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Pediatrics > History and examination > Flashcards

History and examination Flashcards

1
Q

What are the key features?

A
  • (Name and) Age
  • Nature of the problem
  • Observing the child
  • NB! Parents know their child best, never ignore or dismiss what they say
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2
Q

Taking history intro

A
  1. check name and age
  2. introduce yourself
  3. determine relationship
  4. observe the child
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3
Q

H, presenting symptoms

A
  • Open q
  • Site, Onset, Character, Radiation, ass sx, Time, Exacerbating factors, Severity
  • what did family do ?
  • has the family been affected?
  • what prompted referral
  • what parents think/fear
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4
Q

General enquiry in history

A
  • General health, how active? When were they last normal?
  • Normal growth? following centiles?
  • Feeding, drinking, appetite
  • Any recent change in behavior?
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5
Q

Past medical history

A
  • Maternal obstetric problems, incl antenatal scans, screening blood, delivery
  • Birthweight and gestation
  • Perinatal problem, if admitted to special care baby unit
  • Jaundice
  • Immunizations
  • Past illnesses, hospital admissions and operations, accidents and injuries
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6
Q

Medication

A
  • Past and present meds

- Known allergies

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7
Q

Family history

A
  • Have any member of family/friends had similar problems or any serious disorder
  • Any neonatal/childhood deaths?
  • (Consanguity)
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8
Q

Social history

A
  • Info about family and community
  • Occupation, economy, housing, relationship, smoking, marital stresses, is the child looked after
  • Is the child happy at home? or nursery / school ( in older child (heads- home/environment, Education, employment, activities, drugs, substances, sexuality, suicide, depression, safety)
  • What impact illness has to child and family
  • Adult problems: alcohol, drug abuse, unemployment, poverty, poor damp creeped household, parenteral mental health disorders, unstable relationship
  • Any social worker involved
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9
Q

Development

A
  • Parental concerns about development, vision, hearing
  • Key developmental milestones
  • Previous child health surveillance development checks
  • Bladder and bowel control
  • Temperament, behavior
  • Sleeping problems
  • Concerns and progress at nursery/school
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10
Q

Addapting to age

A

baby- couch w parent next to them
toddler - on lap or over shoulder
preschool - while playing
older - concerned about privacy

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11
Q

Cooperation

A
  • Eye contact and smiles
  • Get on level and try to engage in play or conversation
  • Explain what you are doing and what you want them to do( dont ask as they will often refuse)
  • Be confident and gentle
  • Start mock exam eg. teddy or parent, on hand or knee
  • leave unpleasant procedures until last ( ear, throat, eyes)
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12
Q

Observation of severity

A

In 60 sec

  • Airway and breathing, RR, effort, stridor, wheeze, cyanosis
  • Circulation: HR, pulse volume, peripheral temp, CRT
  • Disability: level of consciousness
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13
Q

Measurement

A

Weight, length, head circumference, temp, BP

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14
Q

Posterior fontanelle close

A

2-4m

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15
Q

Anterior fontanelle close

A

18m to 2y

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16
Q

General appearance

A
  • Head and neck
  • Face
  • Hands
  • Dysmorphic features
  • Fontanelle and sutures
  • Congenital abnormalities
  • Dehydration
  • Jaundice
  • Anemia
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17
Q

What signs examine in resp system ?

A
  • Cyanosis
  • TP
  • Chest shape
  • Clubbing
  • Dyspnea
  • Palpation
  • Auscultation
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18
Q

Cyanosis

A
  • Peripheral: decreased oxygen in RBC or decreased oxygen given to body
  • Central: best observed on lips/tongue, circulatory/ventilatory problem that leads to poor oxygenation in the lungs
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19
Q

TP

A
  • Neonate >60
  • Infant > 50
  • Young child > 40
  • Older child > 30
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20
Q

Clubbing

A

Usually associated w chronic lung disease (CF) or cyanotic congenital HD. Sometimes seen in IBD or cirrhosis

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21
Q

Palpation of resp/chest

A

Chest expansion, if abnormal check w tape measure. Trachea if central but seldom helpful an disliked by child. Location of apex beat to detect shift of mediastinum

