History and

Examination

Abbas Mohammad A .A .J
 This book created by Abbas Mohammad A .A .J with help dr. Hussein Ali and DoCray A.sabah student at thi-qar university collage
of medicine

For any information or feedback, please tell us :

https://www.facebook.com/abbas.mohammad.104

5/8/2018
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 History
 Personal history (identity)
 Name of pateint
 age of patient
 Address of patient
 blood group of patient
 Blood group of parents
 name of next of kin
 Source of history (person who give you the information’s)
 date of administration

 Chief compliant
Main problem brought the patient to hospital. For example:
 Abnormal body movement
 Frequent bowel motion
 Raised body temperature
 Vomiting
 Crying

 Presenting of illness
‫في هذا الجزء تذكر االحداث من بدايه ظهور االعراض الى لحظه تواجدك امام المريض وكذلك‬
‫بعدها تقص القصه من لحظه خروج المريض ألجل‬.. ‫تذكر االعراض المرافقه وتحليل كل واحده‬
‫يعني تذكر شنهي راجع اول مره ( مركز صحي اوعياده خاصه او‬.. ‫المراجعه الى هذه اللحظه‬
‫الخ‬...‫طورائ‬
‫وكذلك يجب ذكر كل اجراءه تم اتخاذه للمريض في هذه االماكن من فحوصات وعالج وتشخيص‬
‫وشنهي نوع‬.. ‫وهل من العياده الخاصه او المركز الصحي تحول الى مستشفى عام ألجل الدخول‬..
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 ‫السياره الي تحول بيهه يعني سياره اسعاف (تدل على انها حالة طارئه ) او سياره خاصه‬

‫‪During administration:‬‬
‫وهذا جزء من ال‬
‫‪presenting of illness‬‬
‫وتسأل عن كل اجراء تم اتخاذه للمريض اثناء فتره دخوله للمستشفى من تحاليل وادويه‬
‫وتشخيص‬

‫‪Only calcium and‬‬

‫في أي حالة يرافقها فقدان للسوائل‬ ‫‪sodium deficiency‬‬
‫‪Fluid loss‬‬ ‫‪cause abnormal body‬‬
‫‪movement.‬‬
‫يجب السؤال عن ال‬
‫‪Potassium not cause‬‬
‫‪Urine output and if there is any abnormal body movement‬‬
‫( ‪because urine output decrease with dehydration and‬‬
‫‪abnormal body movement due to electrolyte disturbance‬‬
‫وبما انه‬
‫في اي مرحلة من مراحل‬
‫‪Urine output‬‬ ‫الهستري عندما يذكر‬
‫المريض انه قد اخذ‬
‫يجب حسابها خالل اربع وعشرين ساعة فقد ال تعرف األم كميتها لذلك اسأل عن‬ ‫عالج ال داعي لذكر اسم‬
‫‪ Number of napkins changed daily‬‬ ‫او شكل او جرعة العالج‬
‫‪ Color of urine‬‬ ‫وانما تقول‬
‫‪In dehydrated patient the urine concentration increase‬‬ ‫‪The patient take‬‬
‫‪so become deep yellow‬‬ ‫‪medications‬‬

‫يجب ان تسأل عن التالي‬

‫من باب حدث العاقل بما ال يعقل فأن صدق فال عقل له ‪ ،‬اذا كان عمر الطفل‬
‫صغير بحيث ال يتكلم ‪ ،‬ال يجوز ان تذكر ان هناك ألم الن األلم ال يشعر به اال‬ ‫‪ Physical activity‬‬
‫المريض حتى وان أم الطفل تقول ان طفلها يعاني من الم يجب ان تسألها كيف‬ ‫‪ Feeding‬‬
‫عرفت مثال تقول انه يبكي كثير ‪.‬هنا ال تقول الم وانما‬ ‫‪ sleeping‬‬
‫يعني هل حركة ونشاط الطفل قل وكذلك‬
‫‪3‬‬

‫‪The patient is carrying A lot‬‬

‫‪Page‬‬

‫هل اكل او تغذيه الطفل قلت خالل فتره ال‬

‫‪Presenting of illness‬‬
 ‫وآخر شيء تختم ب ذكر حاله المريض هل تحسن كلش او قليل (يجب ذكر التغير في األعراض مثال‬
‫الحرارة انخفضت ولكن التقيؤ الزال مستمر وهكذا‬

‫مختصر ال‬
Presenting of illness
 Analysis of chief compliant
 Analysis of associated symptom
 Ask about physical activity and feeding
 During first consulting
 Referral
 During admission
 Patient condition now

 Review of systems
‫ االشياء التي يشعر بها المريض نفسه فقط‬.‫من باب حدث العاقل بما ال يعقل فأن صدق فال عقل له‬
‫بحيث ال يمكن مالحظتها على الطفل يجب ان ال تسأل عنها في هذا الجزء اذا كان عمر الطفل ال‬
‫يمكنه من الكالم اال اذا كان الطفل بعمر يسمح له بالكالم‬
‫هناك نوعين من األعراض‬

 Positive related symptoms : the symptoms in review of system that are related to
the patient condition
‫األعراض التي لها عالقة بحالة المريض مثل‬
Vomiting in case of abnormal body movement )vomiting cause
)electrolyte disturbance
‫هذه االعراض حتى وان لم توجود يجب ذكرها‬
 Negative related symptoms: the symptoms in reveiw of system that are
not related to case
‫االعراض الغير متعلقه بحالة المريض مثال‬
Constipation in case of abnormal body movement
‫وهذه االعراض اذا كانت غير موجودة ال داعي لذكرها‬
Gastrointestinal tract
 Vomiting
 Diarrhea
 Constipation
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 Hematemesis
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  regurgitation
 Blood per rectum
 Melena
 Jaundice
 Abdominal distention

Cardiovascular system
 dyspnea
 syncope
 leg edema
 central cynosis
 Peripheral cyanosis
 Generalized edema
 Finger clubbing Negative related symptoms if not
present you mention them only as
Respiratory system "unremarkable" while the positive
 Dyspnea related symptoms if not present you
 Cyanosis should mention each one by its term
as “no...”
 Cough
 Wheezing
 Hyperventilation
 Apnea
 Stridor
 Finger clubbing

Central nervous system

 seizure
 paralysis
 tremor
 coma
 Abnormal body movement
 aphasia )dysphasia(
 Vision
 Hearing

Musculoskeletal system
 muscular wasting
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 joint swelling
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 joint deformities
  Muscle weakness
Genitourinary system
 Haematuria
 polyuria
 frequency
 color of urine

Skin
 skin rash
 erythema
 bruising
 skin ulcer
 scratching

 Neonatal history
Divided 3 parts including:
 Antenatal (prenatal history) : during pregnancy
 Perinatal history : during labor
 Postnatal : first 28 days after delivery

 Antenatal history (prenatal history)

Ask about the following (during pregnancy)
 Maternal chronic & acute diseases
 Maternal fever
 Maternal exposure to radiation as X-Ray
 Antenatal care (regular or no. Number of visiting per each trimester. Site of visiting as
health care center or private clinic ...etc.
 Maternal Vaccinations during pregnancy
 Maternal smoking Antenatal care
 Maternal drug intake during pregnancy
‫معناهه مراجعات األم خالل‬
 Vaginal bleeding or discharge during pregnancy
‫يجب ان تسأل اذا كانت‬. ‫الحمل‬
 Maternal Hematological disorders
‫وشكد الفترة بين‬. ‫منتظمة او ال‬
 Getting folic acid during pregnancy or no ‫مراجعة واالخرى اذا كانت‬
‫اما اذا كانت غير منتظمة‬.‫منتظمة‬
 Two or more visiting per each trimester 👉 good ‫ف على االقل اسأل كم مراجعة‬
antenatal care ‫في كل‬
 One visiting per each trimester 👉 fair antenatal Trimester
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care
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 Less than one visiting per each trimester 👉 poor

antenatal care
  Perinatal history
Ask about the following:
 Type of delivery (vaginal or caesarian section or assisted delivery by instrument )
Do not mention that the type of delivery is “normal vaginal delivery” unless all of the following are
present:
 Term
Gestational ages
 37 - 40 weeks 👉Term
 40 - 42 weeks 👉 postdate
 More than 42 weeks 👉post term
 34 - 37 weeks 👉preterm
 32 - 34 weeks 👉 moderate preterm
 28- 32 weeks 👉 extremely preterm
 Spontaneous delivery (not induced or assisted delivery )
 Alive baby
 Cephalic presentation (baby come on his /her head)
 Single

