremitus, chest
expansion and tracheal position
Purcusion
Normal - resnonance
Abnormal -dullness or hyper resonance
Check diaphragmatic excursion in older and
cooperative children

27. Cont…
Auscultation
normal breath sounds
vesicular-low pitched and fine heard during
inspiration
bronco vesicular-Areas of tracheal bifurcation
bronchial –high pitched and harsher sound
heard both expiration and inspiration over the
trachea.

28. Cont…
Abnormal breath sounds
bronchial breath sounds out of the normal site
absent or decreased air entry
crepitation, wheeze ronchi
egophony and brochophony

29. Cardiovascular system examination
Begin with inspection for cyanosis,clubing
Arterial exam :
Check all peripheral pulse and compare the right
and left
Check radio femoral delay
Check pulse rate ,rhythm character and volume
Venous exam:
Jvp –normally<4cm
Neck vein engorgment

30. Cont…
Precordial examination:
Inspection
activity,bulging,visibility of apical impulse
Palpation
Point of maximal impulse- taping or thrusting
difuse or localized
Thrill(palpable murmur)
Parasternal and apical heave
Check palpable p2 at pulmonic area

31. Cont…
Auscultation
heart sounds(s1 ,s2,s3 and s4)
Murmurs
Gallop rhythm
Pericardial friction rub
There are four basic heart sounds S-1, S-2, S- 3, and S-4. S1
and S2 are the most distinct heart sounds and should be
characterized separately. S3 and S4 may or may not be
present, their absence is not an unusual findings. They
must be evaluated in relation to other sounds and events
in the cardiac cycle. S1 is louder than S2 at the apex
where as S2 is louder than S1 at the base

32. Cont…
S1 is usually heard as one sound. S2 is actually two
sounds that merge during
expiration. During inspiration P2 occurs slightly later,
giving S2 two distinct
components split S2. Normally A2 and P2 are separated
by 0.04 to 0.05 seconds during
inspiration with a single S2 heard during expiration.
Wide splitting is when the splitting
is wider than normal and is seen in ventricular septal
defect, mitral insufficiency and
total anomalous of pulmonary venous return.

33. Cont…
Murmurs are caused by disruption of blood flow
into or out the heart .
Characterization of heart murmurs:
1.Timing and duration
a)Early systolic-begins with s1 and end before s2
b)Mid systolic –begins after s1 and ends before s2
c)Late systolic –begins mid to late systole and ends
at s2

34. Cont…
Holo systolic –begins with s1 occupies all of
systole and ends at s2
Early diastolic-begins with s2 end before s1
Mid diastolic -begins at clear interval after s2
Continuous murmurs-starts in systole
continuous with out interruption through s2
on to all parts of diastole

35. Cont…
2.Pitch- high, medium& low depending on pressure and rate of
blood flow
3. Intensity
grade 1-barely audible on quite room
grade 2 -quiet but clearly audible
grade 3-moderately loud
grade 4-loud with associated thrill
grade 5-very loud ,audible with sthetescope partially
off the chest
grade 6-very loud ,audible with sthetescope not in
contact with the chest

36. Cont…
4.Pattern
crescendo murmur
decrscendo murmur
5.Quality
Blowing ,rumbling,harsh,machinery and musicial
6. Anatomic location- the anatomic landmark for
maximal intensity
7.Radiation e.g murmur of mitral regurgitation
radiates to axilla

37. ABDOMINAL EXAMINATION
Use the four cardinal ways of examination.
Patients should lie down on their back relaxed. In
infants usually they should sit on the lap of their
mother for the best relaxation. In describing
findings topographic regions should be used.
Commonly the four quadrants namely the right
upper and lower, the left upper and lower
quadrants are used. To be more specific
epigastric, periumbilical, suprapubic and flanks
can be used for description.

38. Cont…
• Inspection
Patients should be undressed fully so that
hernial sites could be inspected. Look for
appearance (scaphoid, distended, full)
symmetry, movements with respiration,
umbilicus (inverted, everted or flat), scars,
dilated vessels, flank fullness, congenital
abnormalities.

39. Cont…
• Palpation
Let the patient assume a relaxed position either
supine or on the mothers lap. Ask if the child
has any pain in the abdomen. Start from areas
that are reported to be not painful. Use a
warm hand gently avoiding tender areas

40. Cont…
Superficial palpation to check for tenderness
and mass, then deep palpation moving
synchronous with respiration for mass at all
quadrants, for liver and spleen describing their
size below the costal margin, consistency,
surface, edge and tenderness. If there is any
mass describe its location, size, mobility and
attachment to the underlying tissue,
consistency, shape, tenderness and surface.

41. Cont…
• Percussion
Percuss the abdomen which is normally
tympanic.
Check for fluid thrill
Put on one side of the flank the palm of your hand
and tap at the other flank area. Let an assistant
put the hand at the umbilicus vertically by the
ulnar side. This will avoid the wave that can be
produced by the abdominal wall. Appreciate the
thrill by the palm of your other hand.

42. Cont…
• Check for shifting dullness
Let the patient lie on the back relaxed. Start
percussing from the umbilicus where you
found tympanicity. Then proceed percussing
horizontally to the left side until you find
dullness. Do not move your finger from that
site. Holding your finger at that spot rotate
the patient to the right side. Then percuss at
the site where you found dullness.

