Hutchison's Paediatrics Krishna M Goel, Devendra K Gupta
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Paediatric History and ExaminationChapter 1

Krishna M Goel,
Robert Carachi
 
THE HISTORY
Semeiology (The study of symptoms).
 
Disease
‘A condition in which, as a result of anatomical change or physiological disturbance, there is departure from the normal state of health’. There is a lot of variation in normal people.
 
CLINICAL MANIFESTATIONS OF DISEASE
 
Symptoms
Something the patient feels or observes which is abnormal, e.g. pain, vomiting, loss of function. A good history will provide a clue to the diagnosis in 80% of patients.
 
Signs
Physical or functional abnormalities elicited by exami-nation, e.g. tenderness on palpation, a swelling, a change in a reflex picked up on physical examination. Always inspect, palpate, percuss then auscultate.
 
The Patient
Why do patients go to the doctor?
  • They are alarmed. They believe themselves to be ill and are afraid
  • Relief of symptoms
  • Cure
  • Prognosis.
 
The Doctor
  • Helps diagnose disease
  • Symptoms + signs → differential diagnosis → Δ definitive diagnosis
  • Acquired knowledge allows recognition + interpretation + reflection → therapy + prognosis.
 
How is Knowledge Acquired?
  • Reading: 10% – 20% retention
  • Taught by others: 10% retention, e.g. lectures, tutorials, computer programs
  • Personal experience: 80% retention, e.g. bedside teaching
 
A Description of the Disease
  1. Knowledge of the causation (aetiology).
  2. Pathological, anatomy and functional changes which are present (morphology).
  3. Assembly of all the relevant facts concerning the past and present history (symptoms).
  4. Full clinical examination and findings (signs).
  5. Simple laboratory tests such as an examination of the urine or blood and X-rays (investigations).
 
Prognosis
Depends on:
  1. Nature of the disease.
  2. Severity.
  3. Stage of the disease.
Statistical statements about prognosis can often be made, e.g. the average expectation of life in chronic diseases or the percentage mortality in the acute cases. These must be applied with great caution to individual patients. Patients expect this more and more with internet access. Often information has to be interpreted. They may be testing your knowledge and comparing it to other doctors or information obtained.
 
Syndrome
A group of symptoms and/or signs which commonly occur together, e.g. Down's syndrome, Wiedemann-Beckwith syndrome (*).2
* Oxford Dysmorphology Database
 
History and Documentation History of Present Condition
 
a. General Description
The taking of an accurate history is the most difficult and the most important part of a consultation. It becomes progressively simpler as the physician's knowledge of disease and experience increases but it is never easy. As far as possible the patients’ complaints list should be written (in order of relevance), unaltered by leading questions but phrased in medical terms. When the patient's own phraseology is used, the words should be written in inverted commas, e.g. “giddiness”, “wind”, “palpitation” and an attempt should be made to find out precisely what they mean to the patient.
  1. Onset – The order of onset of symptoms is important. If there is doubt about the date of onset of the disease, the patient should be asked when he last felt quite well and why he first consulted his doctor.
  2. Therapy – Notes on any treatment already received and of its effect, if any, must be made as it might alter disease states, e.g. appendicitis masked by drug treatment for a UTI.
 
b. Symptomatic Enquiry
After the patient has given a general description of his illness, the system mainly involved will usually but by no means always, be obvious. The patient should then be questioned about the main symptoms produced by diseases of this system. This should be followed by enquiries directed towards other systems. Remember different systems may produce similar symptoms.
This systematic enquiry runs from the ‘head to the toes’ (32 questions). However, relevant questions are grouped together under systems. Here are some examples.
 
