HISTORY AND PHYSICAL EXAMINATION IN PEDIATRICS.ppt

EXAMINATION history takeing and physical examination

1. HISTORY AND PHYSICAL HISTORY AND PHYSICAL
EXAMINATION IN EXAMINATION IN
PEDIATRICS: A GENERIC PEDIATRICS: A GENERIC
APPROACHAPPROACH
Prof Francis E. OnyangoProf Francis E. Onyango
Paediatrics and Child HealthPaediatrics and Child Health
Class: MB ChB VClass: MB ChB V Date: Date: 14 Sept 201614 Sept 2016

2. BACKGROUNDBACKGROUND
Important component in diagnosis and Important component in diagnosis and
managementmanagement
Each pediatric patient may need emphasis Each pediatric patient may need emphasis
on specific areas of history and examinationon specific areas of history and examination

3. Diagnostic Tests: Clinical Diagnostic Tests: Clinical
diagnosis is based on diagnosis is based on
History as presented by the patientHistory as presented by the patient
Physical Examination as observed by the Physical Examination as observed by the
clinicianclinician
Investigations, which include laboratory Investigations, which include laboratory
teststests

4. Diagnostic Tests: Clinical Diagnostic Tests: Clinical
versus Lab. Testversus Lab. Test
Most diagnoses are based on good Most diagnoses are based on good
clinical evaluation than on laboratory clinical evaluation than on laboratory
test test
Laboratory test may not contribute Laboratory test may not contribute
anything further to a clinical diagnosisanything further to a clinical diagnosis

5. Diagnostic Tests:Frequency Diagnostic Tests:Frequency
of correct Diagnosisof correct Diagnosis
Correct DiagnosisCorrect Diagnosis
Reference Based on
Clinical
History only -
%
Based on History
and Examination
- %
Crombie, J.Coll.
Gen. Pract. 6:579;
1963
88
Sandler, Am. H.J.
100:928, 1980
56 73

6. PreparationPreparation
–SettingSetting
–InformantInformant
–Etiquette and RapportEtiquette and Rapport

7. HISTORY HISTORY

8. Classify your patient by ageClassify your patient by age
NeonateNeonate First 28 days of lifeFirst 28 days of life
InfantInfant Less than 12 monthsLess than 12 months
Under FiveUnder Five Less than 5 years (60 Less than 5 years (60
months)months)
Preschool agePreschool age 12 months to 5 years12 months to 5 years
School ageSchool age 5 years to 15 years5 years to 15 years
ChildhoodChildhood 1 year to 15 years1 year to 15 years
AdolescentAdolescent 13 years to 19 years13 years to 19 years

9. Components of HistoryComponents of History
Identification detailsIdentification details
Presenting complaints and durationPresenting complaints and duration
History of presenting illnessHistory of presenting illness
Past medical history including drug history/allergiesPast medical history including drug history/allergies
Family historyFamily history
Social HistorySocial History
Birth historyBirth history
Developmental historyDevelopmental history
Nutrition historyNutrition history
Immunisation historyImmunisation history
Review of systemsReview of systems

10. Biodata Biodata
Name of patientName of patient
AgeAge
GenderGender
ResidenceResidence
Informant Informant
Caregiver Caregiver

11. Presenting complaints Presenting complaints
The patients own versionThe patients own version
Little interference from the doctorLittle interference from the doctor
Duration Duration
Documented in a chronological orderDocumented in a chronological order
Common presenting complaintsCommon presenting complaints

12. History of Presenting History of Presenting
Complaints (HPC)Complaints (HPC)
In the patients own words (avoid your In the patients own words (avoid your
interpretation or perceptions)interpretation or perceptions)
Taking presenting complaints one at a Taking presenting complaints one at a
time as chronologically presented.time as chronologically presented.

13. Past Medical History (PMH)Past Medical History (PMH)
Details of all illnessesDetails of all illnesses
–AdmissionsAdmissions
–Non admissionsNon admissions
–Consultation – provider consultedConsultation – provider consulted
–No out of home consultations (home care)No out of home consultations (home care)
Medications given and how well usedMedications given and how well used
Result of the managementResult of the management
Check on records of previous medical Check on records of previous medical
attendances.attendances.

14. Family History (1)Family History (1)
Father and the mother (ages)Father and the mother (ages)
Siblings (alive and dead)Siblings (alive and dead)
–AgeAge
–GenderGender
–Occupation Occupation
Any other person living with the family Any other person living with the family
including the house help.including the house help.