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22
Q

Dyspnea

A
  • Labored or increased work
  • Judged by 1) nasal flaring 2) expiratory grunting 3) use of accessory muscles (SCM) 4) Retraction of the chest wall: suprasternal , intercostal and subcostal 5) difficulty speaking or feeding
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23
Q

Chest shape

A
  • Hyperexpansion or barrel shape = asthma, CF, bronchiectasis, bronchiolitis, langerhans histiocytosis, COPD
  • Pectus excavatum (hollow) or pectus carinatum (pidgeon chest)
  • Harrisons sulcus ( undraping of the chest wall from long term diaphragmatic tug = poorly controlled ashma)
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24
Q

Auscultation lungs

A
  • Quality of breathing, equality
  • Cough, note character
  • Hoarse voice
  • Stridor: harsh, low pitched, mainly inspiratory from URi
  • Sounds
    1) Vesicular = norm
    2) Bronchial = higher pitched, length, is equal (prolonged in asthma
    3) Wheeze = high pitched, exp, intraairway pressure
    4) Crackles = discontinous moist sounds, from opening of bronchioles
    5) Rhonchi =
    6) Rales
    7) Crepitations
    NB! Remember to ask if before or after inhalation
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25
Q

What do you assess in cardiac system?

A
  • Inspection
  • Cyanosis
  • Clubbing
  • Pulse
  • Palpation
  • Percussion
  • Hepatomegaly
  • Femoral pulses and brachial
  • Auscultation
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26
Q

Pulse

A 
<1y = 100-160
2-5y = 95-150
5-12y = 80 120
>12 = 60-100
- Rhythm, sinus arrhythmia
- Volume: small in circulatory insufficiency (AS), increased in high output state ( stress, anemia), collapsing in PDA and AR
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27
Q

Inspection of chest (heart)

A
  • Resp. distress
  • Precordial bulge caused by cardiac enlargement
  • Ventricular impulse: visible if thin or hyper dynamic circulation or LV hypertrophy
  • Operative scars: median sternotomy or left lateral thoracotomy
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28
Q

Palpation of heart

A
  • Apex at 4th-5th intercostal space, midclavicular line (not palpable in some infants)
  • Thrill = palpable murmur
  • Heave frem ventricular hypertrophy, lower left sternal edge
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29
Q

Percussion of heart

A

Cardiac borders are rarely helpful in children

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30
Q

Percussion of lungs

A

Needs to be done gently, comparing one side w the other, using middle fingers. In infants, only informative when clear cut signs. Localized dullness: collapse, consolidation, fluid

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31
Q

Femoral pulse

A

Always in neonate, CoA

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32
Q

Hepatomegaly (heart)

A

An important sign of HF in infants, normally palpable 1-2 cm below costal margin.

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33
Q

Auscultation heart

A
  • Split S2 is usually easily heard and normal
  • Fixed splitting of s2 = ASD
  • S3 in mitral area is normal in young child
  • Murmurs: 1) Timing (sys/dia/continous) 2) Duration (midsys/pan) 3) Loudness 1-2 are sof and difficult to hear, 3 easily heard, 4-6 loud w thrill 4) Site of max intensity 5) Radiation: neck (AS) , back (CoA or PS)
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34
Q

Features of significant murmur

A
  • All over precardium
  • Loud
  • Thrill (4-6gr)
  • Any diastolic murmur
  • W abnormal cardiac signs
35
Q

Abdomen ass. signs

A
  • Eyes: jaundice
  • Tongue for cyanosis
  • Mouth for oral health and ulcers
  • Fingers for clubbin
36
Q

What to assess in abdomen

A 
Inspection 
Auscultation
Percussion
Palpation 
Hepatomegaly
Splenomegaly
Rectal 
Kidney
Genital
37
Q

Inspection of abdomen

A
  • Normally protuberant in toddles and young child
  • Dilated veins and spider nevi
  • Abd striae
  • Operative scars
  • Peristalsis (pyloric stenosis, obstruction)
  • Buttocks normally rounded? ( wasted in malabsorption eg celiac /malnutrirtion
38
Q

palpation of abdomen

A
  • ask of pain or tenderness

- systemic: liver, spleen, kiney, bladder

39
Q

Tenderness ddx

A
  • Location : appendicitis, hepatitis, pyelonephritis, generalized medenteric adenitis, peritonitis
  • Guarding: pain on coughing, moving osv..(back bendt on walking may be from posts inflame.
40
Q