Alimentary Tract Questions
  • Abdominal pain or discomfort (24):
    Site, character, e.g. constant or colicky, radiation, relationships to food and bowel actions. Shift in site.
  • Nausea and vomiting (15):
    Frequency and relationship to food, etc. (positive vomiting), amount of vomitus, contents, colour, blood (haematemesis), etc.
  • Flatulence (16, 26):
    Eructation (belching) and passage of flatus.
  • Bowels (25):
    Constipation (recent or long standing, severity); diarrhoea (frequency and looseness of motions); presence of blood and mucus in faeces; altered colour of faeces – black from altered blood (melaena); clay coloured in obstructive jaundice; bulky and fatty in steatorrhoea, piles. Tenesmus painful sensation and urgent need to defecate (Rectal Pathology).
  • Appetite and loss of weight (17):
    Recent looseness of clothing. Types of food in diet, amounts eaten.
  • Difficulty in swallowing (18a):
    Food hard or soft, fluids, level at which food ‘sticks’. Pain, regurgitation. Progression from solid food to liquid.
  • Heartburn, acid eructations, “and belching”.
  • Jaundice (17):
    Constant or fluctuating.
    N.B. Steatorrhoea: bulky pale foul smelling and greasy stools due to
    1. Depressed fat digestion (pancreatic lipase and bile)
    2. Depressed fat absorption (small intestine mostly jejunum)
 
Cardiovascular System Questions
  • Breathlessness (11):
    On exertion (DOE) (degree) on at rest (DAR), time especially if wakes at night, position, relieving factors, gradual/sudden onset, change, duration (PND), precipitating factors, number of pillows used.
  • Pain in chest (19):
    Site on exertion or at rest, character, radiation, duration, relief by drugs, etc. accompanying sensations, e.g. breathlessness, vomiting, cold sweats, pallor, frequency, other relieving factors.
  • Swelling of ankles (23):
    Time of day.
  • Swelling of abdomen (27):
    Tightness of trousers or skirt, bloatedness.
  • Palpitation (20):
    • Patient conscious of irregularity or forcefulness of heart beat.
    • Dizziness and faints – hypertension pain.
  • Pain in the legs on exertion (22):
    Intermittent claudication at rest or exertion, other vascular problems.
  • Coldness of feet (23):
    Raynaund's phenomenon.3
  • Dead fingers or toes (22):
    Pain, sensation, ulceration, diabetes.
 
Respiratory System Questions
  • Cough (12):
    Character, frequency, duration, causing pain, timing. Productive.
  • Sputum (13):
    Quantity, colour (frothy, stringy, sticky odour), colour when most profuse (during the day and the year and the affect of posture (bronchiectasis) presence of blood haemoptysis. Is the blood red or brown? Is it pure blood or ‘specks’? e.g. acute or chronic bronchitis.
  • Breathlessness (11):
    On exertion or at rest. Expiratory difficulty, precipi-tating factors, cough, fog, emotion, change of environment, wheezing.
  • Pain in chest:
    Location, character, affected by respiration, coughing. Position? (↑↓ pain). Weight loss.
  • Hoarseness (10):
    With or without pain (involvement of recurrent laryn-geal nerve. Other associated features eg neurological.
  • Throat (10):
    Soreness, Tonsillitis, ulcers, infection.
  • Nasal discharge or obstruction (7):
  • Bleeding from nose (8):
    Epistaxis.
  • Sweating (14):
    Day or night, associated symptoms, amounts.
  • Wheezing (12):
    Asthma, chest infection, relieving factor, COPD
  • Smoking.
 
Central Nervous System Questions
  • Loss of consciousness (1):
    Sudden, warning, injuries, passage of urine, duration, after effects. Precipitating factor, witnesses?
  • Mental state (3):
    Memory, independent opinion of relative or friend sought. Orientation.
  • Headache (2):
    Character, site, duration, associated symptoms, e.g. vomiting, aura, timing.
  • Weakness or paralysis of limbs or any muscles (21):
    Sudden, gradual or progressive onset, duration, visual disturbance.
  • Numbness or ‘pins and needles’ in limbs or elsewhere (22):
    Paraesthesine, backpain, diabetes.
  • Giddiness or staggering (5):
    True vertigo, clumsiness, staggering, ataxia.
  • Visual disturbance (4):
    Seeing double (diplopia) dimness, zig zag figures (fortification spectra).
  • Deafness or tinnitus (6):
    Discharge from ears, pain, hearing loss.
  • Speech disturbance (9):
    Duration, onset, nature. Problems with reading or understanding.
 