15. Family History (2)Family History (2)
Detailed Medical history ofDetailed Medical history of
–Each of the siblingsEach of the siblings
–Each of the parentsEach of the parents
–Each and every other person staying with the Each and every other person staying with the
familyfamily
Family tree for inherited disordersFamily tree for inherited disorders

16. Social History (1)Social History (1)
Marital status of the parentsMarital status of the parents
Living together or not (family relationships)Living together or not (family relationships)
Education of each parentEducation of each parent
Occupation of each parentOccupation of each parent
Hobbies of each parents (alcohol, cigarettes, Hobbies of each parents (alcohol, cigarettes,
drugs and others)drugs and others)

17. Social History (2)Social History (2)
ResidenceResidence
Water supplyWater supply
Waste and refuse disposalWaste and refuse disposal
Environmental sanitationEnvironmental sanitation

18. Birth History Birth History
Antenatal historyAntenatal history
Intra-partum historyIntra-partum history
State of the baby at birthState of the baby at birth
Immediate postpartum historyImmediate postpartum history

19. Growth and Developmental Growth and Developmental
History (1)History (1)
Anthropometrics measurementsAnthropometrics measurements
–WeightWeight
–HeightHeight
–MUACMUAC
–Head circumference Head circumference
–BMIBMI

20. Growth and Developmental Growth and Developmental
History (2)History (2)
Developmental milestonesDevelopmental milestones
–Social smile Social smile (4-6 wks)(4-6 wks)
–Head control Head control (1-3 mths)(1-3 mths)
–Turning towards origin of sound Turning towards origin of sound (2-3 mths)(2-3 mths)
–Extend hand to grasp a toy Extend hand to grasp a toy (2-3 mths)(2-3 mths)
–Sitting Sitting (5-9 mths)(5-9 mths)
–Standing Standing (7-13 mths)(7-13 mths)
–Walking Walking (12-18 mths)(12-18 mths)
–Talking Talking (9-24 mths)(9-24 mths)

21. Nutrition HistoryNutrition History
First six (6) monthsFirst six (6) months
–Exclusive Breast Feeding (EBF)Exclusive Breast Feeding (EBF)
–Twenty four hour dietary recallTwenty four hour dietary recall
Six to twenty-four (6-24) months Six to twenty-four (6-24) months
–Complementary FeedingComplementary Feeding
–Twenty four hour dietary recallTwenty four hour dietary recall
Twenty-four months and aboveTwenty-four months and above
–Family FoodsFamily Foods
–Twenty four hour dietary recallTwenty four hour dietary recall

22. Immunization HistoryImmunization History
BirthBirth
Six weeks, ten weeks and fourteen weeksSix weeks, ten weeks and fourteen weeks
Nine months Nine months
Others Others

23. Systemic Reviews (1)Systemic Reviews (1)
SystemsSystems
–GIT: diarrhoea, vomiting, nausea, appetite, GIT: diarrhoea, vomiting, nausea, appetite,
difficulty in swallowing, abdominal pain, difficulty in swallowing, abdominal pain,
constipation, abdominal swelling, nature of constipation, abdominal swelling, nature of
stool, stool,
–RS: cough, sputum, coughing blood, difficulty RS: cough, sputum, coughing blood, difficulty
in breathing, wheeze, chest pain, nasal in breathing, wheeze, chest pain, nasal
discharge, nasal blockage, itchiness in the discharge, nasal blockage, itchiness in the
nose, sore throat,nose, sore throat,
–CVS: cough, shortness of breath, chest pain, CVS: cough, shortness of breath, chest pain,
palpitations, tiredness, swelling of the legs, palpitations, tiredness, swelling of the legs,

24. Systemic Reviews (2)Systemic Reviews (2)
–CNS: headache, CNS: headache, convulsions, confusion, level of convulsions, confusion, level of
consciousness,consciousness, p paralysis (weakness of the aralysis (weakness of the
limb/s), disturbed sensation (touch, pain, limb/s), disturbed sensation (touch, pain,
pressure, temperature,), fatigue (low energy), pressure, temperature,), fatigue (low energy),
dizziness, sleep abnormalities, nervousness, dizziness, sleep abnormalities, nervousness,
anxiety (feeling of fear, uneasy state), anxiety (feeling of fear, uneasy state),
depression (sadness), abnormal movements depression (sadness), abnormal movements
(tremors, abnormal gait,)(tremors, abnormal gait,)
–EENT: ear pain, ear discharge, sore throat, nasal NT: ear pain, ear discharge, sore throat, nasal
blockage, bleeding from the nose, blockage, bleeding from the nose,