Hepatomegaly

A
  • Palpate from iliac fossa

- Measure extension

41
Q

Kidneys

A
  • usually not palpable

- one can get above them unlike the spleen/ liver

42
Q

Splenomegaly

A

A palpable spleen is at least x2 its normal size

43
Q

Percussion abd

A
  • Liver dullness delineates
  • Spleen
  • Ascites, shifting dullness
44
Q

Auscultation of abd

A

increased sounds = obstruction or diarrhea

reduced/absent = paralytic ileus, peritonitis

45
Q

abd tumors

A
  • Wilms tumor, do not cross midline
  • NB, irregular, firm mass, may cross midline. Child is usually very unwell
  • Fecal mass, mobile, nontender, indentable, often left iliac fossa
  • Intussuception, acutely unwell, mass may be palpable, , often in RUQ
46
Q

Rectal exam

A

Not performed routinely. Does the anus look normal.

47
Q

Genital area

A
  • Penis normal size, hypospadias, chordee
  • Scrotum, swelling
  • Palpable testis
  • Ext. female genitalia
48
Q

Neuro in infant

A

posture and movement of limbs, when lifting: tons, head control

49
Q

What is assessed in neuroexam

A

CN, inspection of face, muscle tone, coordination, reflexes, sensation, patterns of movement

50
Q

CN1

A

smell, need not tested in routine practice

51
Q

CN2

A

visual acuity, determined by age

52
Q

CN3,4,6

A

full eye movement, squint, nystagmus

53
Q

CN5

A

clench teeth + sensation

54
Q

CN7

A

Close eyes tight, smile, show your teeth

55
Q

CN8

A

hearing, whisper

56
Q

CN9

A

Levator palati, saying aagh, deviation of uvula

57
Q

CN10

A

Recurrent laryngeal hoarseness or stridor

58
Q

CN11

A

Trapezius, SCM power, shrug shoulders

59
Q

CN12

A

Tongue, atrophy or deviation

60
Q

Inspection of face

A
  • Myopathic face: expressionless, often w ptosis and drooping of corners of the mouth (NM disease)
  • Ptosis: 3rd nerve palsy (unilateral) , MG (bilateral)
  • Tongue fasciulation: SMA
61
Q

Inspection of limbs

A
  • Wasting: CP, meningomyelocele, muscle disorder, polio
  • Increased bulk: calfes (Duchenne), myotonic conditions
  • Contractures: windswept posture ( increased tone, hypotonia, decreased movements in utero)
  • Fasciculations: LMN lesion
62
Q

Muscle tone

A
  • Posture of limbs: scissoring/pronated forearms,/fisting/extended legs (increased tone), frog like ( hypotonia) abnormal posture/ extension (dystonia)
  • Power: 5 normal 1 minimal, 0 no movement
  • Truncal tone: in extrapyramidal tract disorders, trunk and head tends to arch backwards. Floppy child cannot sit (muscle or CNS)
  • Head lag: pull the child up from supine position
63
Q

Coordination

A
  • Fingernosetest
  • Walk heel to toe, jump
  • Build one brick upon another, do/undo buttons, draw, copy pattern and write
64
Q

Reflexes

A
  • Test child in relaxed position
  • Explain what you are doing with hammer
  • Absent: NM problem, lesion in SC, inexpert tecnique
  • Brisk: anxiety in child or pyramidal disorder
  • Plantar: unreliable <1y. Upping response provide evidence of pyramidal dysfunction
65
Q

Sensation

A
  • Likely if meningomyelocele or spinal lesion
  • More detailed w wooden stick as in adults
  • In spinal/ cauda equina lesion: palpable bladder or absent perineal sensation
66
Q

Patterns of movement

A
  • Child >5y can manage to walk heel toe
  • Hemiplegic gait: one arm flexed while dragging the ipsilateral affected leg
  • Toe-heel pattern: pyramidal tract(corticospinal) dysfunction or pelvic girdle NM weakness
  • Broadbased: immature gait, cerebellar disorder, or lower limb weakness
  • Waddling gait: proximal weakness round pelvic girdle
  • Difficulty walking on the heels: foot drop eg hereditary motor neuron sens neuropathy
  • Tight achilles tendon: weakness suggesting hemiplegia or myopathy
67
Q

How to asses bones and joints

A

pGALS: pediatric gait, arms, legs, spine. If abnormality is found, a more detailed regional exam of affected joint (as well as the one above) should be performed

68
Q

pG in pgals

A

Posture and gait. Observe standing from front, back and side. Observe walking on tip toes and heels.