If one or more of these conditions do not present you, mention only

"" Vaginal delivery "" then the abnormal condition as breech presentation or preterm
 Mode of delivery
I. Precipitated or induced delivery (may be associated with asphyxia)
II. Assisted delivery (by vents or forceps)
III. Spontaneous
 Fetal birth weight (normally 2.5 - 4.5 kg but average is 3.5 kg) and length (normally 50 cm)
 Less than 2.5kg 👉 low birth weight
 Less than 1.5kg 👉 very low birth weight
 Less than 1kg 👉 extremely low birth weight
 Apgar score if possible
Apgar score measured three times:
 Immediately after delivery
 In the 5th minute after delivery High birth weight
occur in diabetic
 In the 10 minute after delivery
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mother
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  Duration between rupture of membrane and delivery (normally less than 18
hours. Duration more than 18 hours associated with high risk of neonatal
sepsis )
 If the neonate has get tactile stimulation
 If the baby required restoration including :
 Positive pressure ventilation
 Endotracheal intubation
 Oxygen mask

 Onset of first feeding and type of feeding. Normally

• Feeding immediately after vaginal delivery
• Feeding immediately after recovery from anesthesia after C.S

 Onset of first bowel motion (meconium ) and urination and first carrying .Normally
 Bowel motion within first 72 hours(if delay may be due to hypothyroidism)
 Urination within first 24 hours
 First crying immediately after delivery
 If the newborn admitted to NICU or not .if he/she admitted , mention the cause ,
duration , drugs and investigations done during admission, baby condition when
he/she is discharged from NICU

 Postnatal history
Ask if the baby admitted to NICU or not .if he/she admitted, mention the cause, age, duration,
drugs and investigations done during admission, baby condition when he/she is discharged from
NICU
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NICU = neonatal intensive

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care unit
  Past medical history
If the baby has previous same condition or previous medical problem, hospital admission (cause,
age, duration, medications, investigations)
The important diseases in past medical history including:
 Fever
 Diarrhea
 Skin rash
 Vomiting
 Jaundice
 Infectious disease

 Feeding history
There are three types of feeding
1. Breast feeding
2. Bottle feeding
3. Dieted feeding

Breast feeding
Ask about the following:
 If the feeding on demand or schedule
‫يعني هل األم ترضع طفلها حسب جدول او متى ما احتاج الطفل‬
 Duration of nursing (normally more than 5 minutes)
 Frequency of nursing
 Using of single or both breasts during the same nursing ( normally use left breast firstly
then right then left again then right again)
 If the baby is given water along with milk (normally not required water until age of ...)
 Signs of satisfaction : including
 Sleeping
 Pass urine or stool on feeding
 Emptying breast of mother
 Weight gain
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 Rejection reflex
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 Differences between breast milk and cow milk

Variable Breast milk Cow milk

Energy Similar to cow milk Similar to breast milk
Carbohydrates Higher Lower
Protein Lower Higher
Lipid Lower Higher
Water Similar to cow milk Similar to breast milk
Calcium Lower Higher
Other minerals Lower Higher
Vitamins Lower Higher
Iron Higher Lower

Advantages of Breast Feeding

 Advantages for mother
 Decreased risk of post-partum hemorrhage
 Longer period of amenorrhea
 Reduced risk of ovarian and premenopausal
Breast cancers
 Reduced risk of osteoporosis
 Enhances mother-child relationship
 Advantage of the ‘breast feeding to society
 Reduce health care costs owing to lower illness in breast-fed infants and reduced
employee absteeism for care attributable to infant illness.
 It is cheap and suitable for poor families
 Advantages of Breast Feeding to Infant
 Provide the ideal nutrition for infants during the first 6 months
 lt is always available at proper temperature and require no time for preparation
 It's sterile
 Has anti-infective properties
 Breast feeding improves cognitive development
Disadvantages of breast-feeding
 Unknown intake of milk volume may cause worriedness to mother
 Transmission of maternal infection to infant
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 Transmission of drugs
 Breast milk Jaundice
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  transmission of environmental contaminants as nicotine ,alcohol ,caffeine
 Less flexible e.g... family members cannot help in feeding , more difficult in public places
Contraindications of breast-feeding
 Maternal infection known to be transmitted through breast milk
 Maternal drugs known to be transmitted through breast milk
 Metabolic disorders in infant as galactoseamia and phenylketonuria
 Sever illnesses in infant as: extreme prematurity, sepsis
,cerebral trauma congenital cardiac lesion, cleft palate or micrognathia
 Bottle feeding
Ask about the following:
 Cause of bottle feeding (why not breast feeding)
 Onset of bottle feeding
 On demand or schedule
 Amount of milk (number of unces and scoops)
 Frequency of bottle feeding
 Number of bottles and tits (normally the number of tits is double of number of bottles
 Way of sterilization (normally put the bottle in boiling water for 10 minutes and tits for 5
minutes)
 Source of water used
 The water used is boiled or no
 Signs of satisfaction (same signs mentioned in breast feeding)
Unce + scoop =OZ =20 kcal (energy)
‫كيف تحسب كمية الحليب للطفل في كل يوم (لو سألتك أم شكد انطي الطفل حليب ؟‬
‫الطفل الطبيعي يحتاج طاقة‬
110 kcal /kg/24 hours
Energy per 24 hours = body weight × 110
‫مثال لو كان وزن الطفل عشرة كيلوغرام‬
Energy per 24 hours =10× 110=1100 kcal
Unce water + scoop powder =OZ=20 kcal
‫ يعطي طاقة مقدارها‬. ‫يعني كل خاشوكة حليب ورقم واحد ماء (االرقام على الممية‬
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20 kcal
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 ‫نقسم الطاقة الكليه على عشرين لنستخرج كم رقم حليب يحتاج‬
1100/20 = 55 OZ

‫يعني يحتاج‬
55
‫ نقسم االرقام على عدد الساعات‬. ‫رقم حليب خالل اربع وعشرين ساعة‬
55/24 = 2 OZ/24hours
‫لذلك يتم اعطاء‬. ‫بما انه من الصعب ارضاع الطفل كل ساعة‬. ‫يعني كل ساعة يحتاج رقمين حليب‬
‫الطفل مثال اربع ارقام حليب كل ساعتين‬

Example
Baby of 15 kg body weight. Measure the amount of milk required
Energy = 15 × 110 = 1650 kcal/24 hours
Number of OZs = 1650 /20 = 82 OZ/24 hours
82/24 =3 OZ/hour

 Diet feeding
Types of diet are:
 Solid diet
 Semisolid diet
 Liquid diet

Ask about the following:

 Onset of diet
 Type of diet
 If there is allergy to specific diet

 Vaccination history
Ask about the following:
 If the patient take the vaccines or no
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 If not take vaccines, ask why?

