PEDIATRIC HISTORY The mark of an excellent physician is the proficiency with which he takes the history and performs

s the physical examination and then on the basis of the findings utilizes the laboratory accurately and cost-effectively, when necessary, to approach a final diagnosis and initiate effective therapy History Taking o Unique and distinctive for the following reasons Content variations Prenatal and birth history Developmental history Social history of family environmental risks Immunization history Feeding history Indirect source of clinical information commonly given by parents Parents interpretation of clinical features may affect accuracy of data o Malaria convulsions o Measles rash Reliability of parents vary Parental behaviors/emotions are important Basic Concepts of a Good Clinical History o Start interview with parents or guardians on a positive note First contact is the most important connection First impressions last o Be flexible in your approach to obtain clinical data o Pursue the symptoms relentlessly o Keep on track o Pursue the clinical features that enable the parents to reach conclusions o Keep an open mind and follow the clue

Relationship with patient Number of hours stay with the patient o More hours = more reliable Educational attainment Involvement with the care of the patient

HISTORY General Data o Name, age, sex o Classification Neonate: <28 days old o Race: ethnicity o Religion o Birth date, birth place o Present address o Number and date of hospital admission o Name of the informant and relation to the patient o Reliability of information (Percent reliability) Reliability of informant depends on:

Chief Complaint o Why was the patient brought to the hospital o Expressed In a word or two o Single symptom or a group of related symptoms o Duration of symptom o Not diagnostic terms or names of diseases Eg. Thrombocytopenia, anemia o For OPD patient: follow-up, CP clearance, well baby care, immunization o Give the exact words of the informant whenever possible Do not use the vernacular: translate it to medical terminologies o Must already have an impression History of the Present Illness o Signs and symptoms should be described in chronological order, from start of illness Use specific number of hours or days or weeks or months prior to admission Not last Monday or a few weeks ago o Good history You can have a diagnosis at the end of the history o Chronic illnesses: state also the date and age at onset If the patient is a newborn and or the present problems are related to the prenatal and perinatal, the maternal and birth history should be incorporated in the HPI o Elaborate on symptoms as to: Onset Acute: <14 day Chronic: >14 days Intensity of symptoms Interference with activity, quality, location, duration, extent, severity and frequency Factors that aggravate or relieve o Medication Generic and brand names Actual dose mg/kg/day or mg/kg/dose Duration of treatment How did the medications affect the symptoms Abate or worsen Brand names should be written in parenthesis

Include any outside medical treatment, consultations or hospitalization Find out medical care prior to the visit and the reason for change o Associated symptoms described as to: Onset, course, chronology, intensity If the history suggests a particular disease, inquire about signs and symptoms characteristic of the disease Describe the symptoms Pertinent negatives are of value in the differential diagnosis To rule out other impressions Other symptoms o Re-admissions: if previously admitted to this hospital or had OPD consultations, obtain these records from the hospital and summarize Records of any admission to other hospitals should also be obtained and summarized If previous admission is related to this admission Interval history Summarize the pertinent information o Pertinent laboratory date o Final diagnosis Interval History o Describes the course of illness since the last hospital admissions related to the present illness and then elaborate the present symptoms and its associated manifestations Included in the first paragraph of the HPI Previous admissions not related to the HPI are placed under Past Illnesses o Based on the HPI, the physician should already have an initial impression and differential diagnosis Personal History o Gestational History (Pre Natal History) Age of mother during pregnancy, her parity, prenatal check ups, health, nutrition, infections, intake of drugs, roentgen exposures etc, duration of gestation (when pertinent, especially in infants) o Birth (Natal) AOG: Term/premature/postmature Hours of labor Longer Shorter possible intracranial bleed? Manner of delivery NSVD LSCS always place the indication for the operation Bag of waters Spontaneously ruptured

Artificially ruptured Meconium stained Clear Persons who attended the delivery Midwife or hilot Home delivery Hospital delivery Birth weight APGAR score Appearance Pulse Grimace Activity Rate st 1 minute: reflects the need for resuscitation 5 minutes: reflects how successful the resuscitation is

Neonatal History Jaundice age of onset Normally on the second day nd If before the 2 day: pathologic o Check blood type of patient and mother Convulsions Go back to prenatal and birth history Hemorrhage Respiratory or feeding difficulties Congenital abnormalities Birth injury especially in infants, when pertinent Blood type Included in histories of patients less than 2 years old If >2 years: may not include this anymore unless the condition is related to the neonatal period Feeding History Infancy <2 years old Type of feeding

