PEDIATRIC HISTORY AND CLINICAL EXAMINATION
‫الدكتور عبد المهدي عبد الرضا حسن الشحماني‬
PhD,Pediatric & Mental Health Nursing
Differences between Adult and Pediatrics
 History is given by second person.
 The parents may place their own interpretation on events(any fever may be
called tonsillitis).
 The cooperation of the child cannot be guarantied
 The expression of the disease may be influenced by the child’s developmental
status(apnea may indicates convulsion in newborn)
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Differences between Adult and Pediatrics
The predominant impact of the disease may be on growth and development
(UTI, Chronic illness).
Physiological norms are more constant in adults, variable with age in infants
and children( HR, RR)
Clinical signs of the disease may differ from those of adults (Liver is palpable
in infancy).
Age Groups In pediatrics
Neonatal period
1st month
Infancy
1st year
Childhood
1-15 years
-Toddler
2 years
Pre-school child
2-5 years
school child
5-15 years
Adolescent 13-19
Pediatric history
Introduce yourself to the parents and child.
A worm greeting and friendly smile to allay anxiety and promote confidence.
Encourage the parents to tell the story with minimum of interruption and listen
carefully.
You should not swallow the diagnosis given by the parents.
It is essential to find out what the concern of the parents are.
Pediatric history
Presenting Complaint.
History of present illness and important related positive & negative symptoms.
Systems review
Past history
Pediatric history
Maternal history (Pre-natal).
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Birth history (Natal).
Post-natal history.
Nutritional history.
Vaccination
Growth and development
Family history
Social history
Pediatric history
Maternal history:
Multiparity, any miscarriages, stillbirth or congenital malformation.
Maternal health during pregnancy, regular antenatal care, Rh isoimmunization.
History of drugs ingestion during pregnancy, oligohydroamnios or
polyhydroamnios
Pediatric history
Birth history:
Mode of delivery.
Crying immediately or not.
Apgar score
History of asphyxia
Meconium stained amniotic fluid.
Pediatric history
Post-natal history:
NICU admission
How much did the baby stay in the nursery.
Did the baby required mechanical ventilation ?
Oxygen was given ? Duration of oxygen.
Baby had history of jaundice? Exchange transfusion done?
Any illness during first month of life: meningitis, convulsion, fever ..etc.
Pediatric history
Nutritional history:
Breast or bottle feeding
Type of formula
How much milk is given , number of feeds/day
How is the milk prepared
When the solid food or cereals is introduced, content of food, any allergy to
the food.
Pediatric history
Vaccination history:
Vaccination program in details( National, UNRWA)
Any special vaccination was given.
When the last vaccine was given
Any complication of given vaccine
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– Any contraindications for certain vaccine?
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Pediatric history
Growth and development history:
Details of development milestones, smiling , sitting, standing, walking,
speech,
Bladder and bowel control
School performance, behavioral and emotional history.
Pediatric history
Family history;
Father and mother age, consanguinity, level of education and they are
healthy or not.
History of smoking in either parent
Siblings: number, sex, and their ages.
History of similar disease, unexplained death and genetic diseases.
Draw family pedigree
Pediatric history
 Social & Environmental history;
– It is necessary to build up a picture of the child’s social and cultural
environment
– Appreciate fears and stresses at home( parental attitudes, separation,
divorce, absence of parent)
– Jealously at the arrival of a new baby
– Unexplained injuries may raise the possibility of child abuse.
Pediatric Examination
 Important points to remember:
– The examination of infants and children is an art, demanding qualities of
understanding, sympathy and patience.
– Heart rate, Respiratory rate, BP, liver size, heart size varies with age.
– Keep disturbing or painful procedures to the end.
– It is not necessary to be systemic in your examination , but should be
complete.
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Pediatric Examination
General inspection:
The first step is ascertain quickly if the baby is well, mild or severely ill.
Assess state of consciousness, breathing pattern, position, reaction to
environment.
State of nutrition, speech, cry, size relative to the age.
The child should be as completely undressed as possible, but not
necessarily all at once.
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Pediatric Examination
 General appearance:
– If the child is seriously ill ABC and vital signs must be taken without delay
and necessary immediate intervention is undertaken.
– Describe any dysmorphism, abnormal movements, unusual position he
assumes, his mental status and activity.
Pediatric Examination
 Measurements: should include
– Height (length)
– Weight
– Head circumference
– All given with percentile for age.
