Welcome toWelcome toCourseCourse

473 Peds 473 Peds

Dr Mohamad-Hani Ali TemsahDr Mohamad-Hani Ali TemsahAsst Professor of PediatricsAsst Professor of Pediatrics

Pediatric IntensivistPediatric IntensivistKKUH ndash King Saud UniversityKKUH ndash King Saud University

Riyadh ndash Saudi ArabiaRiyadh ndash Saudi Arabia

GoalsGoals

bull By completing this course each student is expected to

Have general knowledge about pediatrics

Master the basic principles and skills of pediatrics that will allow him to work as an efficient and safe intern

Keys to Success in this course

bull Punctualitybull Motivationbull Lots of clinical exposurebull Critical thinkingbull Make good use of your teachersbull Reading hellip Practicing hellip

Feedback

Recommended ReadingsRecommended Readings

httpwwwgeocitiescomkkuh_pedia

Student s Guide Studentrsquo

Distribution

10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups

1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7

Activities

1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp

participateparticipate

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

GoalsGoals

bull By completing this course each student is expected to

Have general knowledge about pediatrics

Master the basic principles and skills of pediatrics that will allow him to work as an efficient and safe intern

Keys to Success in this course

bull Punctualitybull Motivationbull Lots of clinical exposurebull Critical thinkingbull Make good use of your teachersbull Reading hellip Practicing hellip

Feedback

Recommended ReadingsRecommended Readings

httpwwwgeocitiescomkkuh_pedia

Student s Guide Studentrsquo

Distribution

10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups

1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7

Activities

1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp

participateparticipate

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Keys to Success in this course

bull Punctualitybull Motivationbull Lots of clinical exposurebull Critical thinkingbull Make good use of your teachersbull Reading hellip Practicing hellip

Feedback

Recommended ReadingsRecommended Readings

httpwwwgeocitiescomkkuh_pedia

Student s Guide Studentrsquo

Distribution

10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups

1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7

Activities

1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp

participateparticipate

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Recommended ReadingsRecommended Readings

httpwwwgeocitiescomkkuh_pedia

Student s Guide Studentrsquo

Distribution

10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups

1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7

Activities

1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp

participateparticipate

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Student s Guide Studentrsquo

Distribution

10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups

1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7

Activities

1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp

participateparticipate

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Distribution

10486984 Major groups ABC and D each subdivided into 3 subgroups (eg A1 A2 A3) total of 12 subgroups

1048698 subgroups in KKUH1048698 subgroups in KFMC RMC1048698Swab in week 7

Activities

1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp

participateparticipate

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Activities

1048698Tutorials always come prepared1048698Clinical sessions 9-12 am 2wk1048698Ward rotation as a sub intern1048698OPD AM or PM1048698ER 8-12 12-4 4-81048698Nursery AM or PM1048698Morning report important to attend amp to attend amp

participateparticipate

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Activities

bull Clerking bull Should be genuinebull Hand written readable and clearbull Stick to the given formatbull Strictly adhere to time limitsbull Different cases from different

systems

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Exams

bull MCQsMid-Cycle usually in week 9Final week 12Case scenario format

bull OSCE week 125 stations including history taking

physical examination and oral

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Extra Notes

bull Extra sessions arranged for the whole group should only be on Thursdays

bull Remember to fill the course evaluation sheet and submit it during the mid-cycle exam

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull Remember We are here for you

bull WE WISH YOU THE BEST OF LUCK

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

History Taking in Pediatrics

Similar to adults Plus

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Historybull Patient ID

bull Present Complaint(s) ( CO)

bull History of Present Complaint(s) (HPI)

bull Past Medical History (PMHX)

bull Pregnancy and delivery

bull Neonatal History

bull Systemic Review

bull Family History (FHX)

bull Social History

bull Vaccination History

bull Nutritional History

bull Developmental History

bull Drugs

bull Allergy

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Identifying DataIdentifying Data

bull Patients name age sexPatients name age sex

Informant (parent) ReliabilityInformant (parent) Reliability

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Chief Compliant (CC)Chief Compliant (CC)

bull Reason that the child is seeking Reason that the child is seeking medical care and duration of the medical care and duration of the symptom symptom