 Ask about any side effects of vaccines (fit , excessive crying , fever )
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 Iraqi schedule of vaccination

Date Vaccines
First 24 hours HBV0 HBV0
1st week BCG , OPV1
2 months Hexa1 , OPV2 ,Rota1 , pneomococcal1
4 months Hexa2, OPV2, Rota2, pneumococcal 2
6 months Hexa3 , OPV3 , pneumococcal3
9 months Measles , vitamin A 100000 units
15 month MMR1
18 months Penta , OPV1(booster) ,vitamin A 200000 units
4- 6 years Tetra , OPV2 (booster ) , MMR2

 BCG = bacillus calmette Guerin (for TB)

 Hexa vaccine = DPT (diphtheria , pertussis, tetanus ) , hepatitis B vaccine , hemophilus
influenza B , injectable polio vaccine
 Penta vaccine = DPT , hepatitis B, hemophilus influenza B
 Tetra vaccine = DPT , hemophilus influenza B
 OPV = oral polio vaccine
 HBV = hepatitis B vaccine
 MMR = measles , mumps , rubella The dose of vaccine is different from booster
Dose: is vaccine itself for individuals who are previously
unimmunized that induce immunity against specific
organism
‫األرقام الصغيرة في‬
‫الجدول تعني رقم‬ Booster: is not vaccine and not induce immunity but it
‫الجرعة‬ strengthens the vaccine in individuals who are previously
immunized

the BCG given in left shoulder which lead to

formation of scar which may appear within
two months (delayed hypersensitivity) .If the ‫اسأل المريض هل يأخذ اللقحات‬
‫ تقول‬، ‫اذا نعم‬. ‫حسب الجدول‬
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scar not appear in more than 2 months this

indicate failure of vaccination ( in history you The patient take his/her
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should search about scar in left shoulder, if vaccines according to

not present , search in right shoulder Iraqi schedule of
vaccination
‫لماذا يتم زرق لقاح ال بي سي جي في‬
‫الكتف األيسر؟‬
‫ فقط من اجل ان يكون شيء‬: ‫الجواب‬
‫موحد في كل البلدان وليس له اي غرض‬
‫يعني ليكون‬. ‫علمي‬
Standard

 Developmental history
First 3 months
 Gross motor
 1st month ➡️ raise the head at the level of body
 2nd month ➡️ sustain the head elevated at the level of body
 3rd month ➡️ raise the head above the level of body , head control
 Fine motor
 3rd month ➡️ plantar grasping
 Vision
 1st month ➡️ follow the objectives in 90° to either side
 2nd month ➡️ follow the objectives in 180° to either side
 Social
 6th week ➡️ smile
6th - 12th month
 Gross motor
 6th month ➡️ sitting without supporting
 7th month ➡️ creeping
 9th month ➡️ standing with hand holding
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 9th - 10th month ➡️ crawling

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 Fine motor
  9th month ➡️ starting on pincer grasping , able to release objectives from hand , wave
bye bye
 11th month ➡️ fully developed pincer grasping
 Speeching
 9th month ➡️ say mama , dada with meaning
 Social
 Stranger anxiety
Second year (12 - 24 month)
 Gross motor
 12th month ➡️ take few steps alone
 18th ➡️ running , climate stairs
 20th month ➡️down stairs
 24th month ➡️ running about (move from save area to dangerous area
 Fine motor
 15th month ➡️ able to put pellets inside bottle , put cube on the top of another
 18th month ➡️ able to out the pellets from bottle , make tower from 4 cubes , drawing
vertical line (I)
 20th month ➡️ draw horizontal line (➖)
 24th month ➡️ make tower from 7 cubes
 Speeching
 18th month ➡️ have 10 words
 23th - 24th month ➡️ joining two words together
Preschool age (3rd - 6th years)
 Gross motor
 3rd year ➡️ alternative movement of lower limbs on ascending of stairs , standing on one
foot
 4th year ➡️alternative movement of lower limbs on descending of stairs
 5th year ➡️ skipping
 Fine motor
 2.5 year ➡️ draw circle (○)
 3 years ➡️ draw plus (+) , draw person with only head , arms and legs
 4 years ➡️draw Rectangular ( ) , draw person with only head, trunk, arms , legs
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 5 years ➡️ draw triangle (🔺️) , draw person with 6 parts of body

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 6 years ➡️ )◇(
  Speeching
 3 years ➡️ make short sentences together
 4 years ➡️ counting for 10
 Social
 3 years ➡️ know his age , know his sex , play with others , controlling of urination
 4 - 5 years ➡️ controlling of dedication

 Past surgical history

Ask if the patient done surgery in past

 Drug history
Ask if the patient take drugs for chronic disease and drug allergy

 Family history
Ask about the following:
 Both parents are relative or no and degree of relative (2nd degree or beyond 2nd degree)
 Age of parents
 Blood group of parents
 Number of babies who they have .mention the age of largest one and youngest one and
order of patient

‫تسأل عن عدد االطفال وعمر أكبر واحد واصغر واحد وترتيب المريض بين اخوانه‬
 Patient's brothers &sisters are healthy or no
 If the mother has history of intrauterine death or early death of babies
 Congenital anomalies in family
 Other chronic disease in family

 Social history
Ask about the following:
 If the parents are smokers, alcoholic
 Water supply: including water for drinking and water for usual uses as washing, cooking,
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showering. ...etc.)
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 animals : including indoor and outdoor animals also the history of having animals
  house details including (area ,owning , poor or good ventilation, poor or good sunlight
exposure , number of rooms ,)

 Important notes
Vomiting
 : Bile stained vomiting is due to
 sepsis which cause paralytic ileus
 Intestinal obstructio
 congenital pyloric stenosis
 :Projectile vomiting is due to
 Raised intracranial pressure
 Intestinal obstruction
 Increase the intraabdominal pressure due to repeated cough as in pertussis
 Vomiting +diarrhea +abdominal distention 👉hypokalemia
 Diarrhea +vomiting 👉decrease urine output due to dehydration
 Projectile vomiting in first day of live 👉congenital pyloric stenosis
 The most common cause of vomiting is viral gastroenteritis )rota virus(
 :Feculent vomiting is due to
 Distal intestinal obstruction
 Colonic obstruction
 Presence of gastrocolic fistula

Bowel motion
 First bowel motion is called meconium
 Delayed meconium passage more than 72 hours then passed spontaneously without
intervention ,This due to hypothyroidism
 : No passage of meconium is due to
a. Congenital rectal Artesia
.b Rectal fibrosis
c. Hirschprung disease (agangloinic colon)
 Acute diarrhea persistent less than 2 weeks while chronic diarrhea
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persistent more than 2 weeks

 Most common cause of diarrhea is viral gastroenteritis (Rota virus)
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  :Differences between viral and bacterial gastroenteritis
Variable Bacterial Viral
Temperature > 38.5 C° Yes No
Bowel motion more than 8 Yes Unusual
times/day
Vomiting Yes Unusual
Duration > 5 days Yes Unusual
Pus and mucus in stool Yes No
Hematochezia (fresh blood in Yes No except in Rota virus
stool)
Abdominal pain Yes Unusual

Febrile Convulsion
 Febrile Convulsion : is non repetitive body movement caused by sudden onset of fever
 The range of age occurrence is from 6 months to 6 years
 Each attack occur once during 24 hours or more but not more than one attack during the
same 24 hours. If it's recurrent during the same 24 hours or when occur focally , it's
called atypical convulsion
 Febrile convulsion divided into :
 Simple febrile convulsions : single attack for less than 15 minutes
 Complex febrile convulsion : multiple attacks for more than 15 minutes
 There are many types of convulsion :
 Tonic : muscular origin
 Clonic : nerve origin
 Atomic : muscular origin
 Wasting syndrome: occur only in infant only at morning
 How you can differentiate between body movement due to clonic convulsion and body
movement due to hypocalcemia?
 Body movement due to clonic convulsion is not stopped by catching by hand while in
hypocalcemia the movement will stopped when you catch the limb of patient by your
hand
 Apnea + tachycardia 👉fit
 Apnea + bradycardia 👉serious condition rather than fit
18

