Physical Examination - Pediatric Characteristics PDF

Maciej Szczukocki Physical examination Clinical Characteristics of Pediatrics Pediatric Characteristics in Basic Medicine Physiology Heart rate, blood pressure, routine blood test results and composition of body fluids are variable according to age Limited kidney's ability leads to electro...

Maciej Szczukocki Physical examination Clinical Characteristics of Pediatrics Pediatric Characteristics in Basic Medicine Physiology Heart rate, blood pressure, routine blood test results and composition of body fluids are variable according to age Limited kidney's ability leads to electrolyte and acid-base disorders in children More liable to hypothermia, hypoglycemia, hypoxia and dehydration  Paediatric Respiratory Rates  Paediatric Heart Rates Immunology 3-5 months after birth, the diminished concentration of immunoglobulin and other immunologic factors and the decreased function of neutrophils and other cells involved in the response to infection put infants at increased risk for infection. sIgA and IgG is not sufficient , thus the infants are vulnerable to respiratory and gastrointestinal infections. Pathology Onset of illnesses is very rapid. Atypical presentations: Neonate with severe infection is always weak in response, apathy, rejects feeding, but has neither fever, nor increase in WBC counting or other obvious clinical manifestations. Treatment The pediatric drug dose varies in different age groups and given according to body weight or surface area. Fluid therapy is critical in amount and composition. Nutritional support is important Efficient nursing is essential Prognosis The clinical manifestations change rapidly. They have good potential for recovery. But when they decompensate they crash suddenly and rapidly. Early diagnosis and prompt treatment are very important. Rapid tissue recovery. Prevention Prevention in the health care of infants, and children is at the core of the field of pediatrics. Planned immunization (vaccination) Genetic consultation and screening test Injury prevention Parents counseling Stages of children by age Infancy period Rapid growth period. Baby weight increases 3 times more than the birth weight. Height increases 1.5 times compared with the birth height. Head circumference increases from 35 to 47 cm. Every organ system continues developing and completing, most importantly the brain. Toddler period From 1 to 3 year-old Features: – growth becomes slower – more vigorous, contact more objects, intelligence develops faster – poor ability of identifying damage. Health care: – enough nutrition – Prevention of diseases – Prevention of accident Preschool age 3 years old until 6-7 years old Features: – growth becomes slower, – more mature intelligence. – strong desire for knowledge – imitating adult’s behavior – poor ability to identify damage Health care: – enough nutrition – prevention of diseases – prevention of accident School age From 6-7 years old until adolescence Features: – growth becomes relatively steady – more mature intelligence developed – increasing desire for knowledge – decreasing incidence of diseases Health care: – enough nutrition – prevention of problems in psychology, emotion and behavior Adolescence From 2nd sexual character appearing until sexual mature and growth stopped – girl: from 11-12 yrs to 17-18 yrs – boy: from 13-14 yrs to 18-20 yrs Features: – the second fastest period of growth and development – neuroendocrine regulation unsteady – having problems in psychology, emotion, behavior Health care: – enough nutrition – health care of adolescence – education Physical examination Approach Infants older than 6 months and anxious toddlers often are more comfortable when held by their caregiver. try using a calm approach, a reassuring smile, and a toy or bright object as a diversion Infants younger than 6 months who have no stranger anxiety and children older than 30-36 months who are familiar with the examining clinician and/or who possess a trusting demeanor generally cooperate during the examination without being held. Physical examination of 5- to 12-year-old children usually is easy to perform because these children are not typically apprehensive and tend to be cooperative. General appearance The examiner may gain significant insight by observation alone when entering the patient's room. Describe a patient's general appearance include degree of comfort (calm, nervous, shy), state of well-being (normal, ill-appearing, distressed), activity level (sedate, alert, active, fidgety), physical appearance (neat, disheveled, unkempt), behavior and attitude (happy, sad, irritable, combative), body habitus (overweight, underweight, short, tall), and nutritional status (malnourished, normal, corpulent).  Physical examination The examiner should wash his or her hands thoroughly before beginning and after completing the examination. Physical examination The order in which the physical examination is conducted often is age- specific and depends upon examiner preference.  