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PEDIATRICS II
1.1A PEDIATRIC HISTORY & PHYSICAL DIAGNOSIS

If you do not know what is wrong with a patient after you have taken a
history, then take another history.
If you still dont know , take a third history.
If you do not know then, you probably never will.
Clifton K. Meador, M.D.
A Little Book of Doctors Rules

PEDIATRIC DIAGNOSIS
differs from adults in many ways
infancy and preschool children - derived from adequate
information from the parents or guardian
reliability of the informant is of utmost importance
older patient may not require an informant
it would even be in the best interest of the patient that he/she
answers questions from the inquirer so that rapport and trust
between the pediatric patient and doctor can be established early
on
RULE OF THUMB
When dealing with adult or pediatric patients,

observe the patient upon being brought to the

examination room

do this while taking a good history and doing a

complete physical examination
When the patient is acutely ill,

a brief history of the present illness is taken before the

child is examined

the rest of the history is completed later

PEDIATRIC HISTORY TAKING
Present Illness:

well organized

nature and date of onset

time of manifestation

negative information

diagnosis is a matter of having in mind the various

possibilities which explain the signs and symptoms
presented

recent exposure to infectious diseases, date, where and

how
Family history:

are parents alive and healthy

size of the family

health and problems of other children

living conditions

economic status
Social Condition:

socioeconomic status

home facilities

family problems

Personal History:

prenatal

birth

neonatal
Feeding
Growth and Development
Behavior
Immunization
Past Illnesses

medical illnesses

operations or accidents

drug reactions
System Review

Special senses

Respiratory

Cardiovascular

Gastrointestinal

Genitourinary

Neuromuscular
Interval History

had previously been in the hospital and has had a

complete history

THE CLINICAL DIAGNOSTIC PROCESS

1. Acquire information from the patient by interview, examination, and
sometimes special investigations
2. The doctor analyses these data, deciding first if the patient is telling the
truth, deciding on the nature of the patients problem
3. Must make a decision about the treatment

1.

2.

3.

PEDIATRIC HISTORY TAKING

Active listening involves the use of silence plus non verbal
indications of interest as nodding, maintaining an open, receptive
body stance, leaning forward and maintaining eye contacts
Silence - usually interpreted positively by patients if attention is
focused upon them
Facilitation may be in the form of door openers, rocking or
repeating
Door openers - statements that invite the patient to describe
symptoms or feelings more fully
Rocking - uses words to indicate that the interviewer is listening
and encourages the patient to go on narrating
Repeating words that the patient just stated will aid the patient
in elaborating his thoughts
Questioning - may require open-ended or specific questions

Open-ended - require more than a yes or a no

Invites the patient to speak

Specific questions - those that probe and seek

clarification
Reflection - a response that repeats something the patient just
said
Provide feedback to the patient the information he just given
Confrontation

focuses the patients attention on a component of his

experience

the interviewer affirms the patients unstated feelings

so as to confront the patient with his emotional
condition

ex: you seem to be not in the mood today. What

happened in school
DATA BASE HISTORY FORM
Demographic Data

patients name, address, date of birth, sex, ethnicity,

place of origin, most recent visit

informants relationship to the patient and reliability

number of admissions
Chief Complaint

primary but not necessarily the reason why the patient

why the parents bring their children to the doctor

most important complaint and duration

History of Present Illness
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Pediatrics II

1.1A PEDIATRIC HISTORY & PHYSICAL DIAGNOSIS

well organized so that a clear detailed and unified

profile of the patients illness is depicted

begin with nature and date of onset

time of manifestation by period prior to admission or

in relation to the age of the patient at the time of
occurrence

accurate description, occurrence and progress of signs

and symptoms

pertinent negative information if they contribute to the

diagnosis or help rule out other possibilities

recent exposure to certain infectious agents, diagnosis

made at previous admissions or consultations and
diagnostic modalities performed

therapy - medical and surgical, course and outcome of

the patient
4. Review of Systems

connected to then HPI

should be reviewed thoroughly as they may have been

missed in the patients history telling

if directly related to the current history, should be

integrated to the HPI
5. Family History

emphasize current health status of the parents

family size, health status of other children, living and

housing conditions and economic status

mothers pregnancies and in chronological order her

attitudes towards them

important disease in the family, aliments which are

relevant to the patients present condition

such as exposure to a family member who has TB and

is under therapy

social condition - epidemiologic factors of the disease

can lead to appropriate management of the patient

if the younger infant feels more secure clinging on to the

mother, examine him in this position, it is better to examine a
quiet child than the one who is struggling
you may get false positive results in a child thats highly
combative
5. In an infant - remove all clothing in an older child
- conduct examination with due respect to the patients privacy
and sensitivities
- some wants to be examined alone
Once you gained trust, patient will volunteer more information which
initially was not divulged
Order Of Examination

