UNIVERSITY OF PENNSYLVANIA SCHOOL OF MEDICINE

MD307 INTRODUCTION TO THE PEDIATRIC HISTORY AND PHYSICAL EXAMINATION

FALL 2011

MD307 Format and Objectives Q: What am I expected to learn during the MD307 course? A: The basic approach to a pediatric history and physical exam.
The goal of this course is to familiarize medical students with the pediatric history and physical exam and the tools needed for its successful completion. Students should be introduced to: Basic knowledge of growth and development and its clinical application from birth through adolescence. Developing communication skills with both children and their caregivers in order to obtain complete and accurate data. Identifying normal (and some abnormal) physical exam findings from birth through adolescence. Appropriate documentation and presentation of the pediatric history and physical exam including formulating an assessment and plan.

Q: How am I expected to learn this material? A: Through scheduled sessions with an assigned preceptor.
1. Each student will be assigned a preceptor at the beginning of the semester. Some preceptors will be assigned more than 1 student. 2. It is the students responsibility to contact their preceptor within 1 week of receiving the contact information. 3. The student and preceptor should have 3 scheduled sessions between September 7, 2011 and December 7, 2011. Some preceptors may choose to do additional sessions with their students. 4. Example of session format: a. Session 1: Preceptor performs pediatric history and physical while student observes followed by Q&A session with preceptor. b. Session 2: Student performs pediatric history and physical while preceptor observes followed by Q&A session with preceptor. c. Session 3: Student performs pediatric history and physical without preceptor followed by Q&A session with preceptor. d. Student will use the H&P from session 3 for the formal write-up. 5. Our preceptors each have unique teaching styles so sessions will vary from preceptor to preceptor. Although students will not have identical experiences each student will be introduced to the complete pediatric H&P by the completion of the course. 6. Email your formal write-up to your preceptor by December 12, 2011. Your formal write up can be modeled after the write-up included in your syllabus and should include an assessment and plan. Your preceptor will contact Drs. Pawel and Mittal with a Pass/Fail grade and comments.

7. A list of reading materials is included in the syllabus to help you achieve the course goals.

Q: When should I contact the course directors? A: Anytime you have a question but especially when:
1. You are unable to contact your preceptor to schedule any of the 3 required sessions. 2. You are consistently unable to meet with your preceptor due to scheduling conflicts. 3. You are unable to complete the course requirements in the allotted time due to medical/personal issues. 4. If there are any errors on the student/preceptor assignment sheets.

Q: What happens if I do not complete my required sessions and write-up? A: You cannot proceed onto your clinical rotations without successful completion of this course. Enjoy the course and feel free to contact us at any time!
Barbara Pawel, M.D. Department of Pediatrics Division of Emergency Medicine Colket Translational Research Building, 9th floor The Children's Hospital of Philadelphia Manoj Mittal, MD Department of Pediatrics Division of Emergency Medicine Colket Translational Research Building, 9th floor The Children's Hospital of Philadelphia

tel.: 215-590-1944 fax: 215-590-4454 pawel@email.chop.edu

tel.: 215-590-1944 fax: 215-590-4454 mittal@email.chop.edu

This syllabus is to be used in association with the general Introduction to Clinical Medicine "Medical History and Physical Examination" syllabus. This information is to be used as a supplement to that document for the Pediatric History and Physical Examination component of MD 306. Pediatric Component (MD307) Course Directors: Barbara Pawel, M.D. Department of Pediatrics Division of Emergency Medicine th Colket Translational Research Building, 9 floor The Children's Hospital of Philadelphia Manoj Mittal, MD Department of Pediatrics Division of Emergency Medicine th Colket Translational Research Building , 9 floor The Children's Hospital of Philadelphia tel.: 215-590-1944 fax: 215-590-4454 pawel@email.chop.edu

tel.: 215-590-1944 fax: 215-590-4454 mittal@email.chop.edu

Text: Mandatory Reading: Chapter 19: Assessing Children: Infancy through Adolescence. In Bates' Guide to Physical Examination and History Taking (9th ed.). Editors: Lynn S. Bickley and Peter G. Szilagyi. Lippincott Williams and Wilkins, Philadelphia, 2005. Recommended Reading: The Infant Patient Encounter (DVD). Editors: Lindsey Lane and Ruth Gottlieb. Lippincott Williams and Wilkins, Philadelphia, 2004 Algranati PS. Effect of Developmental Status on the Approach to Physical Examination. Pediatric Clinics of North America. February 1998. (Available in Suite 100.) Goals and Objectives: The course should be considered successful if the following goals are met: The student should gain basic knowledge of growth and development (physical, physiologic, and psychosocial) and its clinical application from birth through adolescence. The student can perform a pediatric history and physical examination from start to finish. The student can identify normal findings on the pediatric physical examination and can begin to recognize abnormal findings. The student will develop communication skills that will facilitate the clinical interaction with children and their families in order to obtain complete and accurate data. The student can both document and present the pediatric history and physical examination in a clear, accurate, and precise manner. The student will further develop the attitude and professional behaviors appropriate for clinical practice. Patient Sessions: The student will be assigned a preceptor at the beginning of the semester. It is the student's responsibility to contact this preceptor and schedule 3 sessions to occur from September 7 through December 7, 2011. These small group or individual sessions with the preceptor will allow for observation and subsequent practice of the pediatric history and physical examination for each student. The structure of each session is at each preceptor's discretion. A final write-up from one of the sessions must be presented to the preceptor by December 12, 2011.