 Convulsion divided into 3 stages :

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 Pre ictal stage (prior to convulsion) : during this stage

  If there is vomiting 👉raised intracranial pressure
 If there is irritable or pallor 👉aura
 If there is fever 👉 meningitis or encephalitis

 Ictal stage (during convulsion)

 Post ictal (after convulsion attack) : during this stage:
 If the patient return normal 👉 convulsion
 If the patient not return normal 👉 meningitis or encephalitis
 If the patient temporary loss of his memory 👉seizure

Dyspnea
 : If it's occur after cessarian section , it's as following
 If the neonates term 👉 it's tachypnea
 If the neonate is preterm 👉it's respiratory distress syndrome
 RDS occur because of decrease alveolar surfactant due to :
 Diabetic mother
 Preterm baby
Dyspnea may caused by diarrhea and vomiting due to acidosis
 Normal respiratory rate in neonate is 60 breath / minute
 : In heridiatary asthma
 If one of parents is affected , 25% of babies will be affected
 If both parents are affected, 50% of babies will be affected

Jaundice
 : The level of bilirubin as following
 Less than 1 mg/dl 👉 normal
 mg/dl 👉 subclinical jaundice 3- 1
 3 mg/dl or more 👉 clinical jaundice
 The jaundice which started at first day 👉 it's pathological
jaundice
 Jaundice that started after 2nd day 👉 it's may be physiological or
pathological
 The most common cause of pathological jaundice )in first day(
: is Rh or ABO incompatibility . As following
 The incompatibility occur when the fetus is Rh positive and mother Rh negative
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  ABO incompatibility occur when the fetus blood group is A or
B )but not AB ( and the mother blood group is O
 The pathological jaundice have one of the following features :
 Developed at first day of life
 Increase level of bilirubin more than 5 mg/dl per day or 0.5 mg/dl per hour
(even when developed after 2nd day )
 Associated with organomegaly as hepatomegaly or
splenomegaly
 Associated with anemia (hemolytic jaundice)
 Bilirubin level more than 12 mg/dl
 Jaundice persistent more than two weeks
 Jaundice due to G6PDD occur only in male because it's X-
linked disease
 The most common cause of physiological jaundice is breast milk which lead to
errageration of enterohepatic circulation and interfere with conjugation of
bilirubin by maternal enzymes
 When the level of bilirubin exceeds 20 mg/dl it lead to
kinecturus )CNS bilirubin toxicity that lead to cerebral palsy
)CP(
 The color of urine and stool change according to the type of
: jaundice
 Increase indirect bilirubin lead to dark color urine and
stool
 Increase direct bilirubin lead to dark urine and pale stool
 In physiological jaundice only indirect bilirubin increase
 Normal urine color is fantyellow while normal color of stool is
yellow
 Jaundice + fever in neonate 👉 it's sepsis )not hepatitis because
the incubation period of hepatitis is more than 2 weeks and
)the neonatal period is the first week
 The management of physiological jaundice is breast feeding
only
 The management of pathological jaundice is phototherapy or
blood exchange

Blood transfusion mean

20

addition of blood while blood

exchange mean completely
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exchange of blood
  : Indications of phototherapy are
 Bilirubin level more than 12.9 mg/dl
 Low level of bilirubin with other symptoms as acute conditions or sepsis
 Premature baby (regardless the level of bilirubin)
 : The side effects of phototherapy are
I. Rash
.II Fever
III. Dehydration
.IV Diarrhea
 : Indications of blood exchange are
a. No response to phototherapy
.b Bilirubin level more than 20 mg/dl
c. Rapid raising in bilirubin level
 Normal amount of blood exchange is 85 C.C /kg
 The blood exchange applied throughout 1- 1.5 hours
 For each 100 C.C of exchanged blood you should add 1 C.C of calcium
 Complications of blood exchange are :
.I Infection
II. Allergy
.III Anemia
 G6PDD is aggrevated by ingestion of face bean but in neonate it's
aggrevated by stressful stimuli as fever , dehydration , drugs as aspirin
or antimalarial drugs )quinine, chloroquine, or antibiotic as sulfonamid
ciprofloxacin ,
 We can suspect the level of bilirubin clinically (not laboratory) as following :
 If the yellowish discoloration only in face , the level of bilirubin is 5
mg/dl or below
 If the yellowish discoloration extended to nipples, the level of bilirubin
is 10 mg/dl
 If the yellowish discoloration extended to involve whole abdominal, the
level of bilirubin is 15 mg/dl
21

 If the yellowish discoloration extended to involve whole body , the level

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of bilirubin is 20 mg/dl or more

  The yellowish discoloration started in sclera

Napkin rash
 May be bacterial or candidial infection
 Candidial infection involve the skin folds and stellelate lesion
 In dermatitis lesions not involve the skin fold but involve areas of
contact )how you can differentiate between candidial infection and
dermatitis
 Gastroenteritis may cause zinc deficiency which lead to development of redness around
anus and mother

Premature delivery
 Causes of premature delivery are :
I. Antepartum hemorrhage (placenta privia , abroptio placenta)
II. Hypertensive disorders of pregnancy (pre-eclampsia, eclampsia
III. Interpregancy duration less than 18 months
IV. Cervical incompetence (weak cervix which treated by cerculage )
 Complications of premature delivery on fetus are :
1. Apical pneumonia (due to aspiration of early feeding
2. Cerebral palsy
3. Learning disabilities
4. Hypothermia (lead to cold injury)
5. In long term lead to intraventricular hemorrhage (Brian hemorrhage)
6. Jaundice
7. Anemia
8. Hernias

Notes about delivery

22

 Obstructed labor or induced labor may cause birth asphyxia

 Birth trauma may lead to Brian injury or brachial plexus injury or shoulder dislocation
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  If the mother has previous 2 caesarian section, the next delivery must be by caesarian
section due to weak cervix
Birth asphyxia
 In birth asphyxia , the Brian injury graded as following :
 Grade 1 👉 no convulsion
 Grade 2 👉 convulsion during first 24 hours
 Grade 3 👉 cerebral palsy

Drugs that are contraindicated during pregnancy are:

 All antineoplastic drugs
 Anticonvulsant drugs as valproic acid and phenytoin
 ACEIs (angiotensin converting enzyme inhibitors ) as captopril , Lisinopril
 Antibiotics ( sulfonamides , tetracycline, aminoglycosides , chloramphenicol )
 Ant thyroid drugs ( as carbemazole )

Examination
General examination

 Washing of hand , Introduction , permission

 Inspection : through inspection you know :-
I. Conscious level
 Comatose
 Lethargic
 Alert (active)

II. Color of patient

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 Normal
 Pale
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  Yellow
 Bluish
 Any other pigmentation on the body
 Abnormalities of the face appearance
 Earthy pigmented face ➡️ indicate uremia
 Congested face ➡️ polycythemia
 Red raised eruptions on the face from bridge of nose to check ➡️
systemic lupus erythematosus (SLE)
 Pale face ➡️ anemia or hypothyroidism
 Pale +puffy cheeks ➡️nephrotic syndrome
 Malar flush ➡️ mitral stenosis , Cushing syndrome
 Unilateral swelling + redness of the skin on parotid ➡️acute parotitis

III. Dysmorphic features (due to genetic syndrome)

 This is so important because it associated with complication of internal
organs. Commonest one down syndrome
 Dysmorphic feature in patient with anemia is thalasemic
face
 Other dysmorphic feature are microcephaly
microphlalmia , bony abnormalities ➡️ indicate fancony ,
anemia
 Dysmorphic feature in general