Breastfeeding How many minutes Difficulty in feeding Easy fatigability Is suck good? o Bottle formula Reason Formula used How much does the patient consume Dilution and amount of feeding per day Bottle feeding or cup feeding? Complementary foods o Age introduced Normally: 6 months o Consistency of food Pureed, soft, lumpy, table foods Cereals: introduced at 4 or 6 months Lumpy foods: introduced at 8 or 10 months o Frequency of feeding per day Sample diet o Breakfast 1 slice of tocino 1 sunny side up egg 8 oz of milk cup of rice o Lunch o Dinner o Snacks Assess if the 5 basic food groups are eaten daily o Food pyramid o Be very specific Compute for acute caloric intake (ACI) and compare with Recommended Energy and Nutrient Intake (RENI) or compare both the amount and quality of food intake with the food guide pyramid o Only done if the patient is malnourished o Not a routine assessment Food intolerance Multivitamins and iron supplements: dosages and frequency Caregiver: mother, household help, grandparents, siblings Childhood and Adolescents (2-20 years old)

Omit early feeding history unless pertinent to the present illness Assess: Appetite: good or picky eater Sample diet: breakfast, lunch, dinner, snacks Assess if the 5 basic food groups are eaten daily Compute for ACI and compare with RENI or compare both the amount and quality of food intake with the food guide pyramid Food likes or dislikes; feeding difficulties Multivitamins and iron supplements: dosage and frequency Growth and Development o Young Children (1-5 years) Modified Developmental Checklist 2008 Nelson Motor, Adaptive/Personal, Language, Social What can these patients do now Dental eruption Order of eruption 9 months, no eruption = problem Other behavioral problems: Urinary continence o During day and night Day = 2 years Night = 3 years Toilet training, started and completed Temper tantrums Head banging Phobias Pica Night terrors Sleep disturbances If there are indications of developmental delay, do a Denver Developmental Screening Test II (DDST II) Nelson 2008 o Middle childhood (6-11 years old) Inquire about School performance and sexual development (Tanners Maturity rating) What can these patients do now o Adolescence HEADSSS Home Education and eating behavior or habits Activities

Drugs o Therapeutic and leisure Sexual Suicidal ideations Sexual development using TMR Females: include menstrual history

Reaction: fever and rashes about 7-12 days from time of inoculation

Past illnesses o Age when contracted, severity, complications o Contagious diseases: measles, varicella, mumps, pertussis etc Describe the clinical course of illness o Other medical illnesses: Hospitalized? Where and how long o Operations Surgical condition Type and place of operation o Allergies, eczema, asthma, food or drug sensitivities etc o Injuries Include effects if any Verify accuracy by inquiring into signs, symptoms and course of illness Immunization History and Tuberculin Test o Tabulate as much as possible o Types of immunizations given, including ages when given BCG At birth Reaction to BCG: scar formation in 3 months Hepa B st 1 dose: at birth Schedules: o 0, 1, 3 o 0, 1, 6 Reaction: local pain Oral polio and DPT, HiB Simultaneously given Reactions: o Polio: none o DPT: fever Seizures: Pertussis o HiB: fever Can be given separately Measles 9 months

MMR 6 months later from AMV MMR-Cpox: given at 30 months of age Pneumococcal Conjugated o 2 months interval from 2 months of age o Reaction: fever Meningococcal 2 years for life Typhoid and Hepa A

Family History o More concerned with the medical history of the family o Parents State of physical and mental health If not living age of death, cause and nature of symptoms, history of consanguinity o Siblings Number Ages State of health If not living age of death and cause o Familial illness or anomalies TB state contact with patient DM Syphilis Cancer Epilepsy Rheumatic fever Hematologic disorders Mental retardation Congenital defects o Presence of illness similar to patients illness in other members of the family or household o Family pedigree if a genetic anomaly is suspected Socioeconomic and environmental History o Parents: age, occupation, educational attainment o Living circumstances: place and nature of dwelling, number of persons living in the house o Economic circumstances: members of the family who work and sources of funds o Environmental circumstances: exposure to cigarette smoke and other environmental pollutants

o o o

What kind of pollutants Duration of exposure Garbage disposal segregate and recycle Sewage disposal Water source: drinking, washing