Need not be from head to foot

Varies according to factors:

urgency of situation

age and cooperativeness

suspected system of involvement

if asleep may be auscultated

initially

invasive procedures may be done

last
4 Developmental Levels
1. Infancy 0-2 y/o
2. Preschool 2-5 y/o
3. School-age 5-10 y/o
4. Preadolescent and adolescent 10y/o

EXAMINING THE PEDIATRIC PATIENTS

The physician must be an opportunist to get the most of the
physical examination

In a crying child the examination of the oropharynx

may be the first to be performed

If an infant clings to his mother, try examining the back

initially

GUIDE IN EXAMINING PEDIATRIC PATIENTS

1. A keen observation of the child from the beginning to the end of the
consultation, for any deviation from normal is significant
2. Wash your hands before and after examining the patient. rub your hands
against each other to warm them up before touching the patient. This will
protect the child from cross infections. It also serves as an example of good
hygiene
3. Spend a little time winning the childs confidence by starting on friendly
terms
this may not work with the child whose mind is already
prejudiced before he comes to the clinic that the doctor is
someone to be feared and is feared and is expected to give
injections
it is therefore the doctors concern to gradually correct his
misconception
4. Examine the child on the examination table

NEWBORN
APGAR SCORE

Appearance color

Pulse heart rate and tone

Grimace response to stimuli applied to

nasopharyngeal area

Activity neurologic assessment

Respiratory effort
APGAR score

obtained at 1 min and 5 min after birth

if 5min APGAR <7:

CPR should be performed

continue taking the APGAR score every 5

min until the score is 7 and above

note the time the score has improved

GENERAL SURVEY
Inspect head, face and oral cavity, extremities, perineum, palpating the
abdomen, and auscultating the anterior thorax and abdominal wall
A small tube should be passed through the nose and
esophagus, into the stomach to rule out posterior choanal and
esophageal atresia
Aspirate gastric contents to prevent regurgitation and
aspiration
A more extensive examination of the newborn is
performed at after the 12th-24th hour of life
Gives ample time to recover from the trauma of
delivery or when applicable the effects of anesthesia on the mother
DUBOWITZ SCORING SYSTEM
Used to assess both the physical and neurological characteristics of the
patient
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Pediatrics II

Observe the baby lying undisturbed in his bassinet and examine him
right there or place him on an examining table completely undressed
Repeat when the baby is for discharge
ROOMED-IN
Examine the baby with the mother awake
Ask any inquiries regarding her new baby
Answer their queries as best as possible
Observe the neonates breathing color, cry, size, body
proportions, nutritional state and movements of the head and
extremities
Responsiveness is best noted 2-3 hours after feeding
Newborn lies normally in a symmetrical position with
limbs semi-flexed and legs partially abducted at the hip.
The head is slightly flexed and in the midline or turned
to one side

1.1A PEDIATRIC HISTORY & PHYSICAL DIAGNOSIS

Low amplitude high frequency tremors of the extremities - seen

with vigorous crying and at times even at rest during the first 48
hr of life.
On the 4th day of life tremors occurring at night may signify CNS
disease, central or peripheral, neurologic problem, birth
injuries or congenital anomalies

ORTOLANI'S SIGN
Hip abduction maneuver
To find out if a congenital hip dislocation is present

