Pediatrics_history and examination

Thursday, 23 February 2023 9:32 PM

Demographic
1. Name
2. Birth order Growth charts
3. Age • <5yr —> WHO charts
4. Sex • >5y —> IAP charts
5. Education
SAM: any 1 criteria
6. Address
1. MUAC < 11.5
7. Date of admission
2. Weight for height < 3 SD
8. Date of examination
9. Informant 3. Bilateral pedal edema
10. Reliability
Respiratory
Chief complaint • More than >_2 pneumonia in year month is
recurrent
Treatment of pnemonia
HOPI
• If not severe and can discharge: amoxicillin
1. Site
• If require hospitalisation: IV ampilicillin and
2. Onset
3. Character gentamycin
4. Radiation Signs of pneumonia
5. Associated symptoms • Fever:
6. Time • Tachypnoea: most sensitive
7. Exacerbating/relieveing • Chest retraction: most specific
• Dd viral with bacterial RTI:
8. Severity
a. Bacterial
9. Variation
i. Toxic look
a. Postural
b. Diurnal ii. Less systemic manifestation
c. Seasonal iii. No prodromal symptoms
b. In viral
Treatment history i. Px can be active
• Blood transfusion ii. Systemic manifestation like myalgia,
• Hospital admission previously vomiting
iii. Prodromal symptoms present:
Past history corhyza, rhinitis, malaise
Renal
Birth history • Nephrotic
1. Antenatal • Onset
a. Antenatal visits § Nephrotic: within 2-5 yrs after birth
b. IFA and Ca tablets § Nephritic: 5-15 yrs
c. USG done? Any findings? § If onset before 1 yr —> suspect genetic
predisposition
2. Natal
a. Place of delivery • Development: gross motor will be affected
b. Vaginal/c-section due to repeated hospital admission
c. Baby cried • Birth history
d. Any treatment • Decreased liquor(if kidney disease)
e. Breast milk initiated when • Cried at birth(lung activity related to
f. Birth weight oligohydramnios)
• Pallor(bc decreased erythropoetin)
3. Postnatal
• Edema
Immunisation history • PR, RR increased
• Appropriate vaccination up to age • High weight(bc fluid retention), low height
Leukemia
• Two types: adequate and complete? Neonatal history and examinaton
• Swelling size pea, lemon, progressive
• Additional vaccines(in case of splenectomy)?
Demographic
Developmental history • Other normal demographic factors
• Development was adequate in all domains • Tell gestational age
• Or else deficient in which domains a. Early term: 37wk to 38+6
• Development quotient: observed age of attainment/average age of attainment * • Birth weight
100; <70% is significant • Growth status: Small/large for gestational age?
1. Gross motor ○ Use growth charts
a. 5 months: rolls over § On x axis weeks
b. 6 months: sit in tripod fashion § On y axis weight
c. 15 months: walks without support § Bw 10th and 90th centile is appropriate
d. Runs at 18 months • Sex
2. Fine motor: • Singleton
a. 4 months: Unidextrous grasp • Inborn: born in this hospital vs outborn(born outside)
b. 6 months: bidextrous grasp • How many hours old: up to 96 in hours
c. 15 months: imitates scribbling • Ideal time for delivery is 39wk to 40+6
3. Social:
a. 2 months: social smiles Chief complaints/concerns of mother
b. 3 months: recognises mother
c. 12 months: comes when called HOPI
d. 18 months: copies household tasks • Problems within the 1st week mostly linked to antinatal period hence start HOPI
4. Language: from antenatal period
a. 6 months: monosyllables ○ Almost full history
b. 9 months: bisyllables ○ Ask about usg scans
c. 12 months: 1-2 words • If the problems start late(eg 28 days) then can start with" was apparently
d. 18 months: 8-10 months normal..."
e. 2 years: 2-3 word sentences • Talk about delivery(natal period)
5. Vision and hearing ○ Induction of labour with oxytosin causes abnormal Uterine contraction
