Transcript Slide 1

Pediatric History and Physical
Examination
Hiba Abujaradeh
Introduction
History
Investigation
Diagnosis
Examination
Obtaining the Child's History
Interview is a very personal conversation •
with a parent, caretaker, and child/
adolescent during which private concerns
and feelings are shared.
Communication Strategies –
Careful listening –
Strategies to Build a Rapport with the Family
Make a self- introduction •
Explain the purpose of the interview (NCP) •
Provide privacy and remove as many distractions as possible during •
the interview
Direct the focus of the interview with open-ended questions. Use •
close-ended questions or directing statement to clarify information
Ask one question at a time •
Involve the child in the interview by asking age appropriate questions •
Be honest with the child when answering questions or when •
giving information about what will happen. Children need to
learn they can trust their nurse.
Careful Listening
Complete attention is necessary to "hear" and •
accurately interpret information the parents and child
give during the nursing history
pay attention to the parent's attitude or tone of voice •
when the child's problems are discussed the tone of
voice can reveal anxiety, anger, or lack of concern
Observe the parent's nonverbal behavior (posture, •
gestures, body movements, eye contact, and facial
expression)
History taking Outline (Subjective Data)
Identifying data/ Chief Complain •
Present illness •
Past Medical History •
Birth history, childhood illnesses, immunizations, –
hospitalizations and surgeries, allergies, and medications
Family Medical History •
Social History •
Habits/ Activities of daily living (Nutrition, dental, sleep, •
elimination pattern (toilet training), safety/ injury prevention, activity and
exercise, Discipline)
cognitive/ perception ( value and believe, pain)
Developmental behavior •
Review of Systems (ROS) •
•
Case Study
Group work •
Read the case study and find •
Identifying data –
Chief complain –
Past medical history –
Family medical history (draw a genogram) –
Social history –
Habits/ Activities of daily living –
Mile stones that Maria achieved –
ROS –
Maria, one year-old, presents today with her mother at Princess
Basma Center to get one year shot and check her growth and
development.
Maria, who is the third Child to her family, was a product of
Normal vaginal delivery. The mother had healthy and
uncomplicated pregnancy. Maria started crying after birth. She
did not need to be admitted to the NICU.
Maria had healthy childhood with no history of accidents,
injuries, or diseases. Her immunization up to date, and she
presents in the clinic today to get her immunization.
Maria lives with her mom, dad, and two sisters in Amman. Her
dad is an engineer and her mom is a teacher. They are able to
adequately provide for Maria and her sisters needs. They have
private medical insurance.
Regarding Maria habits and activities of daily living, mother
states that Maria drinks whole milk 250- 300 ml daily and eats
table food. She sleeps well during the night and gets one to two
naps during the day. Maria has 1-2 bowel movement, and her
mom changes her diaper every 4 hours, and they are wet. Mom
thinks that Maria is not yet ready for toilet training. Mom states
that she keeps cleaning detergents and medications in a high
locked place. She cleans the floor from little and sharp objects.
Maria goes to the day care as her mom goes to work.
The mother states that Maria is well developed, and she states
that Maria had good head control before four months, sat with
support at 6 months and without support at 7 months, crawled
at 7 months, had first tooth at 8 months, and started waking at
11.
Currently Maria moves around all the time, explores, points all
the time, and waves bye-bye. She puts block in a cup, tries to
eat with a spoon, and bangs 2 cubes held in hands. She says
mama, baba, and bye-bye. She understands simple requests
like “give this to your dad.”
Mother enjoys how her child is so active and smart, loves playing with her
grandparents, aunts, and cousins. She also enjoys when her baby
discovers something new and shows it off to the family.
Review of system
Skin – Mother denies that Maria has pruritus, rashes, lesions, lumps,
itching, dryness, color change, changes in hair/nails, bruising.
Head – denies headache, head injury
Eyes – denies vision problem, or glasses, pain, redness, infections,
tearing.
Ears – denies hearing loss, earaches, tinnitus or noise in ear, drainage
Nose and Sinuses –denies cold, cough, runny nose, congestion,
nosebleeds, hay fever, discharge, obstruction.
