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PEDIATRIC HISTORY ANDPEDIATRIC HISTORY ANDCLINICAL EXAMINATIONCLINICAL EXAMINATION
Faisal AbuFaisal Abu--EkteishEkteish
Professor of PediatricsProfessor of Pediatrics
Jordan University of Science &Jordan University of Science &
TechnologyTechnology
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Differences between Adult andDifferences between Adult and
PediatricsPediatrics
History is given by second person.History is given by second person.
The parents may place their own interpretation onThe parents may place their own interpretation onevents(any fever may be called tonsillitis).events(any fever may be called tonsillitis).
The cooperation of the child cannot be guarantiedThe cooperation of the child cannot be guarantied
The expression of the disease may be influencedThe expression of the disease may be influenced
by the child¶s developmental status(apnea may by the child¶s developmental status(apnea mayindicates convulsion in newborn)indicates convulsion in newborn)
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Differences between Adult andDifferences between Adult and
PediatricsPediatrics The predominant impact of the disease mayThe predominant impact of the disease may
be on growth and development (UTI, be on growth and development (UTI,Chronic illness).Chronic illness).
Physiological norms are more constant inPhysiological norms are more constant inadults, variable with age in infants andadults, variable with age in infants andchildren( HR, RR)children( HR, RR)
Clinical signs of the disease may differ fromClinical signs of the disease may differ fromthose of adults (Liver is palpable inthose of adults (Liver is palpable ininfancy).infancy).
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Age Groups In pediatricsAge Groups In pediatrics
Neonatal period Neonatal period 11stst monthmonth
InfancyInfancy 11stst year year
ChildhoodChildhood 11--15 years15 years--Toddler Toddler 2 years2 years
PrePre--school childschool child 22--5 years5 years
school child 5school child 5--15 years15 years
AdolescentAdolescent 1313--1919
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Pediatric historyPediatric history
Introduce yourself to the parents and child.Introduce yourself to the parents and child.
A worm greeting and friendly smile to allayA worm greeting and friendly smile to allay
anxiety and promote confidence.anxiety and promote confidence.
Encourage the parents to tell the story withEncourage the parents to tell the story with
minimum of interruption and listen carefully.minimum of interruption and listen carefully.
You should not swallow the diagnosis given byYou should not swallow the diagnosis given by
the parents.the parents. It is essential to find out what the concern of theIt is essential to find out what the concern of the
parents are. parents are.
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Pediatric historyPediatric history
Presenting Complaint.Presenting Complaint.
History of present illness and importantHistory of present illness and important
related positive & negative symptoms.related positive & negative symptoms. Systems reviewSystems review
Past historyPast history
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Pediatric historyPediatric history
Maternal history (PreMaternal history (Pre--natal).natal).
Birth history (Natal).Birth history (Natal).
PostPost--natal history.natal history. Nutritional history. Nutritional history.
VaccinationVaccination
Growth and developmentGrowth and development Family historyFamily history
Social historySocial history
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Pediatric historyPediatric history
Maternal history:Maternal history:
± ± Multiparity, any miscarriages, stillbirth or Multiparity, any miscarriages, stillbirth or
congenital malformation.congenital malformation. ± ± Maternal health during pregnancy, regular Maternal health during pregnancy, regular
antenatal care, Rh isoantenatal care, Rh iso--immunization.immunization.
± ± History of drugs ingestion during pregnancy,History of drugs ingestion during pregnancy,
oligohydroamnios or polyhydroamniosoligohydroamnios or polyhydroamnios
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Pediatric historyPediatric history
Birth history:Birth history:
± ± Mode of delivery.Mode of delivery.
± ± Crying immediately or not.Crying immediately or not. ± ± Apgar scoreApgar score
± ± History of asphyxiaHistory of asphyxia
± ± Meconium stained amniotic fluid.Meconium stained amniotic fluid.
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Pediatric historyPediatric history
PostPost--natal history:natal history:
± ± NICU admission NICU admission
± ± How much did the baby stay in the nursery.How much did the baby stay in the nursery.
± ± Did the baby required mechanical ventilation ?Did the baby required mechanical ventilation ?
± ± Oxygen was given ? Duration of oxygen.Oxygen was given ? Duration of oxygen.
± ± Baby had history of jaundice? ExchangeBaby had history of jaundice? Exchange
transfusion done?transfusion done? ± ± Any illness during first month of life:Any illness during first month of life:
meningitis, convulsion, fever ..etc.meningitis, convulsion, fever ..etc.
