Philippine Copyright (@2006, 2009 by the Unversity of Santo Tomas Faclty of Medicine and. Sorgery, Deparment of Pedintics| Allright reserved. No part ofthis bok may be reproduced without the writen permission ofthe copyright holders, Layoue and printing by (fy sereronssmiesinWe dedicate this project To All our STUDENTS. ~ the future physicians To All our TEACHERS - the experts in pediatrics; ‘our inspiration and role models and To The CHILD , our patient and friend ~ who deserves some extra special care because ~ = he is not just a miniature adult, The Staff ofthe Department of Pediatrics UST Faculty of Medicine and Surgery University of Santo Tomas Hospital ‘2008-2009FOREWORD Asin the frst edition, this handbook represents our effort to condense and simplify the approach to pediatric diagnosis by Focusing on the basics of history taking and physical examination, Review of the fist edition started eight after che frst ppuilcaton in 2005 but it was only in 2008 ~ when the staff sae clown and seriously worked 19 come up witha revised and improved cilition. Feedback from the students, tiinees and practicing physicians helped a lot: Mlustraions and tables were added to facilitate reading and recall. Special mention wo Des. Rebeeea Casto and Remedios Ong who did major revisions in history taking and physical examination, We hae included the WHO growth chars in place of the previous NCHS charts as recommended by the World Health Organization and the Philippine Pediatrie Society. In the evelopment checklist ~ several tables from diferent authors were reviewed and the Neurodevelopmental team under Drs. Noemi Salazar and Rhandy PeBenito came up with a more practical guide forthe clinics, More diagnostic procedures have also been included in thie isoue Tam grateful to all she members of the department of Pedinties of the Faculky of Medicine and Surgery and the UST Hospital who have shared their academic and clinial expertise in podiutic health eae ‘Tothe members ofthe editorial board especially ourguests = faculty, Des. Rolando Songeo and Benjamin Co, my sincerest ‘hanks forgiving your precious time and priceless know-how and experience ~ for us to come up with an excellent guide in pedistie diagnosis,| ‘To our department seeretry, Ms Oriel Marybeth Fetalcuin, for painstaking typing, recording, and revising the text I whenever necessary. I “To the Department Chairman, Dz Melinda M. Atienza, for ‘rusting me with the completion of the 2nd Ed of the Isandbook, I Tt is noteworthy that the handbook has helped a lot of students of Medicine and alot of indigent patients in our pecatrcs ward. ‘oat ours and eines, Hhope the ude wl lp 1 southrugh yor ining ad price of mei ! OSALINA Q. DE SAGUN, M.D. | ain, Depo of eis 2o02 a0 [Mead Eo BoardEDITORIAL BOARD ‘Melinda M. Atienza, M.D. , MHPED, FPPS, FPSPME Associate Professor and Chairman, UST Department of Pediatries Chief, Section of Endocrinology Malizza HI. Anzures, MD. Chief Resident LUST Hospital, Department of Pediatries ‘Aurora F. Bauzon, M.D.MSPH, FPPS Professor, UST Department of Pediatrics Rebecca A. Castro, M.D., FPPS, FPSPGN, FPGS Professor, UST Department of Pediatrics, Community Preventive and Family Medicine Chief, Section of Pediatrics Gastroenterology and Nutrition Benjamin B. Co, M.D., FPPS Professor, Department of Pediatrie (eet) UST Faculty of Medicine and Surgery Former Editor in Chief, ‘The Philippine Journal of Pediatrics and the Santo Tomas Journal of Medicine Rosalina Q. de Sagun, M.D., FPPS, FPNA, FCNSP Professor, UST Department of Pediatrics, ‘Neurology and Psychiatry Chief, Section of Child Neurology and Developmental Pediatties‘Agnes G. Llamas, M.D., FPPS, DAAP Associate Professor, UST Department of Pharmacology and Pediatrics Ma. Philomena G. Lopez, M.D. , FPPS Professor, Department of Pediatrics Miguel L. Noche, Je M.D, FPPS, FPSAAI, FAAP Ret. Professor, Department of Pediatries UST Faculty of Medicine and Surgery Remedios C. Ong, M.D., DPPS, FPSAAI ,DABP, ABAI Professor, Departments of Pediatrics and Pharmacology Rhandy PeBenito, M.D. FPPS, FCNSP, FAAP, FAAN Professorial Lecturer Department of Pediatrics, Neurology and Psychiatry Wilfredo F. Santos, M.D., FPPS, FPSNbM Asst. Professor, Department of Pediatrics, Community Preventive and Family Medicine Rolando S. Songeo, M.D., FPPS Chairman Emeritus, Department of Pediatrics Hospital of Infant Jesus Retired Professor, Department of Pediatrics University of Santo Tomas and University of the East Professional lecturer, St. Louis University, Baguio City ‘Ma, Aurora M. Valencia, M.D., FPPS, FPNA, FCNSP Instructor, Department of Pediatrics, ‘Neurology and PsychiatryCONTRIBUTORS Atienza, Melinda M [Andaya, Agnes G. Bauzoa, Aurora F. Beroal, Christine Buzon, Rosalia M. Canonigo Beatrice B. Castro, Rebecea A. Chan, Antonio B. Chan, Remedios D, Co, Benjamin G. Cuaso, Charles C De Leon, Ma. Rhodora G. Deniega, Lester A. De Sagun, Rosalia Q. Go, Olivia C, Hernandes, Emilio A. Jn Heernanclez, Flesida G. Kho, Josie N. lamas, Agnes G. Lopez, Ma, Philomena G. Olonan, Leoneia N. ‘Ong, Remedios C. Peralta, Ma, Louisa Pe Benito, Rhandy D. Rabago, Hilda T. Regal, Agnes S. Rodriguez, Edwin V. Rivera, Clara R Salazar, Ma. Noemi. Santos, Wilfredo R. Sibulo, Ma, Carole Lisa C. $5, Dolores B. Valencia, Ma, Aurora M. Villar, Estrella PPREFACE ‘The handbook “Guide for History Taking, Physical Examination and Diagnosis of Pediais Patients” prepared by the faculty of the Department of Pediatics isa legacy the Faculty Of Medicine and Surgery bequeath to che Furre physicians of our ‘Country and the world in general. Iisa reflection of the desire of our tery able staff who are not only heath care providers but educators Te ell, to: mould our young students ad future colleagues to become frute cinicans Good patient care afer al, stems from excellent Geademic background, sincere rapport with patints and relatives, intensive history taking and thorough physical examination. Ancillary procedures play adjune 0 the dignosis Reading the handbook and asinilatng what are writen will certainly guide usin the practice of our chosen profession. Throwgh this projec, we continue our mission of rearing and shaping our students qo become competent, commited and compassionate physicians wd heemtac GoBzabsl usc. Dean Faculty of Medicine and SurgeryPREFACE [A good physician is one who knows what information 10 gather, how to adequately obtain them and why they were needed fo are a 2 reasonable working diagnosis Its imperative for every Clinician #0 acquire though constant practice, the much needed Snvetigative, analytical and descion-making skis in his task of FMeotiying and managing both common and rare disorders This Ihegins with a set of standardized techniques in histor-aking and physical examination that can be easly used both by beginning and seasoned medial pacttoners Tn 2005, through the efforts of Dr: Rosalinda Quimpo-de ‘Sagun, iumedate past chairperson of the Department of Pediascs bf the UST Faculty of Medicine snd Suryers,a Handbook on History ‘Taking, Physical Examination and Diagnosis of Pediatie Paints” ‘eas published to help undergraduate and postgraduate students of orcs polish their eapabilis in this importan aspect of elinial practice Buc asthe only constiney in tis world is change, we must side with it, and take i a8 an opportunity to beter and further these ‘sting guidlines We must continue 10 seck, learn and implement CSuanges that wil make these blueprints selevant and usefsl ia our present setup of providing optim heal care services winglimited fd somtimes improvised resources [As a developing country, we ate notin a way bandicapped by these restrictions. A good physician is not one who knows what technology to use but one who understinds when and why to use them, "Ths, i eannot be over emphasized that a en diagnostic acumen, a dacersing management syle using avalible diagnostic modalies Spang noc idea but snot only deal buts important achievable “Tis is wha this 2 edition ill about, ‘Lee me extend my sincerest apprecation to the hardworking, committee tasked 0 revise, zeformat and eit this new handbook Their acifcamness and willingness to share and extend chemselves is nero gesture of that pron in teaching that has shept all of us in this profession, There could be no better manifestation of their fommiment to uphold the sandards of pediatic education and Smmpeove the lt future Thomasian physicians than theiecontbution in the completion of this handbook x=‘Let melikewise thank our seasoned mentorsin pediatrics who ‘hough their wilom, foresight and commitment r bring thei eats to near perfection have generously enlightened all of us, students of pediatre medicine, to pat ato publeation what we all believe can hep vety physician deliver whats expected of him-competent, commited fd compassionate cater every child he i destined heal Las, let me offer this handbook, tothe Father Almighty, ‘who through His greatness gave all of us dhe alent, he time and the Uestny to collaborate, merge and synergize forthe fruition of this noble endesvor And to the Filipino children of today and tomorvoss let ‘his be a tesament of our fem belie in the promiseof your bright ature and our unfatering commitment t0 change your les for the ‘etter and make this worlds healthier and safer place for you to grow develop and suced. Department of Pees 209PREFACE “This handbook ented “Guide for History taking, Phys cal Examination and Diagnostic of pediatses Patients” i entitled ro Frelp the undergraduate students develop the at of history taking and phyvieal examination nd to refresh seasoned pediatricians and faculty members i the sills of pedi diagnosis. 1 congetulate the Department of Pediatrics staff led by Prof Rosalina Q, de Sagun, N.D, Department Chai, 2002 ro 2008 and overall Head, revisions Committee of the Handbook and Prof Melinda M, Avent, M.D, cureent chai, Department of Peaties For making this clini “diagnostic rool" one of its major project. “The departments emphasis on this clinical dignostc tol for the undergraduate medical students and post-graduate tang in Pediase Medieine students and post-graduate traning in pediatric “Medicines very relevant especially in ths day and age of advances ia technology, Precepts learned from this handbook help clinicians curb “Sipemsive diagnostic work-ups and atte same time give them sn op: ‘portunity o interact and develop eappor wth patients and thei Fam Hes 1am ualy proud ofthe department’ continuing efforts 1 be ‘one of the academe centers for Pediatrie Medicine in the countey in the Thomasian spit ees WI hegar PRONE On EMRITCS EUSTACIASTRIGOR, MD Chatman, Department of Psiaies 19641999 Daan Fal of Meine and Segery, UST 1980-1982PREFACE TO THE 1° EDITION he explosion of gh echanlns, speciation and sbpeieton he be spbinsenced dgrostc and therapetc proces SRE Rha evr pnetons an eines se est in mal Speci Beton and eaten Inte process medal Fs Bas recom eeapenive aed ufTordabe Putra number of anda or soem chins a ceo of pia cil) 8 8 Feo ak diac Knowle in wen caamiatons but beens aa en condacing a sory and pial examination and ned of deen hs he mot as ndinexpensve oon aegis Sa yc uaderazed ~ 2 god Kiwoey and pertinent post tetas eons hatin mst nwtances, “86% ofthe goss ca De mde rons a he norman ls us phys examination coats a et pacdures wil prove a ral percentage”, Mos sxsond 2a et tne Gina aay pa of we eS Ct 0 HEN ci evade 1 ean and ew Bem 1 dal ae ito of one portant grou fale n ory eng = et ght onal penenotherise” These statements erpse he eee of an acne Rory an persia peal amin ring agnosis icin therefore in ti comes shat conga he Depaeest a Panne ur the abl ladenkp of Prot Rosine. de San, ae Hercean fir cameo with is handbook The Sona exer fay colt te coins fom se eating cor glad by the parent este eof out at aa ln ee Dt Rent Ma, Gace rine forsale sme ym of um the depart who ate ale Sar th ty Fxmidable ero epee of sue to ee appenethedpreent eee of smmeden ie agen ling 2 god sry ads ciao oe strum ay lea DSv0 _—m m1. vu. TABLE OF CONTENTS History ‘Taking ssn a Physical Examination : 7 6 History and Physical Examiaaion of the Nevly Born nanan 38 Neurological Examieation of the Newborn, Infants and Older Childe. 33 ‘Technique of Diagnoss. 7 Common Pediatrie Procedures mwa 8 Append : 2 98 Normal Valucs of commonly used tests in Cie, toeeeeeeetaeee 08 Food Exchange of Common Foods. 108 “Acral Calorie Intake - Sample Caeulation 10s, Recommended Energy and ‘Nuatint Intake (REND. 109 Developmental Checklist (0-6 years). noe 10 Denver H Developmental Sereening Test (DDST) oe 114 Primitive and Developmental Refleses ~ Nouinal and Pathologie sol 16 ental Development eee eee Red Flags for Developmental Delaessnennnnnenn 9 WHO Growth Charts and Instruction fo" Usenet “Tanner's Sexwal Maturity Rating (SMR) MB CCassieation of Neworn and Gestational Age Lubehenge0) ncn 146which HISTORY TAKING ‘The mark of an exellent physician is the profcieney with he takes the history and performs the physical examination and then on the basis of the findings wilzes the laboratory accurately and costeffecivel, when necessary, approach a fal diagnos and clfectvetherpy. ‘An adequate histony is essential forthe physician to make a correct diagnosis, To obtsin a complete history with data properly ‘econded chronologically and in appropriate detail isan art which is cquired only with patience and experience. ‘Children are not nature adults 5 woch the history takingisin pediatric patents is unigue and distinctive for the following resons: 1). Content Variations 4) Prenatal and birth history 1) Developmental history «Social history of family environmental risks 4) Immunization History «) Feeding History 2) Indirect souree of clinia informasion commonly given by Patens 8) parent’ iterpretation of clinical Features may alfect sceunaey of data reliability of parents observation vais 6) patental behaviors/emotions are important Some basic concepts in obtaining a very good elniea history of the psn + Goafiee the symptom lke a hound dog’ and pursue the symptom relendesly + Failure to keep “om trace Teads to error in diagnosis and unnecessary Iboratory procedures + DONT accept che dagnosis given by parents but persue the ence Features dat enable parents to reach sch conclusion + Keep an open mind and follow the seen ue lke an expert detective. + Be flexible in your approach to obtain cliniea data especialy athe ER or during acute office visit ‘Start interview with parents or guardian in a postive note since fist contac is the most important connectioncero Tn Parc Strurenme Duoneec Aue Ps HISTORY “The historian should realize thatthe information ina pediansic bistory is usually obtained fom a person other than the patent bimsel Thetefor, itis up to the historian to evaluate the accuracy and relevance of the dita given by the informant I. General Data ‘Name;age (bin dat) sexsrace (thay); bilthpace religion; present address, umber and date of hospital admisions arm ff informant and relation to patent; selabilty of informant should be stated: if possible qualify in percentage (1). This should be assessed atthe end of history taking Reliliy of ‘he infra dipond om te lesing factor: 1) Reltioip of the Inj the ato (2) Nan of aa iafrmant yt the oto (3) cational tine oft informant; 4) iabemeat of ‘he informant inte are of the patio I, Chief Complaint “The answer to the question “why was the patient brought 10 the hospital?” expressed in a word or two without describing ‘or qualijing the reply This may bea single symptom or group fof related symptoms: this should norinelude diagnostic terms ‘or mames of diseases; the duration ofthe symptom may also bbe mentioned, For OPD patients, may wat for follow-up, (CP clearance, well baby care and immunization, “Gi heat wore of hiro honor pose IML, History of the Present Ilness (HPD: Inquiry tthe HPI hd be conde a flows A. The signs and symptoms should be éeserbed in chronological order, from the start of the less, with appropriate panigraphing and underlining for emphasis so that the reader may obtain che maximum iaformation ia ‘minimum reading time. Use specif number of hours oF days. weeks ormoaths, not “lst Money” ora few weeks ‘ago” forthe time of onset. Inga of chron nesses, tate tlso the date and age at onset." Yt pate is 2 mentor and} or the pent probe aerated to the rental a perinatal ro, he mtn and rh ir sau incrporated ii the HPLB. Elkborate on the symptoms a 1. onset (acute or ehronie) 2 inensity of symptoms: how severe the pain sand whether itinerferes with activity, ts qual, locaton, duration, etn, severity and frequency, factors that aggracae/slieve che main symptoms 44 medications (genei¢ and brand names) including actual dose fin mg/kg/day or mg/kg/dose) and duration of treatment, “Brand name of the deugs should be writen in parenthesis Include any ouside medial teatment, consultations or hospitalization. Find out