REVIEW OF SYSTEMS Elaboration of data in systems not covered in HPI o Help uncover symptoms in other organs or systems that may be related to the present illness o Ask only symptoms applicable to the age of the patient Do not ask a 3 month old patient if he is dizzy General: o Weight loss/gain o Activity level o Delay in growth Cutaneous o Rash, pigmentation, hair loss, acne, pruritus Head o Include eyes, ears, nose, mouth, throat o Headache, dizziness, visual difficulties, lacrimation, hearing, aural discharge, otalgia, nasal discharge, epistaxis, toothache, salivation, sorethroat Cardiovascular o Orthopnea, cyanosis, easy fatigability, fainting spells Respiratory o Chest pain, cough, difficulty of breathing Gastrointestinal o Vomiting, bowel movements o Diarrhea, constipation, encopresis, passage of worms, abdominal pain, jaundice, food intolerance, pica Genitourinary o Color of urine, burning sensation, frequency, discharge, enuresis, swelling of hands and feet o In prepubertal females: Discharge and itching o In pubertal and adolescent female Get history of menstrual periods Onset, frequency, regularity, pain Date of last period Endocrine o Breast asymmetry, pain or discharge, palpitations, cold/heat intolerance, polyuria, polydipsia, polyphagia Nervous/Behavioral

Tremors, sleep problems, convulsions, weakness or paralysis, mental deterioration, personality or behavioral changes, memory loss, eating problems, school failures, mood changes, temper outbursts, hallucinations Musculoskeletal o Pain in bone, joint or muscle, swelling in bone, joint or muscle, limitation of motion, stiffness, limping Hematopoietic o Pallor, bleeding manifestations, easy bruisability

PHYSICAL EXAMINATION Confirms impression 50% of PE is done by looking at the patient and the caregiver Playful interaction and distraction Minimum clothing Can be carried by their caretaker or parent Uncooperative patients: properly immobilized More unpleasant or uncomfortable parts of the PE are done last o Most common: throat and genitalia Flexion: strongest position of the patient General Survey o Mental state of sensorium, level of activity o Presence of cardiopulmonary distress o Ambulatory or bedridden o Nutritional state Well, under or overnourished o State of hydration o Ill looking o Acute Illness Observational scale 1 Strong cry with normal tone Contented and not crying Cries briefly and then stops Contented and not crying If awake, stays awake If asleep and then stimulated, awakens quickly Pink Normal skin and eyes 2 Whimpering or Sobbing 3 Weak cry, moaning, or high pitched cry

Quality of Cry

Reaction to Parental Stimulation

Cries off and on

Cries continually or hardly responds

State Variation

Color Hydration

Closes eyes briefly when awake Awakens with prolonged stimulation Pale extremities or Acrocyanosis Normal skin and eyes

Falls asleep or will not arouse

Pale, cyanotic, mottled or ashen Doughy or tented skin

Moist mucous membranes Response (Talk, smile) to Social Overtures, Over 2 months Smiles Alerts

Slightly dry mouth

Smiles briefly or alerts briefly

Dry mucous membranes Sunken eyes No smile, anxious face, dull expression or does not alert

6-12 months 1-3 years 3-6 years 6-12 years 12 years

80-120 70-110 65-110 60-95 55-85

80-100/55-65 90-105/55-70 95-110/60-75 100-120/60-75 110-135/65-85

25-40 20-30 20-25 14-22 12-18

Vital Signs o Temperature deg C Axillary: take for 3 minutes using mercurial thermometer Mercury: banned due to health reasons Could use: digital or strips used in forehead or axilla o Disposable: use only for 5 times Ear: Thermoscan o Cardiac rate/Pulse rate take for 1 full minute describe the pulse rate according to: volume: thread, bounding rhythm: regular or irregular rate o Respiratory rate Take for 1 full minute o Blood pressure If more than 3 years old Pediatric Blood Pressure Monitoring BP cuff should completely encircle the arm Inflatable bladder should cover at least 2/3 of the upper arm length and 80-100% of its circumference A more accurate cuff size is one whose inflatable bladder width is 40% of the arm circumference midway between the olecranon and the acromion Method If less than 3 years old: Use Flush method o You can only get the systole o Squeeze arm until it blanches and then release the cuff about 2-3 mmHg per second o First time you see a flush of color going back systole Age Premature 0-3 months 3-6 months Heart rate (bpm) 120-170 100-150 90-120 Blood pressure (mmHg) 55-75/35-45 65-85/45-55 70-90/50-65 Respiratory rate (bpm) 40-70 35-55 30-45

