Pediatric clinical examintion

Pediatric age group is further divided into various subgroups:

Neonatal period Infancy Pre-school child School child first months of life first year of life 1- 5 years 5-15 years

pediatric diagnosis relies heavily on history, partly on examination and partly on investigation. Obtain the history from the mother, whenever possible, other family members may be more vocal or dominant, but they should be discouraged.

Mother are usually very good observers although some of them may need encouragement to give a good description particularly those with little or no education.

Supplementary questions are often needed during history taking as parents tend to emphasize their effort s more at seeking the treatment than describing the child`s symptoms. Terms used by then may also need to be further elaborated

Many times parents volunteer their own interpretation of child symptom which may not true. E.g. mother often attributes undue crying of the baby to abdominal pain while actual problem may be somewhere else.

The older child may give an accurate and detailed acout of their illness and should be questioned directly. It may be sometimes important to talk to a grown up child and his parents in the absence of the other part.

The pattern of writing the history is the same as in adults with additional information about birth history, developmental history, feeding history and immunization.

PRESENTING COMPAINTS
These should be recorded in chronological order.

HISTORY OF PRESENT ILLNESS

Ask details of all the symptoms listed under presenting complaints, one by one. Remember that the young child`s ability to express himself is every limited and similar symptoms like crying, poor feeding, lethargy, vomiting, fever etc may signal many different illnesses.

A worried anxious mother may forget or ignore a symptom or detail of it. To avoid missing significant information about the child`s illness

Ask questions about all the important symptoms in the form of systemic inquiry, after the mother has finished has narration.

SYMPTOMATOLOGY
Same questions are useful in older children in most of the situation. Some presentation of the disease are peculiar to the pediatric age group. These are briefly described below.

FEVER
Fever is perhaps the most common symptom of disease in childhood and infection- localized or generalized- the most common cause. Ask about duration of fever, its pattern, and any associated symptom. In the absence of localizing features malaria and enteric fever are the likely possibilities.

In child with fever throat examination is the single most important examination and urine examination is the single most important investigation.

FEEDING
Refusal to feed is an important symptom in children and indicates the severity of illness. Ask about any change in milk intake( in case of young child) or food and water intake ( in cases of older child since illness started

VOMITING
It is very common in sick children. Vomiting and diarrhea together due to gastroenteritis are one of the most common pediatric problems in third world countries. Vomiting may be an associated symptom in high grade fever or cough

Persistent vomiting accompanied by distension or abdomen suggests intestinal obstruction. Ask about following details:
Colour and contents of vomitus Force and frequency of vomiting Relationship of vomiting with feeding

Remember that effortless regurgitation of milk is common in normal infants and should not be confused with true vomiting.

BOWEL HABITS
Normal bowel habits of an infant may vary from 5 or 6 times a day to once in a couple of days. Diarrhea is very common in infancy. Often there is associated vomiting of fever. Infections of gastrointestinal tract are the most common cause of diarrhea.

Other causes include anywhere else in the body, overfeeding or underfeeding, drugs etc. ask questions about:
Duration of diarrhea Frequency, quantity, consistency, color contents of stool particularly the presence of blood or mucus in the stool

CRYING
Young children generally cry when sick; they also cry when hungry, thirsty, wet, warm, cold or lonely. (Mother usually can distinguish these physiological cries of their infants from abnormal cries due to disease).

On the other hand, a severely ill infant may be too weak to cy. Similarly, a child mental handicap and developmental delay may be very quiet and placid.

COUGH
Respiratory tract infections are very common in children and cough is an important presenting symptom. Long spasm of cough associated with a whoop and vomiting are characteristics of whooping cough.

Ask the following questions about cough:

Is it dry or wet ( children usually swallow the sputum)? Is it worse at a particular time of the day ( late nigh or early morning cough may be due to asthma)? Is there any relation with feeding (cough during feeding may indicated aspiration of mild)? Is it accompanied by wheeze or fever?