where the chid is geting their medial care poor to visit and the reason For change 5. associated symptoms must be described as to: onset, ‘course, chrooology, intensity I the history suggests a parscular disease, inguire about signs and symptoms characteristic ofthis disease. Pertinent negatives ae of vale in the diferencia diagnosis. Readmissions if previously admited co this hospital or had Ou- Paviear Department consultations, obtain these records from the hospital and summarize. Records of any admission to her hospitals ‘should alo be obtained and summarized. IF these press hospital fudmissions appear elated tothe HPL sumimasize the pertinent fnfarmation (neluding pertinent laboratory date, final diagnosis); following this comes the Interval History which deseribes the course fof iiness since the lst hospital admissions related to the present ilaess and then elaborate ofthe presea symptom) and its associated manifestations on this admission. These wil all now consttte che LHL Previous admissions not related othe HPL are placed under Past Minesses “the previonamisiont are rated 0 prs ies, the shld be writen inh fst paagaph of te HPL Based on the History of the Preset Illness, the physician should already have an inal impression and differen diagnosis,1. Elaboration of dita in systems not covered in the history of dhe present ilineses. This wil help uncover sypoms in ‘ther engans or systems that may be related to the pesent Anes. "Ask nh imptoms splat eof the patie 2, Genet Weight loss/ gain aetivty levels appetite: delay in growth Cutaneous: sash; pigmentation; nr loss; acne: proias Head (incude eyes, car, se, mouth and throats breadache; dizziness, visual difcalties;lcrimaion: hearing, sural discharge; nasal discharge; piss toothachesalivation, Sore throat. Canliowseular orhopnes; cyanosis; easy ftgailiys fainting spells ee. ‘Respzaony: chest pin; cough diffiuty of breathing Gastzintesinal-vomitng:bowelmavements-diatthes, constipation; encopresis; passage of worms; abdominal pains od intolerance; pica Genitourinary: color of wine; burning, sensation; equeney, discharge; enuresis, edema of ands and fet in ‘puspubzal female askabout discharge anditchingrinpubsxal Ehdadolecent female - get history of mensiaal periods (onset frequency, regal, pain), date of las pesod. ‘Endocrine: breast asymmetry, pain or dichanss: palpitations; cold/hest intolerance; polyuria, poldipsia, polsphaia tremors; sleep problems consulions; weakness or paras, mental detonation; enonalty of behavios changes; memory loss; cating Problems, schoo fares; mood changes temper oubursts hallucinationsvse ‘Musauladialetal pain in bone, joint of muscles sweling in bone, joint or muscle; limitation of motion; Ssiffiaess, limping Hematopoietic: pallor bleeding manifestations, easy bruisabily Personal History: 1 Gestational Hisors: age of mother daring pregnancy, her patty health, auton, infedons, intake of drags, roeaigen Exponute, etc duration of gestation (when pertinent, ‘expecially in infants, ‘a. Bis term or prematate or post mare; manner of delivery pperons who arene the delivery; birth weight (especially fa infants of when pertinent, NeonatalHistory:APGARSCORE:spontaneousresptation fr required restsitation; cyanosis, pallor er; junlie age fof onset); convulsions; hemorthage: respiratory or feeding ‘ica, congenital abnormalities, birth injury especially in infants, or when pertinen te gestatonl hth ad momtal strc son be tle only in pts <2 [aif late the es fo ile >2 3 4, Pocding history: Infancy (<2 y/o) 1 Type of feeding: breastfeeding: exclusive or mixed how many mes pet day; how long each brest if not Dreastleeding, give reason: formula wed, dition and mouat given per day, bot feeding or eup fcdings TL Complementary foods age introduced, foods italy and subsequent introduced, consistency of food (pureed, tof, lumpy, able foods, frequency of feeding per day TIL Ustal Food intake for breaks, lunch, dinner, soaks (am, pm); Assessif the Five basic Food uroups (ereals/ ree Ets, vegetables (ely, non leafy &yellow vegetable, rmeat/fish/ chicken, beans/exg mill, o/s) are eaten daly, 1V. Compute for actual calorie ineake (ACI) and compare ‘ih Rerommended Energy & Notsent Intake (RENN) Sr compare both the amonnt and quality of food intake‘withthe food gid pam X. Food intolerance: Vi Muliviamia and ion supplements: dose, frequency VL caregiver: motes, houcbold el, grandpueas, slings. Childhood and Adolescents (2-20 years): Omit easly othe presen illness, 1. Appetite: good appetite, picky exter: 1, Usual food intake al amount per day for breast Ise, dinner, snacks (am, pra) IL, Assess if the five basic food groups (cereal ice fruits, vegetables (cay, aon-leafy & yellow vegetable), meat shy chicken, beans, egg, mil, fits, sugar are eater daly, IV. Compste for the actual lorie intake (ACD) and ‘compace ACI with the Recommended Enesgy Nutrient Intake (REND) o¢ compare both the amount 8 quality of food intake withthe food guide pram Food likes or dss feeding ditficulies, Vi. Mukiitamins & iron supplements: dosage & frequency. (See Appendix for food exchange lst and sample caeulason, REND, & Development / Behavioral History 1) Young Children (15 years): Inquire about the 1. development sing the Modifed Developmental Checklist, (See Append): 1, Dental eruption: other behavioral problems: urinary continence, dang by and night; oer taining, started and completed; temper tantrums; head banging, phobias; piea abt terrors; sleep disturbances. “IF there ae indications of Developmental Dela, DO Denver Developmental Screening Test Il (DST), See ‘Appendix. 2) Middle Childhood (6-11 year), Tnguice about school performance, And sexualfationanoDaceseer Ra ‘with dhe food guide pyramid V, Pood intolerance; Vi. Mulevtamin and iron supplemens: dosage, frequency: Vit caregiver: mother, housebold help, grandparent, bling. Ccilanood and Adolescents 2-20 year): Omit aly feeding story uals its perénen to the presear illness. Aes [Appetit good appetite, picky ete, Ti Coal food intake and mouse per da for beast, Tue, de, sac (am, Ps IIT Awe if the fve base food groups (eases, frees vegetables (ea none & yelow vegebl), trate Ea eicken, ets, oy mil ts, separ areten dal TN. Compute forthe senal eric intake (ACI) and Compare ACI wih the Recommended Energy Nutrient Tnrake (REND or compare both the amouns & quay of food intake withthe food guide pyramic, Y. Fond likes or dikes: eding dieu Vi Mativizmins Ge iton supplements: dosage & frequen. {See Appendis for food exchange list and sample taleulaton , REND. ‘e. Development / Behavior! History 1 Young Children (1-5 years): Tague about the P development using the Modified Development Checklist, See Append): Dental eruption; [HL other behavioral problems: uinary coninenee, ding Gay and sight, ike taining, started and completed, temper tanrams; head banging: phobias piss night terrors: hep dseurbances ‘AF there are indications of Developmental Delay, DO Denver Developmental Sereening Test (DDS), See Appendix 2) Middle Childhood (6-11 year) Trquire about school performance, And sexta‘development wing Tanner's Maturity Rating (See Append) 3) Adolescence (10-20 years): Inquire about |, HEADSSS: Home, Education, Eating lichavior oF habits, Activies, Drugs, Sexual, Suicidal ideations; i, Sexsal Development sing the Tanaer Sexual Matuiy Rating (SMR); i. For female: Tnehale Menstrual History Past Illoesses: state age when contacted; severing complications) 1. contagious seses: measles, varicella, mumps, permit. “Des thecal ear ofthe ess 2, other medical iineses: hospitalized? If so, where fd for how long? 5. operntionssurgial condition, type and place of operation 4 allergy, cezema, asthma, food oF drug sensitivities, injures include effects iF any (verify accuracy of diagnosis by inguitng nto signs, sprmproms, course of Aine) ‘Vi -Immunization History and Tubsreulin Test: ‘Types of immunizations given, including ages when given, place (health center, dort clinic, ec) where given and untoward ‘VEL Family History Parents age, occupation, state of physical and mental health; if noc iving- age of death, cause and nature oF symproms, history oF consanguinity. Siblings: mumiber, ages, state of heals if not lving- age of sath and ease amit ilaess or anomalies: tuberculosis (sate contact with patient) diabetes melitus, syphilis, cancer, epilepsy Theumatie fever, allergy, hereditary hematologieal disorders, rental retardation, congenital defects, etc. (verify accuracy of “tagnoss by inguising into signs, ymaptoms, course, sequelaeand tweatment piven); presence of illness simile co patents ‘nes in othee members of the family or household, family pedigree if a genetic anomaly is suspected. ‘VIII - Socioeconomic History: Living Circumstances: place and nature of dveling, number ‘of pertons living in the house, ete Beonomie circumstances: members of family who work, sources of Funds 1X - Environmental History: “Environmental circumstances: j exposure to cigaete smoke and other environmental pollatant “include what pollatants snd the duration of exposure) fi. Garbage disposal (segregation, sceyelings i Sewage Aisposal i. Water souree; drinking, washing~ PHYSICAL EXAMINATION A good and complete PE lagely depends the approach ‘of the examine. The sual order inthe examination of adults is oot ‘fen appropiate for young cldee, In genera iis best to leave the drove unpleasant o# uncomfortable parts of the PE tat. The clinician Facto adapt tothe vasous sitatons and circumstances surrounding the caamination and yet do a thorough examination, ie, auselate the heart anal lungs while patent is asleep and inspect uaront wea Jutcn s ering The patient est examined wit the minim of Fotki on, Anyone examining a pediatric paint should lear the art Sf pln ateracons ad dsactins to ala anne ofthe child and to facie the examination. Infants and young cldeen can be cased by thes eareabe or arent while being examined Ia uneoopersive Patient the physician should property immobilize the pten 0 that ‘ertain procedures ea be carried ou sul. General Survey: Take note of the following: mental state or sensoriam, level of activity {presence of cardiopulmonary distress or not, color + pmbulatory or bedridden ‘notional state (well, ueder, or over nourished) + sate of hydration “yn Table, Ace Miness Observational Scale bp demic quis ©> ar ect eer te is wel wil it ors il ta Vital Sins: Temperature (T°), Candie Rate (CR)/Pulse Rate (PR), Respentony rate RR), Blood Presuee (BP) >3 90. Pr Cheand RR should be corrated tthe condition in which they were taken to be considesed clinically significant ic, ‘oes the cid quer, aeep active, crying and string et. Oral TC should not be taken in children who are 100 Youngand orare unable 1 understand instroetions. Axillary Roane safer to obtain ant ae usally 0.5°C lower than ota TPC. Aura or rectal °C can alo be obtained. Howeres, ever insert rectal dhermoneter eto-an infant who can st pon hs own, epecily i itismade of glass wah mereity The pulse ean be described based ons tte (permit), thon (gular ireglr) & volume fl, weal, thread or compres)“Tuble_L_ Awe ioss Observational Seale: Gamer | er waN | Mees BSE =o ae Spake |e Tae Rat ee 3 Time estas PENA SineTo town B [mest [Sa hy PET? | caret “eble2, Vial signs a vsious ges, uc: ee Sons “tee | CRibeasinin) a (beet) Peso | 20-190, 0-70 | S785 3 ma. | 100-180 3558 ess S6m0—|— 90-100 S045 | Tos0s0-68 12 | w100 2540 [wo 55-65 13: 7-10 3030 | 9058-70 3 0257 | 9s-1060-75 iz az | 1o0-1206075 Say Tg | 110: 13965.85 + Pedisri Blood Pressure (BP) Monitoring: BBP cuff should completely encircle the arm. The infiatble bladder should covet atleast 2/3 of the upper arm lenge sand 80-10% of it cecumference. A more accurate cuft size is one whose inflatable bladder width is 40% of the farm circumference midway between the alzeranon and the feromion, Using too lage of too small a cu can lead £0 falsely low or high BP readings respectivelyMetin: Ener cuff on bare skin of sper arm (igh arm frefuabh) sog Clothing onthe arm arial aes be «Canc she inal badder one brachial ane ~ Pasa am shoal besapportdand gy Heed a the {Tb Th cata fows sul bet the eve of he heart ‘The sethosnpe bel shouldbe placed over the brachial sry pa prosinl& mdi 0 the eb fossa, elo {he liotom eg ofthe uf sbou 2m above te xl fou [BP shoal be measured afer 3-5 mines of retin the sete potion = Taste ine testo BP SBP) by pation metho 1 fat the cf rp level abo he nnpeted SBP {hum dete et? hy arate of 2-9 mm/s Auth is bei def the onset of the “ping” Korot? sounds sigs the SBR, whie the dase BP (DBP) isthe ll at which the Korot? sounds Seppe = Tatly BP eating’ should ao be obtained on the et tem and oe lower exemi BP shold be messed at kext ewce on cach ocxsion the merge tthe sjaticand dst BP rang be bined a feo BP percense shold then be determined from BP omgeams scoring to en age ander of te pati crete er eases ody 9 Up ok Feta td pone fens Oe ¢. Anthropometric data: 5 major growth paneer ince 1 ihe i 2 Leng a) or eileen <2 y/o) or Height) or 2 2s/0 $end Circumference (HO) (or <3 9/0) nem ‘Other measurements for special eccumstances: + Chest circumference (CO in em + Abwminal rewrference (AC) in em {Arm span & U/l. sato for chide with growth disorder, How should anthropometric measurements be done? ‘Weight is preferably taken with minimal elating on using the same seale which has beun cabrated before we. An Jnfane weighing sale should be used fo children <2 y/o.2 the pen at in «supine poston ona recumbent length table or measuring board The crown of the head should touch the stationary vertical headboard, Align the line fof vision perpendicular to the plane of the measuring sutfice. With the shoulders and the bustocks fat on the stfice align dhem at right angle tothe long axis of the body, Extend the legs a the hips & knees fat aginst the table, Rest the arms aguas the sides of the trunk “Ensure chat the legs remain fla om the table & shift che movable board against the els. Extend the legs gently {& rocord the length tothe nearest 0.1 em. eight is measured using a vertical board with an ached metre rule and a horizonal headboard that ‘an be brought into contat withthe uppermost point fon the head. With the child wearing lide clothing so that body posidoning can be seen, stand him on a Hat ‘surface, with weight dstibuted evenly on both fee, heels together and the head positioned so that he in of vision is perpendicular to the body. The atms hang Feely by the sides, and the head back, buttocks nd heels arein contact ‘vith the vertical board, Anyone who cannor stand stright inthis manaer should be positioned verseally so cat only the buttocks and the heels or the head aren contact with the vertial board. As the child to inhale deeply saying {ally erect. The movable headboard is brought onto the topmost point on the head with sufficient pressure 10 ‘compress the har. Recon measurements tthe nearest 1.1 em on the growth chart, (Source WHO Tel Rot Serie AS: “Ps Sean The Use snd nerretinn of Raepema 195) sgl seeweerermemims 12 Momma = HI should be metsured using» nondistensble plastic tape measure placed over the suprrorbital sidge in front and extended circumferentally to include the ‘most prominent part ofthe oceipa giving the lagest possible measurementChest circumference should be measured in mid- inspiration with the espe running horizontally around ‘the ches sing the xpboid note as reference point = Abdominal circumference is measured acess the ‘embicusin infants In older cen, dhe subject sands swith body we evenly diatbated om both feet, & with fet about 25:30 cm apart The measurement is ker smdway between the inferior margin of the last ib the crest of the dium, ina horizon plane. AC i measure to the nearest 0. eat the end of normal expizaio, (Searce WHO Tena Repr Si 8S“ Suns The Use {iu terpemton cf Ancepney 155) «Arm span is messured by asking the patient to stand seught with arms outstretched sidewise parallel 10 the found and palms icing front Measure ftom the tip oF the right othe tip ofthe lft ida gee. = Lower (L) segment of body is measured as follows + 0-3 y/or with child supine, measure from umbilicus to up of toes wid feet Hesed 90 at hel + > 3yforwith child standing, mesure fom antesior superoeliae spine tothe oor = Upper (U) segment = Lx or He minus lower segment = Normal values for U/L ratio: Abin: fa mwah w 3yfor 13. +> 3 y/os 10 With dita on We & Lt or Ht, ealelate for body mass index (BMI) using the following formula: BMI= Wein Kg? (LeorFit in meter) ) fispnoria a) 12) eae 9 oben [Atty 20/20 toy To) and the examiners line of vision are at the same level as the cls eyes The distance between the penlight, target object and the childs eyes should ‘be about 1416 inches. Have che patient focused his yes on target object, and shine the penlght from hove the target objzcrrowards the center of the forehead just above the ejes. Note the relections of the ight on the comes, "The light reflections should appear symmetrical ‘on the ehidls pupils and slighty nasal wo che center of the pupil = Asymmetric reflections suggest presence of «80 (cefeeion deviated laterally on involved eye) or ‘exotophia (fection deviated medialy on involved 2°: = In ehildren who appear “erosteyed” {peeudostabissmss) due to presence of epicanthal fold or flat and wide nasal bridge, corneal ight reflex wll be aoe CGross-cover teat is sed t check for tendeney of the jes to misalgn wes fusion isinterrupted. oc tanger object is eld 14-16 inches in fron of the chil, Hold the occas infront of the child’ ight tye and hold it for a count of 3 without wouching the chills eye. Pass the oecder over the bridge fof the nose to the left eye. Wate the right eye a8 it becomes uncoxered for any movement. Hold the occluder over the left exe fora count of 3, and quickly move ove to the tight eye again, Watch the Tefteyeas it hscomes uncovered for any movernent. “This procedure should be eepened. 