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Pediatric historyPediatric history
Nutritional history: Nutritional history:
± ± Breast or bottle feedingBreast or bottle feeding
± ± Type of formulaType of formula ± ± How much milk is given , number of feeds/dayHow much milk is given , number of feeds/day
± ± How is the milk preparedHow is the milk prepared
± ± When the solid food or cereals is introduced,When the solid food or cereals is introduced,
content of food, any allergy to the food.content of food, any allergy to the food.
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Pediatric historyPediatric history
Vaccination history:Vaccination history:
± ± Vaccination program in details( National,Vaccination program in details( National,
UNRWA)UNRWA)
± ± Any special vaccination was given.Any special vaccination was given.
± ± When the last vaccine was givenWhen the last vaccine was given
± ± Any complication of given vaccineAny complication of given vaccine
± ± Any contraindications for certain vaccine?Any contraindications for certain vaccine?
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Pediatric historyPediatric history
Growth and development history:Growth and development history:
± ± Details of development milestones, smiling ,Details of development milestones, smiling ,
sitting, standing, walking, speech,sitting, standing, walking, speech,
± ± Bladder and bowel controlBladder and bowel control
± ± School performance, behavioral and emotionalSchool performance, behavioral and emotional
history.history.
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Pediatric historyPediatric history
Family history;Family history;
± ± Father and mother age, consanguinity, level of Father and mother age, consanguinity, level of
education and they are healthy or not.education and they are healthy or not.
± ± History of smoking in either parentHistory of smoking in either parent
± ± Siblings: number, sex, and their ages.Siblings: number, sex, and their ages.
± ± History of similar disease, unexplained deathHistory of similar disease, unexplained death
and genetic diseases.and genetic diseases.
± ± Draw family pedigreeDraw family pedigree
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Pediatric historyPediatric history
Social & Environmental history;Social & Environmental history;
± ± It is necessary to build up a picture of theIt is necessary to build up a picture of the
child¶s social and cultural environmentchild¶s social and cultural environment
± ± Appreciate fears and stresses at home( parentalAppreciate fears and stresses at home( parental
attitudes, separation, divorce, absence of attitudes, separation, divorce, absence of
parent) parent)
± ± Jealously at the arrival of a new babyJealously at the arrival of a new baby ± ± Unexplained injuries may raise the possibilityUnexplained injuries may raise the possibility
of child abuse.of child abuse.
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Pediatric ExaminationPediatric Examination
Important points to remember:Important points to remember:
± ± The examination of infants and children is anThe examination of infants and children is anart, demanding qualities of understanding,art, demanding qualities of understanding,
sympathy and patience.sympathy and patience. ± ± Heart rate, Respiratory rate, BP, liver size, heartHeart rate, Respiratory rate, BP, liver size, heart
size varies with age.size varies with age.
± ± Keep disturbing or painful procedures to theKeep disturbing or painful procedures to the
end.end. ± ± It is not necessary to be systemic in your It is not necessary to be systemic in your
examination , but should be complete.examination , but should be complete.
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Pediatric ExaminationPediatric Examination
General inspection:General inspection:
± ± The first step is ascertain quickly if the baby isThe first step is ascertain quickly if the baby is
well, mild or severely ill.well, mild or severely ill.
± ± Assess state of consciousness, breathingAssess state of consciousness, breathing
pattern, position, reaction to environment. pattern, position, reaction to environment.
± ± State of nutrition, speech, cry, size relative toState of nutrition, speech, cry, size relative to
the age.the age. ± ± The child should be as completely undressed asThe child should be as completely undressed as
possible, but not necessarily all at once. possible, but not necessarily all at once.
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Pediatric ExaminationPediatric Examination
General appearance:General appearance:
± ± If the child is seriously ill ABC and vital signsIf the child is seriously ill ABC and vital signs
must be taken without delay and necessarymust be taken without delay and necessary
immediate intervention is undertaken.immediate intervention is undertaken.
± ± Describe any dysmorphism, abnormalDescribe any dysmorphism, abnormal
movements, unusual position he assumes, hismovements, unusual position he assumes, his
mental status and activity.mental status and activity.
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Pediatric ExaminationPediatric Examination
Measurements: should includeMeasurements: should include
± ± Height (length)Height (length)
± ± WeightWeight ± ± Head circumferenceHead circumference
± ± All given with percentile for age.All given with percentile for age.
