PEDIATRIC HISTORY & PHYSICAL EXAM
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1 PEDIATRIC HISTORY & PHYSICAL EXAM
2 Outline of the Pediatric History: Chief Complain History of Present Illness Past Medical History Pregnancy and Birth History Developmental History Feeding History Review of Systems Family History Social History Immunisation History
3 HISTORY Differences of a Pediatric History Compared to an Adult History: I. Content Differences A. Prenatal and birth history B. Developmental history C. Social history of family - environmental risks D. Immunization historyii. II. Parent as Historian
4 Pregnancy and Birth History Maternal health during pregnancy: bleeding, trauma, hypertension, fevers, infectious illnesses, drugs, alcohol, smoking, rupture of membranes, gestational age at delivery Labor and delivery - Type of delivery (vaginal, cesarean section), use of forceps, breech delivery. Neonatal period - Apgar scores, breathing problems, use of oxygen, need for intensive care, hyperbilirubinemia, birth injuries, feeding problems, length of stay, birth weight.
5 Birth History Born at 34 weeks Emergency Section, kg, foetal distress Spontaneous labour and PROM Pregnancy and scans fine Was on SCBU for 3 weeks Needed CPAP for 1 day and then some oxygen for a while No oxygen when went home
6 Developmental History A. Ages at which milestones were achieved and current developmental abilities - smiling, rolling, sitting alone, crawling, walking, running, 1st word, toilet training, riding tricycle, etc (see developmental charts) B. School-present grade, specific problems, interaction with peers C. Behavior - enuresis, temper tantrums, thumb sucking, pica, nightmares etc.
7 Developmental History Smiled at 10 weeks Sat at 6 months Never crawled Walked at 13 months Started talking around 18 months No problems with hearing or vision Average progress at school
8 Feeding History A. Breast or bottle fed, types of formula, frequency and amount, reasons for any changes in formula B. Solids - when introduced, problems created by specific types.
9 Family History Dad got eczema and hay fever Maternal grandma has diabetes Paternal Grandfather had TB Mum and Dad separated Younger 2 year old brother also has eczema No consanguinuity
10 Immunisation History up to date didn t have MMR - cousin with autism
11 PHYSICAL EXAMINATION-
12 Differences in Performing A Pediatric Physical Examination Compared to an Adult:
13 General Principles & Tips Get down to their level A lot of information can be gained by INSPECTION alone, before you lay an hand on the patient Beware of asking the child s permission Know a conversation topic / latest craze / TV characters / films relating to different age groups Examination needs to involve play and be opportunistic but thorough
14 Keep Mum close at hand and in child s view or reach Keep child in the position in which they are comfortable. No need to lie them down unless you have to - children are very vulnerable in this position Save the nasty things to the end so that you don t lose trust (eg ENT)
15 Techniques of Physical Assessment Inspection Palpation Percussion Auscultation Inspection Auscultation Palpation Percussion
16 Vital signs Normals differ from adults, and vary according to age See charts of age-adjusted normals A. Temperature Tympanic vs. oral vs. axillary vs. rectal B. Heart rate 1. Auscultate or palpate apical pulse. 2. Palpate antecubital or femoral pulse in infant and radial pulse in older child
17 C. Respiratory rate Observe for a minute. Infants normally have periodic breathing so that observing for only 15 seconds will result in a skewed number. D. Blood pressure Appropriate size cuff - 2/3 width of upper arm E. Growth parameters - must plot on appropriate growth curve: 1.Weight 2.Height/length 3.OFC: Across frontal-occipital prominence so greatest diameter
18 Developmental assessment Gross Motor Fine Motor Language Social
19 Basic Newborn Assessment
20 Skin PE of the skin, what does and can it mean? Cutis Marmorata Harlequin Color Change Ecchymosis Macule Petechiae Vesicle Pustule
