Pediatric Clinical Diagnosis

Hartono Gunardi, Sudigdo Sastroasmoro,

Irawan Mangunatmadja,
Department of Child Health, Medical School
University of Indonesia, Jakarta
Spectrum of pediatric age
Differences Adult and Pediatrics

A child is not a small adult !

• History is given by second person.
• The parents may place their own interpretation on
events(any fever may be called tonsillitis).
• The cooperation of the child cannot be guarantied
• The expression of the disease may be influenced by the
child’s developmental status (hypothermia may indicates
severe infection in newborn)
 Differences Adult and Pediatrics
• The predominant impact of the disease may be
on growth and development (UTI, Chronic illness).

• Physiological norms are more constant in adults,

variable with age in infants and children( HR, RR)

• Clinical signs of the disease may differ from

those of adults (Liver is palpable in infancy).
 Clinical exam in infants
and children:
Why special attention?
A child is not a small adult!

Keywords: growth and development

Any information about history, physical, and

laboratory / supporting exams should be
judged in relation with the child’s stage of
growth and development.
The diagnostic
paradigm:
Pediatric History
(Anamnesis)

Auto-anamnesis: self reporting by the patient

Allo-anamnesis: any information other than by
patient
Supporting exam: 5%

Physical exam 10-20%

History: ≥80%
 Pediatric history
• Introduce yourself to the parents and child.
• A warm greeting and friendly smile to allay
anxiety and promote confidence.
• Encourage the parents to tell the story with
minimum of interruption and listen carefully.
• You should not swallow the diagnosis given by the
parents.
• It is essential to find out what the concern of the
parents are.
 Anatomy of history taking
1. Patient’s identity
2. Chief complaint
3. Clinical course
4. Previous illness
5. History of maternal pregnancy
6. History of delivery
7. Feeding history
8. Immunization status
9. Growth and development
10. Family history
11. Environment
 Pediatric history
• Presenting/Chief Complaint.
is a brief statement of the reason why the
patient was brought to be seen
Develop DD/

• History of present illness and important

related positive & negative symptoms.
to exclude by anamnesis
 History of present illness
1. Time (onset, duration, frequency, course)
2. Place (site)
3. Quality (Character eg. Pain)
4. Quantitiy (severity of fever, no of diarrhea)
5. Provocative/alleviative factors
6. Associated symptoms
7. Treatment if any
 History of present illness (2)
Systemic enquiry
1. General (weight loss, loss of appetite)
2. CVS (shortness of breath, etc)
3. Respiratory symptom (cough, runny nose,
earache, hemoptysis)
4. GI symptom (diarrhea /constipation,
vomiting)
Are there any symptoms regarding GI such as …
 History of present illness (3)
5. CNS (fits, headache, weakness, etc)
6. GU symptom (dysuria, frequency,
hematuria)
7. Hematological symptom (pale, bleeding)
8. Rheumatological symptom (limp, joint
swelling)
Adapted from Hutson JM, Beasley SW. 1988. The Surgical Examination of Children. Heinemann Medical Books, London.
 Maternal history

– Multiparity, any miscarriages, stillbirth or

congenital malformation.

– Maternal health during pregnancy

(hypertension, TORCH), regular antenatal
care, Rh iso-immunization.

– History of drugs ingestion during pregnancy,

oligohydroamnios or polyhydroamnios
 Birth history
– Mode of delivery.

– Crying immediately or not.

– Apgar score

– History of asphyxia

– Meconium stained amniotic fluid.

 Post-natal history
– NICU admission?

– How long did the baby stay in the nursery.

– Did the baby required mechanical ventilation ?

– Oxygen was given ? Duration of oxygen.

– Baby had history of jaundice?

Exchange transfusion done?

– Any illness during first month of life: meningitis,

convulsion, fever ..etc.
 Nutritional history
– Breast feeding or bottle feeding

– Type of formula

– How much milk is given , number of

feeds/day

– How is the milk prepared

– When the solid food or cereals is introduced,
content of food, any allergy to the food.
 Immunization history
– Vaccination program in details (National)

– Any non-program vaccination was given.

– When the last vaccine was given

– Any complication of given vaccine

– (Any contraindications for certain vaccine?)