hence can lead to Fetal bradycarida
Personal history • Talk about breastfeeding
• Sleep ○ When was first time
• Vegetarian/non-vegetarian ○ Frequency of feeds
• Bowel and bladder movement § 7 to 8 times is good
• Addiction ○ Pre-lacteal feed?
○ Any other food given
Diet history ○ Adequate feeding
• Up to 1 yr: 100kcal/kg/day
§ Stops crying after feeding
• 1 yr to puberty: (age-1)*100 + 100kcal/kg/day
§ After birth 5 to 10 percent wt loss by day 5 or 6
Family history
• Neonatal jaundice
1. Nuclear/joint family
○ If severe can lead to bilirubin induced neurological dysfunction(BIND) and
2. Non-consanguineous marriage
eventually kernicterus
3. No. Of members
○ Negative history
4. Family history of significant disease?
§ H/o hemolytic anemia, gallstones
○ Bilirubin is a good antioxidants which is why physiological jaundice is okay,
Socioeconomic history
but sometimes it becomes extra
States of neonates
Examination
1. State 1: deep sleep(NREM)
• Conscious
a. Eyes closed
• Don't say oriented to time place person if baby cannot speak
b. No limbs movement
• Active, crying, position in mothers lab
c. Normal breathing
• Cannula, ecg leads, ryles tube, chest tube
2. Sleeping but lightly active(REM)
• well nourished, no gross deformities,
a. Occasional limb movements or ye movements
3. Calm
Vitals:
a. Awake
1. Temperature
b. No limb movements
○ More than(core temp) 100.4 degree Fahrenheit or 38 Celsius is fever 4. Slight movement
○ Axillary is 1 degree lower than core, but same cut off hence 99.4 Fahrenheit a. Awake and moving limbs
or 37.4 celcius
5. Crying
2. Pulse:
• State 3 and 4 are best for cns examination
○ Rate: • State to state variability is healthy
Preterm neonate 120-160
Term neonate 100-140 Examination
1. Colour
§ 1month to 1yr 100-120 2. Breathing
1-5 yr 90-110 • Colour and breathing for respi
3. Posture and movements(for cns)
5-10 yr 80-100
Vitals
○ Rhythm 1. Temp: most imp bc hypothermia risk
○ Volume ○ Axilla: tip in roof of axilla
○ Character: abnormal is collapsing pulse etc ○ 36.5 to 37.5 is normal
○ Radio-radial delay, radio-femoral delay(in neonates) 2. Pulse
○ Peripheral pulses: Dorsalis pedis a. Radial or brachial
b. Check femoral also for coarctation of aorta
3. Respiration 3. Resp rate
○ Take for 1 min bc breathing can be irregular pattern a. Check for 1 min bc varian of rate
○ Rate b. Normal is 30 to 60 for newborn
i. Less than 2 months: should be less than 60 4. Cappilary refil time
ii. Bw 2 months and 1 yr: should be less than 50 a. Check in sternum
iii. Bw 1 and 5 yr: should be less than 40 b. Not fingers bc if hypothermia
iv. 5-10 yr: less than 30 5. SpO2
○ Character: periodic, Cheyne stokes a. Check preductus(structures before ductus arteriosus)
○ Retractions § Structures by common carotid
○ Accessory muscles: scm during inspiration □ Nose
○ Flaring of nasal alae □ Ears
4. BP □ Lips
○ Cuff at level of heart, right arm, sitting § Left subclavian may be just at ductus hence left limb not used to
○ 5th centile: 70 plus age×2 is the 5th centile of systolic check
§ Less than 5th centile is hypotension b. Check post ductal
○ Normal: 90 + agex2 ○ Both should be above 95%
○ 95 percentile to 95 percentile + 12mmg: stage 1 hypertension ○ Difference bw the 2 should be less than 3%
○ Above 95 percentile + 12mmg: stage 2 HTN
○ Pulse pressure:
○ If hypertension, check 4 limb BP
5. Sp02
○ Normal is 100
○ Above 95 is normal
○ Less than 90 is severe distress
○ After birth 60 is normal
○ Can use extremities, but if they are cold can use ear lobe
6. Capillary filling time
○ Press on sternum(neonates) and for 3 seconds(children) and refill should
occur in less than 3 seconds
7. JVP