Anthropometric Data o 3 Major Growth Parameters Weight in kgs: infant weighing scale for less than 2 years old Length (for children less than 2 years old) or Height (for children more than 2 years old) in centimeters Length: 2 observers, supine, record to the nearest 0.1 cm o One examiner would support the head of the patient nd o 2 examiner will move the movable board to the foot of the patient, make sure the foot is flexed Height: upright, buttocks and heels or head are in contact with the vertical board, record to the nearest 0.1 cm o Double examiner: One would hold the ankles o Single examiner: Make sure the back of head, body, buttocks and heel would hit the board The movable board should flatten the hair

Head Circumference (HC) For less than 3 years old In centimeters Supraorbital ridge to occipital prominence

Other measurements for special circumstances Chest circumference (CC) in cm Mid inspiration Xiphoid notch Abdominal circumference (AC) in cm Infants: supine, across the umbilicus Older children: upright, feet 25-30 cm apart, midway between the inferior margin of the last rib and the crest of the ilium Nearest 0.1 cm at the end of normal expiration Arm span and U/L ratio for children with growth disorders Tip of the right to the tip of the left middle finger Palm should face the examiner

0-3 years

Lower segment of the body Supine From umbilicus to tip of toes with feet flexed 90 degrees at heel From anterior superior iliac spine to the floor

>3 years

Standing

With data on weight and length or height, calculate for the body mass index (BMI) BMI = weight in kgs / height in m2 Weight, Length, BMI, Head circumference should be plotted on the WHO growth chart Length or Height for age: identify children who are stunted or short due to chronic malnutrition or repeated illness or those who are tall for age due to genetic or endocrine problems Plot as precisely as possible Weight for age: reflects body weight relative to the age on a given day and is used to assess whether a child is underweight or severely underweight Not used to classify a child as overweight or obese A child can be underweight due to short length/height or thinness or both Presence of edema: severely undernourished Plot to nearest 0.1 Weight for length or height: reflects body weight in proportion to attained growth in length or height Especially useful if age is unknown Low: wasted or severely wasted due to recent illness High: risk of becoming overweight or obese BMI for age: useful in screening for overweight or obesity Similar results with weight for length or height Plot to nearest decimal Color, tissue turgor (wrinkling or loss of elasticity), loss of subcutaneous tissue, rash or eruptions, hemorrhages, scars, edema, jaundice Do not report anything that you do not see Eg. No pallor, no jaundice not allowed Examine skin fold test at the abdomen Positive: tenting of skin for 2 seconds or more Not useful for patients who are marasmic Head

Skin o

Upper (U) segment Length or height lower segment Normal values for U/L ratio o At birth: 1.7 o 1 month-3 years: 1.3 o >3 years old: 1.0

o o

HEENT o

Hair: quantity, color, texture, strength, surface characteristics Quantity: diminished, decreasing Color: Flag sign Texture: rough Strength: for fungal infections Surface char: presence of lice Shape or contour Scalp, fontanels, sutures Auscultate the skull for bruits to detect AV malformation

 Face

Normal in <4 years old with fever Unusual facies, deformities, lumps and bumps o Most common facies: Trisomy 21: slanted downwards Upturned nose

Eyes Lids, conjunctivae, sclera, opacities, discharge, red orange reflex, periorbital edema, eyeballs (sunken or not), tears Diminished ROR: o Retinoblastoma o Cataract o Toxoplasma infection Corneal reflex test: tests for Strabismus o Hirschbergs test o 14-16 cm from examiner o Patient focuses on something o Examiner flashes a light directly to the patient o Notice the reflection of the light o If the reflection of one eye is Cover test o Cover one eye o Focus on something 40 cms from patient o Then release the cover o If the eye moves: problem in accommodation o If it doesnt move: no problem Edema o Do not report as no sunken eyeballs Report eyelids o Downward slant: Trisomy 21 Ears and Mastoids Size, shape, location and position of the ear in relation to the rest of the head, ear discharge, tympanic membrane, ear canal Normal location of ear: 20% of ear would be at the imaginary line made by the 2 inner canthi High set ears: above the imaginary line Describe cone of light in the tympanic membrane Newborns and infants: upward Pull pinna backward and upward when examining the ear Older children: forward and downward Pull pinna upward and backward when examining the ear Tympanic membrane: Continuity: intact or perforated Color: light pink or translucent Cone of light Bulging or concave Presence of effusions or bubbles Mobility Nose and Paranasal Sinuses Patency of nares, alar flaring, presence and character of discharge, position of septum Nasal crease above the nose: suggests allergic rhinitis If turbinates are pale and boggy: allergic rhinitis o Erythematous: bacterial If unilateral foul smelling discharge: foreign body Sinus tenderness Press below both eyebrows and on both maxillary areas