2-3. more [A child pases the testi 90 movements observed ‘on the uncovered eye Any movement of the uncovered eye warrants ‘feral of re-screening Suc: Vion Seesing One Taig roar, Many normal infants may have imperfect cootdination of the ese movement and aligament floing the early days -& weeks ut proper ‘ootdinason should be achieved by 36 months sualh. row ee Ofenere ~/ pcunahs q Pan Bn Ears and mastok +The size, shape, location & position of the ear ia relation to the rest of the head should be noted. ‘Normally, when an imaginary horizontal line is drawn ‘perween the two inner eanthi and chat ine is extended to the ears 20% of the total length of dhe ext lobe ‘Should he located above this imaginary line. If les than this, low sear shouldbe strongly suspected. + Discharge fom exe cana: watery, purulent or bloody + Inapece also the posturcular & mastoid areas + To ensure success, etoseopy. should be done with proper positioning & immobilization ofthe child. To ‘isualize the tympanic membrane (TM), the oroseope “houlel be inserted in the appropriate angle ino the ear Cama. In newborns & fants, the direction ofthe eat To moreenadeanal is wpwstd, wile i older children, the direction is downward & forward, Thos in infams, ee pinna of the eat shoul! be pulled dowawards & posteriorly, in folder eilden, up & back and the speculum should be inserted into the ear canal in corresponding direction “ooking your way in”, aot blindly. The handle of the onoseope Hold be held ke a pen. When inserting the Deoseope, the knckes of the fingers ae steadied on the ipsilateral check of the child with the handle held horizontally or in ine withthe childs line of vision ‘while the other hand is holding the eatlobe of the paten. ‘When viewing the TM, note for the following features: ‘Gontinity: intact or perforated Color norsnaly ight pik o« pearly ranslascent ‘white; peripheral edoess in a crying child, red ll ‘ver if inflamed dl or perulenin infection = Gone of light, if absent, sgnies loss of luster ‘of TM de ro nammation. Bulging or concave Presence of fasion, bubbles Mobily of ‘TM through air sympanomesry by sgemly blowing of air through the otoscope using 2 pacumate bulb, Impaized mobility of TM may ‘be due to thickened TM in chronic OM, middle et cfftioa, eustachian tube dysfunction,Guceronton Te Pa. i + Check for pateney of mares, alse faring, presence & eancter of discharge, posion of septum, sinus tenderness + For berer visualization of sasl cai, have patient seated, il patients head up facing che examine, then ese i he ip of the nose upward to enlarge the ‘opening of the nares. Place otoscope without the speculum near the nares with lights on & view through ‘the magnifying ens the nasal cavity 4+ To detect snus tenderness, press below both eyebrows and on both manilay ares, able 6. Nava ‘Mouth and doa: fps, gums, tongue, mcs membrane, denton, plate, posteio pharyogeal wall, tonsils "Lips: Check for colo (ale, cpa, cherry re, moisture or dryness, excoriation, ee + For throat exam, use bright light. Ak the atest so open mouth and say “Aaahh. Inspect the aneior frucrarey, then the tongue and nde, then the posterior sracares which eam best be isnized sng tongue depressor + Gums color eadish and bla easy in gigi, sesh wih hyperopia chien who wer hen Peay), consouiy (ler, vesicles in hespesie Sngvosiomatiis, leading. Go purpus, sauna, leaker) + Tongue Size (are in Beckwith syndrome) moisture (ly with dbydrtion, color (pale, blue in canal cyanosis, seawbesry tongue in sat fever & Kawai dseas), = miky white eowings that bleed when seated (Gory= "geograpic”tongue:a benign lesion characterized Fone oF more smooth bright red patches with a ray or white meenbranous margin on the dorsum (fs roughened congue ankgloglossia_(tonguete): characterized by a Se ein fcr ones vent Dut muciy causes feeding or specch problem, ‘The ffenulam usually lengthens as child grows ‘olde, Surgical correction maybe indicated ifthe frenulum extends all the way t0 the tip of the rongve lets abnormal movements (tremors in thyrotoxicosis, trombone in chorea) ‘+ Examine throut using tongue deprestors.Immobilze the child uncooperative. Hold the tongue depressor with the dominant hand &e the penlight with the ther Ihand. The 4th & 5 Singers ofthe hand holding the tongue blade should rest on chin or fice so thatthe hand can move along with the face whea the child moves his head. The tip of the tongue blade is then plced atthe center and athe junction of the anterior 2/3 and posterior 1/3. of the tongue, pressing the tongue downward firmly to get a good view of the ‘ropharyngx. * Caution: iNepblotis is stongly suspected, do ot do theoat ‘Oropharyngeal mucosa: noe for presence of thrush, vesicles, ulers, Kophie spore Palate de uve age ‘Note symmeay. Bulging on one sce with uvula shift contralateral side may signify the presence Of pertonillarabsces or parapharyngeal timor. Note for presence of left, rash Hike petechie, vesicles ulers, thrush, High arched pate in congenital malformation syouromes ‘The posterior pharyngeal area contains collection of Iymphoid tissues spread out over the surface, During ‘upper sespirstony tract infections, the Iymph nodes Ibypertophy and give the surface 2 cobblestone appearance Note for presence of post nasal dkippings + Denison: ‘There ate 20 milk teeth chat should be present by 28 months of age, Note color, moting of‘Gacerentisonr tan Praca BannorounoDucuncr Hergue -Cbbke chme ae ppchety ce pitting of enamel (Huorosis), dental eaies + Nowe for excesive drooling Chilven normally drool in the frst year of life but usually noe after 18 mo of ge + Tonsile presence or absence, sie, sutfice color, exudates adherent membrane. Tonsil size should be coreelaed to the age of the patient. They ae usually dymehnetes “hypertrophied” during ea childhood from toler Wee oanthosti “ngrent » =— te school age period. Tle. Grading oasis Pig. Grading tonsil sie. (rewsciclabs) +The color of healthy oral mucosa in generals usually pinkish-reddsh. Congestion or erythema of the oral mucosa should be redder han the usual When assessing tonsils & postesor pharyngeal wall congestion, they should be compared with the rst ofthe oral mucosa. Necks venows engorgement, Aesbilts,rgiiy, masses, Jymph odes + Swelling in severe diphtheria (ball nee, subautanecns emphysema, webbing of eck i THEE symdrome, obesity + Postion: cortical pisthoromus + Masses: mph nodes, dermoid eyst, dyroglosal duct cyst, branchial est, enlarged typi, esse hygroma. (All should be deseribedl asco loeaton, size, rate of growth, shape, margin, surface, consistency, color, warmth, pulsation, adhesion to surrounding strvemey + Dining lymph aodes as ia serofula + Among overweight or obese childten, look for “acanthosis nigricans”, sehich consists oF velvety hypespigmeated grayish coarsened skin at the neck, til, groin, and is strongly aswcited swith Hosaren aun “ible. iter rating system (WHO): (cars — aka aia Caen | FR tate Pashia asa Hie HeSanan scm eegta ac (Chest and Lungs: “The chest creumference (CO) is smaller than dha of the head in the fire 9-12 months of life. After 1 y/o, the CC ould be lager than the HC.‘ small dhoracie cae cen in Elis van Crevald syndsome. 5, laspection: 2 'lae and shape: in infancy, AP diameter is eqn wanwverse diameter after 297% transverse dameter> AP damece. “Tbte9. Chest findings and thee clinical implications | ena nn oad arabe ‘Gna Sec na ee —— es aoe a Sea nk Soon Pe red ieee oT Sibialhastowr aa ‘+ Movement with respinsions Ta newborns & young infants, movement is monty abdominal, Att 4-3 ye of age, most of the respiration sd 0 imvereostals muscles + Chest setractions: subcostal, intercostals, sopricavialar i Cheat expansions Assesed by placing che pals of the yhandaymmetsially onthe posteor surface ofthe chest ‘ih the thumbs touching each other in. he mine "The fingers ae spread over the sides oF dhe chest. The reunions of the pal are noted with each inspiron. ‘Nowa the palms move equally as demons’ by the symmetrical movements of the thumbs moving ‘Ruy fom the midline wth each inspaon & coming tourthcr during expntion. When the 2 sides do not Trane symmetncally, the excursions ae inte on one Tide the dumb dose aoe move avay From the midline fon the affected side, ofthe movernents of the tums gre asmmetneal This agzamery should saggest he Jreseee of effesions, cops orconsolidaton of teJuagon the side with decrensed excursions of the chest. ‘i Noeal fremitas:"The chilis asked wo repeat the word “estes” oF “net ine” repeatedly while the examiner palpate all areas of he chest back. The palmar ot llnar surface of both hands should detec distinct rations of equal intensity on corresponding areas of 2 sides oF the chest. ‘Table 10, implication of abonnal remus Gin : ‘lin pene esa ‘in Pscsson: Diner peresons with 1 Bger aver the chest walls any done on amalinfats ges alae information but requires experince. ‘The indirect, 2 ange technique is the most common method for pectin the chest. Fam Fig 5. Two finger technique of ereusion Source es, Si seemed cra Chal Ned eco Pn Sh Banco Poise, Mo. wreckage on) "The middle Singer (pleximetet) of the left hand or ‘nondominant hand is placed firmly but not hard) on the chest wal The index or middle finger of the plesimeter finger is than stuck with the sp ofthe sida finger (plesoe) of the sight or dominant hand. ‘The movement of the stking finger should ornate from the wnt and not ftom the elbows The seking finger should land perpendicubey w the pleximeter finger & should spring back quikly afer the strike <0 thar dhe resonance generated snot dampened. For boeh chest and the buck, pereun om sie 0 sie, and top to ‘botom systema, comparing one side to the other checking for smmmery or asymmetry. 15 Aseultation: Stethoscope shouldbe placed on the bare skin ofthe chest wall Warm the ches pice ssi ies cold. Use the bela younginfants as che diaphragm ea piek up sounds from larger areas. If feasible, auscukate systematically fom top to orto, sde to side, back & front and compat breath sounds (BS) for symmetry or ssymmetey in findingsEemuror so DacnestoF Roum Pas Jang on the side with deceased excursions ofthe chest fit Nocalfremitus: "The chi is wked to repeat the wos “nes tre” or “ninety ine” repeately while the examiner palpate all areas of the chest & back. The palmar or ulnar surface of both hands should detect ditiaee vibrations of equa imensiy on coresponding acts of 2sides of the chest. “able 10, Implications of aboormal emits findings: Sein on eas J, Percussion: Direct pereussions with 1 finger over the chest wali exiy done on small infants & pves valuable information but requtes experience. The indirect, 2 finger technique isthe most common method for petewsing the chest, Fig 5 Two finger technique of \ percussion Sauces JH Nemeth ea Cla Mesh The sory Poa ‘Danerort Paar ea) ‘The middle finger (pleximetet) of the left hand or rondominant band is placed fray (but not hard) on the chest wall, The index or middle finger of the pleximeter finger is than struck with the sp of the idle Enger (peso) of the right or dominant hand. ‘The movement of the suiking finger shoul! originate from the wrist and aot from the bow. The sing finger should lind perpendiculy eo the pleimetee finger & should sping back quickly afte the strike 50 thatthe resonance generated i not dampened For both cles and the hue, pereus rom side ose, and 2op%0 botwom systemically comparing one side to the other checking fr symmetry or asymmetry 1 Aaseulaton Stethoscope shouldbe placed on he bate skin of the chest wall Watm the chest pice fist f tis old. Use the bella younginfunts asthe diaphragm can Pick up sounds fou larger areas. If feasible auseutate “systematically frm top to bottom, de to si, back 8 frontand compare breath sounds (BS) forspmmetry or asymmetry in findingscn Bae “Tuble 11 Naito in persion nots & linia implations Tein | heen | Cine me Tipe | Hato a fist | Pees er ia eepet, “le 12. Atormal oc Adsntious BS: «| Satie armament Sirtg staan Seaetnbmeefe scien Sector > = ST Seay cmes | ae + [RR Scenes | + | Pacha ae aaa . Moneaawmarnamre | * pein a SecoGece bon Te Pore Py + Normal BS are of 3 pei = Broachisl heard over midline, elsewhere, is usualy pathologic = Vedula normally heard over the chest, avila & infrasespalae areas Bronchovesculat: heard more on infants with thin chest wall + Abnormal or Adventious BS: sce‘Table 12. + Altered voice sounds in lobar pouonis Bronchophooy: spoken words are louder & clearer when normaly, they ate muffled & indistinct Egaphony spoken “ee” i heard as “ay” when narmally should be heard as “ee” ‘Whispered peetodlogui: whispered words are heard louder & cleatex when normally hey ae faine & indistinct or are not head all sm Heat & vascular system: precordum,vsble pulsations, apex bea, thls, heaee i Inspection: sounds pulses. + Precordum:adynamic or d)namic + Look for visible pulsations over various parts ofthe ‘chest and in the epgaseias, + Apexbeatcorresponds to the lowest and outcemost point ofthe eardac impulse normally loesred athe {# LICS NCL. unt 7 y/o when t shits wo the Sth LCS MCL bl 13. Clinical inpistions of cst Findings, Peng ints pc Fopancpeonsan | Fer peryradon, Take ‘Sts pes penne ‘ve ley Sel AR PIRATSAW | ar nee 4 Plpasion + This “poring” vibaory sensations felt by the palm placed over the precondium. ‘They are the palpable equivalent of murmurs & correlate with the area of maximal asscukatory intensity of ee ‘+ Subsremal ehrast indeates presence of right sentir volume or pressure oveoad + Takenoteof characterof pulses Table 14 summarizes the clinical impestions oF ndings on pulses.uc s na Dues PES PAS + Normal BS are of 3 pe = Bronchial heard over midline, elsewhere, iis usually pathologic = Vesa normally heard over the chest, alla & infrasapular areas = Bronchovesiula: heard more on infines with thin chest wll ‘+ Abnormal or Adventious BS: see Table 12. “+ Altered voice sounds ia lobar paeumonia © Bronchophons: spoken words are louder & clearer when norm, chey are muffled & indistinct. = Bgophony: spoken “ee s heard as “ay” when ‘ormally it should be heard as “x”. - Whispered pecrologuy: whispered words are Ine louder & clearer when normaly they ace fain ndistines of ate not beard a al sm, Heart & vascular system: precordum, vise plsations, apex bea, hil heart sounds, ples, Inspection: + Precondim:sdynami or dynamic: + Look for vine plsaions over vatious pars ofthe chest and inthe epigatium. + Apexbeatcorresponds¢o dhelowest and outermost pint ofthe cardiac impulke normally located ac the ‘4b LICS MCL unt 7 y/o when it silts to the 5th ICS MCL “bie 13, Clinica inplctions of ches findings. ind “st mpi [Aston ein Tien elas | Fee bpermonin Tvoaae ada [Sse pen pen eu ire mye om ns ara | ac oe iter _ Salto Cae Z| 4 Papation: + "Ths “porting” ibearory sensntons fle by the palm placed over the precoedium, ‘They are the Pulpable equivalent of murmurs 8 comeate with the aea of maximal ausealtatory inensty of the + Sobstemal cheust indicates presence of right ‘ventiulr volume o pressure overload + Takenoteof charscerof pulses Table 14 summarizes ‘he eal impiestions oF Snadngs on pulsesPraca Bauwsnon “Tho 1. Varian ple ndings and hei cil inlets pasta nea —| Re ee aa oO ‘ih eatamer ims [oe Ii Auseleason + Diaphragm oF he stethoscope i placed Seely on chest wall to auscultate for high-pitched sounds, ‘while dhe Bellis placed ight to detect ow pitched sounds ‘+ Theexaminershould fist characteiz the individual Ineat sounds & their variations with respiction. “The Isehear sound 1 is caused by closure ofthe AV (icuspid mite valves & js best head athe apes The nd hear sound (82) is caused by closute ‘of the semilunar (artic & pulmonic) valves & is bese heart a the upper let & righ steral borders, "Normally 82 is spt dating inspiation & lst «0 in ‘expiration. The 3rd heart sound ($3) i best heard atthe apex in midediastole $3 is heard as gallop shythm