 Down syndrome ▶️Mongolian face

 Buffy face ➡️hypothyroidism

 Moon face ➡️cushing syndrome or steroid intake

 Abnormal head shapes:
 Caput quadratum ➡️ box- like head
 Hydrocephaly ➡️ large central vault due to enlarged ventricles
24

 Microcephaly ➡️small central vault

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  Oxycephaly (turricephaly ) ➡️enlarged skull with prominent vertex
 Brachycephaly ➡️ anteroposterior diameter is greatly reduced
occipital flattened may occur in mongolism (down syndrome )
 Megalocephaly ➡️ larger cranial vault
 Scaphocephaly ➡️ longer narrow skull
 Plagiocephaly ➡️ asymmetrical skull result from fetal posture
 Dolichocephaly ➡️ anteroposterior diameter is longer .opposite to
brachycephaly

IV. Degree of illness

 Look well
 Look ill

V. Posture
 Tripod posture
 Arching posture
 Hemiplegic posture

VI. Abnormal body movement

 Myoclonic
 Athetosis
 Repeated movement (‫)تختفي عند مسك اليد‬
Immatiated patient
VII. Nutrition status indicate chronic
 Normal diseases
 Obese
 Immatiated
 Wasted Normal head
shape is the long
1/3 larger than
25

 Palpation width and

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rounded at back
 I. Hair
 Color
 Distribution
 Shape

II. Anterior fontanelle (must examined in sitting position and no crying

There are six fontanelles in newborn:-
 Anterior (one )
 Posterior (one )
 Sphenoidal(two)
 Mastoidal (two )

Posterior fontanelle has the following features:-

 Closed by 2-3 months of life
 1 cm in diameter
 Has rounded shape

 There are three suture in neonate skull, sagittal, coronal, lambdoidal

and this suture closed in 6 months of life. delayed closure due to raised
intracranial pressure .if closed early this condition is called
craniosynostosis

 Delayed fontanelle closure indicate :-

 Hypothyroid
 Rickets
 Hydrocephaly
 Achondroplasia
 Down syndrome Muscle wasting with edema
indicate kwashiorkor
 Vitamin D deficiency disease
 Osteogensis imporfecta
26

III. Eye examination

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  Jaundice ( yellow sclera )
 Anemia (pale conjunctiva )
 Other problems ( as sub conjunctival bleeding )

IV. Mouth
 Oral cavity (ulceration, white plaque, pigmentation and other abnormalities.
 Tongue for cyanosis

Protruded tongue in Down syndrome not due to large size (it is normal size but due to small
oropharynx)

 Abnormalities of the tongue :-

 Large tongue (macroglossia ) + protruded tongue ➡️ backwith wiedeman syndrome
 Normal size tongue + protruded tongue ➡️ down syndrome
 Ankyloglossia ➡️ lingual frenulum is short

 Lips
(Herpetic lesion, angular stomatitis, cyanosis, pigmentation,
ulceration.
 Micrognathia ➡️ small jaw
 Micrognathia + cleft palate ➡️ pierre
robin syndrome

V. Neck
 Increase neck skin folds with neck
 L.N
 Skin
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VI. Chest examination

  Pectus carinatum (pigeon test ) :- prominence of sternum
 Funnel shape (pectus excavatum )  depressed lower end of sternum
 Kyphosis exaggevated anterior curvature
 Scoliosis  lateral curvature
 Barrel chest ➡️ hyperinflation (asthma or emphysema)
 Any other abnormalities
 Skin (color,scar,injury)

VII. Abdomen
 Skin wrinkled
 Any injury , scar , site of burn abnormal distention
 Umbilicus (inverted or everted or flat , any umbilical discharge)
VIII. Groin region
 L.N
IX. Lower limb
 Edema
 Other abnormalities
X. Hydration status
 Well hydrated
 Dehydrated
 By examine the following :-
 Conscious level
 Anterior fontanelle
 Tear
 Mouth ( moisture by hand palpitation )
 Skin turgor (in abdomen )
 Capillary refill ( in top of fingers)

XI. Vital sign

 Temperature
 Axillary temp.= temp. in thermometer + 0.5
 Rectal temp. = temp. in thermometer - 0.5
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  Pulse ( especially in dehydration )

 Heart rate according to age :-

 Newborn 120 – 160 BPM (140 average )
 1 year 110 BPM(Beat Per Minute )
 3 years 100 BPM
 8 years 90 BPM
 11 years 80 BPM

Fever may causes tachypnea, each degree centigrade of fever increase

heart rate by 10 BPM

 Respiratory rate
 Respiratory Rate (RR) according to age
 Newborn - 2 month ➡️ 40 – 60 BPM(Breath Per Minute) tachypnea > 60 BPM
 2 month – 1 year ➡️ 30-50 BPM (tachypnea >50 BPM)
 1 - 5 years ➡️ 20 – 40 BPM (tachypnea > 40 )
 More than 5 years ➡️ 10- 30 BPM (tachypnea > 30 )
XII. Growth parameters
 Weight
 Height (in patient who able to stand )
 Length ( in patient who unable to stand)
 Head circumference

Cardiovascular examination
29

 Introduction , take permission , washing of hands

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 Inspection
  Position of the patient
 Neonate ➡️ on the bed
 Infants & children ➡️ in his mother hands
 Adolescent ➡️ as adults

 Exposure
- Neonate and infant ➡️ take off the clothes
 Look to the surrounds of the patient
 Look for any tools related to CVS problem like oximeter , monitor,
oxygen mask
 General inspection
 Any dysmorphic feature (down syndrome that associated with CVS
problems
 Built of the patient (as immatiated in chronic illness)
 Color of the patient related to CVS as ( cyanosis)
 Growth parameters
 Weight
 Height (in patient who able to stand )
 Length (in patient age unable to stand)
 Head circumference (OFC)

 Hand examination
 Finger Clubbing
 Splinter hemorrhage (infective endocarditis)
 Pulse (rate , rhythm , volume ) in neonate pulse examination in brachial
artery
 BP (blood pressure)
 Cyanosis
 Capillary refilling

 Face examination
 Dysmorphic feature related to CVS
 Eye abnormalities related to CVS as pallor
 Mouth abnormalities :-
30

 Cyanosis
 Dental caresses (risk for infective endocarditis)
Page
  Neck examination
- JVP ( in pediatric JVP is difficult to measured so we examine the liver
(hepatomegaly ➡️ raised JVP)

 Pericardium
 Anteriorly : if there is scar of median sternotomy or left lateral
thoracotomy
 Posteriorly for any scar
 Chest shape
 any visible palpitation
 If there is visible apex beat (hyperkinetic apex beat)

 Palpation
 If there is any tenderness
 Apex beat ( normally in the 5th intercostal space on the left )
 If there is impalpable in the left side you should search about Apex beat in
the right side (dextrocardia )
 Palpation for any thrill

If the examiner ask

about examination
Thrill: is palpable of pericardium, in
murmur general you should
exam the tracheal
position

Note / not forget to If you do not palpate the apex beat

examine the liver in in supine position, you should turn
heart failure. the patient to the left side and
palpate the apex beat
31

 Percussion :- not necessary in cardiac examination

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  Auscultation (hallmark of examination )