GPE
1. Pallor
a. Sites: lower conjunctiva, palms, nail beds, tongue(dorsum)
b. Comment if mild moderate severe
• Severe if even palmer crease becomes pale
c. Normal Hb
i. 11: in 6 months to 5 yr
ii. 11.5: Till 11 yr
2. Icterus
a. Bilirubin more than 2 can be seen as icterus
b. Upper sclera: seen easily bc white background, connective tissue
c. Can be checked at lower tongue

3. Cyanosis
a. Hb has to be more than 5 for cyanosis to be seen
b. Central cyanosis
i. O2 Saturation below 85%
ii. More problematic
iii. Oral mucosa, tongue lips
c. Peripheral cyanosis
i. Nail beds
§ If found, warm the area and recheck

4. Clubbing
a. Proliferation of soft tissue due to hypoxia
b. Schamroth window test
c. Grading
i. 1: check fluctuation at nail base, if present it will fluctuate
ii. 2: levibond angle obliterated
iii. 3: parrot beak appearance
iv. 4: hypertrophic osteoarthropathy
d. Causes
i. Lung cancer, Lung abscess, Cystic fibrosis, Tb
ii. Cyanotic heart disease, IE
iii. CLD, liver abscess, liver cancer
iv. Mcc of single finger clubbing is trauma
e. Differential clubbing
i. Diff bw clubbing in Limbs
ii. Coarctation of aorta, pda reversal

5. Lymphadenopathy
a. Areas
i. Cervical and axillary more than 1 cm, inguinal more than 1.5cm
ii. Submental, submandibular, preauricular, post auricular, occipital,
upper cervical(in front of SCM, tilt head towards the examining side to
loosen SCM), middle cervical(below upper), lower cervical, post
cervical(behind SCM)
iii. Axillary:
• Size: pea shape, lemon
• Firm consistency
• Smooth surface
• Mobile
• No tenderness
• Pus point
• Matted: cannot demarcated separate lymph nodes
6. Edema
a. For pitting press for 30 seconds and should be pitted for at least 10 seconds
b. Pitting
c. Non-pitting
i. Hypothyroidism
ii. Advanced filariasis

Anthropometry
• 85, 35 is 1 SD
• 3, 97 is 2 SD
• In head circumference +2 to -3 SD is cutoff, in rest it is +2 to -2 SD
1. Height
2. Weight
3. BMI
4. MUAC(upto 5 yr) < 11.5 is SAM
5. Head circumference: less than -3 SD
6. Chest circumference
7. Terms
a. Stunting
i. Moderate: -2 to -3 SD
ii. Severe: less than -3 SD
b. Weight for height: acute malnutrition, wasting
c. Height for age: chronic malnutrition, stunting
d. Weight for age: underweight, acute or chronic
e. Short stature
i. Familial: height for age is less than 3 centile but is within range of
midparental height
ii. Constitutional
• Types
1. Proporionate
2. Disproportionate:
a) Upper segment short: spondyloepiphyseal dysplasia,
mucopolysaccharidosis, potts spine
b) Lower segment: rickets, achondroplasia
• Normal: at birth 1.7, then decrease by 0.1 to 7 years

Head to toe examination

1. Cranium: normal shape and size
a. No soft swellings
i. Caput succedaneum: cross suture lines
ii. Cephalhematoma: doesn’t cross suture lines
b. Fontanels
2. Face
a. facies
i. Characteristic facies: mongoloid(down), elfin(william), moon(cushings)
b. Hair:
i. Dense or sparse
ii. Strong or easily pluckable
§ Flag sign: alternately pigmented and depigmented hair in malnutrition
§ Kinky hair: menke’s disease
§ Low posterior hairline: turner syndrome
c. Oral cavity
i. Tonsils: hypertrophy, membrane
ii. Palate: cleft, high arched
iii. Tongue: macroglossia, microglossia
iv. Mouth: retrognathia, micrognathia
v. Teeth: hypodontia, andontia
d. Forehead
i. pointed forehead is suggestive of trigonocephaly and midline brain
defects
ii. Vertical height of the forehead is increased in hydrocephalus,
iii. narrow forehead due to a low frontal hairline is present in Hurler
syndrome
3. Eyes
a. Test the functions of the extraocular muscles
b. light reflex
○ Placement: hyper/hypo telorism
○ Slant and palpebral fissures
4. Ears
○ Low set
○ Microtia
5. Nose
○ Size: small in trisomy 18
○ Nasal bridge depressed in syphilis, down syndrome, hurler syndrome
6. Neck
○ Stiffness: meningitis, tetanus
○ Swelling: cystic hygroma, LN, thyroid
7. Hands feet and limbs
• Size and shape: eversion, equinus, rocker bottom feet, club foot
• Color of palms and soles: hand-foot-mouth disease, raynaud phenomenon,
jaundice
• Rash
8. Skin
• Pigmentation, scars, rash, hemorrhages
9. Genitalia
a. Testis
i. Presence of testis in scrotum: undescended genitalia
ii. Size: large in fragile X
iii. Urethra: hypo or epispadiasis
b. Girls
i. Breasts: sexual maturity