INFANCY
Little difficulty will be encountered when performing physical
examination
Provide some form of distraction:

like colorful block or mobiles

a game of peek-a-boo
Baby may be examined on the examining table or seated on the
mothers lap
Observe the interaction between mother and infant
This can give you clues on problems in mothering practice and
can be part of your treatment goals later on
PRESCHOOL
Establish rapport with your patient in this age group
When you are able to communicate with your patient ask him
about his activities and how his daily activities are
Attempt to observe the preschool child
If with abdominal pain:

ask patient to lie down palpate abdomen while

inquiring about school performance and if with truly
an acute abdomen, will not be distracted, by the
inquiry of the observer
Key points: weight and length
Head circumference not routinely obtained
Check for blood pressure
Observe for behavioral features appropriate for age
May complain of:

night fears

eating and sleeping disturbance

toilet training difficulties

temper tantrums, poor social contact with adult or

peers

may have repeated accidents

SCHOOL-AGE CHILDREN
Deal with the child as an increasingly independent individual
Communication is vital and need not be limited to verbal
exchanges

ask them to draw

write their names or a few numbers

Weights, heights, blood pressure, hearing evaluation and visual
acuity - routinely performed
Check immunization status recommend completion if
incomplete
Dental care- important
ADOLESCENT AND YOUNG ADULT YEARS
More aware and become inquisitive of the physiological changes
in their body
Privacy is an important term to contend with
Examine for changes and appropriateness of secondary sexual
characteristics
Confidentiality is important
Increased involvement with each visit gives the pediatrician more
time to discuss with the patient his or her problems
Physical examination - usually done without the parents unless
requested
Constant conversation is necessary
Reassure patient on findings
Assess over-all health, muscle strength and joint flexibility
Demonstrate self examination techniques of the breast and
genitalia
Sexual activity should be inquired

SUGGESTED ORDER OF EXAMINATION

1. Take weight and measurements: head circumference, length or height
2. Inspect patient: cyanosis, respiratory distress
3. Palpate anterior fontanelle: open, bulging
4. Auscultate heart and lungs: followed by palpation and percussion
5. Palpate abdomen for tenderness, rigidity, organomegaly
6. Test back and spine, hips, joints
7. Inspect external genitalia, Tanner staging
8. Test motor system, reflexes, coordination, sensory response
9. Examine eyes and optic fundi
10. Examine ears, use otoscope
11. Take blood pressure
12. Assess development, behavior, intelligence
13. Observe gait
14. Rectal examination if indicated

Consider different rates of growth of the various systems of the

body

The growth and development of the cardiovascular, CNS, and the

reproductive system do not parallel each other nor the general
and somatic growth

Begin with the approach to the patient

3 developmental levels:

infancy: first 2 years

early childhood: 2 5 years

late childhood: > 6 years

GENERAL SURVEY

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Pediatrics II

1.1A PEDIATRIC HISTORY & PHYSICAL DIAGNOSIS

Vital signs and body size taken since deviations from the
normal are apt to be the first and often the only indicators of the
presence of disease in infants and children
Weight and height - taken periodically
Pattern of growth over a period of time is more important than a
single measurement
TEMPERATURE
Average temperature

higher in infancy and early childhood

usually not <37.5C until age 3

18 months 50% has T> 37.8C
In the presence of overwhelming infection:

infants - normal or subnormal temperature

early childhood- extremely high (39C) may be

observed even in minor infections
PULSE
Heart Rate of infants

more readily affected by illness, infection and physical

exertion than in adults

palpate pulsations of the carotid, femoral or brachial

arteries

or by directly auscultating the heart if the rate is very

rapid
Older children radial artery at the wrist may be palpated
Infants use temporal arteries
RESPIRATORY RATE
Greater range
Very responsive to illness, exercise and emotion
Newborn: 3040/min at rest and asleep
Early childhood: 20-40 /min
Late childhood: 15-25/min
15 years: adult level
Prematures and Newborns

RR varies with periods of rapid breathing alternating

with short periods of apnea called the Periodic
Respiration

Periodic respiration is normal for this age group

Infancy and Early Childhood

Breathing is abdominal

Auscultation or putting the stethoscope in front of the

mouth is useful

Direct palpation of the thoracic region may also be

used
Older Child

Auscultatory blood pressure should be done for older

child

Cuff should cover 2/3 of upper arm

HEAD & NECK
At birth shape is modified by the duration of labor
Measure head circumference at birth and periodically

Microcephaly slow increase in HC

Hydrocephalus excessive increase in head

circumference
Slow or rapid increase indication for neurologic evaluation
Anterior fontanel closes at 12 18 months
Delayed closure - hydrocephalus