Temperature Pulse Respiration Blood pressure (both upper Vital signs extremities, lower if indicated) Pulse oximetry readings should be noted if applicable Temperature The technique and appropriate site for measurement are age dependent. Rectal temperature recordings in infants and young children are preferred, although axillary recordings are acceptable; axillary measurements are consistently lower than rectal measurements, but the absolute difference varies too widely for a standard conversion. Respiratory rate The respiratory rate varies with activity in infants and young children, and in these patients is best assessed by counting for a full 60 seconds The normal range for the respiratory rate depends upon the age of the child Heart rate The heart rate can be measured by direct auscultation or palpation of the heart or by palpation of peripheral arteries (carotids, femorals, brachials, or radials). Like the respiratory rate, the normal heart rate varies with age. A heart rate above the upper limit of normal may indicate primary cardiac disease; it also can occur secondary to an underlying systemic or metabolic disorder, infectious disease, or high fever. Blood pressure Yearly blood pressure measurements are measured in children ages ≥ 3 years. In most circumstances, routine blood pressure measurements should not be attempted in younger children unless they have evidence of underlying renal disease, such as a tumor, nephrotic syndrome, glomerulonephritis, pyelonephritis, or renal artery stenosis. Another reason for measuring the blood pressure in children under the age of three is the finding or suspicion of underlying cardiovascular disease, such as coarctation of the aorta or patent ductus arteriosus (PDA).  Blood pressure As with pulse and respiratory rates in children, blood pressure varies with age. Population values for BP tresholds are based on: Age Sex Height General measurments Height (length) and weight Height (length) and weigt is measured at each periodic well-child visit. In the child younger than two years, measuring body length when the child is in the supine position is preferable. In older children, the height measurement should always be done with the patient standing. Head circumference When to measure – Occipitofrontal circumference (OFC) should be measured in all children at health maintenance visits between birth and three years of age. OFC should also be measured at each visit in children of all ages with neurologic or developmental complaints. Measurement of OFC in the newborn may be unreliable until the third or fourth day of life since it may be affected by caput succedaneum, cephalohematoma, or molding. Head circumference – how to measure Measurement should be attempted at the conclusion of the physical examination because young children generally dislike having their head measured. The measuring tape should encircle the head and include an area 1 to 2 cm above the glabella anteriorly and the most prominent portion of the occiput posteriorly Examining the body systems and organs I. Skin Texture rashes (describe type and Color distribution) Pallor Petechiae Cyanosis Purpura Jaundice local swelling Temperature Edema Turgor dilated veins subcutaneous fat insect bites evidence of weight loss Scars pigmentation signs of injury II. Lymph nodes Cervical Occipital post-auricular Axillary Epitrochlear Inguinal other superficial nodes. Note size (mm), tenderness, consistency, mobility. III. HEENT - Head Size and shape Fontanelle(s) Size Tension - calm and in the sitting up position Sutures – overriding Scalp and hair III. HEENT -Head - fontanelle The normal time of fontanelle closure depends upon the patient's gestational age at birth. The posterior fontanelle usually cannot be palpated after two months of age. The anterior fontanelle generally closes between 10 and 24 months of age. The fontanelles of premature infants tend to close at a later time. III. HEENT - Head - fontanelle Early closure — Early closure of the anterior or posterior fontanelle is not uncommon in an otherwise normal child. However, it should alert the examiner to the possibility of developing microcephaly. Other causes of early closure of the anterior fontanelle include: Craniosynostosis Hyperthyroidism Hypophosphatasia Hyperparathyroidism The approach to the child with early closure of the anterior fontanelle depends upon associated clinical findings, including ridging at the suture lines (suggestive of craniosynostosis), decreasing head circumference (suggestive of microcephaly), etc. III. HEENT - Head - fontanelle Delayed closure — The most common causes of delayed closure of the anterior fontanelle include: Normal variation Congenital hypothyroidism Primary megalencephaly Increased intracranial Down syndrome Rickets III. HEENT - Eyes General Strabismus Slant of palpebral fissures Hypertelorism or telecanthus EOM Pupils Brushfield spots, epicanthus Conjunctiva Sclera Cornea Plugging of nasolacrimal