25. Systemic Reviews (3)Systemic Reviews (3)
–MSS: pain in the limbs, pain in the joints, MSS: pain in the limbs, pain in the joints,
swollen joints, gait, swollen joints, gait,
–UGT: urine output-nature and amount, colour UGT: urine output-nature and amount, colour
of urine, pain on passing urine,of urine, pain on passing urine,
–Skin: colour, wounds, rashes, itchiness, Skin: colour, wounds, rashes, itchiness,
dryness, dryness,

26. ThanksThanks

27. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
General ExaminationGeneral Examination
Systemic ExaminationSystemic Examination

28. General Examination (1)General Examination (1)
General ConditionGeneral Condition – good/fair/poor, – good/fair/poor,
AVPUAVPU
Vital SignsVital Signs – Temperature, Respiratory – Temperature, Respiratory
Rate, Pulse, Blood PressureRate, Pulse, Blood Pressure
Nutritional StatusNutritional Status
–Weight, Height, MUAC (Head Circumference)Weight, Height, MUAC (Head Circumference)
–Well nourished, Malnourished (Skin, Hair, Well nourished, Malnourished (Skin, Hair,
Muscles)Muscles)
Hydration Status Hydration Status – Eyes, Skin, GC, – Eyes, Skin, GC,
DrinkingDrinking

29. General Examination (2)General Examination (2)
SkinSkin – head, neck, upper limbs, trunk, – head, neck, upper limbs, trunk,
lower limbs and perineumlower limbs and perineum
MouthMouth – ulcers on lips and mouth cavity, – ulcers on lips and mouth cavity,
thrush, teeth, jawsthrush, teeth, jaws

30. General Examination (3)General Examination (3)
AnaemiaAnaemia – eyes (conjuctiva), mouth, palm, nail – eyes (conjuctiva), mouth, palm, nail
bedbed
JaundiceJaundice – eyes (cornea), under the tongue, – eyes (cornea), under the tongue,
skinskin
CyanosisCyanosis – eyes (conjuctiva), lips/buccal – eyes (conjuctiva), lips/buccal
mucosa, tongue (central cyanosis), fingers, nail mucosa, tongue (central cyanosis), fingers, nail
bed (peripheral cyanosis)bed (peripheral cyanosis)
Lymph NodesLymph Nodes – cervical, axilla, epitrochleal, – cervical, axilla, epitrochleal,
inguinalinguinal
ClubbingClubbing – fingers, toes – fingers, toes
OedemaOedema – feet, legs (pitting? non-pitting?), – feet, legs (pitting? non-pitting?),
sacral, face/cheeckssacral, face/cheecks

31. SYSTEMIC EXAMINATIONSYSTEMIC EXAMINATION
Cardiovascular System (CVS)Cardiovascular System (CVS)
Respiratory System (RS)Respiratory System (RS)
Gastrointestinal System (GIS)Gastrointestinal System (GIS)
Nervous System (NS)Nervous System (NS)
Muskulo Skeletal System (MSS)Muskulo Skeletal System (MSS)
Ear, Nose and Throat (ENT)Ear, Nose and Throat (ENT)
Genito Urinary System (GUS)Genito Urinary System (GUS)

32. Systemic Examination: General Systemic Examination: General
PrinciplePrinciple
InspectionInspection
Palpation Palpation
Percussion Percussion
Auscultation Auscultation

33. Cardiovascular System (1)Cardiovascular System (1)
PulsesPulses
Blood PressureBlood Pressure
InspectionInspection
–Chest Wall - ?Normal, Abnormal, Sternum Chest Wall - ?Normal, Abnormal, Sternum
(Pigeon Chest Deformity)(Pigeon Chest Deformity)
–Pulsations Pulsations
Palpation Palpation
–Apex Beat, Parasternal Heave, Thrills, Apex Beat, Parasternal Heave, Thrills,

34. Cardiovascular System (2)Cardiovascular System (2)
Percussion Percussion
–Cardiac dullnessCardiac dullness
Auscultation (Mitral Area, Tricuspid Area, Auscultation (Mitral Area, Tricuspid Area,
Aortic Area and Pulmonary Area)Aortic Area and Pulmonary Area)
–Heart Sounds I and II (Normal, Loud, Muffled)Heart Sounds I and II (Normal, Loud, Muffled)
–Other heart soundsOther heart sounds
–Murmurs (Systolic, Diastolic, Grade)Murmurs (Systolic, Diastolic, Grade)