EARS
Superior border of the ears should align with the eye
External ear and auditory canal should be visualized using
otoscope
Tympanic membrane backward tug on the auricle
Eardrum glistening pearly membrane
Impairment of hearing should be assessed
EYES
Newborn

Difficult to examine - lids are held tightly closed

Dolls Eye Test - hold baby upright , turn slowly in 1

direction, his eyes will look in the direction toward
which he is being turned, when rotation stops, they
look in the opposite direction, following a few quick
unsustained nystagmoid movement
Red Eye Reflex

Set ophthalmoscope at o diopter

View pupil at distance of 10inches

Red or orange color is reflected from the fundus to

the pupil

Opacities partial red reflex or a white reflex

Up to 4 months eyes normally cross
If persists after 8 months investigate
Jaundice demonstrated in the sclera
Fundus examination - requires dilatation
Vision measured as early as 3 years
NOSE
Patency examined at birth, if in doubt pass a rubber catheter to
the nasopharynx
In bigger child ask to close the lips and breath through the nose
Alar flaring - seen in respiratory difficulty
Nasal septum examine for deviation, perforation, malformation
Inspect for polyps, foreign bodies, source of bleeding
Mucosa if pale, boggy or atrophic
MOUTH TONGUE AND THROAT
Color of lips and circumoral area
Natal teeth may be present at birth
Delayed eruption systemic or nutritional disturbance
Hyperfluorosis discoloration and pitting
Tetracycline - yellowish stain
Hutchinsons teeth congenital syphilis
Incomplete /imperfect dentition ectodermal dysplasia
Oral findings in measles leukemia, Addissons disease,
Coxsackie disease
Lips contour, color presence of freckles, atrophy, papules,
swelling
Cheek gently retract to observe opening of the Stensens duct
Tongue

Shape, thickness, character of the papillae, mass

Rare lingual thyroid red midline mass on its base

Oral Mucosa and Gums

Color, presence of enanthems, Kopliks Spots, oral

thrush

Mumps pouting red salivary orifices

Tonsils

Exudate and membrane

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Pediatrics II

1.1A PEDIATRIC HISTORY & PHYSICAL DIAGNOSIS

Enlargement usually due to physiologic lymphnode

hypertrophy or effect of frequent respiratory tract
infection
Epiglottis child must be gently gagged
Larynx inflammation is better heard than seen

NECK
Newborn infant relatively short neck
Webbings, hygromas, cutaneous hemangiomas
Masses, cervical lymph node
Thyroid gland may be physiologically enlarged in the adolescent
girl
Meningitis pain on flexion of the neck
THE CHEST
Auscultate the chest before the baby starts to cry
Shape barrel-shaped, elliptical
Circumference

nipple line

between inspiration and expiration

1st month: CC < HC

9th month: CC=HC

Respiration

Rate:

slower as the child grows older

of the cardiac rate

Depth

shallow CNS and alkalosis

deep peripheral

Symmetry
Inspiratory, suprasternal, supraclavicular, intercostal, subcostal
retractions
Severe dyspnea alar flaring
Most of the childs activity is effected by abdominal motion until
age 6 or 7, there is very little intercostal motion
Later thoracic motion becomes responsible for air exchange
Vocal Fremitus

Determined when the child is crying

Sensation of vibration

Decrease in fremitus obstruction or hydrothorax

Pericardial or Pleural Friction Rub

Fine vibrations

Axillary Nodes
More resonant chest wall is thinner and muscles are smaller
Posterioriorly: shoulder to 8th-10th rib
Anteriorly: below the clavicle to (R) level of dullness of liver, (L)
heart
Dullness scapulae, diaphragm, liver and heart
Mediastinum

Corresponds to the cardiac dullness

Heart - triangular area

- in infants more horizontal, apex is to the left, of the nipple
line
Impaired Resonance or Dullness