Mouth & Throat –denies condition of teeth and gums, sore throat,
hoarseness, halatosis. States that Maria has two lower central and four
upper incisors and now the lower lateral incisors are coming up.
Neck – denies lumps, swollen glands.
Cardiac – denies cardiac murmurs, cyanosis, fatigue, palpations.
Gastrointestinal – denies vomiting, diarrhea, constipation
Physical examination
Sequence of the examination
• The sequence of children examination follows
head-to-toe direction. The main function of
such systemic approach is to provide a general
guidelines for assessment of each body area to
minimize omitting segments of the
examination.
Pediatric Developmental Periods
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Neonatal period – Birth to 1 month
Infancy – 1 month to 1 year
Toddlerhood – 1 to 3 years
Preschool years – 3 to 6 years
School age years – 6 to 12 years
Adolescence – 12 to 18 years
Age specific approaches to physical examination
during childhood
Infant
Position:
•Infants younger than 6 months of age: on exam table or parent’s
lap in supine or prone position
•Infants older than 6 months of age: more comfortable when held
by their caregivers
Sequence:
•If quiet, auscultate heart, lungs, abdomen
•Record heart and respiratory rates
•Elicit reflexes as body part is examined
• Proceed in usual head-to toe direction perform traumatic procedure
last
• Elicit reflexes as body part is examined
Preparation
•keep the parent to provide security for the infant
•Completely undress if room temperature permits (keep diaper on male
infant)
•provide physical comfort during examination by feeding, using a
pacifier, cuddling, or changing the diaper to keep the infant calm and
quiet
•Gain cooperation with distraction (bright objects, rattles, talking,
clicking noises)
•observe the infant for general level of activity, overall mood, and
responsiveness to handling
•Smile at infant , use soft gentle voice
•Enlist parent’s aid for restraining to examine ears, mouth
• Avoid abrupt jerky movements
Toddler
Position:
Because of stranger anxiety, toddlers feel more comfortable when held by
their caregivers
Sequences
•Inspect body area through play; “ count fingers,” “ tickle toes”
•Use minimal physical contact initially
•Introduce equipment slowly
•Auscultate, palpate, percuss whenever quiet
•Perform traumatic procedure last
Preparation
•Have parent remove outer clothing
•Allow to inspect equipment; demonstrating use of equipment is usually
ineffective
•If uncooperative perform procedure quickly
•Use restraint when appropriate; request parent’s assistance
•Talk about examination if cooperative; use short phrases
•Praise for cooperative behavior
Holding toddler for mouth exam
Parent can hold the child closely to the chest with
legs between the parent's legs
Preschool child
Position
Usually cooperative
Prefer parent’s closeness
Prefer standing or sitting / cooperative prone- supine
Sequence
If cooperative, proceed in head- to-toe direction
If uncooperative, proceed as with toddler
Preparation
•Request self undressing
•Allow to wear underpants if shy
•Offer equipment for inspection, briefly demonstrate
• use Make up story about procedure: “ I’m seeing how strong your muscles
are “( blood pressure)
•Use paper doll technique
•Give choices when possible
•Expect cooperation; use positive statements :” open your mouth
• Use distraction such as asking the child to count, name colors/ give positive
feedback
School-age child
Position
•Prefer sitting
•Younger child prefers parent’s presence
•Older child may prefer privacy
Sequence
•Proceed in head-to-toe direction
•May examine genitalia last in older child
•Respect need for privacy
Preparation
•Request self undressing
•Allow to wear underpants
•Give gown to wear
•Explain purpose of equipments and significance of procedures such as
otoscope to see eardrum which is necessary for hearing
•Teach about body functioning and care
Adolescents
Position
Same as for school-age child/ Offer option of parent’s presence
Sequence
Same as older school –age child
Preparation
•Allow to undress in private
•Give gown
•Expose only area to be examined
•Respect need for privacy
•Explain findings during examination: “ your muscles are firm and
strong”
•Matter-of-factly comment about sexual development
•Examine genitalia as any other body part; may leave to end
Pediatric physical Examination
Outline
Physical Growth measurement •
Physiologic measurements •
General appearance •
Skin - head and neck -eyes – ears- nose, mouth •
and throat - lungs-heart – abdomen - genitaliaback and extremities - neurologic assessment
Growth measurements
•Length: less than two years
•Height: more than two years
•Weight
•Head circumference: taken in all children up to
36 months of age and in any child whose head
size is questionable. The head is measured at its
greatest circumference
•Chest circumference: measure the size of chest
by placing the measuring tape around the rib cage
at the nipple line during inspiration and expiration
and take the average.