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

History of Present Illness History of Present Illness (HPI)(HPI)

bull Describe the course of the patients Describe the course of the patients illnessillnesswhen and how it began when and how it began character of the symptoms character of the symptoms aggravating or alleviating factors aggravating or alleviating factors pertinent positives and negatives pertinent positives and negatives past diagnostic testing past diagnostic testing

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Past Medical History Past Medical History (PMH)(PMH)

bull Medical problems Medical problems bull hospitalizations hospitalizations bull operationsoperations

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Perinatal HistoryPerinatal History

bull Gestational age at birth Gestational age at birth bull obstetrical complications type of obstetrical complications type of

delivery delivery bull birth weight birth weight bull Apgar scores Apgar scores bull complications (eg infection complications (eg infection

jaundice) jaundice) bull length of hospital staylength of hospital stay

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

NutritionNutrition

Breast feeding vs bottle

Amount and frequency

Quality of food

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

MedicationsMedications

bull Names and dosagesNames and dosages

bull Allergies to Rx or FoodAllergies to Rx or Food

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Developmental History

1 Gross Motor eg sitting and walking2 Fine Motoreg Pincer grasp and scribble3 Languageeg say ldquomamardquoldquobabardquoand two

words sentence4 Social eg smiling playing with others bull Relationships with siblings peers adults Relationships with siblings peers adults bull School grade and performance School grade and performance

behavioral problemsbehavioral problems

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Immunizations

bull Know the local schedulebull Type of vaccine killed or live-

attenuatedbull How they are givenbull Adverse reactionsbull Avoid ldquoup to daterdquo

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Family History

bull More detailed

bull Learn to draw family pedigree

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Family HistoryFamily History

bull Medical problems in family Medical problems in family including including the patients disorder the patients disorder diabetes seizures asthma allergies diabetes seizures asthma allergies

cancer cardiac renal or GI disease cancer cardiac renal or GI disease tuberculosis tuberculosis smokingsmoking

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Social HistorySocial History

bull School level and gradesbull Relationship with parents and

siblingsbull Friendsbull Family situation smoking drugs Family situation smoking drugs bull Parental level of education Parental level of education bull Safety Child car seats smoke Safety Child car seats smoke

detectors bicycle helmetsdetectors bicycle helmets

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Review of Systems (ROS)Review of Systems (ROS)

bull GeneralGeneral Overall health weight loss Overall health weight loss behavioral changes fever fatiguebehavioral changes fever fatigue

bull SkinSkin Rashes moles bruising Rashes moles bruising lumpsbumps nailhair changeslumpsbumps nailhair changes

bull EyesEyes Visual problems eye pain Visual problems eye painbull Ear nose throatEar nose throat Frequency of Frequency of

colds pharyngitis otitis mediacolds pharyngitis otitis media

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Cont ROSCont ROS

bull Lungs Lungs Cough shortness of breath Cough shortness of breath wheezingwheezing

bull CardiovascularCardiovascular Chest pain murmurs Chest pain murmurs syncope syncope

bull GastrointestinalGastrointestinal Nauseavomiting Nauseavomiting spitting up diarrhea recurrent abdominal spitting up diarrhea recurrent abdominal pain constipation blood in stoolspain constipation blood in stools

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Cont ROSCont ROS

bull GenitourinaryGenitourinary Dysuria hematuria Dysuria hematuria polyuria dischargepolyuria discharge

bull MusculoskeletalMusculoskeletal Weakness joint Weakness joint pain gait abnormalities scoliosispain gait abnormalities scoliosis

bull NeurologicalNeurological Headache seizures Headache seizuresbull EndocrineEndocrine Growth delay Growth delay

polyphagia excessive thirstfluid polyphagia excessive thirstfluid intake menses duration amount of intake menses duration amount of flowflow

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

TIPS

bull Some parents may exaggerate or mislead you so ask specific questions

bull Avoid leading questionsbull Show appreciation and empathy

with parents anxiety and worrybull Be aware of the sensitivity of some

issues in the family lifebull Take note of the parents behavior

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

QuestionsQuestions

bull Contact e-mailContact e-mail

kkuh_pediayahoocomkkuh_pediayahoocom

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Pediatric Physical Pediatric Physical Examination Examination

Video DemosVideo Demos

(45 minutes)(45 minutes)