35. Respiratory System (1)Respiratory System (1)
Inspection Inspection
–Respiratory RateRespiratory Rate
–Lower Chest wall In-drawingLower Chest wall In-drawing
–Chest Cage Chest Cage
Configuration – normal, deformity (pigeon chest, Configuration – normal, deformity (pigeon chest,
Harrison sulcus, kyphosis, scoliosis)Harrison sulcus, kyphosis, scoliosis)
–SkinSkin
–PulsationsPulsations
–Moving with respiration Moving with respiration

36. Respiratory System (2)Respiratory System (2)
PalpationPalpation
–TracheaTrachea
–Apex Beat, Apex Beat,
Percussion Percussion
–Note – resonant, hyperresonant, dull, stony Note – resonant, hyperresonant, dull, stony
dulldull
Auscultation (all lung fields)Auscultation (all lung fields)
–Air entry – normal, reducedAir entry – normal, reduced
–Breath Sounds – Vesicular, BronchialBreath Sounds – Vesicular, Bronchial
–Added Sounds – Crepitation, Rhonchi Added Sounds – Crepitation, Rhonchi

37. Gastrointestinal System (1)Gastrointestinal System (1)
Examination of AbdomenExamination of Abdomen
Nine Areas of Abdomen – vertical and Nine Areas of Abdomen – vertical and
horizontal landmarkshorizontal landmarks
InspectionInspection – shape (normal, scaphoid, – shape (normal, scaphoid,
distended:- general, localized), skin (scars, distended:- general, localized), skin (scars,
blood vessels, movements, moving with blood vessels, movements, moving with
respirationrespiration

38. Gastrointestinal System (2)Gastrointestinal System (2)
Palpation:Palpation:
–Light palpation - areas of tenderness, Light palpation - areas of tenderness,
masses, guarding, masses, guarding,
–Deep palpation – organs (Liver, Spleen, Deep palpation – organs (Liver, Spleen,
Kidneys, Bladder), masses, Kidneys, Bladder), masses,
PercussionPercussion – note (resonant, hyper- – note (resonant, hyper-
resonant, dull), shifting dullness, fluid thrill resonant, dull), shifting dullness, fluid thrill
AuscultationAuscultation – bowel sounds (normal, – bowel sounds (normal,
increased, absent) increased, absent)

39. Nervous SystemNervous System
Level of consciousness (AVPU)Level of consciousness (AVPU)
Orientation – person, time and spaceOrientation – person, time and space
Meningeal irritation (neck, Kernig’s sign, Meningeal irritation (neck, Kernig’s sign,
Brudzinski’s sign)Brudzinski’s sign)
Cranial NervesCranial Nerves
Motor System – muscle bulk, tone, relexes Motor System – muscle bulk, tone, relexes
(deep tendon, superficial, primitive), power, (deep tendon, superficial, primitive), power,
co-ordination co-ordination
Sensory System – touch, pain, position, Sensory System – touch, pain, position,
temperature, vibration. temperature, vibration.

40. Musculo Skeletal SystemMusculo Skeletal System
Bones – deformities, point tenderness, Bones – deformities, point tenderness,
Joints – swellings, pain, range of Joints – swellings, pain, range of
movements, movements,
Soft tissues - swellings, tenderness. Soft tissues - swellings, tenderness.

41. Ear, Nose and ThroatEar, Nose and Throat
Ears – shape, size, position, pinna, Ears – shape, size, position, pinna,
external meatus, ear drum,external meatus, ear drum,
Nose – shape, nasal bridge, skin, Nose – shape, nasal bridge, skin,
discharge,discharge,
Throat – pharynx; colour, tonsils (size, Throat – pharynx; colour, tonsils (size,
membrane).membrane).

42. Genito Urinary SystemGenito Urinary System
Genitalia – normal, abnormal (describe), Genitalia – normal, abnormal (describe),
male (testis descended), female (labia, male (testis descended), female (labia,
clitory).clitory).
Kidneys – renal flanks tenderness, Kidneys – renal flanks tenderness,
bimanual palpation, size. bimanual palpation, size.
Urinary Bladder – distended, tenderness,Urinary Bladder – distended, tenderness,

43. WORKING DIAGNOSIS WORKING DIAGNOSIS
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
PLANNED TESTSPLANNED TESTS
MANAGEMENT PLANMANAGEMENT PLAN

44. ThanksThanks