Professional Conduct: All students are expected to present themselves in a professional manner. Physicians must have welldeveloped interpersonal skills that facilitate communication and must demonstrate attitudes, behaviors, and beliefs that promote the patient's best interest. In summary, the tenets of professionalism include: Altruism, Accountability, Duty, Excellence, Honor and Integrity, and Respect for Others. During pre-clerkship and clerkship training, professionalism can be diminished by arrogance, misrepresentation, breach of confidentiality, lack of conscientiousness, conflicts of interest (developing personal relationships with patients or their family members), and impairment. Resources for professionalism are found at http://www.abim.org/pubs/p2/index.htm and http://www.abp.org/abpfr1024.htm. Any behavior that demonstrates that the student lacks professionalism is taken very seriously. Written evaluation of the students performance in the course, by the course director, will be submitted to the students file in such an event if remediation does not clarify the behavior. Dress and Appearance An extension of this code of professionalism is that the students appearance should be respectful of the patient. To that end, the student should dress appropriately to interact with children and their families and should appear clean and neat. Clothing that is seductive or overtly casual sends the wrong message to the patient. White coats are appropriate but not required (some Pediatricians refrain from wearing white coats in order to decrease the apprehension of some of the younger patients). Baseball hats, tennis shoes, and jeans are not appropriate and should not be worn during patient interactions. Evaluation: Students will be expected to have read the required texts and demonstrate a minimum proficiency in the practical skills of patient interaction. Any student felt not to be minimally proficient by the preceptor will be required to undergo remediation. Attendance is required at all scheduled sessions with the preceptor. Templates and Documentation: At the end of this syllabus (see Appendix I) are several templates for documentation of your history and physical examination. The final write-up should be in a form discussed with your preceptor; however, these templates may be helpful to you. The Children's Hospital of Philadelphia Admission History and Physical Examination Form Adolescent Initial History and Physical Examination Form Well-Child Encounter: Birth Through Two Years Well-Child Encounter: Three Through Eleven Years Appendix VI contains a sample Pediatric History and Physical write-up, which may be helpful as well.

Unique Aspects of the Pediatric History and Physical Examination Overview Patient interviews will occur in a variety of clinical settings and at a variety of ages and stages of child development. These may include a newborn examination, initial history for a hospital admission, well-child visit, acute care visit, emergency department visit, interim visit for a child with chronic health condition, or adolescent examination. The student should develop an awareness that in conducting each different medical interview it may be more appropriate to obtain a complete medical history or perform a more focused interval history. In this course the emphasis will be on obtaining complete histories. Further experiences will provide opportunities to do more focused histories in the future. Identifying the historian is important in the pediatric H&P. In many cases the patient will not be the primary source of information. In a number of cases, the parent may also not be the historian. The child may be accompanied by a legal guardian other than the parent, a foster parent, a relative, a friend, or social worker. Depending on the source of information, the accuracy of the history may vary greatly. However, any child that is verbal should be included in the history taking process. You can elicit important information when using age appropriate terms with almost all verbal children. The developmental level of the child guides the approach and order of the history and physical examination. Young children with normal "stranger anxiety" will become more relaxed and cooperative after you have spent several minutes talking with their trusted caregiver. If you establish a good rapport with the parent you may have gone a long way on the road to winning over the child. However, an adolescent may greatly appreciate being interviewed concerning his or her sexual history or school performance only when the parent is not present. The lungs of a sleeping infant are much easier to auscultate than the lungs of a crying child. Therefore, the lung and cardiac exam is usually the first component of the physical examination in a sleeping child. Looking in the child's ears or mouth first is sure to wake them and produce a screaming patient. By learning and understanding the fears, development and needs of children, you can use ageappropriate techniques to perform a successful history and physical examination. Issues of privacy and confidentiality should be recognized for all patients, especially older children and adolescents. It is often hardest and yet most important to establish a good rapport with an adolescent and his or her family. This can be fostered by "setting the stage" up front. Discuss with the patient and family how an adolescent's visit is different than a younger child's (a degree of "privacy" is afforded the adolescent that is neither necessary nor appropriate with younger children). Explain that you will talk alone to both the adolescent and the family. This will allow each to express concerns or problems that they may not have expressed as easily in the presence of the other. You should explain confidentiality and its limitations (suicidality, homicidality, abuse). Physical findings must be evaluated in the context of normal growth and maturation. A heart rate above 130/min is expected in the newborn, "poor" speech enunciation is likely from the 2 year old, abundant lymphatic tissue is normal maturation in the 5 year old child, most 9 year old girls are "amenorrheal," etc.