Sinuses Frontal Ethmoid Maxillary Sphenoid

Developmental time line for Paranasal sinuses Development 8 years old At birth At birth 3-5 years old Aeration Adolescence 4 months 4 months 7-8 years old

Mouth and Throat

Lips, gums, tongue, mucous membranes, dentition, palate, posterior pharyngeal wall Lips Color: pale, cyanotic, cherry red Moisture or dryness Excoriations cleft Throat exam Use a bright light o Use a yellow light o Led light (white) makes congestion pale False negative Patient says Aaaah Examine the buccal mucosa first throat Never examine the throat of a patient suspected to have epiglotitis Gums Color Continuity: ulcers, vesicles Bleeding Tongue Size, moisture, color, milky-white coating Geographic tongue o Check Frenulum: tongue tied Ankyloglossia: tongue tie o Doesnt interfere with feeding or speech o Lengthens as the patient grows Ulcers Oropharyngeal mucosa Thrush, vesicles, ulcers, enanthems Palate and uvula area Symmetry, cleft, high arched o If asymmetric: Quincys abscess Posterior pharyngeal area Post nasal drippings Dentition 20 milk teeth at 24months of age o First to appear: lower incisors then upper incisors Color, mottling, pitting of enamel (Fluorosis), dental caries Baby bottle syndrome o Lactose is downgraded to sucrose Sucrose degrades the enamel Note for excessive drooling: not usual after 18 months of age

Tonsils

Presence or absence Size, surface, color, exudates, adherent membrane Most common misdiagnosis given to patients who have fever o Inflamed tonsils should be much redder than the surrounding areas o Tonsilitis is different from enlarged tonsils

o Neck

Color of oral mucosa: pinkish red Compare with color of tonsils Venous engorgement, flexibility, rigidity, masses, lymph nodes Swelling: Diphtheria, subcutaneous emphysema, webbing, obesity Position: Torticollis, Opisthotonus Masses: location, size, rate of growth, shape, margin surface, consistency, color, warmth, pulsation, adhesion to surrounding structures, goiter

Chest and Lungs o Inspection Size and shape: Round/barrel Shield shape Pectus excavatum Pigeon chest Rachitic rosary Harrisons groove Infancy: AP diameter = transverse diameter After 2 years: Transverse diameter > AP diameter Movements with respirations Newborns and young infants: abdominal After 4-5 years of age: Intercostal

Palpation Vocal fremitus tres tres, ninety-nine Increased in consolidation Decreased in atelectasis, pneumothorax, pleural effusion o Percussion Direct with one finger over the chest wall for small infants Indirect Middle finger (pleximeter) of the left hand is placed firmly on the chest wall Index or middle finger of the pleximeter is then struck with the tip of the middle finger (plexor) of the right or dominant hand Tap from side to side, top to bottom symmetrically o Auscultation Stethoscope on a bare skin Warm the chest piece Auscultate symmetrically from top to bottom, side to side and compare Clear breath sounds, rales, wheezes, rhonchi, bronchial or tubular breath sounds, pleural friction rub, stridor, grunting Normal breath sounds Bronchial: midline Vesicular: over the chest, axilla, infrascapular area Bronchovesicular: infants with thin walls Abnormal or adventitious sounds Altered voice sounds in lobar pneumonia Bronchophony o Spoken words are louder and clearer when normally, they are muffled and indistinct Egophony o Spoken ee is heard as ay Whispered pectoriloquy o Whispered words are heard louder and clearer when normally they are faint and indistinct or not heard at all Heart and Vascular System o