Systemic examination

Resp examination
1. Inspection
a. Patency of nares, flaring
b. Nasal septum deviation
c. Nasal polyps
d. Scars on chest
e. Distended veins
f. B/l equal rise
g. Trail sign: the side where trachea deviates, that side SCM will become more
prominent
h. Retractions: indicates difficulty breathing
§ Subcostal
§ Substernal
§ Intercostal
§ Suprasternal
§ Supraclavicular
i. Chest shape and symmetry
§ Elliptical is normal
§ Barrel shape: air trapping: untreated asthma
§ Flattening: vol loss: collapse
j. Apex beat
2. Palpation
a. Chest expansion
b. Trachea position
c. Tactile fremitus
d. Apical impulse
3. Percussion: all chest areas, compare to opposite side
4. Areas of auscultation
• Move in z pattern: compare with contralateral side immediately
a. Supraclavicilar
b. Infraclavicular
c. Mamillary
d. Inframammary
e. Axillary
f. Infraxillary
g. Suprascapular
h. Interscapular
i. Infrascapular
• Vocal resonance
§ Bronchophony: voice of the bronchus where spoken voice is heard
loud (near the earpiece of stethoscope) but not very clear.
§ Egophony
§ Whispered pectorileqy: whispering pectoriloaay, the whispered sound
is also heard clearly (not otherwise heard over normal lung tissue).
5. Breath sounds
○ Bronchial: inspi and expi equal or expi longer and pause in bw
i. Cavernous: if cavity
ii. Amphoric: bronchopleural fistula
iii. Tubular: consolidation
§ In consolidation
§ Normally up till 2nd ics
○ Vesicular: inspi more than expi and no pause
○ Adventurous breath sounds:
i. crackles/crepitus: popping effect
1) Coarse: pneumonia
2) Fine: Interstitial lung diseases
ii. Strider Nutritive value
iii. Wheeze: Item Kcal Protein
Rice(100gm or 1 katori) 110 2
CNS examination
1. Higher mental function Roti 85 3
• Consciousness Dal(1 katori) 125 7
A. Fully conscious: alert, aware of surroundings Sabsi(green leafy)(1 katori) 130 2
B. Lethargy: arousable, not alert
C. Drowsiness: arousible by verbal stimuli • Potato sabsi(1 katori) 130 2
D. Stupor: sleeping but arousable by painful stimuli Biscuit(100g) 450 6.4
E. Coma: not arousable
Milk(250ml)(1 glass) 212.5 9
• Orientation
• Memory Chai(100ml) 100 3.6
1. Immediate Fruit 80 1.1
2. Recent
3. Remote Egg 80 6
• Speech
A. Aphasia
B. Dysarthria
• Intelligence
• Attention
2. Cranial nerve
a. Olfactory
b. Optic
A. Visual acuity: keep something some distance away
B. Field of vision: sit in front of child and close eye of mirror image and
then move finger away from midline
C. Colour vision
D. Pupillary reflex
c. CN 3,4,6: make H in front of the child’s face
d. CN 5:
A. Sensory: touch face
B. Motor: open jaw or clench
e. CN 7: puff mouth, close eyes,
A. UMNL: bilat supply
B. LMNL: unilat supply
f. CN 8: rinne, weber
g. CN 11: shrug
h. CN 12: protrude tongue
3. Motor system
a. Bulk
b. Power
1. Zero: no movement
2. One: slight movement
3. Two: movement without gravity
4. Three: movement against gravity, but not against resistance
5. Four: movement against resistance
6. Five: normal
c. Tone
A. Rigidity: non-dependant on speed, extrapyramidal lesion
1) Cog-wheel
2) Lead pipe
• In agonist and antagonist
B. Spasticity: increases with speed, but after a point lets go(clasp-knife),
pyramidal lesion
• Affect upper limb flexors
• Lower limb extensors
C. Hypotonia: cerebellar
d. Reflexes
A. Superficial
1) Plantar
2) Cremasteric
3) Anal
4) Abdominal
B. Deep tendon reflexes
1) Biceps
2) Supinator
3) Triceps
4) Knee
5) Ankle
4. Sensory
a. Touch
b. Pain
c. Temp
d. Vibration
e. Stereognosis
f. Proprioception
g. Romberg test
5. Autonomic examination
6. Cerebellar sign
a. Slurred speech
b. Nystagmus
c. Dysdiadokokinesia:
d. Finger to nose test:
e. Heel shin test
f. Gait: swaying gait, tandem walking
• Make Px walk on a straight line
g. Intention tremor
h. Hypotonia
7. Signs of meningeal irritation
a. Neck rigidity: touch chin to sternum
b. Kernig(K for knee): flex hip and knee, on extension of knee there is pain
c. Brudzenski: on flexing neck legs semiflex
d. Benda sign: move chin towards one and the opposite shoulder will lift up
8. Skull and spine