69
Q

Arms

A
  • Put out straight and make a fist
  • Pinch every finger with thumb
  • squeeze my hands
    (put together palm to pal, reach and touch the sky, put behind neck)
70
Q

Screening questions in pgals

A
  • Do you have pain or stiffness in joints, muscles or back?
  • Do you have difficulty getting yourself dressed w/o any help?
  • Do you have any difficulty going up and down stairs?
71
Q

legs in pgals

A
  • Feel for effusion in knee
  • Bend and straighten you knee (active)
  • Passive movement of hip
  • Temporomandibular joint
72
Q

Neck and spine

A
  • Touch your shoulder w your ear
  • Observe lateral flexion of cervical spine
  • Bend and touch your toes
  • Observe curve of spine
73
Q

Regional ms assessment

A

Look, feel, move, function

74
Q

Look ms

A
  • Sign of discomfort
  • Skin abn: rashes, scars, bruising, color, nail
  • Limb alignment, leg length, muscle bulk and evidence of asymmetry
  • Bony deformity, soft tissue , joint swelling, muscle change
75
Q

feel ms

A
  • Each joint, long bones and neighboring soft tissues
  • Palpate along bones and joint line for tenderness
  • feel for warmth ( inf, inflame)
  • delineate bony or soft tissue swellings
  • check for effusion, most readily at the knee
76
Q

move ms

A
  • for each joint, ask child to moe the joint first
  • observe for discomfort, symmetry and range of movement
  • passively move joint, noting range of movement ( compare sides but note bilateral changes)
  • lateral and rotational movements may be as important as flexion and exertion
77
Q

function ms

A
  • lower limb: gait

- small joints such as hands: check grip

78
Q

what do you assess in neck

A
  • thyroid

- lympgnodes

79
Q

thyroid

A
  • Inspect: swelling, uncommon in childhood, occasionally at puberty
  • Palpate from behind and front for swelling, nodule, thrill
  • Auscultate if enlarged
  • Look for signs of hypo/hyperthyroid
80
Q

Lymphnodes

A
  • Children have easily palpable LN, particularly ant. cervical, inguinal and axillary
  • Bilateral ant. cervical up to 2cm are often found in older healthy children, or if experiencing/recovering from URI
  • Supraclavicular nodes of any size at any age and nodes that are firm, non-tender of viable size and mottled together warrant further investigation -> malignancy
  • Nodes of variable size and consistency, is it TB?
  • Bilateral axillary nodes up to 1 cm and inguinal node up to 1,5 cm are found in older children (and younger child with eczema)
  • Generalized lymphadenopathy may be present with viral inf. eg. exanthema of mono or systemic disease (JIA), idiopathic arthritis or Kawasaki
  • Erythema, warmth, tenderness and fluctuation of node suggest lymphadenitis of inf. origin
81
Q

What not to forget on the head?

A
  • Eyes
  • Ears
  • Throat
82
Q

Eyes exam

A
  • Inspect eyes, pupils, iris, sclerae
  • Are eye movement full and symmetrical
  • Any nystagmus
  • Pupuls: equal, central, reactive to light, squint
  • Ophthalmoscopy: in infants red reflex is best seen from a distance of 20-30 cm. Partial or complete absence of red reflex occurs in corneal clouding, cataract and RB
  • Fundoscopy requires experience and cooperation, in infants mydriatics are needed. Should not be examined in child with headache, DM, HT
83
Q

Ears exam

A

Usually until last. Examine ear canals and drums, look for redness, anatomical landmarks, perforation, dullness, fluid

84
Q

Throat exam

A
  • Until last together with ears
  • Observe tonsils, uvula, pharynx, posterior palate
  • 5y + will open mouth w/o spatula
  • Look for redness, swelling, pus or palatal petechie, teeth for dental caries and other gross abnormalities

Pediatrics (4 decks)

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