Chief Complaint The chief complaint (CC) is what brought the patient to seek health care today. For the pediatric patient it may be in the child's own words or in the words of the caretaker who brings the child.

History of Present Illness The information desired in the history of present illness is similar in the adult and pediatric interview. However, the technique in obtaining this information may differ. In children it is often difficult to get certain answers to your questions, or even for parents to give you the needed data. For example, a 6-month old will not be able to tell you or his parents that his abdomen is hurting, an 18-month old can't describe blurry vision, an adolescent may not readily divulge that he is having penile discharge with his mother in the room. Allow historians to express concerns by asking general question, then direct the interview to obtain relevant information realizing that they may not be able to easily tell you everything you need to know. Be sure to allow the parent or patient the opportunity to express his or her (sometimes hidden) concerns.

Past Medical / Surgical History Often (but unfortunately not always) the past medical history of a child is shorter and less complex than that of an adult patient. However, there are several areas of particular concern in the pediatric patient. Birth History should be obtained for all children until that information is no longer clinically useful. For most children with "normal" birth histories this is approximately until the 2 years of age. However, the birth history of a child with developmental delays and spastic diplegia after a delivery complicated by meconium aspiration will be significant and should be noted throughout childhood and adolescence. Birth history should include:

Prenatal History Para/gravida of mother Maternal age Prenatal care Prenatal maternal illnesses, infections, medications, substance abuse Preterm labor Other complications Psychosocial issues (adoption, teen mother, lack of support) Labor and Delivery Site of Birth Gestation length Length of labor Complications of labor (e.g. maternal fever, prolonged rupture of membranes) Mode of delivery Presentation Complications of delivery (e.g. nuchal cord, meconium) Birth Weight Agpar Score at 1 and 5 minutes Neonatal History Newborn nursery or "rooming in" vs. neonatal intensive care unit Length of stay Complications (e.g. prematurity, hyperbilirubinemia, hypoglycemia, birth trauma) Feeding and elimination history

Childhood Illnesses: Communicable illnesses such as chicken pox or measles are becoming much less common due to immunizations. However, you should note when such illnesses have affected the child, as well as chronic or recurrent "childhood" illnesses such as chronic otitis media, tonsillitis, urinary tract infections, or asthma.

I.

Habits (Nutrition/Elimination/Physical Activity/ Sleep Problems) A detailed history of nutrition is especially important in infants and children when others provide all dietary intake. For infants, you should document the form of feeding (breast or bottle or both), type of formula and appropriate formula preparation if bottle-fed, feeding schedule with amount and frequency. For toddlers or older children determine the age of solid intake, milk/juice intake, nutritional content variation. For older children and adolescents any abnormal eating behaviors or patterns may become evident during the interview. Toilet training or elimination difficulties, "excessive" activity or lack of physical activity, and sleep patterns are important historical issues for children and their caregivers. Infants: o # wet diapers/day o # stools/day; color/consistency The SHADSSS Assessment is useful to evaluate adolescents' habits. Using this mnemonic you move from the least threatening topics to more intrusive questions. Place this part of the history when the patient is most comfortable (parents not in room, well into you interview or physical when the patient "knows" you best).

School (How is school going? How are your grades and are you satisfied with them? What do you plan to do after high school?) Home (How are things at home? Who lives there? Is there enough space for you to find privacy when you need it?) Activities (What do you do in your spare time? Whom do you like to spend time with?) Depression / emotional health (Who do you talk to if you have a really bad (or good) day? How do you feel about yourself? Do you feel depressed some (or most) of the time? Have you ever thought about hurting yourself? If so, when? Have you ever tried to hurt yourself? What do you do when you get very sad or stressed?) Substance Abuse (Have you seen drugs at school? at home? with your friends? How do you feel about it? Do you smoke? marijuana? other drugs? Do you drink?) Sexuality (Is there someone you have special or romantic feelings for? Tell me about that person. Do you have sex with that person? Any contraception? STD protection?) Safety (When was the last time you got into a physical fight? Is anybody currently physically hurting you? Do you carry a weapon? Is anybody threatening you? How do you handle conflict?)

Some important questions to elicit sleeping behavior may be: Does the child share a bed or bedroom with anyone? Is the child a good sleeper?

Medications As for adults, ideally medication bottle should be examined. However, this ideal situation is infrequently available. The patient or caregiver should recite how and when the medications are given. Be aware that most children less than 10 years old cannot swallow pills. Therefore, their medications are given by the teaspoon or milliliter (a teaspoon is 5 ml). Appropriate dosages of medications in children are determined by weight (mg of medication per kg of child's weight). In order to determine if the child is getting the right dose of medication, you must know the exact name or "kind" of medication. For example, Tylenol Infant Drops are 80mg/0.8ml and usually measured by a dropper provided (a teaspoon would be 500mg) but Tylenol Syrup for Children is 160mg/5ml (a teaspoon would be 160mg). Over-the-counter medications are extremely important to document in children. Many OTC cough and cold preparations contain acetaminophen or antihistamines that could greatly affect the presenting illness or produce substantial side effects in children.