Abdominal
1. Inspection
• 9 regions of liver
a. Shape
A. Full and Distended: ascitis, gross organomegally
B. Localised swelling: small bowel obstruction, organomegally
C. Scaphoid: malnourishment, CDH
b. Abdominal movements
A. With inspiration it rises bc of diaphragm
1) If diaphragmatic paralysis then it will not expand on inspiration
c. Umbilicus position and shape
A. Everted: if abdomen is grossly dilated
B. Transverse: abdomen dilation
C. Umbilical hernia
d. Scars
e. Dilated veins: portal hypertension, venous obstruction
f. Peristalsis
• Normally not seen
• Normal direction is left to right
g. Pulsations
• If RVH then epigastric pulsations
h. Groin and scrotum
• For hernia
2. Palpation
a. Superificial/light
A. Local rise of temperature
B. Tenderness
C. Rebound tenderness: sign of peritonitis
D. Guarding: not allow to touch
• peritonitis
E. Rigidity: muscles contract on palpation
• peritonitis
b. Deep
A. Liver
• With inspiration move hand a little forward and with expiration
feel the liver
• Percussion
1) Size: how much palpable below right costal margin
• Normally not palpable
2) Span: distance bw upper and lower border
• Upper border detected by percussion
3) Surface
a) Nodular: cirrhosis, cancer
b) Smooth: portal HTN
4) Consistency
a) Hard: malignancy
b) Hepatitis: soft
5) Margins and tenderness
a) Smooth: normal liver
b) Sharp and Leafy: cirrhosis, cancer
• Tender in: hepatitis, CHF, abcess
B. Spleen
• Keep hand on abdomen in right iliac fossa, with fingers pointing
towards, move forward with expiration
• Keep left hand at 10,11,12 posterolat ribs to give support
• Normally not felt at all
1. Spleen tip
2. Size
a) Mild: just tip palpable or 2cm below subcostal margin
diagonally
b) Moderate: 3-7cm
c) Severe: >7cm, crossing midline
3. Notch
4. Consistency
a) Soft: enteric fever
b) Firm: hemolytic anemia
5. Tenderness
3. Percussion
a. Puddle sign
• Min 120ml required, minimal fluid
• Prone position for 5 min, put in knee-elbow position, percuss at
umbilicus
b. Shifting dullness
• Moderate fluid, 1-1.5 litre in adult
• Px in supine, percuss midway between umbilicus and
xiphisternum(plexor, pleximeter), and move laterally in both directions
while percussing
• Normal: Tympanic everywhere
• Fluid present:
1. tympanic in the middle and dulness on moving laterally: note
point of transition
2. After shifting to 1 side: at the point of transition tympanic
c. Fluid thrill
• Severe fluid accumulation
• Supine, keep 1 hand at one side flank and flick at the other side and
should feel vibration while keeping an assistant’s hand in the middle
4. Auscultation
a. Bowel sounds
• Normal is 3/min
b. Renal bruit: lumbar region

CVS examination
1. Inspection
• Chest shape
• Apex beat: where, diffuse(if LV behind RV), heaving(AS),
hyperdynamic(increased vol), tapping(MS,
• Visible pulsation
• JVP
2. Palpation
• Apical impulse
○ Heaving: pressure overload, AS
○ Hyperdynamic: vol overload, AR
○ Tapping: low output: MS
○ First keep hand, localise to ulnar border and then fingertip
• Thrill
1. Pulp of fingers: palpable heart sound, apical impulse(shocks)
2. Thrill(palpable murmur): lower fingers
3. Heave: base of hands
3. Auscultation
• S1S2 etc S3 S4
• S1 soft or loud
• S2 soft loud, splitting

Mohit sharma a 7 year old firstborn child,product of non-consangioneous marriage, with

smooth parinatal transition, supervised pregnancy, immunization till age, development
appropriate for age presented with the chief complaints of:
• Imp negative history
• 1 line from each