 Pulmonary valve in the left 2nd intercostal space

 Aortic valve in the right 2nd intercostal space

 Mitral valve in the left 5th intercostal space

 Tricuspid valve in the lower left sternal border opposite 4th intercostal
space

 Heart sound
 1st heart sound (S1) ➡️ closure of mitral and tricuspid valves
 2ed heart sound (S2) ➡️ closure of aortic and pulmonary valves
 3rd heart sound (S3) ➡️ in the apex due to filling of both ventricles
(abnormal in adults and may be normal in pediatrics).
 4th heart sound (S4) in the apex of the heart always pathological. It is
abnormal just before first sound. It's due to contraction of atrium
against resistance (as valve stenosis or hypertrophied ventricle
 Additional sounds (abnormal ) as :
- Murmur (diastolic and systolic )
32
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 Note / if there is systolic murmur, there are six grades:

Grade 1 Very soft, heard by an expert in quite room

Grade 2 Soft, heard by a non-expert in quite room

Grade 3 Heard by non-expert and not require quite room without thrill

Grade 4 Loud heart sound with thrill

Grade 5 Very Load heart sound with thrill

The murmur can be heard by stethoscope near the skin but not in touch
Grade 6 with it

FIRSTLY EXAMINE THE NORMAL HEART

SOUND (S1, S2) THEN EXAMINE IF THERE IS
ADDITIONAL SOUND (S3, S4, MURMUR)
33
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 Murmur of mitral stenosis (mid
diastolic murmur) radiated to axillary
region while the murmur of aortic
regurgitation (early diastolic murmur
radiated to carotid region (neck) so
when you found these murmurs you
should auscultate these regions to
detect the radiation
Murmur of mitral stenosis
best heard by turn the patient
on left side at mitral area
.while the murmur of aortic
regurgitation best heard in
sitting forward position

Causes of murmur
 Systolic murmur
 Ejection systolic murmur
 Aortic valve stenosis
 Pulmonary valve stenosis
 ASD (atrial septal defect )
 Pansystolic murmur
 Mitral regurgitation
 Tricuspid regurgitation
 VSD (ventricular septal defect
 Diastolic murmur
 Early diastolic murmur
 Aortic regurgitation
 Pulmonary regurgitation
 Mid diastolic murmur
 Mitral stenosis
 Tricuspid stenosis
 Continuous (machinery) murmur
 PDA (parents ductus arteriosus )
 Back auscultation
- To detect any radiated murmur and auscultation of lung base for
crepitation
34

 Liver and spleen examination

 Enlarged liver in heart failure
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  Splenomegaly in infective endocarditis
 Scrotal region for detecting edema in heart failure.

 Neonatal examination
 Introduction
 Take permission
 Wash your hands
 Inspection
 Posture
 Partial flexion (normal posture)
 Frog leg posture (sign of hypotonia due to any cause)
 Decebvirate posture ➡️ arm extended at the sides indicate asphyxia
 Opisthotonic posture ➡️ head and neck and trunk are arched backward
indicate kinecturus
 Decorticate posture ➡️ arms flexed on chest due to pain or brain injury
 Asymmetry of movement due to fracture of clavicle ,humerus or brachial
plexus injury or congenital osteomyelitis.

 General look
 Sign of trauma
 Meconium staining (in nails ,umbilicus , skin ) which is green yellow
indicate fetal distress
 Any skin rash (magnesium spot, Kefalas spot, erythema toxicum) normal
cutis mamorata.
 Any sign of respiration distress (supraclavicular recession , intercostal
recession (use of accessory muscles )
 Any pallor (examine the conjunctiva gently)
 Jaundice ( difficult to seen in sclera so see in skin)
 Cyanosis (most important one is central cyanosis while peripheral
cyanosis is normal in neonate)
 Clubbing (unlikely in neonate )
 Look for back (for any defect of spinal cord as meningiomyelocele or
spina bifida )
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  Regional examination
 Head
 Shape and size (microcephaly, macrocephaly, anencephaly)
 Scalp defect

Cephalohematoma Caput succedaneum

Frim Edematous and soft
Without discoloration With discoloration
Limited to specific bone in skull not exceed the According the size and may exceed the suture
suture
Disappear with 2 weeks to 3 months Disappear within first few days
Jaundice and anemia No jaundice or anemia

 Fontanelle (in siting position , quite neonate )

 Boundaries ( anterior is normal diamond shape)
 Diameters
 State (bulging, depressed, pulsatile) normally not bulging with limited
pulsatile.
 Posterior fontanelle (normal 1 cm diameter)

 Eyes
 Sub conjunctival hemorrhage
 Size of the eye ( microphthalmia ➡️small eye )
 Any abnormalities as dropped upper eyelid indicate hovner syndrome or
3rd cranial nerve palsy
 Epicanthic fold in down syndrome
 Congenital cataract and glaucoma
 Eye discharge

 Ears
 Any abnormalities
36

 Position of the ear ( lower or normal , there is no upper position

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 To examine the position of ear. Take imaginary line from inner angle of
the eye to the ear, normally 1/3 of the ear is above the line and 2/3 below
the line

 Nose
 Any abnormalities (as asymmetry of the nose due to displaced nasal
cartilage )
 Chonial atresia ( membrane close the posterior part of the nose)
 Saddle nose

 Mouth
 Cyanosis , pallor
 Cleft lip , cleft palate
 Protruded tongue down syndrome , cretinism
 Movement of the tongue
 If there is tongue band
 If there are temporary teeth

 Look for mandible

 Micrognathia ➡️ small jaw
 Big jaw ( macrognathia in gigantism.

 Chest examination
 Chest shape (normally in neonate barrel shaped while in adult elliptical )
 Breathing ( normally in neonate abdominothoracic while thoracoabdominal
in adult)
 Sign of respiratory distress
 Nipples (if there is abnormal widely spaced nipple)
 Sternum ( if there is short sternum )
 If there is Pigeon chest(pectus carinatum ), funnel chest (pectus
excavum)
 Cardiac examination
 As last topic (CVS examination)
 Abdominal examination
 Normally protruded abdomen
 Umbilicus (bleeding ,redness ,infection )
37

 fusenitis infection of umbilical cord ,

 omphalitis  infection of umbilicus
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  Hernial orifice
 Organomegally (hepatomegaly , splenomegaly )
 Liver examination
‫(التفاصيل في الموضوع القادم‬
 Genital examination
 For any abnormalities or absence of testis from scrotum
 Extremities
 Length of limb (short , amputated (amniotic band) )
 Movement of limbs (asymmetry or symmetry)
 Hands (cyanosis , (acrocyanosis), palmar cresses )
 Digital abnormalities :
 Excess digit (polydactyly)
 Fusion of fingers (syndactyly )
 Long sling finger  arcinodectaly
 Overlapping of fingers
 Clindodectaly (inner curvature of little finger in down syndrome)
 Neurological examination
 Posture (hypotonic,)
 Any abnormal movement
 Alternation in color of patient , excessive chewing movement, excessive
salivation (all this included in fit)
 Apnea
 Gitternus ( fine rapid movement )start by stimulation and stop by handing
, it is sign of hypoglycemia
 Power and tone
 Power (movement against resistance )
 Tone (resistance against positive movement)

 Tone examined in neonate in :-

1. Traction response (neonate try to control head when tracted upward ,
visible by sternocleidomastoid contraction
2. Elevation of infant under axilla (normally can sustained ) (abnormally
slip between your hands )
3. Ventral suspension (normally the infant try to maintain the head with
level of body with extension of limbs)(abnormal  the infant body
become inverted U shape )
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 Primitive reflex
  Clinical significant of primitive reflexes is “if disappear or weak during
period from delivery to 4-6 months , this include CNS suppression either
by local or systemic causes “
 Local causes as (infection , asphyxia )
 Systemic causes as (kernicterus , hypoglycemia )
If these reflexes continue beyond this period it indicate cerebral palsy
 Primitive reflexes are :-
1) Moro reflex
2) Glabellar reflex
3) Rotting reflex
4) Sucting reflex
5) Grasping reflex
6) Trunt curvature
7) Placing reflex
8) Stepping reflex
9) Atone neck reflex
10) Baraschote reflex