Length
Height
CDC Growth Charts
The available clinical charts include
the following:
Infants, birth to 36 months:
Length-for-age and Weight-for-age percentiles
Head circumference-for-age and Weight-for-length percentiles
Children and adolescents, 2 to 20 years
Stature-for-age and Weight-for-age percentiles
BMI-for-age percentiles
Preschoolers, 2 to 5 years
Weight-for-stature
www.cdc.gov
Is Ameena growing normally??
Ameena is nine-month-old girl. •
Ameena’s length= 69 cm, weight =9 kg, and •
Head circumference = 45 cm.
The mother asks you if Ameena’s length, •
weight, and head circumference are normal for
her age or not?? Explain
Is Ahmad growing Normally??
Ahmad is 5-year-old boy •
Height = 112 cm –
Weight = 23 kg –
Find Ahmad’s BMI and if he is growing •
normally?
Physiological parameters
Temperature: can be easily measured at several body sites via oral, •
rectal , axillary, ear canal or skin.
Substitutes for the no-longer-used mercury glass thermometer are •
electronic thermometers, infrared ear-based thermometers, chemical
indicator thermometers, skin plastic strips, and digital thermometers.
All of which offer advantages: rapid temp taking, minimal intrusion, •
and reduced cross contamination.
Recommendation based on research vary •
From 2-3 min for oral. Normal 37.0c* 1-2 min for rectal. 1 degree higher than oral (subtract) 5-7 min for an axillary reading. 0.5 degree lower than oral (add) -
Tympanic Temperature
Physiological parameters
Respiration count in the same manner as for the adult patient •
In infant observe abdominal movements because respiration are primarily diaphragmatic.
Count respiration for 1 full min for accuracy -
Normal Respiratory Rates
Age
Breath Per Minute
Neonate
1 yr
2yr
4yr
6yr
8yr
10yr
12yr
14yr
16yr
18yr
Adult
30-40
20-40
25-32
23-30
21-26
20-26
20-26
18-22
18-22
16-20
12-20
10-20
Physiological parameters
Pulse: •
Can be taken radially in children older than 2 years. In infant and young children the apical impulse (heard through a stethoscope) is more reliable
Count the pulse for 1 full minute in infant and young children because of possible irregularities in rhythm .
For greater accuracy, measure the apical rate while the child is a sleep. Compare brachial and femoral pulses at least once during infancy to check for coarctation of aorta.
Normal Resting Pulse Rates Across Age Groups
Age
Average ( Beats Per Minute)
Normal Limits
Neonate
1 yr
2yr
4yr
6yr
8yr
10yr
12yr
Female
Male
14yr
Female
Male
16yr
Female
Male
18yr
Female
Male
Adult
Aging
120
120
110
100
100
90
90
70-190
80-160
80-130
80-120
75-115
70-110
70-110
90
85
70-110
65-105
85
80
65-105
60-100
80
75
60-100
55-95
75
70
74-76
74-76
55-95
50-90
60-100
60-100
Physiological parameters
• Blood pressure:
- Measure using noninvasive method
- BP should be measured annually in children 3 years of age through
adolescence
- Use an appropriate cuff size.
- Position limb at level of heart
- Rapidly inflate cuff to about 20 mm hg above blood pressure baseline
- BP is classified by systolic BP and diastolic BP percentiles for
age/sex/height.
How to interpret findings??