II.

Allergies Allergen Type of reaction Immunizations The Recommended Childhood Immunization Schedule 2008 from the American Academy of Pediatrics is presented in Appendix II. You may use this as a guide to completeness of immunization history presented by the historian.

III.

IV.

Primary Medical Care Provider Documentation of the primary care provider (PCP or PMD) both identifies that the child actually has one and also facilitates communication between providers.

V.

Developmental History Open-ended questions (such as "How does the child compare with other children of the same age?" How does this child compare with your other children when they were his age? Do you have any concerns about your childs development?) are helpful in screening for developmental delay Determine age at developmental milestones: first social smile (4-8 weeks), rolling over prone to supine (4 months), sitting alone (6 months), stands (9 months), mama/dada (10 months), walks (12 months), knows age (3 years). See Denver Developmental Screen as discussed below and presented in Appendix V.

VI.

Family History Obtain the ages of parents and all siblings, illnesses in siblings or parents (seizures, asthma, sickle cell anemia, bleeding disorders, cardiac disease, early or unexplained deaths, cancer, hypertension, diabetes, obesity) Depth of genetic history obtained will depend upon the clinical situation. Routine situations usually call for information on first-degree relatives including name, current age, age at death, cause of death, and presence of any disease/disorder.

VII.

Social History Care of the child always includes understanding and involvement with the child's "family." It is important to determine the definition of family for each patient. You should document the legal guardian of the child, the constitution of the home of the child (including all persons who reside there whether related or not). Children often spend many hours a week in a daycare or school setting. Document situation (nanny, home daycare, licensed center, Headstart facility, school and grade) and time spent there. Family stress and support as with the adult patient can strongly impact upon the child's health. Health Insurance (Determine whether family is covered)

VIII.

Review of Systems Review of systems for the pediatric patient is similar to the adult interview. It should be concise and not duplicate the HPI.

IX.

Physical Examination The physical examination is as much an art as a science. The practiced and successful clinician uses the developmental stage of the child to his or her advantage. The newborn can easily be examined on the table however attempting to exam a 19 month old in the same manner will often result in hysterics. See Appendix III ("Developmental Approach to Pediatric Emergency Care Patients") for some hints. The sequence of the examination for children older than 8 years can mirror that of the adult examination. However, the child dictates the sequence and position of a successful exam of a young child. Always start with observation, you will learn a great deal about the health of the child as well as pick up some techniques for easier examination. Toddlers are best examined in their parent's lap; school age children will usually sit on the bed. Instruments may be introduced and you may allow the child to play with the stethoscope while you are talking to the parent. Your examination should progress from least intrusive (observing extra-ocular muscle movements while child fixes and follows on a toy you present) to most intrusive (otoscope and oro-pharynx examination). Seize any opportunity presented to you: listen to the lungs and heart of a sleeping child prior to anything else, assess the gait of the running toddler, etc. Unless the situation is truly emergent, it is best to delay examination of a painful or injured area until the rest of the physical examination is complete. Read CHAPTER 19 THE PHYSICAL EXAMINATION OF INFANTS AND CHILDREN IN BATES' GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING and INTRODUCTION TO CLINICAL MEDICINE SYLLABUS: PUTTING IT ALL TOGETHER. Only selected components of the pediatric examination will be addressed below, many are similar to the adult examination or are more than adequately covered in Bates' and will not be mentioned separately here.

1. Vital Signs Important growth parameters are considered part of the vital signs in children. Weight and length (height) should be measured for all children, head circumference is measured routinely until the child is 36 months of age. These should be presented both as numeric values (kg or cm) as well as percentiles for age (e.g. 50 percentile for 3 month olds). See Appendix IV for sample growth charts. There are standardized growth curves available for special populations of patients such as premature infants or children with trisomy 21. Sequential growth parameters are plotted for the patient throughout childhood to document the appropriate rate of growth.

Supine recumbent length is measured in children under 2 years old (using a measuring board or marks of exam table paper) and standing height is measured over 2 years. Head circumference is measured at the occipital protuberance and mid-forehead (the "widest" circumference of the head).

Temperature is measured rectally until a child can reliable hold the thermometer under his tongue. It is usually 1 higher than an oral temperature. Ask how temperature was taken by caregiver (forehead strip, ear tympanometer, axillary, or tactile) Pulse is measured at the brachial artery or auscultating the heart in an infant or at the radial artery in a child or adolescent. Heart rates decrease steadily as the child ages (140-160 in an infant to 60-80 in an adolescent). Respiratory rates also normally decrease as the child ages (40 in infants to 25 in school-aged children and 12 in adolescents). Document by auscultating the chest or counting abdominal excursions for a full 60 seconds Blood pressures must be measured with the appropriate size cuff and compared to norms for the child's age (blood pressures increase from infancy through adolescence).