Growth and development history
- Details of weight increment (KMS)

– Details of development milestones: smiling ,

sitting, standing, walking, speech

– Bladder and bowel control

– School performance, behavioral and emotional

history.
 Family history
– Father and mother age, consanguinity, level of
education and they are healthy or not.

– History of smoking in either parent

– Siblings: number, sex, and their ages.

– History of similar disease, chronic ds (TB),

unexplained death and genetic diseases.
– Draw family pedigree
Social & Environmental history
– It is necessary to build up a picture of the child’s
social and cultural environment
– Appreciate fears and stresses at home (
parental attitudes, separation, divorce, absence
of parent)
– Jealously at the arrival of a new baby
– Unexplained injuries may raise the possibility of
child abuse.
 Should complete history be obtained in all
patients irrespective of their illness?

1. A 8-year old girl, 30 kg, 130 cm, 3rd grade of

elementary school, repeatedly had good ranking in
class. She was brought to the clinic due to 3-day
high grade fever, stomach ache, and epistaxis

2. A 12-year old boy, basketball player, suspected

of suffering from radial fracture.
The “My 5 Moments for Hand
Hygiene” approach
 Pediatric Examination
• Important points to remember:
– The examination of infants and children is an
art, demanding qualities of understanding,
sympathy and patience.
– Heart rate, Respiratory rate, BP, liver size,
heart size varies with age.
– Keep disturbing or painful procedures to the
end.
– It is not necessary to be systemic in your
examination , but should be complete.
 Physical examination
In general similar to that in adults, i.e. to obtain
accurate physical status irrespective of the
approach
Needs modification due to nature of infants &
children:
 Start with inspection

 Followed by auscultation: abdomen & heart

 End with examination using equipment

 Pre-exam checklist: WIPE
• :Wash your hands [thus warming them].
Introduce yourself to pt, explain what going to
do.
Position pt [+/- on parent's knee].
Expose area as needed [parent should undress].
• Any unusual behavior.
• If asleep, do the heart, lungs and abdomen
first.
 Pre-exam checklist
• Parent-child interaction, reaction to someone
new walking entering the room (child abuse).

• Ask if tenderness anywhere, before start

touching them.
 Steps in
physical exam

General condition
Vital signs
Anthropometric measurements
Systematic exam
A. General condition

1. Appearance : health, mild / moderate /

severely ill, distressed

2. Consciousness : alert, apathetic, somnolent,

soporous, comatous
3. Color : pale, jaundiced, cyanotic
4. Specific facies: syndromes, facies
cholerica, fish-mouth, facies
leonina, Cooley’s facies
 Cyanosis
• Central cyanosis ( tongue as a slate blue colour)
is associated with a fall in arterial blood oxygen
tension.
Recognised clinically if reduced haemoglobin
> 5 g/dl or O2 sats have dropped below 85%.

• Less pronounced in anaemic child

• DD: severe respiratory disease or cyanotic congenital

heart disease.

• Persistent cyanosis in an otherwise well infant is

nearly always a sign of structural heart disease.
 Cyanosis (2)
• Peripheral cyanosis : is a sign of
decreased peripheral perfusion and not
necessarily hypoxia.
• occur when a child is cold or unwell from any
cause.
 Jaundice
• Yellowish discoloration of skin and mucous
membrane and body fluids (CSF, joint fluid,
cysts) evident as a result of
hyperbilirubinemia with subsequent
deposition of bile pigments in tissue which is
rich in elastin.
 How to examine
• Pre-requisite: Preferably natural daylight
(may not be detected in artificial light)
• Sites:
Upper bulbar conjunctiva (sclera)
Palate
Under surface of tongue
Palms and soles
General skin surface
Assessment of jaundice in neonates
• Press the skin against bony surface for 5
seconds to blanch the skin and observe the
skin color. Gently press over forehead or
chest.
B. Vital signs

1. Pulse : rate, regularity,

volume, equality
2. Respiration : rate, regularity,
pattern
3. Blood pressure : of 4 extremities
4. Temperature : oral, axillary, rectal

Note: always describe complete pulse & respiration!