Chest retractions: report specifically Subcostal Intercostals Supraclavicular Chest expansion: symmetry

o o

Precordium, visible pulsations, apex beat, thrills, heart sounds, pulses Inspection Precordium: adynamic or dynamic Visible pulsations on the chest and in the epigastrium th th Apex beat: 4 ICS LMCL until 7 years old then shifts to the 5 ICS Palpation Thrills: purring vibratory sensations felt by the palm Grade 4/6 or higher Substernal thrust: presence of right ventricular volume or pressure overload Character of pulses Auscultation Diaphragm for high pitched sounds Bell for low pitched sounds st 1 heart sound (S1): closure of AV valves (tricuspid or mitral) Best heard at the apex nd 2 heart sound (S2): closure of semilunar valves (aortic and pulmonic) Best heard at the left and right sterna borders Split on inspiration rd 3 heart sound (S3): gallop Best heard at the apex in mid-diastole Heart failure Murmurs Described according to TILT o Timing (systole or diastole) o Intensity o Location o Transmission Grading of murmurs o Grade I: barely audible o Grade II: Medium intensity o Grade III: Loud but no thrill o Grade IV: Louder with thrill o Grade V: Loud and audible with stethoscope barely on the chest o Grade VI: Audible with the stethoscope off the chest

Abdomen o 9 or 4 quadrants o Inspection Size and shape Scaphoid, flat, globular, protruberant, distended o Scaphoid: investigate for hernias

Prominent vessels: distended veins, pulsations Striae, peristaltic movements, umbilical hernia Movements in relation to respiration: Paradoxical breathing Auscultation Done prior to palpation and percussion Listening to one spot is usually sufficient Abdominal sounds are easily transmissible Bowel sounds: Gurgling in nature Occur episodically at 5-10 seconds interval or longer o 10-30 seconds in infants and younger 5-34 per minute Borborygmi: prolonged gurgles of hyperperistalsis If absent: auscultate for at least 1-2 minutes High pitched and increased in LBM and obstruction Absent in ileus Distant in ascites and peritonitis Percussion Normally tympanic Detect presence of fluid in the peritoneal cavity: Fluid wave and shifting dullness Determine the size of the liver: RMCL Scratch method Place the stethoscope where the liver is Start scratching from the bottom up Scratching sound: lower tip of liver Palpation Patient lies supine with both lower extremities semi-flexed at the knees and hips Ask patient to inhale slowly and deeply Use flat surface of the fingers Palpate away from the site of pain proceeding gently to the painful area Direct tenderness: pain is elicited on pressure Rebound tenderness: pain is felt or is greater on release of fingers o Indicative of peritoneal irritation Spleen: not palpable unless 2-3x its size Shorts maneuver th o Normally: if you percuss the 12 interspace, it is resonant o If it is dull: splenomegaly Castells method

Start from right lower quadrant and push your way up to the left upper quadrant When the spleen enlarges, it follows a diagonal track

Psoas sign Patient flexes the right thigh o Pain: Positive psoas sign Obturator sign External rotation of leg Pain Kidneys: best felt on deep inspiration Fixed Costovertebral angle (CVA) tenderness o Done only in older children and adolescents o Heel of a closed fist (ulnar side) strikes firmly on th the CVA (angle between the 12 rib and transverse process of the upper lumbar vertebrae o Place palm of one hand on the CVA

Inguinal Regions o Hydrocoele, undescended testes, lymph nodes Do transillumination test o Fluctuation in size in relation to coughing and crying, spontaneously resolve or not o Indirect inguinal hernia Most common cause of swelling in the inguinal area extending to the scrotum Males o Lymph nodes Genitalia o Male Prepuce should be easily retractable Phimosis: preputial sac is very narrow and cannot be retracted Urethra opens at the tip of the penis Hypospadia: meatus is located at the undersurface of the urethra Epispadia: urethral orifice is on the dorsal surface of the penis Left scrotum is lower than the right but equal in size Cryptorchidism, hydrocoele, hernia 4 months of age: testes should have descended already o If beyond 4 months of age: suggest surgery o Female Gynecological exam: discharge, laceration, hymen

Sexual maturity testing Anus and Rectum o Left lateral decubitus with legs flexed against the abdomen o Look for location, patency, fissures, tags, hemorrhoids, presence of pinworms, prolapsed o Rectal exam: Index finger in older children Little finger in young infants o Assess sphincteric tone, presence of mass or impacted feces and tenderness Extremities o Color of nail beds, peripheral pulses o Cyanosis, edema, mobility of joints, deformities, test for congenital hip dislocation in neonates o Clubbing: look from the side in profile Schamroths sign

o Spine o

Lymph nodes

Mental state: general behavior and appearance, stream of talk, mood and affective response, content of thought, intellectual capacity, sensorium Sensorium: consciousness, attention span, orientation to place, person and time, recent and remote memory, fund of information, insight, judgment and planning, calculation Orientation to person, place and time States of Decreased Consciousness Lethargy: difficulty to maintain the aroused state Obtundation: responsive to stimulation other than pain Stupor: responsive only to pain Coma: unresponsive to pain For infants: o awake or asleep only Speech: check articulation and comprehension Dysphonia: disturbance in or lack of the production of sounds in the larynx Dysarthria: disorder inarticulating speech sounds Dysphasia: disturbance in the understanding or expression of words as symbols for communication Cerebellar Test coordination: finger to nose test The patient has to sit up because gravity might exaggerate weakness and make the test false positive Pronation and supination is essential Always prompt the patient to do it faster