2. Denver Developmental Screening Test The "Denver" is designed to identify developmental delays in personalsocial, fine motor/adaptive, language, and gross motor development. If a child cannot perform one task at the 90% age or two tasks at the 75% age then further evaluation is necessary. See Appendix V. The Denver is for children from birth to six years old. It is a screening test and does not measure intelligence.

3. Skin

Assess overall skin color, pigmented marks, vascular markings, turgor.

4. Head Inspection: shape/symmetry/facial dysmorphisms. Newborns may have molding, cephalohematomas or caput succedaneum. Palpation: Anterior fontanelle is usually 4-6 cm and closes between 4-26 months of age, posterior fontanelle is usually 1-2 cm and closes by 2 months of age. Palpate and describe fontanelle as open (width)/closed/flat/sunken/bulging. Percussion: (Macewen's sign, Chvostek's sign). Auscultation: Bruit can be normal in children <5yrs over temporal area, older children with bruits may have anemia, AVM, aneurysm, increased intracranial pressure.

5. Eyes Inspection: Newborn or young infants will open their eyes in a dimly light room when held upright and rotated in your arms. Older babies and children will follow a toy or light with minimal encouragement. Observe conjugate eye movement, identify strabismus if present (corneal light reflection and cover/uncover test), observe pupillary reactions. Conjunctivitis in newborns may signify chemical conjunctivitis, gonorrheal conjunctivitis, or nasolacrimal duct obstruction. Observe function of extraocular muscle movements. Determine visual acuity (newbornspresence of visual reflexes; 2-4 weeks of age-fix on object; 5-6 weeks of age-follows object; 3 months of age-reaches for object; >3 years oldSnellen E or picture chart). Check visual fields using bright objects or toys in infants and young children. Fundoscopic exam: Document red reflex for all infants.

6. Ears

Inspection: Note position of ears in relation to eyes. Otoscope examination is difficult in children and as noted before, best left until last for young children. Practice makes perfect in this regard! Observe external canal patency and condition, visualize tympanic membrane. Pneumatic otoscopy is important in the diagnosis of otitis media. Hearing: Acoustic blink reflex in infants, simple auditory screening with whisper in older children.

7. Nose, Mouth and Oropharynx Check for patency of nasal passages in infants by occluding each nostril in turn while mouth is closed. Inspect mouth with light and tongue blade. Palpate the palate in infants to check for any submucosal clefts. Oropharynx is easily visualized when child is crying without tongue blade.

Primary teeth will erupt over a wide range of normal ages (most children have 4 teeth by 10 months of age). Primary teeth begin shedding around 6 years of age.

8. Neck Inspection: fistula, cysts, skin tags Palpation: Clavicle fractures in newborns may be due to difficult deliveries and not identified until callous formation produces a "bump". The neck should have easy range of motion (assess for nuchal rigidity or torticollis). Cervical lymph node size varies greatly in childhood (not palpable in infancy to almost always present in school aged children). Auscultation: Carotid bruits may be transmitted from the neck to the entire precordium in children.

9. Thorax and Lungs Inspection: Assess shape and contour of thorax, respiratory rate and pattern. Tachypnea and visible work of breathing are extremely sensitive indications of respiratory pathology in young children. Palpation: Feel for fremitus or palpable wheezes with whole hand on chest in infants. Percussion: Normally hyperresonant throughout. Auscultation: Use bell or pediatric diaphragm of stethoscope. Transmitted upper airway sounds may be prominent in the infant. Auscultate over the extrathoracic airway (cheeks and lateral neck) to help differentiate. Breast exam: One to 2 week old infants (male and female) will often have breast enlargement due to maternal estrogen exposure. Review Sexual Maturation Rating breast staging

10. Heart / Circulatory system Inspection: Apical impulse may be visible to the left of the midclavicular th line in the 4 intercostal space until 4 years old, then moves to the midclavicular line from 4-6 years, and after 7 years is to the right of the th midclavicular line and in the 5 intercostal space. Be sure to assess for any cyanosis. Palpation: Pulses are palpated most readily at the brachial or femoral arteries in the infant. Percussion: Percussion of the heart size may seem enlarged due to the overlying thymus in young children. Auscultation: Listen in supine and sitting position with the diaphragm and bell of the stethoscope. Identify S1, S2 (may have prominent splitting). Sinus arrhythmia is most common in children. Describe loudness (grade I-VI), timing, pitch, quality, location and transmission of any murmurs.

11. Abdomen Inspection: The infants' abdomen is protuberant due to poor muscular strength. In the newborn be sure to check the umbilical cord and identify the two umbilical arteries and single umbilical vein. Monitor the umbilical stump until complete separation and healing. Identify abdominal wall defects (umbilical hernias, ventral hernias, diastasis recti). Auscultation: Assess bowel sounds Percussion: Assess liver span and air within stomach and intestines. Infants may have more tympany due to swallowed air. Palpation: The liver edge and spleen tip are easily palpated in most infants and many children. In thin children, the aorta can be palpated to the left of the midline. Decrease tickling by distracting the child with conversation, placing your entire hand flush on the abdomen or by placing the child's hand under yours while palpating.