C. Anthropometric measurements

1. Body length / height: sitting, standing

2. Body weight
3. Head circumference
4. Arm circumference
5. Abdominal circumference
6. Nutritional status:
W/A, H/A, W/H
plot in standard normal curve (WHO
or NCHS)
Infant and baby scale

47
Body length or height measurement
 Length-for-age GIRLS
Birth to 6 months (z-scores)
3
70 2 70

65
0 65
-1
-2
Length (cm)

60 60
-3

55 55

50 50

45 45

Weeks 0 1 2 3 4 5 6 7 8 9 10 11 12 13
Months 3 4 5 6
Age (Completed weeks or months)
 Weight-for-age GIRLS
Birth to 6 months (z-scores)
3
10 10

2
9 9

8
1 8

0
Weight (kg)

7 7

-1
6 6
-2
5 -3 5

4 4

3 3

2 2

Weeks 0 1 2 3 4 5 6 7 8 9 10 11 12 13
Months 3 4 5 6
Age (Completed weeks or months)
 Weight-for-length GIRLS
Birth to 6 months (z-scores)
14 14
3
13 13

12 2 12

11 1 11

10 0 10

9 -1 9
Weight (kg)

-2
8 8
-3
7 7

6 6

5 5

4 4

3 3

2 2

45 50 55 60 65 70 75 80

Length (cm)
 BMI-for-age GIRLS
Birth to 6 months (z-scores)
22 3 22

21 21

20
2 20

19 19
1
18 18
BMI (kg/m²)

17 0 17

16 16
-1
15 15

14 -2 14

13 -3 13

12 12

11 11

10 10

Weeks 0 1 2 3 4 5 6 7 8 9 10 11 12 13
Months 3 4 5 6
Age (Completed weeks or months)
Head circumference measurement

• The largest of 3 measurementshe

Nellhaus Head circumference chart for Boys ♂
Nellhaus Head circumference chart for Girls
D. Systematic examination

Head and neck

Chest
Abdomen
Genitals
Extremities
Skin, hair, lymph nodes
Neurological
 Head
Examine the head for shape, asymetry
Sutures, Bone defects
Size and tension of fontanelles
Head circumference, rate of growth.
microcephaly, macrocephaly
other visible abnormalities
The hair and scalp should be examined
 Head shape (1)

Normal Head Shape

Head is 1/3 longer than it is wide

Plagiocephaly Head Shape

Head is flat on one side

Head shape (2)
Brachycephaly Head Shape

Head is wider than it is long

Back of head is flat rather than curved

Scaphocephaly Head Shape

Head is long and narrow

Position
 Eye Examination
– Look for palpebral edema, ptosis, exopthalmus
– Examine the conjunctivae for anemia and sclerae
for jaundice and the cornea for haziness and
opacities
– Pupils size and shape, pupil reflex
– Evaluate for strabismus by position of the light
reflex and the cover test. Strabismus is normal
before 4-6 months.
– Look for nystagmus
– Fundoscopic examination
– Visual fields should be tested in all children old
enough to cooperate
Eye abnormality?
 Ears Examination
• Exam position: same as eye, but child faces
the side.
• Check for position (low set ) and shape of
both ears.
• Discharge, canals, external ear tenderness.
• Otoscope to examine ear drums.
• Evaluate hearing.
• The mastoid also need to be checked
 Nose and sinuses

– The nasal examination is performed to

detect deformities.
– Deviation of the septum
– Color and state of the mucosa and
turbinates
– Presence of foreign body
– Examine the sinuses for tenderness
Mouth and throat

– Breath odor
– The color of lips and mucosa
– The condition of teeth, gums (hypertrophy in
phenytoin) and buccal mucosa
– Look for tongue (geographic tounge), palate,
tonsils and pharynx
– Listen to the voice and the quality of cry and
the presence of stridor
Tonsils
 Neck