BREATHLESSNESS (Dyspnea)
Chest infection (eg. Pneumonia), asthma and heart disease congenital as well as rheumatic are the usually causes of breathlessness in children. It may also be due to metabolic acidosis ask about:
Age of onset Relation with activity Relation with feeding in young infant Present of cough, wheeze or cyanosis

RASHES
These are frequent in children. Common causes are viral infections ( measles, chickenpox, rubella) eczema, scabies allergy and drug reactions. Find out:
Duration Site Changes in color and size Presence of itching

CYANOSIS
It is bluish discoloration of skin and mucous membrane due to excess of reduced hemoglobin. In children it is either due to congenital heart disease or respiratory disorder. As about:
Age of onset Variation in color Relation with recent illness

JAUNDICE
Jaundice occurs in more than 50 percent of newborns. In case of neonatal jaundice the time of onset after the birth is very important. Jaundice developing of the first day after birth may be due to hemolytic disease of the newborn while that appearing on the second or third days is usually physiological.

If jaundice persists beyond 2nd week of age, consider the possibility of biliary obstruction.

LETHARGY AND UNCONSCIOUSNESS

Lethargy is a sign of disease, particularly in acute illness. Unconsciousness is usually due to neurologic or metabolic disorders like meningitis, encephalitis renal failure or hepatic failure.

POSTURE AND GAIT

Rickets, polio, cerebral palsy, muscular dystrophies, hemiplegia and congenital abnormalities can affect the children`s gait and posture ask about any difficulty in:
Walking Running Getting up from lying or sitting position Going upstairs

INVOLUNTARY MOVEMENTS
Get full description of involuntary movements from parents or patient if he is old enough obtain information about:
Age of onset Any relation with febrile illness Progress since onset

CONVULSIONS ( FITS OR SEIZURES)

If doctor himself has not observed the convulsion ( or fits) detailed description by an obser is the main information on which the diagnosis is based. True convulsion should be differentiated from restlessness, jerkiness, volunatary or involuntary movements or breath-holding attacks.

Febrile convulsions- associated with high grade fever- are common in children between six months and five years of age; there may be previous history of such convulsion

HEARING
Hearing defects are frequent in children. Ask whether child responds normally to any voice out of his field vision, and whether he has difficulty in understanding words.

HISOTRY OF BIRTH
It is particularly important in youn children and in children with neurological disorders. It is divided into three periods:

Antenatal
Inquire about health of mother during pregnancy; ask about history of :
Diabetes mellitus Hypertension Swelling of feet Fits Infection ( Tuberculosis, rubella) Drug intake ( dose, duration, and time of gestation) x-rays

Natal
Ask about:
Duration of gestation Place of delivery ( in the hospital or at home; carried out by traditional birth assistant (TBA) midwife, or doctor Duration of labor Mode of delivery ( spontaneous, assisted, cesarean section) Complications during delivery

Postnatal ( newborn)
Information should be obtain about:
First cry immediately or delayed Time of onset of respiration after delivery, any resuscitation required Birth weight Birth injury Feeding difficulty in neonatal period Jaundice, cyanosis, fits, fever, or any other symptom during neonatal period

FEEDING HISTORY
It is particularly significant in malnutrition and other nutritional disorders. Find out:
Time between the birth and the first feed Type of feeding ( breast feeding or formula feeding type of milk) Frequency of feeding; quantity and dilution of bottle feeds Progress in feeding Age at which solids were started and their nature, amount and frequency

 Supplements (vitamins, iron) Current feeding practices before present illness Any change in food intake during illness

IMMUNIZATION
Check the vaccination card if available; otherwise ask about:
Type of vaccination Dates Complete or incomplete Boosters

DEVELOPMENTAL HISTORY
Mother should be asked when did the child first:
Smile Hold his neck Roll over Start responding to voices Sit up with support and without support Crawl

 Start to walk with and without support Talk; single words, sentences Run Start feeding with hands Indicate toilet needs, became dry by day/by night

PAST HISTORY
Details of birth, feeding, development and vaccination are also a part of past history. In addition, inquire about any significant illness in the past, particularly infectious diseases, rheumatic fever or tuberculosis.