inthe seing of heart failure due t0 poor ‘compliance of the ventricle, but may be normal aa soung patient with achyeadi ‘+ Murmurs should be deseribed acconding to tie inseosiy, pitch, timing (rte or dtstoli), ‘arti in intensity wath espration, time to peak lntenss, ateas of maximal intensity, & radiation 0 otherareas.Auscultate aross the upper precordim, down to the left oF sight sternal border, ost %0 the apex & both the aullas de alto over the back, Grading of intensity of murmur sa follows + ebarely audible © Tie mediam intensity © Alloa bu nthe © Welouder with thi © Ve loud & audible with stethoscape barely on the chest + Vicaudible withthe stethoscope off the chest‘Saauurov no Das? Aoumc Paes Fe 6 Sites for susculadon of heart sounds, our: war ‘comlnc con) 1. Abdomen: Abdomen canbedividedintcithee quadrants or 9 parts to failtae localization of PE findings. oo Pen ee Sec — [at eae vr ms | Sens into ae pia nna ee ‘+f thereisahdomiaal distension, measure the abdominal decumference (AQ), 4 Ausealeation oF bowel sounds: ‘+ -Auseultion of abdomen to detect bowel sounds souk ‘be done prior to palpation and percussion as loth procedures ean ale he findings. Warn dhe stethoscope‘ith the palm of your hand. Place diaphragm shy ‘on RLQates oemit-abdomen nd noe the character & froqueney of bowel sounds. Bowel sounds are ‘widely tamsmited dough the abdomen, thus, Tseng in one spots wal slice. However value of bowel sound findings are questionable Iocause the charctersties of the sounds are not lagnone of specie conditions xcept forthe high pitched sounds associated with owe obstrucon. Te is more important t0 observe how dhe bowel sounds change over a period of time, especialy in eases where bowel obstrucion may progress to strnguition & ischemia of bowel loops, at which stage, the bowel sounds may decrease, and in postop cases where presence of bowel sounds signify recovery of bowel fanetions. Bates’ Gude to Physial Exam & History Taking, 2003, 8th eds Insp /aronegastoeesource com /gitestbook) + Bowel sounds are gurgling in nature and occur cpiocealy 5:10 seconds intervals or longer (10- 51 second in infres & younger cies) and they number ~ 534/min. Occasional, borborygmi (consisting of prolonged ures of hypererisals) may behead f bowel sous ae absent, auscukare for at least 1-2 minutes before conlaing se (Gun Phys xan Hy Ting hh 205 pe ssrwsnldeniced/lnen/Nedd) + Characteristics of bowe! sounds in dease conditions Sin ciartheas & in ead intestinal obstracion: ‘ncressed & high pitch eos: absent sie & petals distant Ii, Peseusson + Normally the abdomen sounds tympanic on pereussion except when pereussed over solid omgans Tike the lve o ful badder “+ When dullness sored in areas noeealy ympanitic ‘on percussion, suspet pretence of tid or rumor. ‘When highly tmp, suspece coli, incstinal bstrucon, or ies, + Percussion i sed to: detect presence of Suid in the peitones! feigy dough 2 methods, Le, uid wave & shin dullness ”Saneoronano Dacorum 1 uid wave Fig. & licking fd wave. The csamincr palates the tan of the abdomen with one hand nd tape on the opposite Hank with Sagers oF the other hind An aide or the patient places his | than on the mide to obliterate l the feling oF stething of the shin which may alfet the transmission ofthe fs waves, 1 Suis presen, “waves” wl be fel bythe patent. 2 Shilting dllness Figure 98, icing shiting dullaess. “The patient is ‘xamined on supine positon. Examiner pereusser the abdomen fom midline 10 ‘the sight flank unt dullness ‘spercived, A mark spaced cover the area of teinstion from ympaniem o dullness, Figure 9h The patient is then asked to roll over & s Ji on the righ side for at lease 30 seconds. After fd tested atthe dependens portion of abdomen peress ‘gun from the lef towards the ight tank Note the transon where mpanism changes o dns and mat the spo If Bu is prsene in the abdominal caviy, the aca of dullness wil aie wae GSouceer JH Kenth ca Cl! Mees esc chy, #8 weepsFig. 8 Bling uid wave. The cexsminerpalptes the Hank of ‘he abdomen with oe hand snd tape on the apposite flank with iagers of the other hand Ae aide orth patient pes hie Ihand on the min o obiterte the fecling of swetching oF the ‘in which may affect the transmission ofthe fad waves 1F fs presen, “waves” wil be fl bythe patent. 2 Shing dllness Figure 9, Elictng shifting “ dllnss. ‘The pasent is cxamined on supine position. Examiner pereuses the 4] abdomen from midline to the righ fank until dullness ‘sperceived. A marks pliced lover the area of teanston from tympanism o dullaes, Figure 98, The patient is then asked to roll ovet & lien the right side for at lease 30 seconds. Aer uid ‘has sted atthe dependent porsionof abdomen, percuss yin fom the iefe towards the right flank: Nove the transition where tympanisen changes to dollnes and matk the spot. If ids present in the abdominal cavity, the areas of dullness wil shift upward. (GomctMahe, JM Kenneth et ab Gna Mtoe ‘he Hinry Pipe and Labortory Ea Sh tere Pubes, 19 cc almatgonses)Posen Ewen determine liver size or Hive span Fig. 103, Measuring. the liver span. Pereuss along th ight mideaviela ine MCL). antesoriy with the plesimerer Singer held pce to the ribs along intercostal 105: than B, ToS 2nd: motor: Schamnoths sien Appose the dorsal surfaces of the terminal phalanges af corresponding fingers Normally thee i diamond-shaped pace at the base oF the nal bed: In elabing the space is ost 1g 1 Stamos sin ss) Spine: + Taspect the spine for deformities, sacrococeypal dimple, pilonidal sinus and local tenderness + Palpate the "spine for local endemess especialy if osteomyelitis or vertebral tumor is. suspected “Teneress berween the vertebrae maybe elicited in dise indammation 4+ Sercen for seliois by inspecting the back. Suspect scoliosis if shoulder ix elevated on one sie, with prominent seapulaon sie of involvement, an with eg Tength diserspany. “Bend forward” est can be done by asking patient to bend Forward with both hands hanging ‘down as if to touch the fee. A hump will be seen by the tevaminc fiom dhe pacar back if solos is presentGuceronson tase Pane. Bannon no Dacre PiumcPeacs 1 Lymph nodes: + "Check sine, number, ction, constene, tenderness, ‘oobi decor mated + Most Ipmph nodes are ot esl palpable in the newborn. AS the child grows older ant gets exposed {0 antigen simelacon, lymphoid tisues incre in vome so that dhe erica llr and gaia yp nodes become paable in chlihood especlly during infection They se ot considered enlarged ss they er em fr cavia asilary nodes and> 1S em foringuinal odes + Regiocal adenopathy is usualy the res of infection in the involved node &/oris drainage te. + GencalizedIymphadenopathy chaacesved by enlargement of > 2 noncontiguous node regions is usually caused by systemic dienes He infections Ihmphoprolieatve diseases, meole rage dscses, hisioytedisorders hypersesviy reactions connective fase diseases. + Ditirenasng Inmphadenopathy due to acute baci infeeons, and malignant asses: ‘eute betta infoctons: usually tender, sometimes ‘vith ethema and warmth of che over kn 1B: mabe mated, sometines with dang sins imlgnaney: usualy & noted, maybe mated or fae wo the in or nderying soca Fig. 15. Lymph nos ofthe hel and nek eon. (orwesbemest)References hha, BH and BK Silverman, Pediatric Physical Diagnosis "Appleton-Century-Crois, Connect, 1985 Bichley, LS & Snag, PG. Bates? Gude to Physical Exam tnd History Takings Se ed. Philadelphia, Fippincor, ‘Willams & Watkins, 203. “= Kiiegman, RM, Behrman, RE. etal, Neos Textbook of Pediatrics Saundess, Philadelphia, 2007, 18¢h ed = Park, MK & Trout, RG. Pediatric Cardiology for Practitioners, th ed, 58 Louis, Missouri, Mosby, 2002. = Walker, JH Kenneth et al. Clnial Methods: The History Physical and Laboratory Exams, 3rd ed, Butterworth Publisher, 1990, (wewsnebiin.nih,goveom) 1 »cert SaanorounD PHYSICAL EXAMINATION OF THE NEWLY BORN ‘eal, the fll teem newly born should be examined at last, two and preferably the times between bith and discharge + inthe delvery oom immediatly a bie * in the mustery or rooming-in within 12 hours of birth. Take ‘ime w point to the mother or Father the physiologic variants and explain the pathological ndings "upon discharge, preferably inthe presence of the mother. Give dese eischage instructions at cis me, During the physical examination, atenion should be directed (0 determine whether any congenital anomalies are present, whether the infant has made » suecessal transition from fea life tai breathing, to what extent gestation, labor delivery of anesthetics have affected the newborn and whether be has any sign of ‘nection of metaboiedscte, “The neonatal physical examination includes the principles of inspection, palpation and auscultation. Ie zequies pace, geatleness and procedural desig IF the itant is qulet and relased at the Jaegnning of the exsmination, auscultation of che heat or palpation of the abdomen should be performed fist before other, more discurng ‘manipulations are attempted. [A premature, sick, or congenialy defective infan’s pasticular needs may dictate changes in approach to the physical examination of the ses born Patterns of Activity of the newly born a few minutes frm birth to time of stability: (dapted from Primary Cate of the Newborn Third edition 2001) First 15 t0 30 minutes: 1. Immediate tachycardia vo 160-180 beas per site, with 2 igual drop 10 100 0 120 beats per minut 2. Irregular respirations, cachypnea to 6 to 80 respirations per minut, brief moments of apne 3. Moist ~ sounding lung fields, tinsict granting and 4. Awake, moving, ale, easly stded, crying, tansientPec owen cic Na Boe1 Next 60 ¢0 99 miner: 1. Slepy or sleeping, somewhat unresponsive 2 Heatt rate 100 to. 120 beats per minute, ernsient tachycardia 13. Respiratory rte 50 to 60 respsatons per minute ransient tachypnes 4. Unuly, passage of meconium “The next several hours: Again, awake lr, easly stared, eying, easily stimulated and 1. General appearance, The newborn should be naked when being ‘eamined but aways keep in mind that they easly get hypodermic, ‘Observe the infants poste, skin coos, activi muscle tone and gross ‘congenital abaormalies, IL Vital Signs Infane should have temperstare, respiearory rate and wpe of respiration and andi te monitored every 30 minutes after birth for 2howrs or unl sable, A. Temperature, Indicate whether the temperate is taken per tectum or asl 1 mama for anaes 0 dcp fer ep in repose tenon metal temperate If om info in teateratre is abase 38°C ad reins Chest fer the eminent reer fo nora, rl tmperatre hon be bined Reclame i eit beefed by eavirounent. Infants ‘en come Ips aly in eons tt cold eran ad is more bere aang proteins B. Respirations The normal respiratory rate is 40-60 breaths/ “Th pinay ratte by aking a the apr alia for fl sina At na on inf is othd, h epratry rate and pt changes AMifnt as pra rath han reir breathers . Cardiac Rate. Th normal cri rat is 120-160 bats min It ies ith chan in hein at icrecing ety iyi ate or brat pide decesing when th bal suit ad rating soo ret nfs hae resting bart sot he ge nd of tbe normal rune A casio eater int, yf tbe a Beart rate bar 100 pm Tac wth ate poste rate tha 160 may Be i of ‘mary coun inci CNS ita, onesie ear fa, sista, joerGece toniron Tame Pinca a Date Rr Pas DD. Blood Pressure. Measuring blood pressure saat a routine part of vial signs in the newborn, but is used for infants requiting special cae and for evaluating coarctation of the aorta and congerital ‘art dscass . Blood pressure corcates diet with gestational age, posinatl age and birth weigh “Ta inporae! met for bang arte Mead press ae gut Info propre ff ith with 213 the gg of the pe a The Flush Metbod jor otning non prose ic eater in a coe info and rege only a pygromasant. The aor kis raped withthe (fad intl enh toch the shin. The pracare isl rd mt ‘heal of ra wih pun the prose rand ie is ose as ‘eee ta press Tix Doppler Metbod, ain providing ssl and distac pein egies trons qipment and a gi ingot, BLOOD PRESSURE VALUES IN THE NEWBORN ACCORDING TO BIRTHWEIGHT [aIRTHWEIGHT | MEAN |sysTOHC [oInsTOLIG ie pressure [ane | (ant H6) sa ma [ase wor 1250 [sr 5-48 [9-61 [29.35 vast isn0 [4545 [46-86 [25-35 1501-1750] 5-455 [46-58 [23.35 1751-2000 [36:38 Las.ot [24.35 IML, Anthropometric measurements 'A. Head circumference. Pace the pe measure sound the head, above the label, and dhe oecipiel area This isthe occipto- frontal circumference, which s aormally 35 cm in teem infants B. Weightand percentile nfancweighingscalesused, recorded in lilogeams and plored in Lubehenco’ care. (See Append) '8) Smal for gestational age (SGA) ~ hitb wig io the 10 pervate ‘Symmetric - ont cary in gtton: bin sie cormepod ith oy Eats re eavrmetl sch as king or tags ges asl mater or ramos ier (rneamy 13,18, and 20 dram): inion sch as TORCH, and mealies Asymmetric ~ est is te in atin, wo or minal eats om fal brn gost. "The elegy is somal arpa ‘nnn with elo il pai.b) Appropriate for gestational age (AGA) bir shi ‘wtoen 10th 900 pero 6) Large for gestational age (EGA) ~birth sh abr he ons pent ined ini of eats and bir anc, reat sest mdr, lpm, Most inant br to dc mates are LGA C. Length and percentile, ‘The baby les supine on recumbent length tle or measuring board. The crown of the head ‘euches che sadonary vertical headboard. Ensure thatthe legs remain flar on the table and shifs the movable board against the heel The Tengah is recorded wo the nearest 0.1 em and pled in Labehenc’s chart. (See Appenci) IV. Assessment of Gestational Age “The New Balla Score is performed as soon. as posible afte inital stabilization or by 12 hours after bieth. The examination pens of two pars: neuromuscular maturity and physial manus “The 12 scores are ade and marty rating s expressed in weeks of station. ‘When handling a newbom, i is imporant 10 avoid iting ane “primitive reflexes, ke the toni nec, palmar and planar grap feflcce, Thus most oianewvers should be done with head in the ‘hiding, without grasping the palms and sols. Icis also important: ‘solate the oir being assessed ‘The New Ballard Score NEUROMUSCULAR MATURITY 1. Posuee ‘With the infant supine ad quiet, sore as fallow Aems and legs extended ° Slight and moderate flexion ‘of ips and knees aca Moderate ro strong flexion of hips and knees = 2 gs flexed and abducted arms slightly lesed teats: all exon of arms and eps ‘with Kes ited 4 above level of exoctet tsom Te Pee, Banocrguano Dacre Sacre 2. Square Window [Exerr gentle pressure on the head oF the third metacarpal The angle berween the lypestenar eminence andthe anterior aspect of the fore aem is measured and cored as follows aor = i i 45° 30° fo 3, Arm Recoil With he infant supine, headin miling, grap the sides ofthe writ, ex the forearm for 38 seconds extend the elbow aly bt momenta (30 18 not to fatigue the fexor muscles) and release. Scoee the reaction 3t fellows: Remains extended 180° or with random movements Minimal desi, 140-180° ‘Small amount of flesion, 110-140 = Moderate fexion, 90-10" Brisk retcn to fl flexion, < 90° 44. Popltsl Angle \With the infant supine and pelvis fat on the examining surface, grasp the sides of the ankle, Hex the hip to appose the antenor surface of ‘he thigh agunst the abdominal wall. Estend the knee wl s dette sesistance is fle Note che popliteal angle and score follows: 180° 160° 140° 120° 100° ie 5 mg/d Pal — may be scondary 10 anemia, birth apy, aback or PDA. 6 Gans 6:1 Central eyamosts (ish sin ican one and lp) = ened By lw een tation i te Bd 62 Aeroeyamosts (iuish hands and et onb) — may be rl jor only br nfs eae of ssomatr ati nd perplnal civaatiy dageiebe. 