– Examine for nuchal rigidity

– Swelling
– Webbing
– Lymph node : location, consistency, size,
tenderness
– Thyroid gland
– The position of trachea
 Chest
Inspection
– The general shape (pectus excavatum or pectus
carinatum)
– Abnormal signs : beading (rosary), asymmetry
of expansion
• Asess rate,pattern and effort of breathing
• Identify variations of respiration and signs of
respiratory distress
• Recognize grunting, stridor
 Chest
• Palpation
• Percussion
• Auscultation: breath sounds in children are
usually bronchovesicular. Recognize : wheezing,
crackles and asymmetric breath sounds
Breath sounds
 Cardiovascular system:
• Inspection : Precordial bulge, apical heave.
– Palpation: apex beat : in the 4th intercostals
space in the midclavicular line in children < 7
years ; after that apex : the 5th ics. Thrill ?
– Percussion
– Auscultation: heart sound, murmur
– Note the effect of changing of position and
exercise on the murmur. Splitting of the 2nd
heart sound is common in normal children
 Heat sound
• S1
• S2
• S3 a common finding in children and young
adults. Can be heard at the apex, due to
vibrations in the ventricle as it fills rapidly
during diastole.
• S4 abnormal finding, decreased ventricular
compliance e.g. CHF
Heart Sounds
 Abdomen (1)

• Inspection:
– Shape: Distension, Scaphoid abdomen,
– Visible swellings, hernias.
– Umbilicus, veins.
– Visible peristalsis.
• Auscultation:
– Bowel sounds.
 Abdomen (2)
• Palpation:
– Masses.
– Areas of ternderness, rebound, guarding.
– Liver, spleen: <6 years may palpate up to 2cm
below costal margin.
– Kidneys, bladder.
• Percussion :
– Fluid wave, shifting dullness.
– Liver, spleen.
Penyebab hepatomegali

• Infeksi : hepatitis, malaria

• Hematologi : thalassemia,
leukemia
• Jantung : gagal jantung
• Metabolik : glycogen
storage diseases
 Genitalia
• Recognize genital abnormalities in a boy :
cryptorchidism, hypospadias, phymosis,
hydrocele
• Palpate the testes

• Recognize genital abnormalities in a girl:

signs of virilization, labial adhesions and
signs of injury
 Back
Inspection and palpation:
Posture : lordosis, kyphosis, scoliosis
– Masses
– Tenderness
– Limitation of motion
– Spina bifida
 Anus
– Patency (imperforated anus)

– Presence of fissure, fisulae or hemorrhoids

– Rectal examination if indicated

 Musclo-skeletal system
• Assess symmetry of length and size.
• Observe shape of bones, temp, and color.
• Observe for bowlegs: space b/t the knee more than
5 CM. should disappear after 2-3Y.
• Inspect for knock-knee: from 2-7Y, and distance
between two ankle should not exceed 3 CM.
• Palpate for presence on edema.
• Assess muscle strength and muscle tone estimation.
• Always examine for congenital dislocation of
the hip in infants
 Extremities (1)
• Examine the hips of a newborn for congenital
dysplasia using Ortolani maneuvers
 Extremities (2)
• Identify age-related changes in gait
• Identify age- related variations ,tibial
torsion,genu valgus,flat feet
 Neurological Examination
– Observation
– Mental status
– Cranial nerves
– Cerebellar function
– Motor system
– Sensory system
– Reflexes-primitive (neonatal reflexes, deep and
superficial reflexes.
 Neurologic (1)
• Abnormalities during play.
• Limbs: movement, tone, limp, Gower's sign.
• Head control.
 Neurologic (2)
• 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.
Moro reflex
 Neurologic (3)
• Meningitis signs if indicated: Kernig,
Brudzinski.
Clubbing
• widening and thickening
of the ends of the fingers
and toes,
• as well as by convex
fingernails and
• loss of the angle between
the nail and nail bed
 Use of stethoscope

Use binaural stethoscope

 Bell-shaped side: for low & medium
pitched sounds
 Membrane (diaphragm): for medium to
high pitched sounds
For heart exam
 use bell-shaped side first
 start without pressure, then with pressure
 End with diaphragm side
 Common mistakes in
performing examination
History
Fail to identify the patient first
Make an incomplete history
Provide a disorganized history
Physical exam:
Fail to describe general condition &
vital signs first
Incomplete description of features, e.g. pulse
rate only or respiratory rate only without
further characteristics
How can you be a good
examiner?

THINK,
PRACTICE,
PRACTICE,
PRACTICE
!!!
Thank you