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
2
Q
Taking history intro
A
- check name and age
- introduce yourself
- determine relationship
- observe the child
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
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?
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
6
Q
Medication
A
- Past and present meds
- Known allergies
7
Q
Family history
A
- Have any member of family/friends had similar problems or any serious disorder
- Any neonatal/childhood deaths?
- (Consanguity)
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
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
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
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)
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
13
Q
Measurement
A
Weight, length, head circumference, temp, BP
14
Q
Posterior fontanelle close
A
2-4m
15
Q
Anterior fontanelle close
A
18m to 2y
16
Q
General appearance
A
- Head and neck
- Face
- Hands
- Dysmorphic features
- Fontanelle and sutures
- Congenital abnormalities
- Dehydration
- Jaundice
- Anemia
17
Q
What signs examine in resp system ?
A
- Cyanosis
- TP
- Chest shape
- Clubbing
- Dyspnea
- Palpation
- Auscultation
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
19
Q
TP
A
- Neonate >60
- Infant > 50
- Young child > 40
- Older child > 30
20
Q
Clubbing
A
Usually associated w chronic lung disease (CF) or cyanotic congenital HD. Sometimes seen in IBD or cirrhosis
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
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
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)
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
25
What do you assess in cardiac system?
- Inspection
- Cyanosis
- Clubbing
- Pulse
- Palpation
- Percussion
- Hepatomegaly
- Femoral pulses and brachial
- Auscultation
26
Pulse
```
<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
```
27
Inspection of chest (heart)
- 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
28
Palpation of heart
- Apex at 4th-5th intercostal space, midclavicular line (not palpable in some infants)
- Thrill = palpable murmur
- Heave frem ventricular hypertrophy, lower left sternal edge
29
Percussion of heart
Cardiac borders are rarely helpful in children
30
Percussion of lungs
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
31
Femoral pulse
Always in neonate, CoA
32
Hepatomegaly (heart)
An important sign of HF in infants, normally palpable 1-2 cm below costal margin.
33
Auscultation heart
- 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)
34
Features of significant murmur
- All over precardium
- Loud
- Thrill (4-6gr)
- Any diastolic murmur
- W abnormal cardiac signs
35
Abdomen ass. signs
- Eyes: jaundice
- Tongue for cyanosis
- Mouth for oral health and ulcers
- Fingers for clubbin
36
What to assess in abdomen
```
Inspection
Auscultation
Percussion
Palpation
Hepatomegaly
Splenomegaly
Rectal
Kidney
Genital
```
37
Inspection of abdomen
- 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
palpation of abdomen
- ask of pain or tenderness
| - systemic: liver, spleen, kiney, bladder
39
Tenderness ddx
- Location : appendicitis, hepatitis, pyelonephritis, generalized medenteric adenitis, peritonitis
- Guarding: pain on coughing, moving osv..(back bendt on walking may be from posts inflame.
40
Hepatomegaly
- Palpate from iliac fossa
| - Measure extension
41
Kidneys
- usually not palpable
| - one can get above them unlike the spleen/ liver
42
Splenomegaly
A palpable spleen is at least x2 its normal size
43
Percussion abd
- Liver dullness delineates
- Spleen
- Ascites, shifting dullness
44
Auscultation of abd
increased sounds = obstruction or diarrhea
| reduced/absent = paralytic ileus, peritonitis
45
abd tumors
- 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
Rectal exam
Not performed routinely. Does the anus look normal.
47
Genital area
- Penis normal size, hypospadias, chordee
- Scrotum, swelling
- Palpable testis
- Ext. female genitalia
48
Neuro in infant
posture and movement of limbs, when lifting: tons, head control
49
What is assessed in neuroexam
CN, inspection of face, muscle tone, coordination, reflexes, sensation, patterns of movement
50
CN1
smell, need not tested in routine practice
51
CN2
visual acuity, determined by age
52
CN3,4,6
full eye movement, squint, nystagmus
53
CN5
clench teeth + sensation
54
CN7
Close eyes tight, smile, show your teeth
55
CN8
hearing, whisper
56
CN9
Levator palati, saying aagh, deviation of uvula
57
CN10
Recurrent laryngeal hoarseness or stridor
58
CN11
Trapezius, SCM power, shrug shoulders
59
CN12
Tongue, atrophy or deviation
60
Inspection of face
- 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
Inspection of limbs
- 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
Muscle tone
- 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
Coordination
- Fingernosetest
- Walk heel to toe, jump
- Build one brick upon another, do/undo buttons, draw, copy pattern and write
64
Reflexes
- 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
Sensation
- 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
Patterns of movement
- 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
How to asses bones and joints
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
pG in pgals
Posture and gait. Observe standing from front, back and side. Observe walking on tip toes and heels.
69
Arms
- 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
Screening questions in pgals
- 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
legs in pgals
- Feel for effusion in knee
- Bend and straighten you knee (active)
- Passive movement of hip
- Temporomandibular joint
72
Neck and spine
- Touch your shoulder w your ear
- Observe lateral flexion of cervical spine
- Bend and touch your toes
- Observe curve of spine
73
Regional ms assessment
Look, feel, move, function
74
Look ms
- 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
feel ms
- 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
move ms
- 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
function ms
- lower limb: gait
| - small joints such as hands: check grip
78
what do you assess in neck
- thyroid
| - lympgnodes
79
thyroid
- 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
Lymphnodes
- 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
What not to forget on the head?
- Eyes
- Ears
- Throat
82
Eyes exam
- 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
Ears exam
Usually until last. Examine ear canals and drums, look for redness, anatomical landmarks, perforation, dullness, fluid
84
Throat exam
- 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