 Abdominal examination
Divided into 2 parts
1) End bed assessment ( general looking from end of the bed)
2) Near patient assessment .this divided into 2 parts :-
a) General abdominal examination
b) Specific abdominal examination

1) End bed assessment :- to look

 ill or well
 Sign of illness
 Built
 Position
 Abnormal face
39

 Abnormal movements
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 Extra devices (as I.V cannula , catheter , oxygen )

  If there is distention of the abdomen also look for asymmetry of distention
2) Near patient examination :-
a) General examination (to ensure the end bed symptoms)
 Stand on the right side of the patient (except in suspected pyloric
stenosis stand on the left side )
 Introduction and permission
 Better to set at the level of the patient
 Head examination
 Pallor
 Jaundice ➡️ eye examination
 Discharge
 Cheek examination
 Prominent zygomatic arch  muscle wasting
 Mouth examination :-for
 Angular stomatitis iron deficiency anemia
 Glossitis  vitamin B1 deficiency or iron deficiency anemia
 Size of the tongue (macroglosia  hypothyroidism
 Red smooth tongue  vitamin B12 deficiency anemia
 Ulcers ( herpes simplex ulcer)
 Pigmentation

 Neck
- L.N ( size , tender or no , matte together or no ,take antibiotic or no)
Most important is supraclavicular L.N ➡️ abdominal cancer

 Hands
 Nails (kolynectia, brittle nail )
 Finger clubbing
 palmar erythema
 spider navae abnormal dilated vein due to estrogen level (2-3 spider
navae are normal but more is abnormal )

 Legs
 Edema (one inch compression from medial mallus , bilateral ) if there is
edema , examine the sacrum also
 Skin (ecchymosis , petchia , scratch )
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 General Abdominal examination

  Visible pulsation
 Movement of abdomen
 Visible peristalsis
 Cough pulsation

b) Specific abdominal examination :-

 Exposure from nipple to thigh
 Palpation
 Liver examination
 Tender or not
 Soft or hard
 Span
 Spleen examination
 Begin from the right iliac fossa and upward laterally toward the left
upper quadrant. If no palpation of spleen in small aged patient, you can
palpate the spleen from the left iliac fossa.
 Superficial palpation of the abdomen for superficial mass or
tenderness
 State of umbilicus
 Everted or inverted or flat
 Discharged
 Deep palpation (for liver and spleen )
 Kidney examination by:
 ballottement method ( Keep your anterior hand steady in the deep
palpation position in the right upper quadrant lateral and parallel to
rectus muscle. Attempt to ballot the kidney with the other hand in
costophrenic angle. An enlarged kidney should be palpable by the
anterior hand. Repeat the same maneuver for the left kidney.
 Alternate method for the right kidney: Place your left hand behind the
patient between the rib cage and iliac crest and place your right hand
below the right costal margin. While pressing your hands firmly
together, ask the patient to take a deep breath. Attempt to feel the
lower pole of the right kidney. Repeat the same maneuver for the left
kidney.
 Normally: In an adult, the kidneys are not usually palpable, except
occasionally for the inferior pole of the right kidney. The left kidney is
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rarely palpable. An easily palpable or tender kidney is abnormal.

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 However, the right kidney is frequently palpable in very thin patients
and children.
 percussion
 ascites :- examine for ascites if there is one of the followings:-
 edema
 abdominal distension
 palmar erythema
 ecchymosis
 plural effusion
 jaundice

The ascites exam by the followings:-

1) shifting dullness :- percussion from center of abdomen towards any side at supine
position (in supine the fluid accumulate in both sides of abdomen )the percussion
sound at center is tympanic but when reach the sides where the fluid accumulate the
percussion sound change to dullness , you must stop and turn the patient on other
side and wait for one minute then either continue by percussion toward the side and
percussion become tympanic on side or return toward center and percussion change
to dullness on center due to accumulate of fluid in center .
2) transmitted thrill ( this difficult in children and use only for massive ascites
 auscultation
1- ( only for bowel sounds)when:-
 there is marked distention of abdomen (for bowel sound)
 if there is hypertension (for bruit )
2- bruit of liver , renal artery

 exposure for genitilia and examination

 hernia orifice
 hydrocele

Hydrocele Hernial orifice

Can get above it Cannot get above it
no cough pulse Cough pulse positive
Testis not feel Testis feel
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  PR examination ( not necessary )
 Back of patient (for spina bifida or others )
 Inguinal L.N examination
 Bladder examination ( by left hand and start slightly below the umbilicus and downward)

Liver, spleen enlargement:-

 If it is soft  acute
condition
 If it is hard chronic
condition

 CNS examination
 General examination
 Oriented to surroundings
 Position
 Comfortable or not
 Built
 Look healthy or ill

 General CNS examination (any sign related to CNS

 Posture :-
 Normal postures are :-
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 Supine
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 Prone
  Upper and lower limbs holded with good flexion

 Abnormal postures are :-

 Hypotonic posture :- can seen in :-
 Cerebral palsy
 Septicemia
 Metabolic disorder

 Neck retraction :- can seen in:- (increased ICP)

 Meningitis  after 18 months
 Tetanus
 Intracranial hemorrhage  after 18 months
 Torticollis posture (deviation of neck )
 Spasmus nutans
 Sandifer syndrome
 Myasthenia gravis

 Water tip position (Erbs palsy ) ➡️ indicate injure in C5 ,C6 roots.

 Hemiplagic position :-
 Stroke
 Brown sequard syndrome
 Traumatic brain injure
 Upper meter neuron syndrome

 Scissor posture :-
 Peripheral palsy
 Abnormal movements
 Convulsion
 Tremor
 Myoclonic
 Athetoid
 Jutriness movement

 Skin
 Hyperpigmentation
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 Hypopigmentation
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  Café au liat spot  indicate neurofibromatosis specially on chest and
back and have followings:-
 More than 5 in number
 More than 5 mm in diameter
 Facial palsy
 Nystagmus
 Size of head
If there is hydrocephaly, you should examine the back for neural tube
defects as spinal bifida or meningomyelocele
 Jaundice ( in Wilson disease )

 Hand examination (upper limbs )

 General inspection (SWIFT)
 S  Scar
 W Wasting
 I Involuntary movement
 F  Fasciculation (rapid jerky involuntary muscle movements )
 T  Tremor

 Palpation
 For any tenderness (see facial experience)
 Ask the patient about the pain
 Motor examination :- by
1) Tone :-
a) Hypertonia (indicate UMNL)
 Spastic (difficult movement at beginning then flexible joint ) grasp knife
 Rigid (no movements)
b) Hypotonia (indicate LMNL)

2) Power (joint movements )

 Any joint movement should be examined in all directions
 There are 5 grades of power
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 Grade 0 No hand movement

Grade 1 Movement of hand in its position

Grade 2 Movement of hand at horizontal level

Grade 3 Movement of hand against gravity but not against resistance

Grade 4 Movement of hand against resistance but less than normal

Grade 5 Movement of hand against resistance (normal power)

3) Reflexes
 Better in sitting position
 Firstly relax the tendon and touch it by finger
 Hyper and hyporelaxation should be recorded
 Biceps tendonC5 ,C6
 Triceps tendonC7 ,C8
 Tenton of wrist jointC5,C6
 Fingers joints C8

4) Coordination
 Gage (by walking)
 Finger-noise test
 Finger-finger test
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5) Sensory examination
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  Like-touch test (by cotton )
 Vibration (by tuning fork )
 Proprioception (touch the thumb of the patient by your thumb and index
and ask him to close the eyes then ask him about position of his thumb
while his/her eyes are closed )