Normal BP: SBP and DBP <90th percentile
Prehypertension: SBP or DBP >= 90th percentile
but < 90th Percentile
Hypertension: SBP or DBP percentile > 95th
percentile
**Children and adolescents whose BP exceeds 120/80 mmHg are
considered prehypertensive even if the blood pressure is < 90th
percentile
Is my child BP Normal???
Nagham is 4-year-old girl with a height of 103 •
cm and BP of 100/65. Nagham’s mom ask you
if her child BP is normal?
Nagham Height: 103  75 percentile •
Nagham BP:
According to BP levels for girls by age and height –
percentile normal BP is between
110/71- 92/52
This means that Nagham has Normal BP
Physiological parameters
Pain (the fifth vital signs- Subjective)
•
Physiological parameters
Pain (the fifth vital signs- objective)
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General appearance
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Faces (dysmorphic features, congenital abnormalities, pain)
Posture, position and types of body movement (the child with
hearing or vision loss may tilt the head in an awkward way to hear or
see better
Hygiene
Nutrition
Behavior (level of activity, reaction to stress, frustration, interactions
with others, degree of alertness…etc)
Development
Parental bonding
Skin
• Skin Color (Mongolian spot, erythema toxicum, acrocynosis,
jaundice)
• Texture
• Thickness
• Mobility and turgor  over abdomen
• Hair (lanugo)
Head and neck
• Palpate the skull for patent sutures, fontanels (anterior closed
at 12-18m, posterior closed at 2nd- 3rd m), fracture and
swelling.
• Observe the face for symmetry, movement and general
appearance.
• Inspect the neck for size and palpate it for associated
structures: normally short with skinfolds between the head and
shoulders during infancy, it lengthens during next 3-4 years.
• Eyes : red reflex. Absence of red reflex can indicate
retinoblastoma
Head and neck
Ears: •
Ear abnormalities are commonly associated with renal •
anomalies. Low set ear can be associated with down syndrome
Examination of the tympanic membrane: •
Pull pinna down and backward in children younger than 3 years old and –
Up and backward in children older than 3 years old.
Nose, mouth, and throat: Encouraging opening the mouth to •
Inspect the teeth, gum, tongue, hard and soft palate and tonsils.
Examine paranasal sinuses: only the maxillary and ethmoid •
sinuses are present at birth.
Head and neck
Ear tags
Position of eardrum in infant
child older than 3 years of age
Chest
Inspect the chest for size, shape, symmetry, •
movement, breast development and the presence of
bony landmarks formed by ribs and sternum
During infancy the chest normal to be rounded (By 2 •
years of age the lateral diameter is greater than the
anteroposterior diameter)
Costal angle 45-50 degree. •
Assess breathing sound. •
Child rib cage
Auscultate the breathing sound
Example of a sequence for auscultation of the chest
Heart
Position: •
Use palpation to determine the location of the •
apical pulse :
Just lateral to the left MCL and fourth ICS in children younger than 7 years of age.
At the left MCL and fifth ICS in children older than 7 years of age.
Auscultate origin and differentiating of heart sound.
Infant apical pulse
Child apical pulse
Direction of heart sounds for anatomic
valve sites and areas (circled) for
auscultation
Assess heart sound
Abdomen
Examination orders: inspection, auscultation, •
percussion and palpation.
Inspect for abdominal hernia (umbilical, internal or •
external inguinal canal, femoral hernia).
Male genitalia: examine the penis, glans and shaft, •
urethral meatus (hypospadias), scrotum (undescended
tests).
Female genitalia: examine for external structure •
(ambiguous genitalia).
Infant's Abdominal palpation
Umbilical hernia
Back and extremities
Spine: examine for curvature (scoliosis). •
Inspect the back for any tufts of hair. •
Inspect the extremity for symmetry of length and •
size.
Count the fingers and toes to be certain of normal •
number ( polydactyly, synductyly)
Back and extremities
Joints: palpate for heat, tenderness, swelling, •
and range of motion.
Note symmetry and quality of muscle •
development, tone, and strength.
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