Inspect for deformities, sacrococcygeal dimple, pilonidal sinus and local tenderness o Screen for scoliosis: Bend forward test Lymph nodes o Check size, number, location, consistency, tenderness, mobility, discrete, matted o Most are not palpable in the newborn o Not considered enlarged unless they exceed 1 cm for cervical and axillary nodes and >1.5 cm for inguinal nodes o Generalized lymphadenopathy: enlargement of >2 non-contiguous node regions Acute bacterial infection: tender, erythema and warmth of the overlying skin TB: matted, draining sinus Malignancy: firm, non-tender, matted or fixed to the skin or underlying structures Neurological Examination o Cerebrum

A: normal o Smooth trajectory throughout movement B: Cerebellar hemisphere dysfunction o Tremor increases in amplitude as finger approaches target C: Parkinsonian o Tremor may be present at initiation of movement, but smoothes out as finger approaches target

D: Essential tremor o Low amplitude fast tremor throughout trajectory, may worsen as finger approaches target Ataxia, Intention tremors, dysynergia Ask child to reach for and manipulate toys Check for clumsiness and incoordination Check the ability to perform rapidly alternating movements Pat the examiners hand Rapid pronation and supination of the hands Rapid tapping of the foot Cranial Nerves Olfactory nerve (CN I): olfaction Purely sensory Let the patient smell coffee, chocolate, vanilla using one nostril at a time while the other is occluded Never use alcohol, perfume or anything citrus o May stimulate maxillary branch of CN V Fully developed at 5-7 months of age o Get baseline cardiac rate introduce an aromatic substance take cardiac rate Increase of about 10-20 bpm in infants that can recognize smells Seldom done, no scientific basis, only anecdotal Anosmia: inability to appreciate odor Optic Nerve (CN II): visual acuity, visual fields and fundi Purely sensory Visual acuity: standard eye charts o Snellen, Jaegger, E charts o >3 years old: Blink reflex Visual fields: confrontation testing o An object is presented in front while another stimulus (bright color) is presented from the periphery Fundoscopy: optic disc o Older children: salmon color o Infants: pale gray color Papilledema: elevation of optic disc, distended veins and lack of venous pulsations, hemorrhages, blurring of nasal disc margins, hyperemia of nerve head Oculomotor, Trochlear, Abducens Nerves (CN III, IV, VI): Extraocular muscle movements

Position of the eyes on primary gaze and the size of palpebral fissures, ask patient to track objects and check for limitation of extraocular movements Nystagmus and subjective complaint of double vision Pupillary size, reactivity to light, accommodation and convergence Look for abnormalities o Strabismus: Squint or abnormal ocular alignment due to a muscle imbalance o Ptosis: drooping of one or both eyelids o Limitation in extraocular movements o Nystagmus: involuntary rhythmic oscillation of the eyes

Trigeminal Nerve (CN V): facial sensation and muscles of mastication Mixed sensory and motor Sensory: light touch, temperature and pain, corneal reflex o Test sensation using cotton or touch areas from vertex of the head to the face and mandible (ophthalmic, maxillary and mandibular divisions) o Corneal reflex Apply a wisp of cotton onto the cornea, spontaneous blinking results th th with intact 5 and 7 CN Motor: muscles of mastication o Chew and swallow food o Palpate masseter and observe jaw deviation to the weak side Facial Nerve (CN VII):muscles of facial expression and taste sensation over the anterior 2/3 of the tongue Smile, frown, show teeth and close the eyes