7%. Mtg — tas red par may bes lly nas ain ‘hase wit ot tas, Iason, or epi. Perea matting fire ot Cutls marmoratea i ford is nfs with Down paras tamy 13, or aay 38 Mile tiny, sre det et, wht with pibeadsed omen, nual on he chi, mse, fora, and cock, These gp wii af ck afer bi. 2% Eyes tim ~ samcoas small areas of esi with elit papa in the enter Lasoo natalie 38 rs fer Bib ay apr as late a5 7-10 dyad res pontereth, 10, Mike cyte — no nflamaatry, pnp car eck that may suet eap i profane re area ofthe by suo, esing bray deamon ot Iain 14, Neonatal priar moana ~ bight contin whic gues see tery. 1 eharacried ly three sages of dsm: pst, opted veteran | pic bab ‘ppearone andperpiguated mens 12, Maraar hemangioma ~ "srk ies”, re vscar nevus normaly mo the pt ara, lids ad abel, Te sion dapoar sponta within the Toler of Mi 13 Dart in stain fc lm) ~ anally tithes ot ‘anh wit reseed ds ot apa i tie Vi. Head, Note he general shape of the head. Inspect for any cuts bruises secondary to foreeps of fetal monitor leads. Check for ‘microcephaly or maesocepbalyGunccn cra Pc SuehoraunaDuoure PomcP oss - “The sizeof the head should be compared with appropriate standards, Heal size vary with age, sex, and ethnic, and has general ‘correlation with body size. Macrocepbaay ~ did ot bad crane grote tin 19 sandal destin above the sah, May be 8 mnistation of eer evans icing dra ond shell duis. "Microcepbaty — did as bead came dy than the tend deo bb th on. 1 fil theta uaa or renin may eid tings, and yams ec a iy Band 18. “Anterior fontanel-damond-hpe a! tae nth mine at th jamin of tb coal ed atl asa los a 9-18 mons "Posterior fontanel = ited wen the intron of th opted an poral be th yb aed a ih at ast, ads he ipo te rer i024 mts, Lay foto! may br est ithIpayiiom,tisy 13,18, and 20 ‘pda. Smal fata! mayb ciate wt npr, mips, or into 1 Caput sucedannm — commoly shard fer pred lor nnd to acai of ado sum abe the arnt: poorly demarcated of ie vl hat es eter es, with acon ping dome ad srhing eecian,eviynes, ad rp Spann rss win day 2. Ceptathansome— scan) rapt of ld ei tht tasers ‘Ae peat el mre, fe san selina dies tors es with orig sia dirt, No tae! Ise aly robes within 2 west 3 mb. 3 Malig— donna asnoy the al aig fo he it ras. Most fi so in rgd abr and ei ier. A url od shapes mal mained ti ek, VIL. Face. Look for obvious abnormalies. Note the general shape of the nose, mouth, aad chin. The presence of ypertlarism (eyes widely separated) or low-st ears should be note. Facial nerve palsy coud by compo ot fi a ais! ‘esa pomainyo by ana eign be eo fs ving dee. Pass ope on if or cd yo ie The ero th mt dep don the nil is abet te pred ide Th ina may wae sede the more he ip dont ide of prs. Ma ail nee ais ob maa win dy ation fl ey my ene wks ‘aro 6rs aurenon oeib “Mobius symdrome is rome facil ply oad by abe or pops of the 7 ere ss “VIL, Byes. The emphasis on the stature and appetranes ofthe cre adie rerwundings ther hanastessmentof visualacity or exraoelar fruselen Check the rl erage fs (ROR) with an ophthalmoscope, ‘Theses oly open spontaneous the fae held up ae pe Jal orwar and backward Dal pe manors esa of bys aa arenes ie more wef for inpecing de eyes than Forcing the Tis apa “The red orange reflex: womal sto ne disor “Awl gil at fs des aby of He ns ios ft af et men ron Sen of stort we up laty afl lnk. Nevkns with coats snl b eluted Ly om ‘Minat Subconjumetival bemorrbages assay vcr cad seem ve ia nfm ely Transit 2 ww of 1K. Ears. Each ca is examined for shape, size, postion, the presence fof # canal and any tags oF pits “Tenarmal pitied ly raving on maar ent ae rom ean ote clots 7st fat prensa rel Fear a eb he bk of hs es bk ein i, “Tage lar La ea aren ay engl an. PPE. sted skin tex (gillomss) ae ei, a ar foe Hic ems fren ont of kes ler XX. Nose. The nose is assessed for shape size, and patency, and forthe Jrsence of swelling oer the nasolacrinal duct he sz of thephlt, Trl defntion of de nasolabial fds TNs sijrmetn ith aony of te mare and earn ion eves espa fatal onesies ondolg If aiken bird choana reece ac, mas atin i ace yf asa of aga bt hog) bth narod tthe stoma {XL Mouth. The mouth should be checked 10 ensure that there ate aarti nor soft pala clefts, no gum eefis and ao deciduous ath prsent, The tongue, buceal sfc, palate, and back of the mash eee saline. The gums and hard pale ar best assessed Py palpating with a gloved Finger 1. pun pas — eatin ting 9 tc ae marmot ot ti bard oof pdt hich abs potasCeres Tan Pc fot imoOupisermwmePrenss 2 Ranul~ tic align he or of te mth wc dpa pont 3. Mock nal inom th rl as wander trata the ‘ena land dts; ols benign and susie sonoma 4. Natl tb asa er nics, ad are of 00 pet Predeciduous teeth — sual ose, and te rots are het por formed rm ic sary avd apni, ‘True deciduous teetD trac tut that yp earthy sod nt be ett, 5. Marisa eagmet of th mg co boar sind Maia con es i Brkt) deme (nari “gyi, cpl, nd sce lpn) and cot ‘puri XIL, Neck, Elcking the rooting ceflex enutes the infant co turn the bead that allows easier examination of the neck. Palpate the sterooceidomastid for hematoma, dhe thyroid for enlargement, and Check for presence of thyoglossal duct ests "The mast canon ke mace te wera vscaer maha, burma bmp ts, krona sc lyroma a dred yt {IIL Chest. “ AL Observe for symmetry ofthe chest Tachypnea and retrctons indicate respiratory distress Bartel-chestmay be present in babies ‘with meconium apiation pneumonia due to hyperaration and sietapping, Mil stl andi trainees, eo bey wana bate of thr compen ct ale Beane be dapat primary mo of ig with Kk ction by asym ‘hating abdominal “Clavicnlar fracture ir th ait common fran ithe endo, eel among le infants Th may pret with dered rae mover end ain fenders on oot of the a th ace sy, ory end disoorto or te fre sy citar tr rary lg the hv Trot: dnc at ning he ‘mobo pin o dango. Beasts arena 1 i mtr iter mead foo inf They be bora enlarged GA) cay he ff mara rene A wit chars, ammo eral as "Hte D's le” my be pst bth in me and fale infants Smporamerary tipple ee ext ip anda snarl teatZ ca nen oe Ne Bos 1B Listen for presence and equality of breath sounds Absent or unequal sounds may indicate pacumothorax or atlectsi. Absent breath sounds withthe presence of el sounds iadeates laphesgmatie hei. [Nenbort bg ade ar lati more broil han reir be f ber onion of lrg iva snd ars tin ce XIV. Heart, The cxminer should observe for precordial activi, ‘at, ehythm, quality of heart sounds and the presence or absence of The normal ha ste nls 3s 120 40 160 Beats per ‘imate. Some tr ingots are esting bart rate 90 eats er ate I the bart rat ds ot ines spree witha ray cea oul chek, a an etary sh be bine trae art ack ich s common aman int base mates have SLE wero mere dest bs sii te prs of bear dea, er de eae of «mar proid roar of woe. Thema non marr the inate nbs peed ae flow muarmurs the preset ‘rosin fom fal mental ration, Marmars persis tr the fit 12 ors of ie ae Bk orf ormeie en the hy my mo 4b bomadynaical) sic. Father uation is rue fo marr orate yond cera wks a ey nen orf rari pre ina oils Hinge XV. Abdomen. A. Look for obvious defeets Normally, the abdomen of pewboms are lobular and sot on palpason. Ompbatocoele, i sic tntiosaranenilpeitcun on he aici enced, gastroscbsts, iv whith the ‘nines art ener prions A seapboid abdomen 1) ‘aie with omental daplragmaic hernia. 1B Liste fr bow! sounds ts urls aera nav awl send Di fit ay of if they ar extreme prema and wef forever dat rake . Palpate the abdomen for distension, tenderness, or masses "Th bomen i: esi ate if thingie ice Std at he righ sie f th i,t ead Btn ee ad ring he poi rel he chain mst exami athe gt ‘and lt and me herds palate he abdomial ores apation hon tart ow the mica bath side and pred tard he teplegmCee enone In normal cramtancs, the ir tb palpated 2a bl he ‘ext margin and th pos the etal mari. Hepatomegaly an been mith contin art fabs, iat, or sepa Splenomegaly is ound vith CMV wr rll ifsios,o in “Toe hte, pecal onterih sid canoe be ppt Kidney age may often be inva with poi diay, roel wn hams oF pompbrss ‘The umbilicus should be inspected for signs of bleeding, infection, granuloma, of abnormal communication with the inte sbdominal organ. Inspect fr any discharge, edness or edema around ‘the base of the cond that may signify «patent rachis or omphalic “The ans as too arteries and ae ven. The proms of ny ses fone artery and oe wi) old nde renal gmt robes The cord soul be talc rei el lor sets moi taining usualy sede tf dite XVI. Hips, Evaluate for hip dislocation, Orton! mane — ple th ine th jr he ptition. Abd he ‘pry asin tem finger opp ete nad and pour rset grate chante (Ortolant’s sign). ‘Bard maner~ adc hy ip yang the thumb te ply ont ad ack psa or he in igh (Barlow's sign). “A ck of rection and lich of dlchtion are hein fet ait ip dation. If tc dirk i ape, raigph stds ond thc comcaaion cond be bined. XVI Genitaia ‘A. Male, Check for dorsal hood, hypospadias epispadias and chordee. Normal penile length at beth is >2em. Newborn ‘males always have 4 matked phimoris. Determine the ste fof the meatus. Veefy that the testicles are inthe serotum snd examine for roia hernias. “An abnormally ul pei indies reed end ofit oF edd oth harmo atin dari th ced and hind retire. Hydra arcana aly dipper by 8 yar fae fa tests ist ppl i imprint 9 determine if mat ‘epi or rpc. B, Female. The female genitalia should be inspected foe sie and location of labia, clitoris, meatus, vaginal opening, 2nd the reliion of posterior fourchette 10 the anusPac non cre News “A foe mabe har redundant Ima se Tag of ime may ete fr Sa bjoud the i of the iymen. These tue oper tin a fe wok ‘Diary from the sgina is common ond is often bud tinged secondary fo maternal erg withranal ands termed at Prd “Th tein have relations prminet spears, epcaly {if the labia are andre rif the infot is prmtere Coreg may bea sgn of mscicton wv wring tumor. 1 may aio be ad by ined maternal ade prausin or matral deg te “The prone of amiga ita ito medial energy. Aiea ad pity inky mt estab XVIII. Extremities. Examine the arms and ees paying close attention to the digits and creases Diminished ples in all exis indice poor cardiac eur or perihelion, At or died omar pas sagt te pve of corto of aorta 1. Syndatyy~ or ebrml fo of th di, mast ammo inves (he Sad Shing ath 2a ad rd ts. Aston fdlh sory ite 1 Pablacyy— sapermunerary digit onthe baad othe fot. This odin scat th stron andy bstor. 1 Sin rv — sing roses paar creases mes commen se in Doan yvone bi otal normal arian “Tales equinosara (Lit) ~ more common in mal te ftir ved dowmnard and ear, and the sks ed madly "5. Meller ura addin of the fore nally comets pontoon [XIX. Trunk and Spine. Check for any gross defers of the pine. ‘Any abner pignnttion Day ats (fs of bait) ee he over ac snl increas te pion that on wadering srl anamaly exists sch as cod pina bifida, A sca ploidal dpe may inde a al mening or ote noma XX. Anus and Rectum. Check for pateney of the ans vo cule out imperforate anus. Check the positon of the anus. Meconium should pass within 48 hours of bird in tem infants. Premature infants way Fave delayed passage of meconium, XXL. Nervous System, The bases of the neonatal neurologic ‘amination inelode assessment of state spontaneous muscle acvity rtfor assessing amount, quality, and strength passive and active muscle tone; and the functioning of the cranial nerves( See the chapter on [Neurologic Evaluation for 2 more deualed newologie examination) [Neurol elation Deine th the inti beste mad on approaching the ‘infant ad contin as he ingot i prin and simulated fr he remainder of the rte pyc eaminaton. Much cob hard abt the wie tate ay bsg tha hint des on his bron te mor swede ass “hecho indie elmormaiy or thre ar pater isk fcr REFERENCES: 1. Avery GB, Neonsology: Pathophysiology and Management of the Newborn th edion 2005 2 Kis ea, Care of the High Rik Neonte 5h 3. Fanaoff A Maria G, Neonatal Pent Medicine Diseases of Fes an nf ih edison, 206 4. Behrman, leoson, Klan, Stanton; Neon ‘Textbook of Pec [ith don 2007 5. Clohers J Mansl of Newborn Care th on 28 6. Sede Hy Primary Cao the Newborn ed eon 2001 7. Heroandes, Je EDagaog, A ad Santos, W: Sands of Newborn Cre, ee 2008"THE NEUROLOGICAL EXAMINATION “rhe approach toa child with ancuologe manifestation sade ap of comple history and an secure ysl and mew) 2 paso core goingospisiatd usualy expensive agnor “The goal should be dicted cowards answering the following guestions T Docs the ehild have a neurologic disor? 3 Toa where isthe site ofthe lesion ora often the cake in pediawie nerology, does i ineolves all parts of che bain tan equal dees? 43, What is the naare of these lesions? in answer to the ist question 4 good Kisory and a background of do ae tanfestions of searlogcdnesesincieen wos tbe heli “to answer #2 queso, rec and review important seuranatonis Te ee gpd te symprmsresling fom involvements of hese sro anawer the tid question, go back tothe Kstorg. The eos of Te aires ether acute, sub-acute, sai or remiing can Prove se ae mulation of your diagnosis and differential agnosis then follows “The Newrologie Examination (NE) “The NE. is part of a good physial examination. It should come wi x complete peat story apse amination, The ea ADAMton urine ame Ps NEUROLOGICAL EVALUATION FOR INFANTS AFTER ‘THE NEWBORN PERIOD UP TO 2 YEARS OLD In conse to the msessment of adults and older ilies, ‘servation occupies most of the sages of examination in his ae group “This begins as soon asthe eld is brought in the examinstion room and sing the istory-aking esion, ‘The neurological esmination (NE) inthis age group is msily made wp ofthe developmental assessment. The guide forthe aconatal ‘examination may be usd for she younger infanrs wile some techies lose in adsis and older children mabe ted in the older infin, ‘Observation ofthe patent throughout the examination period can reveal locof information onthe patents problems, A cheeks, modified from the emerging pattns of Ichavious in Nekonis Textbook of Peds may be used as a guide in the developmental history and assessment. Do the Denser Development Screening test (Deaver I) 25 putt of the examination, Four aspects of sevlopment are raked ~ gros motor, fine mtor/adapie, personal] ‘social and iaguae. A sample Denver Charts provided this handbook See Appendix ‘The NE muy be divided into 4 pars, most of which is brgely ‘obscrainal, easing the procedures that are more invasive and that may ‘upset the ld inthe ater 2 eae ‘STAGE 1 GENERAL EXAMINATION + Observe forthe els ste of alertness and awareness of sorrounsdngs and fot, 1+ Chiles woealation shouldbe age appropri. + Examine for unusual ices and goss structural abnormalities Indudng hose ofthe hesd and neck. 4+ Head examination shold cove © Asymmetry, promberances (0 Cena str nd fontanels inching dimensions (0 Head droumfeence (© Ausealsion for brit and transilamination & Dine of the cliscompril emi dn te 3 ‘+ Observe for canal nerve function (Refer to previous setion fom the examination of the older child or the newborn in the fet eon ped om a opi of yor patient + Motor eration maybe done by asesing— Muto sor New Bom hes wo Cao Caren © Symmetry of muscle bulk (arophy or ypersophy) or li eng © Symmetry of movements (Nohand prefecence before theage of yea) © Note the gst if ambultony an presence of unusual posesing ‘Spontaneous muscle moxements, parieuhly aginst ‘avi; provide the mone use information for rmusee srg, © Fine motor asessment maybe observed while manip objects (Note matustion of grasp fom palmar to pinces) * Cerebellar function: ited to observation of temots, rune vay while sting, dyameeria while teaching for toys and objec. STAGE 2 MOTOR AND REFLEX EXAMINATION * The child a this ages placed on the table, wih he caregiver standing cose + Observe for head conta and other age appeopiate motor silesones if not yet dane dating sage | + Biamine muscle tone with’ tricion and suspension ‘© Traction maneuver done i an nfne/chid in spine Position and pull 45 degrees angle by eacton onthe Jnands. Normal response: Flexion attheclbowsto ret ‘he pl and flexion ofthe neck tobe able wold the ‘nad the same plane asthe body. Excessive head ag and lak of ebow fleson sigieshypororia © Vertical suspension (Hal in the sllc) normal "sponse is shouker adduction, Abnormal sponse = slipping though” due eo lick of shoulder addston (hypoconia) or scissoring of lower extemicr (dyperonis) © Horizontal suspension (Hold the trunk in prone Position). Normal response: Neckandrunkestsion, limb Hexion Inverted “U" shaped postures a ign of byporoni *+ Test for Developmental Relenes (Persistence, resurgence or sbeence at parila ages signify an abnormal) See Table of Developmental Reflexes in the Appendix *+ Tes for Deep Tendon and Puholgie Reflenes (See previous seeton)Bannan Duco ‘STAGE 3 MANIPULATIVE PROCEDURES/MANEUVERS + Examination of the abdomen, genta, back and anal acai accomplished + Bsaminaton of the tongue, mouth, seraodleidomastid rmscles + Occipcoional diameter is mandatory at this stage i not yet, done + Opvic fund andotogic examinations are kewive done STAGE 4 EXTENDED MOTOR EXAMINATION, GAIT AND. BALANCE + Chilis peed on the Boor foe the assesment of ernwtng, walking and running, + Encourage the child oambulate by rong a ball onthe flor. + Observe for sbaormaltes in gut and balance: Note for wading, fotdrop imp or ata NEUROLOGICAL EXAMINATION OF THE NEWBORN, ‘The neuiogiat examination is not soundly performed as part of the neonatal physical examinason. A complete NE is necesty in the following cases: (1) Low APGAR Scores, 2) Premratiy, (3) Hypotonia, (@ Diminished alernss, (9 Seiares, 6} CNS Infections, () Paes, (8) ‘Trauma, ©) Evidence of dysmarphisms and Congenial anomalies ‘The neonatal neurologic exahution i Bkewise predominantly ‘observational and for sick nconates may foqire mulipe vis and ‘rahtion to make 2 complete assesment. Environmental condiions and timing should aways be taken into consideration as these may affect. the findings, Le feading, eying, col, iat, ete. Repeat ascents smuybe necessary to confirm abnormal findings Important historical data to note: 1. Gestational Age 2. APGAR Scores 3. Matemal and Obstetrical History Important data from the physical examination: 1 Head Examination + Shape and