– Temperature (rectal, oral ,axillary)
– Respiration
– Blood pressure
Pediatric Examination
 Skin:
– Include color
– The presence of cyanosis
– Discolored patches
– Jaundice
– Rash
– Edema
– Skin turgor
– Amount of subcutaneous tissue
Pediatric Examination
 Head:
– Examine the head for shape
– Sutures
– Bone defects
– Size and tension of fontanelles
– The hair and scalp should be examined
Pediatric Examination
 Eyes: make a gross test of vision.
– Visual fields should be tested in all children old enough to cooperate
– Evaluate for strabismus by position of the light reflex and the cover test
– Look for nystagmus
– Examine the conjunctivae for anemia and sclerae for jaundice and the
cornea for haziness and opacities
– Pupils size and shape
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– Fundoscopic examination
Pediatric Examination
 Ears:
– Check for position(low set ) and shape of both ears.
– Examine the tympanic membrane for injection, bulging or perforation
– Evaluate hearing
– The mastoid also need to be checked
Pediatric Examination
 Mouth and throat:
– The color of lips and mucosa
– The condition of teeth, gums and buccal mucosa
– Look for tongue, palate, tonsils and pharynx
– Listen to the voice and the quality of cry and the presence of stridor
Pediatric Examination
 Neck examination:
– Examine for neck rigidity
– Swelling
– Webbing
– Lymph node
– Thyroid gland
– The position of trachea
Pediatric Examination
 Nose and sinuses:
– The nasal examination is performed to detect deformities.
– Deviation of the septum
– Color and state of the mucosa and turbinates
– Presence of foreign body
– Examine the sinuses for tenderness and swelling
Pediatric Examination
 Chest: Inspection
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The general shape of the chest (pectus excavatum or pectus carinatum)
Abnormal signs to look for are beading (rosary), asymmetry of expansion
In infants respiration is diaphragmatic and abdominal
Palpation
Percussion
Auscultation: breath sounds in children are usually bronchovesicular.
Pediatric Examination
 Cardiovascular system:
– Inspection
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– Palpation: the apex beat is normally felt in the 4th intercostals space just to
the left of the midclavicular line in children under 7 years of age. After that it
is felt in the 5th intercostals space in the midclavicular line.
– Percussion
– Auscultation: Note the effect of changing of position and exercise on the
murmur. Splitting of the 2nd heart sound is common in normal children
Pediatric Examination
 Abdomen:
– Inspection –Distension, Scaphoid abdomen,
– Palpation – The lower border of the liver is normally 1 cm below the costal
margin in infants and children. Liver span 8 ± 1.8 cm
An enlarged spleen is extending into the left iliac fossa in infancy and the right
in older children
– Percussion
– auscultation
Pediatric Examination
 Back:
– By employing both observation and palpation, the spinal shape and
posture9lordosis, kyphosis, scoliosis)
– Masses
– Tenderness
– Limitation of motion
– Spina bifida
Pediatric Examination
 Genitalia:
– Undesent of testes
– Hydrocele
– Hypospedius
– Ambiguous genitalia
Pediatric Examination
 Anus:
– Patency(imperforated anus)
– Presence of fissure, fisulae or hemorrhoids
– Rectal examination if indicated
Pediatric Examination
 Musclo-skeletal system:
– Asymmetry
– Anomalies of extremities
– Pain and tenderness of the joint or limbs
– Always s examine for congenital dislocation of the hip in infants
Pediatric Examination
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 Neurological Examination
– Observation
– Mental status
– Cranial nerves
– Cerebellar function
– Motor system
– Sensory system
– Reflexes-primitive (neonatal reflexes, deep and superficial reflexes.
Pediatric Examination
 Developmental assessment
– Gross motor
– Vision and fine motor
– Hearing and language
– Social and adaptive
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Developmental assessment
Gross motor:
Head and neck control in prone position(6-8 weeks)
Able raise head and chest (3months)
Pull from lying or no head lag (4 months)
Sit without support back straight (8-9 months)
Stand without support (10-12 months)
Developmental assessment
Vision and fine motor
Follows moving person with eyes (6-8 weeks)
Follows small ball at 10 feet distance(9months)
Pincer grasp (between index finger and thumb using small object (11-12
months)
Copies a circle (with pencil, build a bridge of 3 cubes when shown (3years)
Developmental assessment
Hearing and language:
Turns eyes to sound-rattle 12 inches(2-4 months)
Says Mama, Baba (7-9 months)
Says simple sentences 3-4 words(2-2.5 years)
Says first name, knows own sex (3 years)
Developmental assessment
Social and adaptive
Smiles when spoken, vocalizes (6-8 weeks)
Reaches for and shakes rattle, puts objects to mouth(5-s month)
Drinks from cup without spilling (18 months)
Wash hands, pull pants up and down (3 years)
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