TREATMENT HISOTRY
Record the details of treatment given including the doses of drugs which usually are, either more or less than needed. Inquire about traditional treatment as well.

FAMILY HISTORY
Ask about the following:
Age of mother and father Parent`s health( present and past) Stillbirths, miscarriages Siblings

 Grand parent`s health (particularly if living with the familya0 If an inherited disorder is suspected, obtain information about health of uncles, aunts and their children. Also find out whether inter-cousin marriages are common in the family and whether parents are closely related to each other.

SOCIAL HISTORY
Find out:
Parent`s education Persons living in the house Parent`s relation with each other Parent`s attitude toward children Financial status of the family

PERSONAL HISTORY
Inquire about:
Particular habits of the child Behavior of the child at school and relationship with other children

ENVIRONMENTAL HISTORY
Inquire about:
Size of the house and number of occupants Home surrounding Cleanliness and general hygiene conditions Source of drinking water

EXAMINATION
Before examining the children it is important to know normal values of various indices in children of various ages. Students are advised to examine and larges number of normal children of all ages before starting to gain an understanding of the disease children.

Examination of children demands patience and a friendly and kindly attitude. Unfortunately, the unnecessary and deplorable practice of giving injections to the children have created in them fear of doctor`s clinics.

So be patient and try to remove child`s fear by talking to him and parents in understandable terms and by offering the child toys suitable for his age. ( toys suitable for children of all ages should be available in the examination room).

Observation (inspection) constitutes the most important method of examination in children. It should start during history taking and should be supplemented by few minutes of keen observation just before actually touching the child.

The principles in the technique of examination of children is STOP.LOOKTOUCH. Children, generally don`t like their clothes to be removed; so exposure should be limited to minimum necessary.

Posture of examination varies with age. Children between the ages of one year and three years are better examination on the mother`s lap because they are too afraid to leave her. Those below this age can be examined on the couch and those above this age can be examined while standing.

Older children can be requested to lie of the couch if they agree. Sequence of examination should be regional rather than systemic. You should be ready to change your routine and order of examination according to the circumstances and child`s response. Frightening and painful procedures like examining the throat should be postponed till the end.

MEASUREMENTS
Measure weight, height, and head circumference routinely during general examination of child and compare with standard values for his age. Charts giving standard values for these measurement at all ages are available and can be used but you should try to remember them as well. Up to 7 years of age, there is little difference between both sexes.

WEIGHT
It is an important parameter of growth and should be measured regularly. Below 5 years of age weight for age is a very good screening test for nutritional status. Regular growth monitoring of children below 5 years of age by measuring their weight and plotting on a growth chart is recommended by WHO. Sometimes weight for height is used to detect current (acute) malnutrition which is also called wasting.

LENGTH OR HEIGHT
It is another parameter of growth. It is measured a crown-heel in infants and as standing height in order children. Decreased height for age is called stunting. It is an indicator or chronic or prolonged malnutrition in children below the age of 5 years.

Causes of inability to attain adequate height in order children include chronic disease and endocrine disorders. While considering adequacy of height in any child, height of parents should also be taken into account. Height velocity is increased in height per years it is maximum in early years and increases again at puberty.

HEAD SIZE
Abnormal head size usually indicates some disease. Occipito-frontal circumference of the head is measured and is compared with standard tables of head circumference at different ages.

Small head size ( microcephaly) may be due to inadequate brain growth ( mostly associated with mental handicap) or premature closure of the sutures while large size is usually due to hydrocephalus.

TEMPERATURE
In infants and children usually skin temperature is taken. In infants groin is the best site with thights flexed to the abdomen. Some prefer rectal temperature which is 0.25 C higher in order children axilla is suitable