± ± Temperature (rectal, oral ,axillary)Temperature (rectal, oral ,axillary)
± ± RespirationRespiration
± ± Blood pressureBlood pressure
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Pediatric ExaminationPediatric Examination
Skin:Skin:
± ± Include color Include color
± ± The presence of cyanosisThe presence of cyanosis
± ± Discolored patchesDiscolored patches
± ± JaundiceJaundice
± ± RashRash
± ± EdemaEdema ± ± Skin turgor Skin turgor
± ± Amount of subcutaneous tissueAmount of subcutaneous tissue
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Pediatric ExaminationPediatric Examination
Head:Head:
± ± Examine the head for shapeExamine the head for shape
± ± SuturesSutures ± ± Bone defectsBone defects
± ± Size and tension of fontanellesSize and tension of fontanelles
± ± The hair and scalp should be examinedThe hair and scalp should be examined
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Pediatric ExaminationPediatric Examination
Eyes: make a gross test of vision.Eyes: make a gross test of vision.
± ± Visual fields should be tested in all children old enoughVisual fields should be tested in all children old enough
to cooperateto cooperate
± ± Evaluate for strabismus by position of the light reflexEvaluate for strabismus by position of the light reflexand the cover testand the cover test
± ± Look for nystagmusLook for nystagmus
± ± Examine the conjunctivae for anemia and sclerae for Examine the conjunctivae for anemia and sclerae for
jaundice and the cornea for haziness and opacities jaundice and the cornea for haziness and opacities ± ± Pupils size and shapePupils size and shape
± ± Fundoscopic examinationFundoscopic examination
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Pediatric ExaminationPediatric Examination
Ears:Ears:
± ± Check for position(low set ) and shape of bothCheck for position(low set ) and shape of both
ears.ears.
± ± Examine the tympanic membrane for injection,Examine the tympanic membrane for injection,
bulging or perforation bulging or perforation
± ± Evaluate hearingEvaluate hearing
± ± The mastoid also need to be checkedThe mastoid also need to be checked
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Pediatric ExaminationPediatric Examination
Mouth and throat:Mouth and throat:
± ± The color of lips and mucosaThe color of lips and mucosa
± ± The condition of teeth, gums and buccalThe condition of teeth, gums and buccalmucosamucosa
± ± Look for tongue, palate, tonsils and pharynxLook for tongue, palate, tonsils and pharynx
± ± Listen to the voice and the quality of cry andListen to the voice and the quality of cry and
the presence of stridor the presence of stridor
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Pediatric ExaminationPediatric Examination
Neck examination: Neck examination:
± ± Examine for neck rigidityExamine for neck rigidity
± ± SwellingSwelling ± ± WebbingWebbing
± ± Lymph nodeLymph node
± ± Thyroid glandThyroid gland
± ± The position of tracheaThe position of trachea
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Pediatric ExaminationPediatric Examination
Nose and sinuses: Nose and sinuses:
± ± The nasal examination is performed to detectThe nasal examination is performed to detect
deformities.deformities.
± ± Deviation of the septumDeviation of the septum
± ± Color and state of the mucosa and turbinatesColor and state of the mucosa and turbinates
± ± Presence of foreign bodyPresence of foreign body
± ± Examine the sinuses for tenderness andExamine the sinuses for tenderness and
swellingswelling
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Pediatric ExaminationPediatric Examination
ChestChest: Inspection: Inspection
± ± The general shape of the chest (pectus excavatum or The general shape of the chest (pectus excavatum or
pectus carinatum) pectus carinatum)
± ± Abnormal signs to look for are beading (rosary),Abnormal signs to look for are beading (rosary),asymmetry of expansionasymmetry of expansion
± ± In infants respiration is diaphragmatic and abdominalIn infants respiration is diaphragmatic and abdominal
± ± PalpationPalpation
± ± PercussionPercussion
± ± Auscultation:Auscultation: breath sounds in children are usually breath sounds in children are usually
bronchovesicular. bronchovesicular.
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Pediatric ExaminationPediatric Examination
Cardiovascular system:Cardiovascular system:
± ± InspectionInspection
± ± Palpation:Palpation: the apex beat is normally felt in the 4the apex beat is normally felt in the 4thth
intercostals spaceintercostals space just to the left of the midclavicular just to the left of the midclavicular line in children under 7 years of age. After that it is feltline in children under 7 years of age. After that it is felt
in the 5in the 5thth intercostals space in the midclavicular line.intercostals space in the midclavicular line.