ducts Red reflex Pathologic white reflex, III. HEENT - Eyes Red reflex technique Red Reflex or individual reflex The traditional red reflex refers to visualizing each eye individually. The American Academy of Pediatrics describes using a direct opthalmoscope with a lens at 0, approximately 18 inches away in a dimly lit room on each eye. Bruckner Test The Bruckner test differs in that one will visualize both eyes simultaneously. Unlike the red reflex, this can help determine if the patient has normal ocular alignment. In order to perform this test the patient and physician are normally approximately 2 to 3 feet away from each other. III. HEENT - Ears Position of ears Low set ears Tympanic membranes Hearing III. HEENT - Ears III. HEENT - Ears AOM III. HEENT – nose Nasal septum Mucosa (color, polyps) Sinus tenderness Discharge III. HEENT - Throat Mouth Mouth examination includes the gingiva, teeth, buccal mucosa, salivary ducts, tongue, palate, tonsils, and uvula. Ulcerations of the lips, gingiva, and/or mucosal surfaces are compatible with herpetic stomatitis, aphthous ulcers, metabolic disorders, drug reactions, or secondary complications from underlying immunosuppressive disease. Obstructed salivary ducts can be caused by concretions, leading to the development of a cyst-like structure in the floor of the mouth (ranula) Fissuring or cracking of the tongue may be a normal variant but also occurs with poor hydration and vitamin deficiency. Geographic tongue (benign migratory glossitis) is a chronic, recurring disorder characterized by pink to red, slightly depressed lesions with irregular, elevated, white or yellow borders. Defects in the hard and/or soft palate, particularly midline cleft palate defects, should be noted. Dimpling of the soft palate and/or a bifid uvula may occur with a submucosal cleft. III. HEENT - Throat Deciduous tooth eruption generally begins around six months of age with the appearance of the lower central incisors, followed over the next 18 months by the eruption of upper central incisors, lateral incisors, canines, and molars. The majority of toddlers have the full complement of 20 teeth by age two. ~ Teeth number = age [month] - 6 III. HEENT - Throat Tonsils (size, color, exudates) Posterior pharyngeal wall (color, lymph hyperplasia, bulging) Enlarged tonsils with exudate may be caused by bacterial infection of the throat and tonsils with group A beta-hemolytic Streptococcus and other infectious agents (eg, diphtheria, Epstein-Barr virus) Tonsillar asymmetry or unilateral tonsillar enlargement may be caused by infection, chronic inflammatory process, or neoplasm (particularly lymphoma). Mononucleosis Strep throat Lymphoma Sore throat IV. Neck Masses Torticollis Rigidity Retraction Webbing - may be associated with Turner syndrome Structures: neck vessels, thyroid, trachea. Distended or pulsating neck veins may indicate obstruction of blood return to the right heart (eg, mediastinal masses) or impaired cardiac function (eg, pericarditis or poor myocardial contractility). Palpate clavicles in the newborns Low posterior hair line webbed-shape neck – Noonan syndrome IV. Neck – Thyroid gland Palpation of the thyroid is accomplished best with the examiner positioned behind the standing or sitting patient. The fingers of the examiner's hands are gently positioned over the respective lobes, which are normally soft, smooth, and not enlarged. The thyroid gland moves upward when the patient swallows. Only repetitive palpation of the thyroid of many patients will give the examiner the feel for normal size, shape, and contour. V. Thorax and lungs Chest wall Normally, the chest is symmetrical and, in the infant or young child, almost round. The transverse diameter increases with age. When a persistently round, barrel-shaped chest is seen in an older child, the examiner should consider the possibility of an underlying chronic pulmonary disease, such as cystic fibrosis or chronic asthma. pectus excavatum (funnel chest) pectus carinatum (pigeon breast) Breasts Breast development staging is based upon standards established by Marshall and Tanner Lungs The rate, rhythm, and depth of breathing should be noted. Shallow, rapid breathing can be seen with anatomical defects, pulmonary infection, pleuritic disease, and metabolic disorders. Slow breathing may occur as a result of central nervous system pathology, metabolic disease, and drug effect. Vigorous exercise, a state of anxiety, and metabolic acidosis may cause deep, rapid breathing. A prolonged expiratory phase occurs in patients with an acute exacerbation of reactive airway disease or true asthma. A sleeping infant may have brief periods of rapid breathing alternating with respiratory pauses Lungs An organized symmetrical approach to auscultation of the lung fields should be used. Sequential auscultatory examination proceeds from one side of the chest to the other, comparing breath sounds in anatomically similar areas. Either the bell or the diaphragm of the