size (percentile)Asoc Emus oF No B94 Wi 800 + Surures (lose, open, gaping) + Fontiel (2b, depressed fll tems, a) Sia lesions + Mine dimpling, ets, ats of hit + Hyper or hypopigmente skin sions + Porine seins 1+ Hemangioms and lagiecaas ‘Masses ~enexphalocoees, mors 44. Dysmomphisms and other congenital anomalies conCoamen [BASIC NEONATAL NEUROLOGICAL EXAMINATION 1, Levelof Alerness * The neonate should be evaluated in 2 ena states slop and wikefalness +The term infantis ofen asleep but ean easily be sowed + There ate pis ofstention to visu, autor and ‘act simulation and may ey vigorously 2 Cranial nerve examination is made largely by ‘observation. Ottery (END) 7 Neomtes can dietiminate olor, manifested by changes in cade and expat res and mover tour these are rly tested, It funtion by $7 ‘months of age. ‘Optic Nerve (CN 1) Gross Visual Acuity testing: + Visual sation on the buman face + Light pereeption (Glare eespons)- blinking with lg ee + Poplay response + Visual ekg may be present Funduscopy. optic dsc i normally ig pik o pa gay in appearance. Chick for retinal hemorrhages ceulomotor, Abducens, Trochlear Nerves (ONT IV, VD Eye movements masbe dhsconjugate at birth. + Observe for spontaneous eye movements in all slsceons.cere Tam Pac scnaron Due cr src Pie * May do Dt cj mance to cack ov one + Ghee orp (CN I) {ply soe ects mmery (roe in cons > 32 weeks AOG) “Trigeminal Nerve (CNV) ‘+ Check ficial sensation with the ooking refs + Cheek for corneal refer presence and symmetry + Check for grimace of any movement, change in espinwory or cardiac rte with ate timation over ‘he forehead checks and mandibular area. Facial Nerve (CN'VI) + Check he symmeay ofthe fice atest and movernent (crying) + Check size and symmeny of palpebral Sosures, muolabial folds, poston oF the comers of the mouth ‘Vestbulocochleat Nerve (CN VIM ‘+ Hearings norally present ia erm babies ‘+ Neoaaies “nk or sare wit oud aie Glostopharyngeal, Vagus, Hypoplossal Nerves (CNIXXXI) Considered actif the following are normal and ative + Sucking: CN V, VILXIL + Swallowing- CN IX, X (Observe coordination) + Gag reflex — CN TX, X (Use small tongue Made ‘everest in gue) Normal response is active cotrction of the soft palit with upward movement ofthe ura and ofthe posterior pharyngeal muscles, + Observe for tongue movement and los of alk CN xu Spinal Accessory Nerve (CN XD) + "Testing cannot he dove on sick neonates since this sees leon ad rion of the head + Forterm newborns, passive raion ofthe +e wil how thea of the ack muses,natn ore Neus Boas ens aPODICHO MOTOR EXAMINATION, “This is done dering the le state of the baby. 34 Posture ‘This provides value information. + Normal term newboens have a fexoe aude, This ‘coupled with spontancoss movement indicates good ‘muse tone and pave “+ Pyterms be nan extension postion. 32 Tone * Passive tone may be tested determining the degree of resistance to passive movements of the joint with fan awake infant (908 crying. This done by genie ‘lapping of the hands and fee + Aetve tone is tested by observing for response 10 seme pulling from supine o prone poston (See Imacton respons) A hypotoaic or Boppy infant wll, show severe Bead ag + Respiratory Rhythm and Chest movements ae served to evahute adequate commaction of the intercostals muscle “sucking or etrsdons ofthe imercoxals sces may indeate lover motor neuron. sci 33. Mowor Suength ‘+ Check spontaneous movements as wallas movements against sesinance + Note symmetry of movements Preferential movements may sugeest hemiparesis Sab Deep'Tendon Reflexes +The Examiner’ index or mide fingers may be used instead ofa hammer smal babies + nce jerks and bicep res are tested a jn oer infants and cildeen. + Ankleconas (pid ythmicplnarfexonin response ro anke dorsiflexion) up t0 10 beats is normal.Guostentere Tae Pas SRN aawiecr pane Pas, 4. DEVELOPMENTAL REFLEXES “These are primitive reflenes that refleet the itegrty of the brainstem arid spinal eon Thr disappearance indicates maration ofthe cerebral ‘heminperesPesstenee beyond the expected date suggests amaturatinal Jig or impaired cena nervous stem function. {See Append forthe Table on Primitive and Developmental Refeses SENSORY TESTING + Limited we and rary needed in che newbom + Gross responses 10 stoking, pin peek, withdrawal, crying aro iil grimace and changes in sucking rates maybe used as behaviour cues. In genera, Fomever, tests fr pain and seasaton are imprecise at ‘his pio References Gon Digs Emin, SE New, MeGrow Hil Deter Tepe he Nail sion: A Panel "Pa ah a New Vs eGo 20 ete Cel PaiaseNemb A Signed Shpnon pnd ih dS Ser 208 Mees, Sse HB Mas BL Tebook of Cai New TE Pind anes Wlams o Waks 5 ‘tenn Rasy and Pt Pot Newly, 2B Pine, (actu abe re 208 | Sama, f Mba SF DAL Rar: Nel Pnp a Prue tnt Now Yo EIS ene, 20 pe. Neu of he Nowra, Sa 2108 pzTHE TECHNIQUE OF DIAGNOSIS “The plyican whois tei to «patie. ow the ans of te silat bore be ca are it.” “Mo-tze (.5dh-Aih century BC) Ethical and Polite Works, Bool IV, Chapter 14 “There in roa dt dg Robert Turtle Morris (857-1945) Doctors ‘versus Folks, Chapter 4 Correct Diagnosis “Corset diggnoss depends upon what enters the doctor’ head as possible and whac his ead dos to sf the possibiltes afer they have entered it 6 well as onthe recognition of signs by physical “To throw open the mind’s door and allow all disease to enter imo consideration each rime we ae called 10 bedside i foolish in the amtempt, and impossible in the performance, Each ease should lead us eo arrange before the mind's eye a selected group of reasonable probable causes for the symptoms complained of and for the sigas discovered. What we select should {Sepend on the ches furishe! by the patent himself, o by the results of our examination. ‘These procedures are useless unless the methods of physieal and chemical dingnosis have been mastered, and unless the narusal bistonyof all common discases has been leaned by observation and reading” Richard Cabot 1868-1939), “Ae you enter the realm of patent assessment, you begin integrating the essentials of linieal cate: emphatic listening the abilty 10 imerview patients of all ages, mood and backgrounds; the techniques for examining the different body systems; and Ball the process of clinical reasoning. Your expenence with history taking and physical ‘examination wil grow and expand, and the steps of clinical reasoning ‘wil soon begin with the fst moments of the patent encounter; ‘ening problem symproms and abnormal findings: inking findings to an undetying process of physiopathology or psychopathology; and Ccablshing andl testing «set of explanatory hypotheses” Bickley LS —a7nGoetensrn Tae Pac “& Selagyi PG in Bates’ Gude vo Physical Examination and History “Taking, Sth Ed, 2008. Salient Features ‘Mier the history and physical examiaation, enumerate the pertinent ‘Sriptoms and signs oF salen features (sini to the problem Lt i the peablem oriented medical ceords syste) in onder to consider Irom easly the eae asa who. A diagram ofthe course ofthe illness ‘Dura it esr emt the important or salient fetus. 1. Choose the sent fetus ofthe patent 2. Group the related features 3, List chem in the onder of their ration to che chiet ‘compli Examples H._ An infant with respsatory manifestations “Age: 2enonths| ‘ale Apparendy symptom-free unt three days prior 10 entry Chie complsine dyspnea ‘Dyspoea with ala ing since a day prior to admission receded wo days eater by fever, coryza, and cough Respirstory rate = 40/minuce; andiae are = 120/ otereostal and subcostal reactions Hyperesonance (Occasional wheezes Noles [No layngeal symptoms 2. child with prolonged fever Aged yeas Male Residence: Marvees, Basan Spmptom-fece until days prior 0 admission nde of els ve, and sweating followed apse of parent well big, oceurtngaknost day ‘Splenomegaly ‘No hepatomegaly Palos [No bleeding manifestationseteomcuter us ‘Steps in the Diagnosis “n digrcy ink of the eas ft” Martin M. Fischer (1879-1962), rom the salient features, choose the “Presenting manifestation” Clinical Diagnosis Confiemarory tests Working diagnosis (bass for teatment) Search for new data Final diagnosis 1) Choose the presenting manifestation "The presenting macifestation i 2 symptom, sla, group of symptoms and/or signs, or a lborarory finding Iris not the sme 1 the chief complaint because the presenting manifesation is the ‘octor’s choice whe the chief complain is the informants choice, and, therefor, they may not coincide, “There ate fve (5) sles in choosing a presenting manifestation 4) Look for symptom, dn, or laboratory finding pathognomonic of 2 sess, Bots spots in asitaminosis A, bas els n leukemia +) Look fora sumpiom, sign, ot bborntory finding pointing to an ‘organ of pat ofan onga system, such as hoarseness which signifies lnwolvement of the subgotie portion of the larynx where the voeal cords ate located. «9 Look fora semptom, sign, or abortory Sinding pointing toa group Df diseases, such as dates.Bnteumauso Ducanor Sauces -d)_Look for a symptom, sign, or laboratory finding whose mechanism ‘swell wndersood, suchas hyperbiirubinemia. 6) Look fora sumpiom, sign, of laboratory finding found in the least umber of diseaws, such as perusoid or paroaysinal cough, Choosing che best presenting symptom wil Facltate che diagnosis 16 dlarshea is used without quaiffing i, the differential dignosis wll be ‘much longes than if eiathea with enesmus and bloody, mucoid stools were used 2) Establish the clinical diagnosis ~ This is based on the symptoms and physical Endings OF the possible diseases, the disease that will «expla alli nor, mostof the patients lisa manifestations becomes the clinieal diagnosis This will serve asthe basis forthe choice of anellry procedures or tests to confirm the diagnosis. In establishing the clinieal diagnosis, the physician must bring ‘ut from his stock knowledge the lite history, pathologie] physiology and symptomatology of ths condition and then compare them with the data that have Been gathered, and al similarities must be tested. Ie ishest 1 compare as a whole te cinical manifestations of the patent with he disease under consideration. The closer the manifestation ly, ‘the mor likey is such disease wo be the corset clinical diagnosis, 2) Using Rue La. A pathognomonic pesenting manifestation “Although the diagnosis is obvious, compat the patient linia pierre ‘with dat deseribed inthe iterate For example: if a patient has Biot spots, the elniclan must first ascertain if the lesions are really Bitots spots IF the clinician is sure thatthe lesions are Btotk spots, he of she must look for other sympcoms and signs of avitsminosis A, detcemine the patient daily inake of Vitamin A, and look for conditions that may bavetiggred the decency in spite of an adequate ineake sich ssteatorthea. These findings must then be compared with the known cinial presetation ‘of aitaminosisA.1F che ally then a clinical diagnosis of avitaminoss Ais definite 1) Using Rule Tb, A presenting manifestation pointing to a definite ‘organ or system Hoarsenes is very good example. It indicates involvement of the vocal cord, and, therefore, conditions involving the portion of the slots must be considered. ‘These may due to infections oF aosinfectious causes. If the hoarseness is accompanied by fever, subglotie infections must beonsidered and noninfeaious enuses excluded “Then consider the duration ofthe lnes. If iis aca, chromic subglotie infections are ruled out, The differential diagnosis will te bemecn acute laryngotrachstis, acute layngoracheobronchits ‘Reuee lnpngotracbeobronchopneumonii Iaryageal diphtheria, and spasmodic croup. HOARSENESS © Vocal cords of the Larynx Consider disease ofthe larynx that may produce hoarseness Infectious Non - infectious (+Feves) \~ - Acute laryngorracheiis Acute Laryngotacheobonehitis “Acatelryngotracheobronchopneamonitis Taryngeal diphtheria Spasmadic croup “The clinical findings ofthe patient are then compased ata whole with ‘peel presentation ofeach ofthe previously menoned sass “Thai veryimporant beeause many dacacs have the sae or similar wei esotone but they differ in the sequence and day of the loess ‘Then they appene The clinical impession wil be the disease that wil ‘Splnin all if ot most of the lina manifestations of the patient «Using Roe te A presenting maiferaton thax pois 3 group of senses or disorders Find out the different diseases in the group, and make 3 ferential diagnosis as discossed ate. wha example wil be eizures. If a patient has seizures, che icin mnt determin if these are acute of recureent. Acute seizures ser ay not be associated wih fever. Tn the presence of feve a etocnous causes are roe out Seizures associated with fever may corn in infections of the central nervous sytem or othe sits Tr these sympuom are associated with abnormal newtloge ndings ‘he ieretel agnosis wil be limited to ening encephalitis and sr cingocneephac Fal Ue evlogy ust be determined sedfon other manifestations. For example, if these manifeations wore associated with porpurs, meningococcal meningitis will be the most ely diagnosis Acute seizure tack ina 3 year old oie Aha nS nfeion sing [None Meningo encephalitis ‘Acute Sub- acute Chronic ) Using the ule Id. A presenting manifestation whose mechanism fswell understood Determine the mechanism involved (physiological, pathological, chemical, physical eause of the symptom “The pathologie physiology shat may explain the symptom ‘must be cazfulycoasidered. More than one mechanism may be able 1 proddce the symprom understudy. That which seems more likely fn the face of a caefl evaluation of the historical and physical data should be sclected as the point of departure for further reatonings. [f Ine, iis necessary, cher mechanisms considered less ely at st _may be approached, and their implications followed ont” (Stans) Edema i a good example of such a presenting manifestation, It can be caused by congestion, a decrease inthe osmotic pressure indlammation, o the eetention of water and sat. Congestion can be due to congestive heart failure ar portal hypertension. Congestive ‘hare fale can be ruled out inthe absence primarily of tachycardia, FeTw Tonaxo: Duos ‘achypnea, exdiomegaly, hepatomegaly, aed other signs, \ reduction Of the osmote pressure can be ruled out ifthe intake of proteins is ‘more than adequate, sbsence of symptoms and signs chat may indiete ‘hepatic disorder that may be associated wich falure of protein synthesis, or there are no indications of an excessive loss of proteins “This lees the last mechaninm retention of water apd sodium, which ‘may be a nephie o nephrotic disease, excessive administration of Saline solutions or costicosterids, The later two conditions ean be readily rulod out ifthe patient was not receiving ether of them, The “iferental diagnosis, then is ast between the nephriie and nephrove syndromes EDEMA > Mechanism is known i Osmoric pressure + Recenvon of waterand salt | Cardiae —-Nephritie Excessive Failure Nephtotic protein loss Excessive Inadequate Portal HPN use of IV protein inatke Saline or Failure in Steroids protein synthesis Review clinics! symptomatology of the dlvease/ conditions considered, Using Rule Le. A. presenting manifestation pointing to the least fhumber of diseases, A good example is fever and chills in older Children which may point vo lobar paeumoni, mala, urinary tact ineeton,ryphok! fever, abscess or abscesses In making a differential tlagnosis lobar pneumonia wil be the fst consideration in the presence of cough and dyspnea or taehypnea and abnormal findings fn one of the lobe Malaia can be ruled out based on geographic Iistory of the patient. Usaary tract infection can be excluded i the absence of urinary symptoms Salmonellosis can be ruled out in the absence of other findings such as brownish Fured congue, Os Spo", ‘hepatomegaly, splenomegaly and bradycardia depending on the sige of the lines The absence of abscesses on physical examination ear be eliminated as a cate of fever and cil.cet tson Te Por, BttnwromoDucwscrRmamcrems Fever with Chills poiating wo lease number of disases, 1. Labae pneumonia 2 Malaria 5, Urinary Trae Infstion 4. Typhoid Fever 5. Abueess Review the clnieal diagnosis she necessary diagnosis procedure must be roquested to contr it With probable clinical diagnosis, the necessary diagnostic procedrcs rust be requested to confirm it Discover unexplained data “Once thea diagnosis as been made, the history, pathology, physiology and symptomatology of this condition are Inought out from the storehouse of the background (knowledge of the disease). ‘This knowledge must then be compared with the data that have been fathered, and all simaries mast be notod, The mote losely the Pictures tally che more likely the tal diagnosis to be correct.” ‘The pretence of unesphined data witrants a thorough reconsideration of the diagnosis. The unexplained data shoal be used as another presenting manifestation and the same diagnosti procedure ‘semployed. These Sings may mean that the diagnosis x aoe correct, foranother disease may be present 3) If the diagnostic procedures contirm the clinical diagnosis, this becomes the working diagnos (On the basis of the working diagnosis, the physician plans treatment and makes the prognos While under treatment, the patient must be followed up regula. Progeess notes should indiate changes in the symptoms and physical ndings, assessment of new laboratory or radiographic findings, evaluation of de overall condition of the patient, change in the diagnosis or an addtional diagnosis, and any revision of the plan fof treatment. These ate writen daly bu in seriogs cscs important changes are written a8 they develop, Recast the diagnosis if ter there should develop doubt as to the cortcetness of the working diagnosis Inthe course of theless new symptom or bnormal physical ding aoe rated eo she working diagnosis develops the clinician must determine its cause by making use of it as another presenting ‘manifestation andthe same diagnostic process is followed, bi- __TeTiomaurer Duos 4) At end of the patient's hospitalization, the final diagnosis, _must be given. emus expla the chief eompaing other diagnoses ae considered 2s sekliional diagnoses No diagnosis shoud be considered a inal ues 2) The disease bas run its entire cour, ') The diagnosis has been proven by 9 Surgery, suaiea pathology i) Mirobiologie toes i) Auopoy (When a patent dies, fina diagnosis has to be given even f there no autopsy) "Th oct tha yor patio ss wel des wet prove tha oar agua co.” Samuel. Meltzer (das1-1921), [Nobody is infallible in terms of diagnosis.cero Ta Pac Sisnumaue Duss Bown: Pe (COMMON PEDIATRIC PROCEDURES 1. Blood Sampling and Vascular Access A. HEELSTICK AND FINGERSTICK “L Indication: Blood sampling in infints for laborory studies unaffected by hemolysis 2. Complications: Infection, bleeding. osteomytiis 5, Procedur fa, Warm bec or Sager. 