± ± PercussionPercussion
± ± Auscultation:Auscultation: Note the effect of changing of position Note the effect of changing of positionand exercise on the murmur. Splitting of the 2and exercise on the murmur. Splitting of the 2ndnd heartheart
sound is common in normal childrensound is common in normal children
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Pediatric ExaminationPediatric Examination
Abdomen:Abdomen:
± ± InspectionInspection ± ±Distension, Scaphoid abdomen,Distension, Scaphoid abdomen,
± ± PalpationPalpation ± ± The lower border of the liver isThe lower border of the liver isnormally 1 cm below the costal margin innormally 1 cm below the costal margin in
infants and children. Liver span 8infants and children. Liver span 8 ± ± 1.8 cm1.8 cm
An enlarged spleen is extending into the left iliacAn enlarged spleen is extending into the left iliac
fossa in infancy and the right in older childrenfossa in infancy and the right in older children ± ± PercussionPercussion
± ± auscultationauscultation
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Pediatric ExaminationPediatric Examination
Back:Back:
± ± By employing both observation and palpation,By employing both observation and palpation,
the spinal shape and posture9lordosis, kyphosis,the spinal shape and posture9lordosis, kyphosis,
scoliosis)scoliosis)
± ± MassesMasses
± ± TendernessTenderness
± ± Limitation of motionLimitation of motion
± ± Spina bifidaSpina bifida
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Pediatric ExaminationPediatric Examination
Genitalia:Genitalia:
± ± Undesent of testesUndesent of testes
± ± HydroceleHydrocele ± ± HypospediusHypospedius
± ± Ambiguous genitaliaAmbiguous genitalia
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Pediatric ExaminationPediatric Examination
Anus:Anus:
± ± Patency(imperforated anus)Patency(imperforated anus)
± ± Presence of fissure, fisulae or hemorrhoidsPresence of fissure, fisulae or hemorrhoids ± ± Rectal examination if indicatedRectal examination if indicated
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Pediatric ExaminationPediatric Examination
MuscloMusclo--skeletal system:skeletal system:
± ± AsymmetryAsymmetry
± ± Anomalies of extremitiesAnomalies of extremities ± ± Pain and tenderness of the joint or limbsPain and tenderness of the joint or limbs
± ± Always s examine for congenital dislocation of Always s examine for congenital dislocation of
the hip in infantsthe hip in infants
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Pediatric ExaminationPediatric Examination
Neurological Examination Neurological Examination
± ± ObservationObservation
± ± Mental statusMental status
± ± Cranial nervesCranial nerves
± ± Cerebellar functionCerebellar function
± ± Motor systemMotor system
± ± Sensory systemSensory system ± ± ReflexesReflexes--primitive (neonatal reflexes, deep and primitive (neonatal reflexes, deep and
superficial reflexes.superficial reflexes.
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Pediatric ExaminationPediatric Examination
Developmental assessmentDevelopmental assessment
± ± Gross motor Gross motor
± ± Vision and fine motor Vision and fine motor ± ± Hearing and languageHearing and language
± ± Social and adaptiveSocial and adaptive
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Developmental assessmentDevelopmental assessment
Gross motor:Gross motor:
± ± Head and neck control in prone position(6Head and neck control in prone position(6--88
weeks)weeks)
± ± Able raise head and chest (3months)Able raise head and chest (3months)
± ± Pull from lying or no head lag (4 months)Pull from lying or no head lag (4 months)
± ± Sit without support back straight (8Sit without support back straight (8--9 months)9 months)
± ± Stand without support (10Stand without support (10--12 months)12 months)
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Developmental assessmentDevelopmental assessment
Vision and fine motor Vision and fine motor
± ± Follows moving person with eyes (6Follows moving person with eyes (6--8 weeks)8 weeks)
± ± Follows small ball at 10 feet distance(9months)Follows small ball at 10 feet distance(9months) ± ± Pincer grasp (between index finger and thumbPincer grasp (between index finger and thumb
using small object (11using small object (11--12 months)12 months)
± ± Copies a circle (with pencil, build a bridge of 3Copies a circle (with pencil, build a bridge of 3
cubes when shown (3years)cubes when shown (3years)
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Developmental assessmentDevelopmental assessment
Hearing and language:Hearing and language:
± ± Turns eyes to soundTurns eyes to sound--rattle 12 inches(2rattle 12 inches(2--44
months)months)
± ± Says Mama, Baba (7Says Mama, Baba (7--9 months)9 months)
± ± Says simple sentences 3Says simple sentences 3--4 words(24 words(2--2.5 years)2.5 years)
± ± Says first name, knows own sex (3 years)Says first name, knows own sex (3 years)
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Developmental assessmentDevelopmental assessment
Social and adaptiveSocial and adaptive
± ± Smiles when spoken, vocalizes (6Smiles when spoken, vocalizes (6--8 weeks)8 weeks)
± ± Reaches for and shakes rattle, puts objects toReaches for and shakes rattle, puts objects tomouth(5mouth(5--s month)s month)
± ± Drinks from cup without spilling (18 months)Drinks from cup without spilling (18 months)
± ± Wash hands, pull pants up and down (3 years)Wash hands, pull pants up and down (3 years)