43. Cont…
• If the dullness is changed to tympanic sound
then there is shifting of the dullness. If there is
a mass on the left side you should percuss
from the umbilicus to the right side and rotate
the patient to left side

44. Cont…
• Check for total liver span
Start percussing at the right chest at mid-clavicular line
vertically downwards until you find liver dullness and
mark the site. Then palpate the abdomen and find the
liver edge at the right mid- clavicular line and mark it,
then measure the distance between the two marks
which gives the total liver span. Total vertical span of
the liver at birth is 4-5 cm and at 12 years it is around 9
cm. In general the liver edge is usually felt less than 2
cm below coastal margin in right mid-clavicular line of
the newborn infant and about 1 cm below coastal
margin throughout childhood

45. Cont…
• Auscultation
Auscultate for bowel sounds, bruit on enlarged liver
and around great vessels. Unlike examination of
other systems auscultation of the abdomen should
immediately follow inspection. Palpation may disturb
bowl sounds.

46. Cont…
Rectal examination
This is part of any routine physical examination.
Use the smallest finger in children.
Check for external lesions, rectal prolapse,
sphincter tone, palpable mass, then check for
blood on examining finger and gross appearance of
stool.

47. Genitourinary system
Costovertebral angle tenderness
external appearance of the genitalia
sexual maturity rate

48. Musculoskeletal system
I. Check for congenital malformations, bone deformities and
shortening.
II. Check the joints for mobility in adduction, abduction, extension,
flexion, internal and external rotation, and describe the limitation.
III. Assess if there are swellings and describe the site, size,
tenderness, hotness and limitation of movements.
IV. Check the spine by inspection for deformities, checking for
tenderness by percussion and by functional tests.
 Kyphosis is abnormal outward lump of the thoracic spine.
 Lordosis is exaggerated incurving of the lumbar spine.
 Scoliosis is lateral curvature of the spine which is best appreciated by
looking at

49. Integumentary system
 Check skin texture, pigmentation, lesions,
turgor.
 Lesions should be described according to their
site and appearance as macular, papular,
pustular, vesicular, bullous, nodular, crustyor
scaly.

50. Central nervous system
A. Mental status examination
I. LEVEL OF CONSCIOUSNESS The initial step in a formal mental status
examination is the determination of the patient's level of consciousness. There
are many general terms used to describe the basic levels or state of
consciousness. These levels represent points on a continuum from full alertness
to deep coma. Most clinicians distinguish five principal levels.
1 .alertness-Alertness implies that the patient is awake and fully aware
of external and internal stimuli.
2. Lethargy- A state in which the patient is not fully alert and tends to
drift off to sleep when not stimulated. Spontaneous movements
are decreased and awareness limited
3. Obtundation- Refers to a transitional state between lethargy and
stupor. The obtunded patient is difficult to arouse and when
aroused, is confused. Usually, constant stimulation is required to
elicit even marginal cooperation from the patient.

51. Cont…
4.Stupor or semi-coma -Used to describe patients
who respond only to persistent and vigorous
stimulation. The patient doesn't rouse
spontaneously and, when aroused by the
examiner, is able only to groan or mumble and
move restlessly in the bed.
5. Coma- Completely unarousable to external or
internal stimulus (Deep or light reflexes may be
there like decorticate and decerebrate posturing.)

52. Cont….
II. Orientation to time place and person
III. Emotional state - reaction to strangers,
depressed, elated, flattening, interest to the environment.
IV. Intellectual performances - response to questions
V. Language - development, fluency, and articulation.
B. Cranial nerve examinations
C. Motor function test
Muscle volume(bulk)
power(stregth)
tone
Deep tendon reflexes
D. Sensory examination
E.Meningial signs
neck stiffness
kernig sign
brudzinski sign

53. Neonatal History and examination
Neonatal history is unique in that majority of cases
arise from prinatal events.
Identification
similar to others
age-minutes,hours(until 72hours)
Chief complaint
specific symptoms such as fever ,fast breathing,
failure to suck etc
Or referral for specific problem

54. Cont…
• HPI-maternal age,parity(alive,stillbirth)
LNMP,GA
ANC follow up
labor and delivery history
Birth weight ,APGAR score,crying,
sucking,breathing pattern ,fever,passage urine
and meconeum
maternal medical illness(DM,HTN,Fever,vaginal
dischrge)

55. Physical examination
General appearance
consciousness
posture(flexed or extended)
distress
dysmorphic features
Vital signs
apical heart rate
respiratory rate
temperature
blood presure

56. cont…
Antropometry
Weight,length,head circumference
Ballard score
HEENT
Head - scalp mass, fontanel
Ear –deformity,tag
Eye –eye discharge,conjuctival hemorrage,icteres
Nose-dischrge,deformity,coanal atresia
Throat –cleft lip and palate

57. Cont…
• LGS
breast bud
goitre
Respiratory system
Inspection
cyanosis,flaring of alanasi,intercoastal and subcoastal
retraction
palpation
tenderness,crepitation,tactile fremitous
AP diametre(internipple distance/chest circumference)
purcusion –dullness,resonant,hyper resonant

58. Cont…
Auscultation
normal and abnormal breath sounds
air entry

59. Cardiovascular system
Arterial examination
Venous examination
Precordial examination
inspection
activity
apical impulse
Palpation
Point of maximal impulse
Heave ,thrill
Auscultation
normal heart sounds
gallop
heart murmurs

60. Abdomen
Follow the cardinal signs of examination
Inspect for meconeum staining of umblical cord
Abdominal wall defect in addtion the others.
GUS-genitalia exam
MSS-deformity, edema
CNS-consciousness,tone,
primitive reflexes
moro reflex
sucking reflex
grasp reflex
rooting reflex
Glabelar reflex

61. Reference
• PEDIATRICS CLINICAL EXAMINATIONS by
TESFAYE TESSEMA, MD &SOLOMON AMSALU,
MD ,2011