stethoscope may be used, depending upon the size of the child; the diaphragm is more appropriate for listening to the lungs of larger patients. Lungs Ordinarily, deep mouth breathing produces clear, soft breath sounds over the lungs. Atypical breath sounds in the form of crackles, rhonchi, or wheezes are heard most often in patients with underlying pulmonary disease. Upper airway congestion in small children often produces coarse sounds that, when transmitted through the larger airways, may give the impression of an underlying lung abnormality. Frequently, coughing and/or vigorous crying will clear a congested upper airway, helping the clinician distinguish between upper and lower airway sounds. Lungs In small children, an inspiratory high-pitched stridulous sound with or without significant respiratory distress may be the result of narrowing at or near the larynx or anywhere along the trachea. This condition can be caused by a croup-like illness, anatomical defect, mass lesion, foreign body, or external obstruction. Patients in severe respiratory distress with stridor may have epiglottitis or croup.  Normal tracheal sound Hollow and nonmusical, clearly heard in both phases of respiratory cycle Transports intrapulmonary sounds, indicating upperairway patency; serves as a good model of bronchial breathing  Soft, nonmusical, heard only on inspiration and on early expiration Normal lung sound Is diminished by factors affecting sound generation (e.g., hypoventilation, airway narrowing) or sound transmission (e.g., lung destruction, pleural effusion, pneumothorax); assessed as an aggregate score with normal breath sound; rules out clinically significant airway obstruction*  Soft, nonmusical, heard on both phases of respiratory cycle (mimics tracheal sound) Bronchial breathing Indicates patent airway surrounded by consolidated lung tissue (e.g., pneumonia) or fibrosis  Musical, high-pitched, may be heard over the upper airways or at a distance without a stethoscope Indicates upper-airway obstruction; Stridor associated with extrathoracic lesions (e.g., laryngomalacia, vocalcord lesion, lesion after extubation) when heard on inspiration; associated with intrathoracic lesions (e.g., tracheomalacia, bronchomalacia, extrinsic compression) when heard on expiration; associated with fixed lesions (e.g., croup, paralysis of both vocal cords, laryngeal mass or web) when biphasic  Musical, high-pitched; heard on inspiration, expiration, or both Suggests airway narrowing or blockage when localized (e.g., foreign body, tumor); associated with generalized airway narrowing and airflow Wheeze limitation when widespread (e.g., in asthma, chronic obstructive lung disease); degree of airflow limitation proportional to number of airways generating wheezes; may be absent if airflow is too low (e.g., in severe asthma, destructive emphysema)  Musical, low-pitched, similar to snoring; lower in pitch than wheeze; may be heard on inspiration, expiration, or both Associated with rupture of fluid films and abnormal airway collapsibility; Rhonchus often clears with coughing, suggesting a role for secretions in larger airways; is nonspecific; is common with airway narrowing caused by mucosal thickening or edema or by bronchospasm (e.g., bronchitis and chronic obstructive pulmonary disease)  Nonmusical, short, explosive; heard on mid-to-late inspiration and occasionally on expiration; Fine crackle unaffected by cough, gravity-dependent, not transmitted to mouth Unrelated to secretions; associated with various diseases (e.g., interstitial lung fibrosis, congestive heart failure, pneumonia); can be earliest sign of disease (e.g., idiopathic pulmonary fibrosis, asbestosis); may be present before detection of changes on radiology  Nonmusical, short, explosive sounds; heard on early inspiration and throughout expiration; Coarse crackle affected by cough; transmitted to mouth Indicates intermittent airway opening, may be related to secretions (e.g., in chronic bronchitis)  Nonmusical, explosive, usually biphasic sounds; Pleural friction rub typically heard over basal regions Associated with pleural inflammation or pleural tumors  Mixed sound with short musical component (short wheeze) accompanied or preceded by crackles Squawk Associated with conditions affecting distal airways; may suggest hypersensitivity pneumonia or other types of interstitial lung disease in patients who are not acutely ill; may indicate pneumonia in patients who are acutely ill VI. Heart General appearance Central and peripheral color, nutritional status, respiratory rate and effort, presence of sweating, chest contour Jugular venous distention, peripheral edema, and evidence of hepatic engorgement suggest right ventricular dysfunction Cyanosis Central cyanosis is evident when systemic arterial concentration of deoxygenated hemoglobin (Hb) in the blood exceeds 5 g/dL (3.1 mmol/L) (oxygen saturation ≤85 percent) Of note, cyanosis may not be readily detectable in patients with severe anemia (eg, Hb