12. Genitalia and Rectum Male: Inspect penis shaft, glans, urethral orifice, foreskin or circumcision, and scrotum. Determine Sexual Maturation Rating of penis, testes, scrotum and pubic hair. Palpate scrotal sac, inguinal canal, and testes (with cremasteric reflex). Female: Inspect in frog-leg position mons pubis, labia majora, labia minora, urethral orifice, clitoris and vestibule with hymen. Determine Sexual Maturation Rating of pubic hair. Rectal Exam is performed in children only as indicated by intraabdominal, pelvic, or perineal complaints. Cutaneous lesions in the sacral area (dimple, tuft of hair, pigmented nevi, hemangiomas) may indicate spinal cord defects such as spina bifida occulta.

13. Musculoskeletal Inspection: All extremities for shape, deformity (congenital or acquired), swelling, or clubbing. Inspect the spine for any overlying hair tuft, pigmented spot, sacral dimple, or curvature (in older children). Observe gait in all ambulating children. Palpation: Infants should be examined for hip dislocation by Ortolani test. Palpate the spine. Assess muscle tone during passive movements. Active and passive range of motion of all joints. Assess muscle strength.

14. Nervous system See Denver Developmental Screen above. Infants: Assess positioning, alertness, spontaneous movements, cry, knee and ankle jerk reflexes, and infantile automatisms (rooting, grasp, tonic neck, and Moro reflexes). Test for sensation by flicking the palm or sole and observing withdrawal or grimace. Unsustained ankle clonus and Babinski response are normal in infants. External anal reflex should be present. Older children and adolescents: The neurologic examination is similar to the adult exam. Children usually enjoy participating in the "game" atmosphere of this component of the examination.

References: Algranati PS. Effect of Developmental Status on the Approach to Physical Examination. Pediatric Clinics of North America. February 1998. Athreya BH, Silverman BK. Pediatric Physical Diagnosis. Appleton-Century-Crofts, Norwalk, 1985. th Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine 5 Edition. Lippincott Williams and Wilkins, Philadelphia, 2005. Chapter 19: Assessing Children: Infancy through Adolescence. In Bates' Guide to Physical Examination and History Taking (9th ed.). Editors: Lynn S. Bickley and Peter G. Szilagyi. Lippincott Williams and Wilkins, Philadelphia, 2005. Melman S. The Physical Examination in Schwartz, M.W., Brown, L., et al (Eds.). Clinical Handbook rd of Pediatrics (3 edition), Lippincott,Williams and Wilkins, Philadelphia, 2003.

APPENDIX I. Please note, these templates are for guidance only. Please discuss appropriate write-up format for each individual encounter with your preceptor. Admission Note (4 pages) Adolescent Initial History & Physical Examination (4 pages) Well Child Encounter Birth Through 2 Years (2 pages) Well Child Encounter 3 Through 11 Years (2 pages)

APPENDIX II.

Recommended Immunization Schedules, United States, 2010 (3 pages)

APPENDIX III. Developmental Approach to Pediatric Emergency Care Patients (from Textbook of Pediatric Emergency Care 3rd Edition, ed. Fleisher GR and Ludwig S.) AGE (yr) Infancy: 0-1 Important Development Issues Minimal language Feel an extension of parents Sensitive to physical environment Receptive language more advanced than expressive See themselves as individuals Assertive will Excellent expressive skills for thoughts and feelings Rich fantasy life Magical thinking Strong concept of self Fully developed language Understanding of body structure and function Able to reason and compromise Experience with self-control Incomplete understanding of death Self-determination Decision making Peer group important Realistic view of death Fears Stranger anxiety Useful Techniques Keep parents in sight and touch Avoid hunger Use warm hands Keep room warm Maintain verbal communication Examine in parents lap Allow some choices when possible Allow expression Encourage fantasy and play Encourage participation in care Explain procedures Explain pathophysiology and treatment Project positive outcome Stress childs ability to master situation Respect physical modesty Allow choices and control Stress acceptance by peers Respect autonomy Stress confidentiality

Toddler: 1-3

Brief separation Pain

Preschool: 3-5

Long separation Pain Disfigurement Disfigurement Loss of function Death

School age: 5-10

Adolescence: 10-19

Loss of autonomy Loss of peer acceptance Death

APPENDIX IV. Growth Charts Boys: Birth to 36 Months, Physical Growth, NCHS Percentiles (2 pages) Boys: 2 to 20 Years, Physical Growth, NCHS Percentiles (2 pages) Girls: Birth to 36 Months, Physical Growth, NCHS Percentiles (2 pages) Girls: 2 to 20 Years, Physical Growth, NCHS Percentiles (2 pages)

APPENDIX V. Denver II, DA Form 5694, May 1988 (2 pages)

APPENDIX VI. Sample Pediatric History and Physical Examination (6 pages)