'b, Clean with alcohol. (Puncture eel using a lancet on the lateral part of ‘he heel, aving the posterior area, (@) Punerare Finger sng laneet on the palmar aera surface of the lager next the ip. ce. Wipe away the ist deop of blood, and then collect the sample asing eaplary tube or container. ‘d. Alternate between squeezing blood from the leg toward the heel fr from the hand roward the finget) tnd then tcleasing the pressure for several seconds 1B, ARTERIAL BLOOD SAMPLING (sada or femoral artery) 1 Indications: Accra blood sampling or frequent blood fect and continuous blood pressure monitoring in an innensve cate sing, 2. Complications: Infection, bleeding oclasion of artery ‘by hematoma or thrombosis schema if ulna éeeuaton isinadequae 3, Procedure: 2 Before, procedure, test adequacy of ulnar blood flow with the Allen test Clench she hand while simultaneously compressing ulnar and radial arteries “The hand will neh, Release pressure from the ulnar ster, and observe the ashing response, Procedure fs sae to perform if entire hand fushes bb Locate the rl or femoral pus {@) Pancrure the pulse witha needle at a 30-10 6 ogee angle over the point of maximal impale Blood should flow fely oto the syringe in a pulsatile fashion, Once the sample is obtained ppt fem, constant pressure for 5 min and then place a presuredessng onthe puncte site ‘Note Dr iy ms Hd rts po Ds ts horteee canovPrwnc cious "VASCULAR ACCESS PERIPHERAL INTRAVENOUS PLACEMENT 1. Indications: To obtain access to petipheral venous relation 0 deliver id, medications, or blood produets 2. Complications: Theombosis infection. 3. Procedure: 1, Choose IV placement ste and prepare with alcohol bb. Apply tourniquet and then insert IV catheter, bevel tu. at angle almost paalel to the ska, advancing unl “ash” of blood ie seen a the catheter hub, Advance the plastic eather only remove the seed, and secure the catheter INTRAOSSEOUS (10) INFUSION 1 Indications: Obtain emergency aecess in children during Iiechrestening, situations ‘This is very useful during ‘atdiopulmonary arrest, shock, burns, and life threatening ‘aus epiepricus 10 Fine can be used o infuse medieatons, blood produto ids, The TO needle shouldbe removed ‘nce adequate vascular access has been established, 2, Complications: a. Race, paticularly with correct technique. Frequency of ‘complications inereass with profonged infesions. bb Extnvasition of fluid from incomplete cortex penctston, infection, beoding, — osteomyelti, Eomparment syndrome, fit embolism, facture, ‘pipiysea inary 5. Sites of entey (in order of preference): fa. Antetomeial surface of the proximal tibia, em below tnd 1 192 em medial the tibial tuberosity on the fat par ofthe bone 'b Distal femar 3 em above the lateral condsle in the ridline. ce Medial surface of the distal gia 1 wo 2 em above the ‘media malleolus. 4. Anteronupetior isc ypine tan angle of 90010 the long aris of te body 4, Procedute: ‘a. Prepae the patient fora sterile procedure. Db. Laser a 15- to 18-gauge 10 needle perpendicule 10 the skin at an angle away from the epiphyseal plate and idvance to the penosteum, With boring rary motion, Denczate theough the cortex unl dere isa decrease i Fesatance, indicating that you have reached the marrow:Goel Tae Pas, BamarouneDuowssos ALAMCP Aus _ ‘e. The needle should sand. Secure the needle careful 4d. Remove the syle and attempt to aspirate marow: Flash with 10 10 20 mi. heparinized NS. Observe for fd extravasation, Marr can be sent for determination of fucose levels, chemistries, blood rype and crossmatch, Ihemoglobin, blood gas analysis, and exkures. ce. Attach sundae IV eabing Tomoucons sete pone ing odd reso il appoch “Theron pom i noe one else of the trevor dig nem fingebe blowte sil hes. (Pw Dinko ya Pls Egy ak Cal Car Pd Se Los ay 199792), E. UMBILICAL ARTERY (UA) AND VEIN (UV) CATHETERIZATION" 1. Indications: Vascular access (via UV), blood pressure (ia UA), and blood gas (va UA) monitoring in eccally il 2, Complications: Infection, bleeding, hemorrhage, perforation of vesecl thrombosis with distal embolization, Ischemia or infarction of lower exremises, bowel, or key, asshythmin if the catheter isin the heat ai embolus 3. Caution: UA eatheteriation should never be performed if ‘omphalts or pesonitis is present. Contrandated in the presence of possible accrotiing enverocolis or intestinal Inypopesfasion, 4, Line placement: ‘a. Arterial ine: Low ine versus high tine. () Law line: ‘The tip of the emheter should lie just above the sori bifurcation berween L3 and LS. (@) High line: The tip of the exthete should be owe the diaphragm between T6 and 9. 4 high tine may Ine recommended in infants weighing less than 750 g, in whom low ne could easly ship out bb UV catheters should be placed inthe inferior vena cava above the level of the ductus venosos and the hepatic ‘eins and below the level of the eight atrium.ee _ConenPrunchosous “e Catheter Kengihy Determine the length of entheter feqpired using. cither a standardized graph or the ‘erersion formula, Add length for the height of she teil stp. (Q) Standardized graph: Determine the shoulder Tobe eagth by measuring the perpendicular line “roped from the dp of the shoulder tothe level of the wimbilews @) Birsh weight (BW) regression forma: Towle UA eaters gt (om) = BW (i) +7 Highline: UA eatheter egg 6m) = Bx BW x] +9 [UWveathcter ng (an) = [05 high ine UA fom] +1 Note: Fond ny aoe appropri or alfresco vg a agonal inf Procedure ee Determine the length of the eateter to be insert for iter high (16 1079) or low (L3 © 9) position by, Prepare and drape the umbilical cord and adjacent skin sing stele technique ce Fluak the catheter with a stele saline solution before 4d. Cor throug the eon horizontally about 15 w 2 em fom thesia ce ently the one lange, thie-valled umbilical vein and evo wae hack walled arteries. Use one ip of open, curved ‘Deceps to probe and dilate one artery oF vein gent. 4. Gop the catheter 1 cm fom ts tp with eorhlessforeps, Se Rect the exter nto the fumen of the artery oF vei ‘Ram te ptoward the fet, and get advance the exh to the deste distance. Do not force. ‘& Confem the poston of the cater tp eadigsaphicaly Secure the eateter with a suture trough the cord hh, Olsawe for complications: Blasehing. or cyanosis of Tree waar, perforation, eheomboxs, embolism, oF infeeson. see ware sini fg th Acris Te Note gra) terri er eS eg az al eked UH as 5 Ufa of pn Nee a pam it munGurontssor Tone Pc Sater Duc or nc Pas acct of uni ancl. A, Dig hte ofthe ie ne erg bed er xe Sewing te en al tinea tbe” meta Wns Sa Pl mg nC Cas rns ai Mab toon 300) aComprtraancPrerots 1H, BODY FLUID SAMPLING ‘A. LUMBAR PUNCTURE 1, Indications: Fxamiaation of spinal Hid for suspected infection ot malgnanes, instilaton of | intathecal chemotherapy, or measurement of opening pressure. 2, Complications: Local pain infection, bieding, spinal id Tea, hematoma, spinal headache, of acquired epidermal spinal coed tomor caused by immplanation of epidermal ‘teil into spinal canal fo syle is used on skin ent. {3 Cautions and contraindication a. Increased ICP: Before lumbar puncte (LP, perform fanduscopic examination. The presence of paplledems, ‘etioal hemorthage, oF clinical suspicion of increased ICP may be contrindieatons tothe procedure 1. Bleeding diathesis: A platelet count >50,000/ Li desirable before LP. e Overying skin infection may result in inoculation of (CSF with organisms 4. LP should be deférted in an unstable patient, and appropriate therapy should be initiated, inching antbiotis if indicated. 4, Procedure: ‘a. Position child in ether the siting position (Fig, 3.9) fof Ine recumbent position, with hips, knees, and fneck Axed, Do not compromise a sim infants Cardioresptstory statu by positioning Db. Locate the dested intervertebral space (ther 13-4 oF LAS) by dewing a imaginary line berween the top of the ie exes, ‘6. Prepare the sin ia sterile fashion Use a 20- to 22-pruge spinal needle with silt. A fenallergivge cele will decease the incidence of spinal headache and CSF lak. ‘e. Puncture the skin in the midline jst caudad to the palpated spinoss process, angling. slighaly cephalad toward the umbilicus 4. Adkvance several milimeters ata time and withdraw the Seyletfequendy to check for CSF flow: In smal infants, ‘one may rt feel a change in essence or “pop” a the dra is penetrated ‘gf resinance is met inilly You hit bone), withdeaw needle to the skin surface and sediect angle slighty.ron Tae Pc Fisica acs Baume Paes hh. Send CSF for appropriate ties: “Tes tube #1: culture and Gram stain “Test ube #2: glucose and proein levels ‘Test tube #3; ell count and ferent count “Test ube 4s ave specimen 1. Accurate measurement of CSF pressure ea be made ‘aly the patient lying quely on his or er side in Gh unflexed position, It is not a reliable messurement fn the siting postion. Once fee ow of spinal fd je obtained, atach the manometer and measure CSF ‘pressure. Opering pressure i recorded as eel at which CSP is steady Lumbar puncte ste in he siting postion TP acs ob Pa Ene el i oe Pdr SoM 12977 3) [Lumbar puncture stein the Intra (ccubent) postion. Trae edo Pas yy an Ct ae Ps Si May 197 9534)Come osmc iocus B. BONE MARROW ASPIRATION 1. Indications evaluation of patents with hematopoietic and non-hematopoietie diseases; pants with splenomegaly, dsprotcinemiss, suspected Iyosomal storage disease, fan vnexplained delcency or excess of peripheral blood Teakooytes of platelets, oF the presence of immature oF morphologically atypiel cells in che peripheral blood 2, Complications: Hemorchage, orteomyit, parplegi 3. Procedure: 4. loti ste for sspiniton. For most children, the posterior ile eres i prefered, For some children $ouger than 3 month, the ubia cas be used. '. Position patient in the prone positon with a pillow clevatng the pelvis ‘Prepare the stein a stele fashion and anesthesize the shi, soe tissue and periosteum with 1% lidocaine 4, Insert needle (16 oF I gauge) with steady pressure ina boring motion, Needle should be directed perpendicular to the surface ofthe bone, The needle should be Szzaly anchored inthe bone. ce. Remove stylet and aspizate marrow with a 10 1 20 uk. syringe Apply peessute ae de procedure. © CHEST TUBE PLACEMENT = AND ‘THORACENTESIS 1L_ Indications: Evacuation of a pneumothorax, hemothoras, ctylothorax, lage pleural effusion, or empyema for diagnostic ve therspetie purposes 2, Complications: Infection; bleeding, pacumothoras; -hemothorax; pulmonary contusion; puncture of eaplagr, splen, or fiver bronchopleurl stu. 43. Procedure: Needle decompression [Note Fi ips erin tit sepa idS {yer gr 1 2g had id la ir iano mt ‘4 When the pleural space is entered, attach eateter co a three-way stopcock and syringe, and aspirate at by Sabsequent insertion of aches tube i still necessary. 4, Procedure 4. Poston child supine or with affected sde up with atm restrained over the head, bs, Point of entys the tid wo ffth inereostal space inthe rid to anterior silly’ line, usually a the level of the nipple (avoid reas sue) oeGuccronron Te Pesca, an Funct ce, Prepare and drape in sie fshion. 4. Pasene may requite sedation. Locally anexthetize skin, fabeutaneous tissue, periosteum of tb, chest wall rmuseles, and pleura with 1% llocine. fe Make s stele 1 to 3m incision one intercostal space blow desired insertion point, and Bunty dissect witha Fhemosta through issue layers unt the superior portion Of the bi eached avoiding the neurovasclat bundle fon the inferior portion of the wb. fash the hemostat over the top of the nib through the pleura, and into the plewal space, Enter pleural space fenatousy and aot deeper than 1 em. ‘g: For s pneumothorsy,isert the tube anteriorly toward the apex. Fora pleural effusion, dec the tubeinfesionty sd posterity th, Awach to a drainage system with -20 to -30 em H2 pressure. Apply a tere occhaive dressing ji. Confem postion and function with ches radiograph. ‘Procedure: Thoracentesis "a Confiton fluid in pleural space by clniest examination and radiographs or uluasonopraphy ‘b. If ponible, place child in siting postion leaning over table; otherwise place supine ce. Point of emuy i usualy inthe Teh intercostal space poseror axl lin. 4, Prepate and drape area in sterile fasion. | Anestheize skin, ubewaneous tissue, ib periosteum, chest wal, ad pleura with 1% lidocaine. {Advance an 18 to 22-gauge TV catheter or large-bore pondle tached v0 asyrnge ono the ib and then “walk” rer the superior aspect ito the pleural space, while providing steady sepative pressure offen popping Sensation is generated. sg Atach syringe and stopcock device to remove fd for agnostic studies and symptomatic ele th. Afer removing acedle or extheter, place an occlusive drcasing over the site and obrain a chest rdiogsaph tO rule oxt pacumothorns,“Technique for serio of chest tbe. IS, ltscoseal pce INV, neuroses KVL, sth sh Mf fom Phir Loi Plt Emery Medi, Slo Baia, Wilber © Wins 200, p 1905) fl ‘Thoracentsis. ICS, intercostal space. (Mad. from Flasher G, Laie S: Pde Emorency Medion, 3 od Balimor, W lis €> Wiking, 2000, p 1906,)Snierauane ucarcrbiumcParogs D. URINARY BLADDER CATHETERIZATION 4. Indications: To obsin une for usialjis and caluse strlly and vo ccutly monior dation tan 2. Complications: Herat infecion, enna to wet or ‘addr intravesical oto eter (ey occa). 3 Procedae: a Tnfr/chdshou not have voided within Thr of proce Prepare the uct opening tsng sterile technique In boys apply ste tno tthe pei ossighen sheurctna Ins the wth once may be iia tose, but tis al immediacy antes othe “aioe Gently inter bated catheter ito the wet Somly vane the exter int existance met the xe sphincter Conined prsare wil overcome this resistance andthe catheter wil ener the bade . Cavfily remove the caterer once the specie is bined and cant te shin fo doe [Note Catnip A a he si Nad ma ‘SUPRAPUBIC BLADDER ASPIRATION"! A. Indications: ‘To obtain urine for urinalysis and culkure sterile in childcen <2 years oF age (void in cidren with genitourinary tact anomalies, coagulopathy, oe intestinal fbstruction). Bypasses distal urea, thereby minimizing tisk for contamination, 2 Complications: Infection (clits), hematuria (osually smieroscop), testinal perforation. 