 Lower limbs examination

 General inspection (as upper limb)
 Palpation (as upper limb)
 Motor examination
 Tone : by
 shaking the lower limbs while are extended and relaxed on bed
 Elevation of limbs and release them to fall on bed while are relaxed
 Power  (as upper limbs)
 Reflexes :- if absence do enforcement by ask the patient to close the eyes
and close teeth strongly while you exam the reflex
a) Ankle joint  S1, S2
b) Knee joint  L3 ,L4
 Sensory examination:-
 Upper lateral thigh  ….., L2
 Lower medial thigh ….., L3
 Medial legL4
 Lateral leg L5
 Lateral sole S1
 Coordination
 Heel-shin test (by moving the sole of the one limb on the anterior aspect
of the other limb )
 Gait  ask the patient to walk and look for any abnormality in
walking or coordination
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 Respiratory Examination
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  Introduction and permission
 General examination
 Conscious level
 Color (most important is central cyanosis ) pallor can seen in chronic
respiratory diseases ,jaundice not important in respiratory
examination .
 Position (semisitting position indicate severe dyspnea also tripoid
position
 Comfortable or not (uncomfortable +irritable hypoxia )
 Sign of respiratory distress
 Surroundings devices (oxygen ,I.V cannula )
 Finger clubbing (in cystic fibrosis , lung abscess and lung or
bronchogenic carcinoma )
 Peripheral cyanosis
 Respiratory rate
 Respiratory general examination
 Exposure
 Respiratory rate
 Chest symmetry
 Asymmetrical chest due to :-
- Plural effusion
- Pneumothorax
 Chest shape
 Barrel chest  asthma
 Pectus carinatum (pigeon test ) :- prominence of sternum
 Funnel shape (pectus excavatum )  depressed lower end of sternum
 Kyphosis exaggevated anterior curvature
 Scoliosis  lateral curvature
 Scar
 Midsternostomy  major open heart surgery
 Right thoracoctomy  mediasternal
 Left thoracoctomy  PDA repair
 Dilated veins
 Sign of respiratory distress
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 Limitation of the chest movements

 Unilateral  pneumothorax or plural effusion
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  Chest expansion (by hand or tape measurement)
 Listening for any abnormal sound as :-
 Wheeze lower airway obstruction
 Stridor  upper airway (larynx , pharynx ,trachea )
 Harsh cough  laryngeal cause
 Palpitation
 Apex beat
 Shifting laterally  pneumothorax , plural effusion
 Shifting medially  lung collapse ,left diaphragmatic hernia , fibrosis
 Position of the trachea (normally central )
 Deviation of the trachea  the same causes of apex beat
 Vocal fremitus  say 44 and palpate at site of auscultation

 Supraclavicular (lung apex)bilaterally

Anteriorly  At the level of 2ed intercostal bilaterally
 Below the nipple bilaterally

Sites of  Below the axilla  bilaterally

Laterally
auscultation

Posteriorly  Above scapula  bilaterally

 Medial side of scapula  bilaterally
 Below the scapula bilaterally

 Percussion ( at same sites of auscultation )

 Heart dullness (normal )
 Lung  resonance normal
 Strong dullness pleural effusion (abnormal)
 Dullness fibrosis, consolidation(abnormal except on heart )
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 Hyper resonance  pneumothorax (air)

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  Auscultation
 Breathing sounds (take deep breath)
 Any added sounds :-
 Rhonchi =wheeze  either expiratory or inspiratory or both but mainly
expiratory
 Crickels
 Bronchial breathing inspiratory = expiratory phases without gap
(normal in trachea )occur in pneumonia
 Normal breathing sound is vesicular which is inspiratory phase longer
than expiratory phase without gap between them
 Rhonchi of bronchial spasm  in all lung
 Rhonchi only in one area of the lung indicate narrowing of one bronchus or
bronchiole which indicate foreign body
 Stridor may be causes by edema (croup) or thyroid tumor ,
laryngospasm ,epiglottitis retropharyngeal abscess
 egophony : While listening to the lungs with a stethoscope at same areas
of auscultation ask the patient to say " EEEEEEE" if you heard this sound as
" EEEEEEE" 👉 it's normal while if you sound this sound as " aaaaaaaaa"
👉 it's abnormal and indicate
- pleural effusion
- consolidation
- fibrosis
 Whispered pectoriloquy : While listening to the lungs with a stethoscope at
same areas of auscultate ask the patient to say " 44" in Arabic , normally
you cannot hear the sound , but if there is lung consolidation you will hear
the sound because increase the transmission of sound through
consolidated area

Note / auscultation of the chest

include the cardiac and respiratory
auscultation

Note / finger clubbing need 6 months

to be appear
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 Developmental examination
You should exam the following findings to follow the developmental age

First 3 months
 Gross motor
 1st month ➡️ raise the head at the level of body
 2nd month ➡️ sustaine the head elevated at the level of body
 3rd month ➡️ raise the head above the level of body , head control
 Fine motor
 3rd month ➡️ plantar grasping
 Vision
 1st month ➡️ follow the objectives in 90° to either side
 2nd month ➡️ follow the objectives in 180° to either side
 Social
 6th week ➡️ smile
3rd - 6th month
 Gross motor
 4th month ➡️ rolling from prone to supine position
 5th month ➡️ rolling from supine to prone position , sitting with support
 Fine motor
 4th month ➡️ take the objectives and bring them to the midline
 5th month ➡️ transferring the objectives from one hand to other hand
 Social
 4th month ➡️ laugh
 Speeching
 5th - 6th month ➡️ say mama, dada without meaning
6th - 12th month
 Gross motor
 6th month ➡️ sitting without supporting
 7th month ➡️ creeping
 9th month ➡️ standing with hand holding
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 9th - 10th minth ➡️ crawling

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 Fine motor
  9th month ➡️ starting on pincer grasping , able to release objectives from hand , wave
bye bye
 11th month ➡️ fully developed pincer grasping
 Speeching
 9th month ➡️ say mama , dada with meaning
 Social
 Stranger anxiety
2nd year (12 - 24 month )
 Gross motor
 12th month ➡️ take few steps alone
 18th ➡️ running , climate stairs
 20th month ➡️down stairs
 24th month ➡️ running about (move from save area to dangerous area
 Fine motor
 15th month ➡️ able to put pellets inside bottole , put cube on the top of another
 18th month ➡️ able to out the pellets from bottole , make tower from 4 cubes ,
drawing vertical line (I)
 20th month ➡️ draw horizontal line (➖)
 24th month ➡️ make tower from 7 cubes
 Speeching
 18th month ➡️ have 10 words
 23th - 24th month ➡️ joining two words together
Preschool age (3rd - 6th years )
 Gross motor
 3rd year ➡️ alternative movement of lower limbs on ascending of stairs , standing on
one foot
 4th year ➡️alternative movement of lower limbs on descending of stairs
 5th year ➡️ skipping
 Fine motor
 2.5 year ➡️ draw circle (○)
 3 years ➡️ draw plus (+) , draw person with only head , arms and legs
 4 years ➡️draw Rectangular ( ) , draw person with only head,trunk, arms , legs
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 5 years ➡️ draw triangle (🔺️) , draw person with 6 parts of body

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 6 years ➡️ )◇(
  Speeching
 3 years ➡️ make short sentences togther
 4 years ➡️ counting for 10
 Social
 3 years ➡️ know his age , know his sex , play with others , controlling of urination
 4 - 5 years ➡️ controlling of dedication

‫يجب ان تفحص هذه األشياء بالترتيب لتحدد العمر‬

‫قد ال يكون عمر المريض بالسنوات يساوي عمر التطور وهذا يدل على ضعف‬
‫تطور الطفل‬
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