21 Cutis Marmorata
22 Harlequin Color Change
23 Ecchymosis (Bruising) Increases Risk for Jaundice
24 Macule
25 Petechiae
26 Vesicle
27 Head to Toe Assessment!
28 Head Measurement: Microcephaly? Macrocephaly? Shape: molding?
29 Skull: fontanels and sutures
30 Face
31 Pustule
32 Nose
33 Mouth
34 Ears
35 Chest
36 Heart Murmur? 4 limb Blood Pressure Pulses
37 Abdomen Size Shape Movement
38 Abdomen
39 Genitourinary
40 Hymenal Tag
41 Musculoskeletal
42 Hip Examination
43 Ortolani
44 Barlow
45 Primitive Reflexes
46 Background Primitive reflexes start to emerge during the late foetal period, Most of these reflexes are already present at birth e.g. Rooting and sucking reflex These reflexes are of sub-cortical origin, arising mainly in the brainstem and to some degree in the Spinal Cord.
47 The majority reflexes are integrated/ disappear by the age of 6/12 (at latest by 12/12) due to the increasing inhibitory effect of the maturing cortex. Those with protective value tend to persist throughout life. The persistence or reappearance of these primitive reflexes after the age of 6/12 is abnormal and usually indicative of cortical or cerebral damage. These reflexes lock the child in a holding pattern and their development becomes stuck, significantly impair their development of postural control, achievement of milestones and volitional movement.
48 Primitive Reflexes ~ Palmar Grasp The palmar grasp reflex one of the most reflexes to is noticeable emerge Appears in utero Endures through the 4 th month postpartum Negative palmer grasp: neurological problems; spasticity Leads to voluntary reaching and grasping May predict handedness in adulthood
49 Primitive Reflexes ~ Sucking Occurs pre-and postnatally Babies are born with blisters on lips Stimulated by touching the lips
50 Primitive Reflexes ~ Search Helps the baby locate nourishment Baby turns head toward the food Usually works in conjunctions with sucking reflex Contributes to head- and body-righting reflexes Stimulus ~ touching the cheek
51 Primitive Reflexes ~ Moro Reflex Palm of hand lifts back of head Hand is removed suddenly so that head begins to fall Head is supported Moro reflex precedes the startle reflex and causes the arms and legs to extend immediately rather than flex Disappears at 4-6 months
52 Primitive Reflexes ~ Asymmetric Tonic Neck Reflex Causes flexion on one side and extension on the other Not always seen in newborn Facilitates the development of bilateral body awareness
53 Primitive Reflexes ~ Plantar Grasp The toes appear to be grasping Stimulus is touching the ball of the foot This reflex must disappear before the baby can stand or walk
54 Parachute reflex Elicited by holding the baby in ventral suspension with the head down, extension of the arms should occur to protect the head This is a protective reflex and appears at six moths and never disappears
55 Elicited by holding the baby in ventral suspension The child will extend his head and legs. This reflex appears at 3 months and disappears by 1 year of age. Landau reflex
56 Primitive Reflexes ~ Babinski Reflex Elicited by a stimulus similar to plantar grasp, but response is different Test of the pyramidal tract activity for later motor movement
57 Postural Reflexes Stepping Stepping reflex is a forerunner to walking
58 Parachuting Reflexes Propping reflexes Related to upright posture This reflex is a conscious attempt to break a potential fall
59 SUMMARY Good Paediatric history taking needs to be through and takes practice 70% of diagnoses can be made on the history alone ALWAYS listen to the mother Children are quite often unco-operative and examinations can be difficult Be prepared to PLAY
60 Questions?
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This article attempts to answer the questions asked by many parents about their children s spinal health. Appearing in Issue #18. Order A Copy Today
Chiropractors have been caring for children for more than a 100 years. Many common childhood ailments will respond to this safe, natural form of health care. More and more parents especially those who
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Lower Body. Exercise intensity moderate to high.
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Assessment of the Adolescent, Pre-Teen, and Teen Student for School Nurses
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LOSING SIGHT. Disclosures. There are no financial relationships to disclose.
LOSING SIGHT Pediatric Hospital Medicine Conference Conundrums Session #1 July 21 st, 2017 Whitney Rolling DO, Fernando Bula-Rudas MD, Carl Galloway MD, Vishnu Kanala MD, Archana Chatterjee MD,Ph.D., Elizabeth