3, Procedure s& Anteror rectal pessuc in gis or gentle penile pressure in boys may be used to prevent urination during the procedure, Child should not have voided within 1 hr of rocedare . Restin the infant in the supine, fog lag poston Prepare suprapubic area in serie fashion. «The site fr puncture is 1 to 2 cm above the symphysis pubis in che midline. Use a syringe with « 22-aauge, Ihinch ace, and punceae ata 10: 1 20-degree angle to the perpendicalar, siming slighlycaudad 4. Exerr suction gently asthe needle is advanced unl wine centers singe, The needle should note advanced morethan 1 neh. Aspsae the urine with gentle suction Clean iadine from skin. pape ner sion me Sr: Pant my onion Prati, a Mn 997 p48) SOFT-TISSUE ASPIRATION so Tndications: Cellulitis that is unresponsive inital TMiard therapy, recuent cellulitis or _abscessch ‘Famunocompromised patents in whom orpanis £6covery inecesnary and may affect antimicrobial thetspy 2, Complications: Pain, infection, bledng, 3, Procedure: Pegcccr site to aspirate at point of mania intarnmation. ‘b. Clean area in sterile fashion, ee Ccalancihesia with 1% lidocaine is optional Si pm tuberculin syinge wih G1 to 02 mL of Tonbacteiosatic see saline and attach co needle. fe Using 18 or 2gauge needle @2-anvge for facial leks), advance’ to appropriate dept and apply tegatve pressure while withdrawing needle {Seed dil fom aspiration for Gram san and cules Treo fad fs obtained, you can sreak needle of BA te, Consider aci-fst belli and fang sais fo Fenmunoeompromisd patentII, IMMUNIZATION/DRUG ADMINISTRATION 1. Indications: immunizations and other medications 2 Complications: Bleeding, infeeson, alleyic reaction, lipobypertopty or lipoatrphy’ after repeated injections, nerve ijn A. SUBCUTANEOUS INJECTION Procedure Locate injection ste: Upperouter armor outer aspect of upper thigh be Clean skin with aleobol fe Insert 25- or 27gauge, OSiach needle into the subeutneous ljer at a 4S-degree angle to the skin, Asplrate for blood, iF aone, thes iject mediation B. INTRAMUSCULAR INJECTION Cautions ‘Avoid intramaseula injections in a ehild with a bleeding disorder or thrombocytopenia. Maximum volume to be injected is 0.5 ml in a small infant, 1 ml in an older infant, 2 mi in a school-aged ‘il, and 3 min an adolescent Procedure: ‘Locate injection site: Amtezolaeeal upper high (vastus Inver muscle) in smaller child, of outer aspect of upper arm (dct) in older one. ‘Clean skin with alcohol €. Pinch mule with freehand and inser 23-07 25 gauge, ‘binch needle wal the bl is ush with che skin surface Fordeltoid and ventral guteal moseles, the acedie should be perpendicular tthe skin. For dhe anterolateral high, the needle should he 43 degeces eo the log axis ofthe thigh. Aspirate for blood f none, inject medication ©. INTRADERMAL Indications skin test, Mantous test Procedure: ‘a Locate injection site: lesor surface of the forearm, '. Clean skin with aleobol ‘6 Introduce 25-27-pauze needle, bevel wp, oto the upper layer of the ska. Inject 0.1 ml of antigen tia 10mm ‘wheal is produce. 4. Measure the area of induration, not the erythematous TaN > ln ine sired pit mini ‘ek er pao on HE saneomen auc Proons OTHER PROCEDURES: A. ENDOTRACHEAL INTUBATION Tntubation: Sedation and paralysis are ecommended for ineubation, ‘except in acboms and in some patients who ae unconscious arin cardioespraory aces ‘4 Indications: Obstruction (functional or anatomic), need for prolonged venslatory assistance or contol, respiratory insufficiency, los of protective airway refleses, or need for route for approved medications be Equipment: SOAP (Suction, Oxygen, Airway Supplis, Pharmacology) ()ETT: ‘The following equation should be used to determin the sizeof the ETT to be used: (Age [rs] +16)/4= internal ameter of ETT sube (um) (@) Have one ETT 05 mm smmllerand one ETT 0S mm large shan the estimated size. () An uncuffed ETT should be used in paienss <8 ‘years ol, The dep of insertion (a entientees; at the teeth or lip) i about cree times the ETT size (©) Resuscitation sapes based on length may be use to cesiate ETT size. {@ Laryngoscope ble and handle with functioning ight: Genctlly «straight blade can be used in all paints. A carved blade may be easier to us in patients >2 years cl (@) Bag and mask should be atached to 100% oxygen (ETT syle should not extend beyond the distal end of the ETT. (Suction: Us a large-bore (Yankauer) scton catheter or 14F to IBF suction cates (@ Nosogssre (or roger) tbe: Size fom nose to angle Of jaw to siphoid process. () Monitoring equipment: Electocardiography (PCG), pulse oximetsy, blood pressure (BP) monitoring, tapnometry (en-ial CO2 monitoring. (Tape to secure the tube «e. Procedure: Artemps should not exceed 30 seconds () Preoxygenate with 100% O2. Assist vention with poriive pressure ventlaion only if the patient effort fs inadequate, (@) Administer intubation medications. {@)Apply ericoid pressure to prevent aspiration (Selick ‘mancuver) duting bag-valveamsk ventilation and ‘ntbation.cere THD PSE Cees ene paar bnem Pe ay wat pearing sine on im se eal nine ey exec pen mah wl SEN hub and a Rng sing sesoing eh ey ingress tae ie be nse blade ito Fhe side oF moh STINE tongue 10 the fost of line of vision. Go nivance Uiae v0 rigors ssraight blade, it Aaeaeacope st ec ios lange seve, Wit cared the tp a ee ess ne vale Cerne ‘pase of of eens) Lt mah oro A he ons and noize the woes oe cn Ge aang dct a the EIT Whe aga omer of He mca THE coms from FE ck ms on he abe eu! Be the Tove of the vocal cords (gy sy ET placement sere all saovement Vest atacand ein ge canon, ca ee Mice nl be a abenegane espns fective Crimson SHE! EO the subs, petprementin oxygen seas radiograph qyoniy when ETT placement “eid should vicoid pressure be removed (40 Sco ope ET in plas oH epi of insertion Kem) at ret oF iP 8 sasooassRiC/OROGASTRIC INTUBATION: 3 ee placed tough he 208 0 omach, tis called 3 Tee ne ube cube plac hous SH ont o the stomach i tat a orl gastric tbe (OG b=). A: for feeding Age decom Procedure: 1 ce ofthe NG ake wh 2 Ten Mec cis noe and TSS NY obs, Then, fom that pont on he pease ove Half Dee fo i he reasoner te save OY ‘porton) Mark Te eube at this pin 2 eal ame of wares SPN inesip of Pa ing ube Never we ol bse we Meng ewar ee er be Pe low sto the Aiming et sa oe geal enue, ep sven wl vearkcd part of tHe DE pret ge (oso itis an oT ESS tsbe) oo4. If the tube does not go in realy emove it. Neer far ibe tbe Change the ells poston, Inbrcate the ip of the tube, and ty agai, Te tube may go down easir if you fave am infant sock on a pacifier. An older child ean dink ‘smal sips of waree while you insere the eae. 5, Keep the tbe in place withthe free end ofthe tape onthe chills aos cure? The NG ube lee HOW TO CHECK THE PLACEMENT OF THE TUBE: Yo msec > make se he ie sin te stoma ate fie a fein. 1. Pail back on the plunger of the singe to draw up Sm, of ais 2. Pace the tp of the sytinge into the open endl ofthe tube 3, Place the stethoscope ove the cs stomach (upper left side of the abdomen).Gorton Tae Pac sono Dur ee PETS 44 Inject the ai into the tube and sen fora “whoosh” sound. This sound wl ll youth tube sin the sghr place. Withdraw the airyou injected eo eheck for placement. IF you do not hear this sound, emove the tube and repeat the steps 5, Pull back on the plinger of the syinge to check for stomach ‘contents Stop paling onthe plunger when you see the stomach ‘onents ia the syringe 6. Slowiy push the plunger to retura the guid 0 the stomach (the ‘contents eoptain important quid thar should not be thrown way) . PEAKELOW METER Tndicaions: monitor ling function, response o treatment, determine the severity of an asthma stack Procedase: “The peak flow meter should red zer0 or is lowest reading when notin use 2. Use the peak flow meter while standing up straight 3. Take in as deep a breath as possble ‘4 Phe the peak flow meter in the mouth, with the tongue under the mouthpiece Close the ips sightyatound the mouthpiece 6. Blow out as hard and fast as possible; do not throw de hea forwatd whi blowing out 11. Breathe a few normal breaths and then cepest the process vo mote times. Write down the highest number obained Do ack average the numbers 8. You should aot the highest PEFR measure achieved his is ‘he "personal best” PEFR. Ths number is used to determine if foture PEFR readings are normal or lo and is also used to create anormal PEFR rang (beeen 80 and 100 pereent ofthe personal best PEFR. 1D. TOURNIQUET TEST or Rumpel-Leede or Capillary Fragility Test Indications: decrmine hemorhagie tendency; defined by WHO as ‘onc of the requisites fe diagnosing Dengue Hemorshagic ever ‘Disadvantages: has low specificity; maybe (#)in other vil infections, a ocgative test may cer in ely stage of dengue Fever Procedure: 1. BP cuff isinfated at a poit between SBP and DBP (mean BP) above the cubital fossa for 5 minutes. 2, After release ofthe cuff, the aumber of peteche within 1 quar ine below the antecubial fossa is counted. 13, Gremce than 20 petochiae is abnormal; indicative of thrombocytopenia. oF plates dysfunction or capillary fagitypenx EXPAATORY FLOW RATE NORMAL VALUES PIRATORY (isrose sean ay 8 oe TTESEESESERE reEesadt meee Face Sis Saat nem REFERENCES: FERENCE, ag cnt hen Te Mens NE ‘et p00, 2 Go. Ree MB. Hane Mes cope © 2, 1h ele 2, co 2 act a Ten hw Dobe ME a MDS “Sanden 30 ped Tosi Ene ea Howe Met aga oerat ee NORMAL VALUES IN CHILDREN BLOOD CHEMISTRIES/ BODY FLUIDS ACID PHOSPHATASE Asjor Souces prose and enthroeytes) ‘CONVENTIONAL | Stuaits | vais Newbom, Tai | Paria 213 yr 641520 | 64-152 UM, Adu male OS10UA [05-110 UA. ‘Adult female 0.295 U/L 0295 UL) [ALANINE AMINOTRANSFERASE (ALT/SGPT) ‘Major Soures: ver, skeletal muscle, myocardium) 05 days, 6550 U/L 6-50 ik 1-19 yr 545 UL 5-5. UL ALKALINE PHOSPHATASE, (Gajor Sours: iver, one, iestinal mucosa, placenta, kidney) ‘male | female | Male | female ease Tal [ sesso | 0500 Ee Le en | in” | osu asin 3s aw | a ee | Man” | sun. Te] B20] 30-1] OS oe | ean | an” [Pin AMMONIA ‘Conventional uni Suns | Saag gals mo] fa | timate i Tear molt {Teo sae a AMTASE AMYLASE ae pancreas, allay gland and ovaries) es ee iss Bate [ANTINUCLEAR ANTIBODY (ANA) Sau 8 Nee a0 asters with linia correlation: (Centromere: CRI'ST ‘Nucleolar Seleroxerma Hlomogenous SLEANTISTREPTOLYSIN O TITER(x rise in pated ‘eral specimens is significant) ees | Pe | oe aw FBTosd as [ietige —1—<183 50 Tad us ARTERIAL BLOOD GAS PH] m0, | PCO, | HCOr (mEa/ty teamin | nmi Nexon fae] | w Jove | 729 Inewbors [737] 7 | 3S w loro, fntinr=p7a0] 90 | wy [2+ mo) fcntaes|om [ = n9 0) radu > [ras] o-t0 | 3-5 p= bo 78 oa Wanos blood Gases ca be used acess ac ase ete Mer vrenaton, POO, averages 6-8 ms Hier ae ES pit slightly lower. Penpheral venous te ee only afte bythe cal culty 27 sms ronment. capillary blood gases corre best ce Stand raoderately well with PaCO, ASPARTATE AMINOTRANSFERASE (AST, SGOT) econ iver, skeesl muscle, kidney, myocardaat und enaheoovies) (esi SE T TESOL oo BICARBONATE, [Bextor Taare Eee Sageceronnon Tae Ps Seer ucus or anc BILIRUBIN (TOTAL) ‘CORD Geen [awa | ] ze woo coed =e Yer = eS en ee ia pe eet es ee ee = es oe Sr ae ea aa Stee a iets ee eso Shes a 3—ter SAMPLE CALCULATION Sete iso enOW 25 5-35 ESO SE (" Exchmges | @ | @ | @ aie are ft — ic [ar Tear x ‘oa Sener Tt oe ett [5 =] ino pa ARTES =245. (presesibed CHO) ‘B3 (puraalsum of CHO) ia 225 =7 ao. OF sce exchanges sear ry tries recreate eae reac Paleo = 24 158 presided PRO) 2. puna sum of PRO) SPE na of meat exchange alias 3 ey rm 35 ve 4 8 300 Pasi sa 35 pcserbed Fa) 0 petal om of Fa) 16 25 = 3 oof faexchanges FuuinvE 3 1S Toot Pe CO) ‘Recommended energy and mutient intake per day "RENT From 0-18 year old) Popalason Wane aay Pro Gop. i eal £ Tans, 0 ‘bit <6 « 500 9 eeciz 5 a0 1s Thires.7 13 6 100 2 46 0 140 3s To. a 100. 6 Saesy wa u 240 s bas so 2s00 m 6.18 38 2340 B 929 3° 200 a 09 2 2320 a 50.64 2170, o ose Ea 90 a Femalny wo. 38 1000 ” Bas ® 250 6 1618 0 2x0 2 oO‘Checklist for Developmental History (Alot on Neon Teno of Pasa Heh 208) Newborn Period (Ia wees) “Les in lesed positon, runs head side 0 side, Head lags on venta suspension ‘May fate face on light in line of vision Dolls eye movernent of eye when trang body Vinual preference for human fe 1) MONTH: Spontaneous motor aii Lifts head momentarily on prot, Head lags when pulled o sit Begins to eogaed surroundings Follows objets mine 2. MONTHS: ‘Mowoe activity generalized Smiles and co0s socal Follows objets past midline Head lags on pal tie SMONTHS ‘Visually sacs objects well ‘esis to have hand regard ‘Good head control on prone and Tooks around Tinproved head conteo on siting position Sustained smiling and cooing 4 MONTHS Begs to each foe toys symmetrically Regards toys and pats them into mouth Removes diaper on face ‘Good head control on siting position “Midline regard (plays with hands) Laughs 6 MONTHS ‘Reaches with either hand ‘Chest up when prone Rolls over May a bey wen placed aug and plas with examiner Lnitazes speech sours ‘8 MONTHS Sits alone Begins to ecep ‘Regan self im mirorBubbles Crude prehension “Traneee object from 1 hand to another Sis papa and mama indiscriminately Responds to comsmands of “na” 10 MONTHS (Crawls an pull o stand esis to cruise around the eb oF furniture eter prehension (¥humb and forefinger ‘opposition Unters ‘mama’ or “dada” Hols bowe eed self with crackers Waves bye-bye Gesture language 12 MONTHS Walks alone with one hana held Stands alone 2 words other shan mama and dada ‘Bevin to food with ngees Kisses on request Releases object on request (Obey commands with gestures 1S MONTHS Independent walking Creeps upstairs Sat words other than mama, dada Drinks fom eup Beis o feed with spoon \Vocalizs and poiats on something ‘Obeys simple commands without gestae 18 MONTHS Walks well ‘Throws a ball Stacks 3-4 blocks 10=word vocabulary Pulls to 00 string 2 YEARS ‘Runs well jumps Uses pronouns and produce 3-word sentences Feeds self with spoon “oiler rained by day Removes clothes Points to body parts am2% YEARS Pally undesss self Daas vertical and Horizontal ines Koos fll ume utes" Helps to pu things aay S YEARS Altenate ft in cimbing tis Pada wie Builds ate of 68 blocks Pays simple games Names drawings Copies ie ater cons ‘Uses plurals and obey preposional eommands Keows age and es Buttons and unbuttoos ats. om shoes Consts 1-10 4 YEARS Runs and climbs well Descends sis on altcnate fst Hops on one toot “Throws bal overbead Dus pen wit head rank, arms ees Counts object Denwsa tangle copes a squae [Names one of more color Sing wags “ait tsned Rte pas 5 YEARS Skis Drews a person Dresses /Uniresses raided Names 4 or more colors ouats >10 Ties shocices Ask meaning of words YEARS, Drsesa perio with hands and clothes Repeats 45 digits forward ows moring and fernoon Knows ight and ifsides, Copies iamond 2ponerPanes rnc Pc (pase fac ssc Sciarauna zl er sai ree sured samestpanon any pw ae) spaende sews | si was meus | syns | gt on SRY DAFTAR HUE Paves MOTT SOS 16demon 01-64 ‘sone ooo sunEIpo4 Hoe pF KSEE “CW ‘OM 2d Hk ema oeEtainoroy wo Daswe Pasa Chronology of Human Dentition of Primary or Deciduous and Secondary of Permanent Teeth Se femme [ea Pa aed fh [ee [ore [ST | | OT tetas [oie [Tome [oom |e = Tes Pe [eee ee aT ea er nee iia [Siege ee ai Aid om car pared PK. Las Haran Sto of Data Mad, ‘nl pied he dt for this able Mand, mandala; Ma; msiRED FLAGS in each area of development: (fi Prentiss Health Care Handivak,PPS, 2008) MORE DELAY > poor head contol by'3 months > hand sl ste by 4-months > Unable to old abjecs by 7 months F Docs notsit in independently by 10 months > Cannot stand oa one le by 3 years LANGUAGE DELAY Does nor en to sound by 6 months Does not babble or use gestures by 12-months No singe woad uteanees by 6 months ‘No 2svord pases by 2 years No S-word sentences by 3 years vvvyy PSYCHOLOGICAL DELAY 1% Nosocal amie by 3 months $F ——Notlaughing in papal situation by 6 months Vireo console, sens when approached by 1 year >» Ineconstane motion, resists discipline % Does nor ply wich other ein a3 years COGNITIVE DELAY >2months Noval eo mother Sémonths Not seatehing for dropped objects > 12 months Nocobject permanence 3 18monds Nointerestin cause-and-effect gimes > 2 yearsDocs not categorize similarities > 3 yearsDoes not know fullname Sa4viyears Cannot count sequentially > 5 yearDocs not kaow lees or colors SS ieyears Does not know own bicthday or addressSCHOOL AGE CHILDREN vy y . Sow to remember fats Slow to learn new sil, relies heavily Poor coordination, unaware of physiat sutroundings and prone to aecidenss ‘May be awl and chimsy, and as rouble wth ine motor sil READING SKILLS (fo school age children) > > > vvvyy Slow in learaing connection berween letter and sounds Confuse basic words [Makes consistent reading errors & Lewerseverals—b-d, pg Leaver inverson~m-w fi, Transpositons — felefe ix Word reversals — was saw Number reversals 14-41 repent omits or adds words Does not ead Suen ‘Does not like reading a all ‘Avoids reading aloud ‘Uses fingets o follow a line of print when readingHow to Use 20062007 WHO Growth Charts How to plot grow charts & purposes of diferent growth, char 1. Plot point for growth indicators Kean Horizontal ference ne athe bottom of ap Some Xores show age & some show length (L2) 0 hehe (9). Pir points on vert lines corresponding tO comple age (ws, moss [mo] of yeas [ts] & 0) Sc /Htsounded tothe acarest cm. Do nor pot berwee verallines by Yani The vertical seferenceline athe fret oF the gap “The Vanes show Lt / Ht,oe wor BML, Plot pints on oF ‘emer hexzontal ines corresponding o Lt / Hort or ‘BMI as precy as posible

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