Check for symmetry of movements Central facial palsy o Asymmetry of labial folds but wrinkling of the forehead on raising eyebrow and eye closure are present and symmetrical Peripheral facial palsy o Both upper and lower parts of the face are affected and movements are assymetrical Test sense of taste by applying solutions of salt or sugar to previously dried and protruded tongue Vestibulocochlear Nerve (CN VIII): test for auditory and vestibular functions Hearing: response to sound o Stay behind the child and create a sound (eg. Clap, car keys etc) Better to approach from behind because if you are in front you wont know if the patient responds to the sight of the object or the sound Weber test: vibrating tuning fork placed on the vertex of the head or forehead Rinnes test: vibrating tuning fork behind the ear over the mastoid bone and just after the sound disappears, hold it beside the ear over the external auditory canal Vestibular functions o Caloric testing Patient in supine position, head flexed at 30 degrees, ice water (10 ml) is injected over 30 seconds into one external auditory canal at a time Coarse nystagmus towards ipsilateral ear No eye deviation Eyes tonically deviated ipsilaterally Nystagmus contralaterally Tonic deviation ipsilaterally No nystagmus No eye changes

Glossopharyngeal and Vagus Nerves (CN IX, X): test for palatal movements, uvular position and movement, gag reflex, phonation, sucking and swallowing Have the child say aah or stick the tongue out then observe symmetry in movement of the uvula and soft palate If the infant can suck and swallow functional CN IX and X Spinal Accessory Nerve (CN XI): test the function of trapezius and sternocleidomastoid muscle Turn head against resistance and shrug the shoulders Palpate for symmetry of muscle bulk, tone and contraction of the SCM and trapezius during head turning and shoulder elevation Hypoglossal Nerve (CN XII): test for tongue muscle Observe for the position of the tongue at rest with the mouth open and during protrusion Look for atrophy, grooving, fasciculations, deviations o Fasciculations: stick out your tongue and there would be movements at the sides of the tongue Gait and Posture Muscle bulk, tone, strength Scoring System for muscle Strength o 5: Normal power o 4: Active movement against gravity and resistance o 3: Active movement against gravity o 2: active movement with gravity eliminated o 1: flicker or trace of contraction o 0: no muscle contraction Coordination Check for Gowers sign o Patient pushes himself up from a sitting position by using the tripod position then pushing against his legs

Motor

Conscious Obtunded Comatose Profound coma/Brain dead

Dolls eye movement Normal: eyes move from side to side when head is turned Abnormal: eyes remain in a fixed position in skull when head is turned

 o Sensory

Check for active and passive muscle tone Look for spasticity, rigidity and hypotonia o

Sensation of touch, pain, temperature Position sense Vibration sense Rombergs sign Closed eyes, feet together, both arms extended to sides Swaying and loss of balance indicates dorsal column dysfunction Stereognosis, two-point discrimination, weight and size discrimination, graphesthesia (figure writing on palm) which are finer sensations Deep Tendon Reflexes Ankle and knee jerks, brachioradialis, biceps, triceps, pectoralis Biceps jerk C5, C6 roots Musculocutaneous nerve Arm slightly flexed, palpate the biceps tendon with the thumb and strike with examining hammer o Look for elbow flexion and biceps contraction Supinator jerk C6, C7 roots Radial nerve Strike the lower end of the radius and watch for elbow and finger flexion Triceps jerk C6, C7, C8 roots Strike elbow a few inches above the olecranon process o Look for elbow extension and triceps contraction Knee jerk L2, L3, L4 roots Leg hanging, tap the patellar tendon, observe for quadriceps contraction Ankle jerk S1, S2 roots Externally rotate leg, foot is in slight dorsiflexion, tap the Achilles tendon, watch for calf muscle contraction and plantar flexion Superficial reflexes: Abdominal, cremasteric Abdominal Stroke the abdomen from all sides towards the umbilicus, umbilicus moves towards the stroked area

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Cremasteric Use a gloved hand or pencil Stroke the inner portion of the thigh Pathologic Reflexes Babinski and its modifications Chaddock Oppenheim: stroke the shin Gordon: squeeze the calf muscles Bing: apply painful stimulus (pin) on big toe Gonda: flick one of the lateral toes Babinski Stroke the lateral aspect of the sole of the foot o Dorsiflexion of the big toe and fanning of the other toes Normal up to 2 years old Kernigs sign Supine, flex the hip and knee each to about 90 degrees, with the hip immobile, attempt to extend the knee With meningeal irritation, there is resistance and pain in the hamstring muscles Brudzinkis sign Supine, flexion of the neck results in involuntary flexion of the knee For infants, primitive and developmental reflexes (rooting, moro, grasp, plantar etc) are age appropriate Persistence, absence, asymmetry or reappearance is pathological