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

ObservationObservation

bull Childs facial expression (pain) response Childs facial expression (pain) response to social overtures to social overtures

bull Interaction with caretakers and examiner Interaction with caretakers and examiner bull Body position (leaning forward in sitting Body position (leaning forward in sitting

position epiglottitis pericarditis) position epiglottitis pericarditis) bull Weak cry (serious illness) high-pitched Weak cry (serious illness) high-pitched

cry (increased intracranial pressure cry (increased intracranial pressure metabolic disorder) moaning (serious metabolic disorder) moaning (serious illness meningitis) grunting (respiratory illness meningitis) grunting (respiratory distress)distress)

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Does the child appear to Does the child appear to bebe

(1) Well acutely illtoxic chronically (1) Well acutely illtoxic chronically ill wasted or malnourished ill wasted or malnourished

(2) Alert and active or (2) Alert and active or lethargicfatiguedlethargicfatigued

(3) Well hydrated or dehydrated(3) Well hydrated or dehydrated

(4) Unusual body odors(4) Unusual body odors

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Vital SignsVital Signs

bull Respiratory rate blood pressure Respiratory rate blood pressure pulse temperaturepulse temperature

bull MeasurementsMeasurements Height weight Height weight head circumference in children up-to head circumference in children up-to 2 years plot on growth charts and 2 years plot on growth charts and determine growth percentilesdetermine growth percentiles

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull SkinSkin Cyanosis jaundice pallor rashes skin turgor Cyanosis jaundice pallor rashes skin turgor edema hemangiomas cafeacute au lait spots nevi edema hemangiomas cafeacute au lait spots nevi Mongolian spots hair distribution capillary refill (in Mongolian spots hair distribution capillary refill (in seconds)seconds)

bull Lymph Nodes Lymph Nodes Location size tenderness mobility Location size tenderness mobility and consistency of cervical axillary supraclavicular and consistency of cervical axillary supraclavicular and inguinal nodesand inguinal nodes

bull HeadHead Size shape asymmetry cephalohematoma Size shape asymmetry cephalohematoma bossing molding bruits fontanelles (size tension) bossing molding bruits fontanelles (size tension) dilated veins facial asymmetrydilated veins facial asymmetry

bull EyesEyes Pupils equal round and reactive to light and Pupils equal round and reactive to light and accommodation ( PERRLA) extraocular movements accommodation ( PERRLA) extraocular movements intact ( EOMI) Brushfields spots epicanthic folds intact ( EOMI) Brushfields spots epicanthic folds discharge conjunctiva red reflex corneal opacities discharge conjunctiva red reflex corneal opacities cataracts fundi strabismus (eye deviation) visual cataracts fundi strabismus (eye deviation) visual acuityacuity

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull Ears Ears Pinnas (position size) tympanic Pinnas (position size) tympanic membranes (landmarks mobility erythema membranes (landmarks mobility erythema dull shiny bulging) hearingdull shiny bulging) hearing

bull NoseNose Shape discharge bleeding mucosa Shape discharge bleeding mucosa patencypatency

bull MouthMouth Lips (thinness downturning Lips (thinness downturning fissures cleft lip) teeth mucus membrane fissures cleft lip) teeth mucus membrane color and moisture (enanthem Epsteins color and moisture (enanthem Epsteins pearls) tongue cleft palatepearls) tongue cleft palate

bull Throat Throat Tonsils (erythema exudate) Tonsils (erythema exudate) postnasal drip hoarseness stridorpostnasal drip hoarseness stridor

bull NeckNeck Torticollis lymphadenopathy thyroid Torticollis lymphadenopathy thyroid nodules position of trachea nodules position of trachea

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull ThoraxThorax Shape symmetry intercostal or substemal Shape symmetry intercostal or substemal retractions retractions

bull Breasts Breasts Turner stage size shape symmetry Turner stage size shape symmetry masses nipple discharge gynecomastiamasses nipple discharge gynecomastia

bull LungsLungs Breathing rate depth expansion Breathing rate depth expansion prolongation of expiration fremitus dullness to prolongation of expiration fremitus dullness to percussion breath sounds crackles wheezing percussion breath sounds crackles wheezing rhonchirhonchi

bull HeartHeart Location of apical impulse Regular rate and Location of apical impulse Regular rate and rhythm ( RRR) first and second heart sounds (S1 rhythm ( RRR) first and second heart sounds (S1 S2) gallops (S3 S4) murmurs (location position in S2) gallops (S3 S4) murmurs (location position in cycle intensity grade 1-6 pitch effect of change of cycle intensity grade 1-6 pitch effect of change of position transmission) Comparison of brachial and position transmission) Comparison of brachial and femoral pulsesfemoral pulses