Consolidation, collapse or massive atelectasis

Shifting Dullness- hydrothorax
Hyperresonance

Increase in the amount of air

Emphysema

Usually accompanied by lowered diaphragm

Small bell stethoscope used to auscultate children

Decreased breath sounds

Indicate decreased respiratory activity

Seen in pneumonia, atelectasis, pleural effusion,

pneumothorax and empyema
Increased breath sounds

Obstructive emphysema and asthma

Expiratory Rales heard as crackles during expiration

Prominent in bronchiolitis, asthma, presence of foreign

body and aspiration pneumonia
Bronchophony or Tubular breathing

Heard in lobar pneumonia during stage of

consolidation

Tuberculosis, atelectasis if remained open

Wheezes

Commonly heard in expiration than in inspiration

Indicate partial obstruction during expiratory phase

Inspiratory wheeze - in children with high obstruction

as laryngeal edema
Pleural Friction Rub

Course grating sound

Fibrinous type of pleurisy

Cardiovascular System

Precordial Bulge right ventricular enlargement

Visible cardiac impulse

Localization and diffuseness

Normally not visible in children

<7 years 4th intercostal space at

midclavicular line later in the 5th ICS
Cardiovascular System

Thrills and pericardial friction rub

Fine or coarse vibrations

Position and timing at the cardiac cycle

should be observed
Cardiovascular System

Heart sounds - should be clear and sharp

distant heart sound pericardial fluid

Poor quality myocarditis, heart failure

Gallop Rhythm indicates failing heart

Pericardial Friction Rub fibrinous pericarditis as

tuberculosis and rheumatic fever

Murmur- location, time, quality, intensity,

transmission
THE ABDOMEN
Flat - when child is in supine position
Depressed and scaphoid

May be normal in other children

In newborn: diaphragmatic hernia

In infants and children: marked dehydration

Pot Belly maybe normal
Distension: accumulation of gas, fluid or solid mass, impacted
feces
Peristalsis

Sign of obstruction

Maybe seen in prematures & thin small infants

In infants up to 2 months of age - visible peristalsis

may indicate pyloric stenosis or pylorospasms
Palpation Done gently

If with pain, should be palpated last

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Pediatrics II

Masses

1.1A PEDIATRIC HISTORY & PHYSICAL DIAGNOSIS

Muscle guarding - surgical

Spleen: palpable 1cm below left costal margin

Liver: 1-2 cm below right costal margin

size, consistency, surface, edge, tenderness

and pulsations

Liver Span

Right mid clavicular line

Measure the distance between the

upper and lower border by
percussion
Congenital renal anomalies

Semi reclining position - deep palpation of the kidney

using thumb, increasing pressure subcostally in
posterior and cephalad direction, shape size and other
anomalies can be detected
Bimanual palpation

For deeper masses

Include inguinal, femoral regions

Hernias, lymph nodes, femoral pulses

Site for determining dehydration
Skin Fold Test

Pull skin and release

If the creases persist dehydration is present

Tympanitic Sound gas in the abdomen
Fixed dullness or flatness - solid masses
Shifting dullness fluid is present
Auscultate first before palpation

Length of time since the patient first felt pain, location,

frequency, duration, radiation of pain

Once localized determine factors that precipitate

aggravate or improve the pain and identify previous
treatments that succeeded or failed

Daily activities of a child: Eating, sleeping, playing,

schooling, changes in activity

Check family status as has great impact on the child

PE of a child with recurrent pains must be thorough

if more localized organic cause

if diffuse and vague unlikely organic

Growth monitoring is important
Determine weight and height
If normal growth and development

not a serious organic disease

Each clinic visit should be attended to maintain the trust and confidence of
the parents.
This way more vigorous investigation may be avoided.
_______________________________________________________________________________________
END OF TRANX
Be kind whenever possible. It is always possible. - Dalai Lama

THE GENITALIA
Done by inspection
Female

Bloody or mucoid vaginal discharge is normal in

neonatal period

Note for imperforate hymen, urethral caruncle

Large clitoris adrenal hyperplasia

Fusion of the labia or ambigous genitalia

Male

Hypospadias, epispadias, hydrocoele

ANUS & RECTUM
Anal fissures

Cut or tear in the mucosa

One of the most common cause of rectal bleeding and

constipation

Prolapse of rectal mucosa

Rectal examination

Must be done in patients with abdominal pain

MUSCULOSKELETAL SYSTEM
Range of motion greatest in infancy
At birth may appear deformed due to fetal position
Congenital hip dislocation femoral head will be seen lying
posterior to the acetabulum

Ortolanis Test - click is heard as it enters acetabulum

in the 90 degrees abduction arc
CLINICAL PROBLEM SOLVING IN PEDIATRIC PRACTICE
Recurrent pains

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