Sample Inpatient Pediatric History and Physical Examination (Courtesy of Dr. Cindy Christian, with minor modifications) 8/21/03 3:30 p.m. Informant: the patients mother seems well-informed and reliable. Chief complaint: this is the second hospital admission to The Childrens Hospital of Philadelphia for this 2 and year old male with a history of asthma, who was admitted for the chief complaint of wheezing. History of Present Illness: The patient was in his usual state of good health until two days prior to administration when he developed a runny nose, cough, and a tactile temperature. The runny nose was described as clear, and the cough was dry and nonproductive. According to his mother, the cough was not paroxysmal. It seemed to be worse at night. Though a tactile temperature was noted, his mother did not take the temperature at home. Tylenol was given, with relief of the fever. One day prior to admission, his mother noted audible wheezing. She started Albuterol treatments, which did not provide relief. He was seen in the emergency room at CHOP, given 2 Albuterol nebulization treatments, and sent home on p.o. (oral) prednisone and Albuterol MDI (multidose inhaler) with spacer treatments every 4 hours. Due to increased wheezing and work of breathing, the patient was seen by his primary medical doctor, Dr. Smith, on the day of admission. The patient was given 2 Albuterol aerosol treatments and referred to CHOP ED. The patient attends day care, where many children are noted to have cold symptoms, according to the mother. She denies any ill household contacts. The patient has had a decreased appetite over the past 2 days, but there has been no change in his weight or urine output. The mother denies a history of diarrhea, vomiting, irritability, or lethargy. She denies foreign body aspiration. She comments that the patient has had decreased activity, and is not his usual self. He has been playful on and off.

His asthma is usually triggered by colds, change in weather, and cigarette smoke. His mother reports that his asthma is generally well-controlled and that he has only had this one attack over the past 12 months. In the emergency room, he was noted to have diffuse expiratory wheezes, intercostal and subcostal retractions. His room air oxygen saturation was 91%:, which rose to 95% on 1 liter of oxygen via nasal cannula. Four albuterol aerosol treatments were given, and oral prednisone was started. There was some improvement in aeration noted in the ER. He was admitted for further observation and treatment of an acute exacerbation of asthma. Current Regimen: Medications: 1. 2. 3. Allergies: No known drug allergies. The patient is allergic to pineapples, which cause a diffuse rash. Past Medical History: Birth: Mother is a 33y.o. G3P2010 female who received prenatal care at HUP. took Albuterol and prednisone during the pregnancy. or alcohol during the pregnancy. weight was 10 lbs. She She additionally had an ICU Prednisone 15 mg p.o. bid (s/p 2 doses). Albuterol MDI with spacer; 2 puffs Q6 hours Tylenol (160mg/5cc) 1 tsp. p.o. q4hrs prn. Last dose 8AM.

admission for asthma, but was not intubated. She denies any use of cigarettes, drugs, She denies any bleeding, infection, STDs, The patient was born at HUP; birth hypertension, diabetes during the pregnancy. premature labor and rupture of membranes. He stayed in the hospital for 3 days. He did not receive oxygen, and did not have problems with jaundice.

He was delivered via C-section at 35 weeks gestation due to

Previous medical History: Diagnosed with asthma at age 7 months. Hospitalized at CHOP at age 7 months for asthma, 3 day stay. Hospitalized at CHOP at age 13 months for asthma, 5 day stay. No ICU admissions. No intubations. No other hospitalizations. Previous Surgical History: Circumcised at birth without problems. Health Practices and habits: He has frequent temper tantrums, but no breath-holding spells. Feeding: as an infant he tolerated Similac formula without difficulty. Now he has a well balanced diet. Growth and Development: birth weight 10 lbs., always a large child. He sat at 6 months, walked at 13 months. and still wears diapers. Diet: table foods, whole milk: 24 oz/day Juice: 24 oz. per day Meal pattern: 3 meals per day, 3 snacks Food variety: doesnt like fruit or vegetables Snacks: cookies, chips
Primary Medical Doctor:

According to his mother, he says, dada, mama,

baby, sis, doggy, eat, go. He puts two words together. He drinks from a cup

Dr. John Smith, (215) 555-1212.

Immunizations: up-to date.

Review of systems: Constitutional: as in HPI. HEENT: no headache, no eye redness or discharge, no epistaxis, no difficulty swallowing. Respiratory: see HPI. Cardiovascular: murmur note at PMDs office. No further work-up done. Gastrointestinal: see HPI. Patient has 3-4 normal bowel movements per day. No constipation. Genitourinary: 5-6 wet diapers per day. Musculoskeletal: no joint pain or swelling. Neurologic: no seizures. Hematologic: high lead level in the past. Endocrine: no diabetes. Dermatologic: insect bites in the past week, eczema as an infant. Family History: His father is 32y.o. and healthy, his mother 33 y.o. with asthma. He has no siblings. There is not family history of eczema or hayfever. There is no family history of heart disease, diabetes, high blood pressure, cancer, kidney disease, liver disease, or sickle cell disease. There is no family history of cystic fibrosis or other lung diseases. Social History: he lives at home with his parents. His father is a plumber, and his mother stays at home. He attends day care where there are 15 other children. At home there is carpet but there are no pets. His father smokes cigarettes, but not in the babys room. They have a smoke detector in their 2-bedroom apartment.
Physical Examination:

Vital signs:

T 37.3 C rectally; pulse 182 beats/minute, respiratory rate 47 weight 18 kg (>95th %), height 92cm (50-75th %), head

breaths/minute, blood pressure 115/60. Growth parameters: circumference 48.5cm (50th %). General: obese, comfortable, mild-moderate respiratory distress.