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull AbdomenAbdomen Contour visible peristalsis Contour visible peristalsis respiratory movements dilated veins umbilicus respiratory movements dilated veins umbilicus bowel sounds bruits hernia Rebound bowel sounds bruits hernia Rebound tenderness tympany hepatomegaly tenderness tympany hepatomegaly splenomegaly massessplenomegaly masses

bull Genitalia Genitalia Circumcision hypospadias phimosis Circumcision hypospadias phimosis size of testes cryptorchidism hydrocele hernia size of testes cryptorchidism hydrocele hernia inguinal masses discharge labial adhesions inguinal masses discharge labial adhesions clitoral hypertrophy pubertal changesclitoral hypertrophy pubertal changes

bull Rectum and Anus Rectum and Anus Erythema excoriation Erythema excoriation fissures prolapse imperforate anus Anal tone fissures prolapse imperforate anus Anal tone masses tenderness anal reflexmasses tenderness anal reflex

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull Extremities Extremities Bow legs (infancy) knock knees Bow legs (infancy) knock knees (age 2 to 3 years) Edema (grade 1-4+) (age 2 to 3 years) Edema (grade 1-4+) cyanosis clubbing Joint range of motion cyanosis clubbing Joint range of motion swelling redness tenderness A click felt on swelling redness tenderness A click felt on rotation of hips indicates developmental hip rotation of hips indicates developmental hip dislocation (Barlow maneuver) Extra digits dislocation (Barlow maneuver) Extra digits simian lines pitting of nails flat feetsimian lines pitting of nails flat feet

bull Spine and BackSpine and Back Scoliosis rigidity pilonidal Scoliosis rigidity pilonidal dimple pilonidal cyst sacral hair tufts dimple pilonidal cyst sacral hair tufts tenderness over spine or costovertebral tenderness over spine or costovertebral tendernesstenderness

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull Neurological ExaminationNeurological Examinationbull BehaviorBehavior Level of consciousness intelligence Level of consciousness intelligence

emotional statusemotional statusbull Motor systemMotor system Gait muscle tone strength (graded 0 to Gait muscle tone strength (graded 0 to

5)5)bull ReflexesReflexesbull Deep Tendon ReflexesDeep Tendon Reflexes Biceps brachioradialis Biceps brachioradialis

triceps patellar and Achilles reflexes (graded 1-4)triceps patellar and Achilles reflexes (graded 1-4)bull Superficial ReflexesSuperficial Reflexes Abdominal cremasteric plantar Abdominal cremasteric plantar

reflexesreflexesbull Neonatal ReflexesNeonatal Reflexes Babinski Landau Moro rooting Babinski Landau Moro rooting

suck grasp tonic neck reflexessuck grasp tonic neck reflexesbull Developmental AssessmentDevelopmental Assessment Delayed abilities for age Delayed abilities for age

on developmental screening teston developmental screening test

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

bull Laboratory EvaluationLaboratory Evaluation Electrolytes (sodium Electrolytes (sodium potassium bicarbonate chloride BUN potassium bicarbonate chloride BUN creatinine) CBC (hemoglobin hematocrit WBC creatinine) CBC (hemoglobin hematocrit WBC count platelets differential) X-rays urinalysis count platelets differential) X-rays urinalysis ( UA) ( UA)

bull AssessmentAssessment Assign a number to each Assign a number to each problem and discuss each problem separately problem and discuss each problem separately Discuss the differential diagnosis and give Discuss the differential diagnosis and give reasons that support the working diagnosis reasons that support the working diagnosis Give reasons for excluding other diagnoses Give reasons for excluding other diagnoses

bull PlanPlan Describe therapeutic plan for each Describe therapeutic plan for each numbered problem including testing numbered problem including testing laboratory studies medications antibiotics and laboratory studies medications antibiotics and consultationsconsultations

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes

Work HardWork HardBecome ExcellentBecome Excellent

Best WishesBest Wishes