HEENT: Head: normocephalic, atraumatic. Eyes: extraocular movements intact, pupils equal and reactive symmetrically to light, sclera white, conjunctivae not injected, no discharge or erythema, no eyelid swelling. Ears: symmetric, normal external canals and auricles. Tympanic membranes with visible landmarks, no fluid, symmetric and sharp light reflex, good mobility with insufflation. Nose: no nasal flaring, mild whitish crusting at nares, septum not deviated. Throat and mouth: mild erythema, no tonsillar exudates. No oral lesions, good Dentition without caries, mucous membranes moist without lesions. Nodes: shotty anterior cervical and inguinal adenopathy, with nodes less than 0.5cm. Neck: supple, with full range of motion. Lungs: poor aeration at bases, inspiratory and expiratory coarse wheezes bilaterally, Inspiration/expiration ratio 1:2, no rales. Chest: symmetric expansion, retractions in supraclavicular and subcostal areas noted. Heart: tachycardia with normal rhythm and no murmurs. S1 and S2 appreciated, no rubs. Pulses: radial, femoral, popliteal, dorsalis pedis pulses symmetric and 2+. Abdomen: protuberant abdomen, nondistended, bowel sounds present in all four quadrants, liver and spleen nonpalpable, no masses, no tenderness. Back: straight spine, no hair tufts or dimples, no lesions. Extremities: normal tone. Genitalia and anal area: SMR I male, circumcised, testes descended bilaterally; anus patent, no fissures. Neurologic: cranial nerves II-XII grossly intact, deep tendon reflexes 2+ throughout and symmetric, normal gait.
.

well-perfused, no clubbing or edema, joints with full range of motion,

Summary: This is a 2 and year old male with a history of asthma admitted with a 2day history cough, runny nose, fever, wheezing and increased work of breathing. Physical exam is notable for diffuse wheezing and mild-moderate respiratory distress, hypoxia and tachycardia despite albuterol, prednisone and oxygen therapy administered at his PMDs office and in the ED.

Impression: 1. The clinical presentation is consistent with an acute exacerbation of asthma. With a history of preceding fever, runny nose and cough this asthma exacerbation is most likely precipitated by a viral upper respiratory infection. Factors such as cigarette smoke and carpeting in the household may also contribute to asthma symptoms. The differential diagnosis for wheezing in this age group includes: Asthma (history of wheezing in past, eczema, family history of asthma, response to albuterol) Viral illness (bronchiolitis) Foreign Body Aspiration (abrupt onset of symptoms; history of choking, drooling; x-ray) Anaphylaxis (allergen exposure, abrupt onset symptoms, associated symptoms rash, hypotension, etc.) Airway mass Gastroesophageal reflux (feeding associated symptoms) Cystic Fibrosis (family history; associated symptoms: sinusitis, diarrhea, failure to thrive) Alpha-1-Antitrypsin Deficiency (associated failure to thrive, liver disease; neonatal jaundice) 2. Tachycardia Most likely secondary to Beta adrenergic effects of albuterol. The differential diagnosis of tachycardia in this patient includes: Albuterol (side effects: tachycardia, hypokalemia with large doses) Fever (documentation) Dehydration (history of vomiting, diarrhea, poor oral intake, decreased urination; physical exam evidence dry mucous membranes, sunken eyes, poor skin turgor) Fear/anxiety

Plan:

1. Respiratory: Goals relief of bronchospasm, decrease inflammation, treat hypoxia Albuterol Beta adrenergic agonist: relaxes smooth muscle to relieve bronchospasm Dose: 0.5 cc in 2cc Normal Saline Q2H via nebulizer Prednisone Corticosteroid: anti-inflammatory action Dose: 2mg/kg loading dose then 1mg/kg BID Supplemental Oxygen: to maintain saturation 95% and above Pulse oximeter Consider chest x-ray (CXR) if poor response to therapy [rule out (r/o) pneumonia, foreign body, pneumothorax, etc.] Asthma Education Prevention - Stabilizer medication versus rescue medication - Home environment (smoking, carpet, pets, etc.) 2. Cardiovascular : monitor vital signs [CR (cardio-respiratory)monitor] 3. FEN: Monitor input and output (Is and Os) - Supplement with IVF (intravenous fluid) if unable to take POs due to respiratory distress Useful websites:

http://us002.lib.uci.edu/medical/video/bates_physicalexam/ http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable http://www.usc.edu/student-affairs/Health_Center/adolhealth/content/a1.html