Genito Urinary System Questions
  • Micturation (29):
    Frequency during day and night, retention, dribbling, amount of urine passed. Pain or smarting (dysuria). Stress incontinence, urgency incontinence.
  • Urine (30):
    Colour and amount – smell, blood, colour, frothy.
  • Lumbar pain (28):
    Radiation. ROM, history of trauma, mechanical.
  • Swelling of face or limbs (23):
    Presence on rising, drugs, improve with movement, pain.
  • Menstruation (31):
    Age of onset (menarche) age of cessation (menopause). Regularity, duration, amount of loss, pain (dysmenorr-hoea). Inter-menstrual discharge – character, blood or otherwise. Vaginal discharge, quantity, colour (nor-mally clear), smell, irritation. Any hormone replace-ment therapy (HRT), child bearing age.
  • Periods:
    Time of menopause
    Postmenopausal bleeding
    Last normal menstrual period LNMP
    Menstrual cycle No. of days/interval, e.g. 4/28
    Regular or irregular, e.g. 2 – 8/
    Interval longest or shortest, e.g. 21 – 49
    Increase or decrease in flow.
 
Locomotor System Questions
  • Swelling:
    One joint or multiple joints.
    Pain – Back (22):
    When worse during day. Effect of exercise. Lifting.
  • Stiffness:
    Effect of exercise.
  • Previous bone or joint injury:
  • N.B. Pain in joints. Where worse in morning or later during day/night. Whether it radiates from one joint to another.4
 
Skin Questions
  • Occupation (32):
    Exposure to irritants and drugs:
  • Rashes:
    Type, situation, duration, any treatment, painful, itching, (psoriasis).
 
Past History
  1. Diabetes
  2. Hypertension
  3. Rheumatic fever
  4. Heart disease
  5. C.F.
  6. Spina bifida
  7. Other illnesses
Illnesses, operations, injuries. Routine X-ray exami-nations. In female – obstetrical history (a) number of deliveries and abortions, e.g. 3 + 1, (b) type of delivery, e.g. NA, SO, forceps, (c) complication of puerperium or pregnancy.
 
Family History
Married, number and health of children, health of partners, any illnesses in parents, grand-parents, brothers, sisters, longevity or short lives, any illnesses similar to patients.
 
Drug History
  • Social and personal history:
  • Occupation:
 
INTRODUCTION
At all times the doctor must show genuine concern and interest when speaking with parents. The parents and the child must feel that the doctor has the time, interest and competence to help them. A physician who greets the child by name irrespective of age will convey an attitude of concern and interest. Parents tell us about the child's signs and symptoms although children contribute more as they grow older.
The doctor-patient relationship gradually develops during history-taking and physical examination. Considerable tact and discretion are required when taking the history especially in the presence of the child: questioning on sensitive subjects should best be reserved for a time when the parents can be interviewed alone. It may therefore be necessary to separate the parent and the child-patient when taking the history especially when the problems are related to behaviour, school difficulties and socioeconomic disturbances in the home environment.
Table 1.1   History-taking—The paediatric patient
  • Presenting problem
  • History of the presenting problem
  • Previous history:
  • Pregnancy and delivery
  • Neonatal period and infancy
  • Subsequent development
  • Other disorders or diseases
  • Dietary
  • Immunisation
  • Family history
  • Parents
  • Siblings
  • Others
  • Draw a family tree if indicated
The medical student having been instructed in the history-taking and physical examination of adults needs to appreciate the modifications necessary when dealing with the child-patient. A basic template for history-taking is useful and serves as a reminder of the ground to be covered (Table 1.1). Initially the medical student may be confused because of the need to obtain information from someone other than the patient, usually the mother. Useful information may be obtained by observing the infant and young child during the history-taking. The older child should be given an opportunity to talk, to present their symptoms and to tell how they interfere with school and play activities.
The simple act of offering a toy, picture book or pen-torch is often an effective step toward establishing rapport. Rigid adherence to routine is both unnecessary and counter productive. A lot may be learned of the family constellation and the parent-child relationship by simply observing the parent(s) and child during the history-taking and physical examination. Therefore watching, listening and talking are of paramount importance in paediatric practice and are invaluable in arriving at a working diagnosis.
 
History of Present Complaint
Even before language develops in the infant (Latin – without speech) parents can detect altered behaviour and observe abnormal physical signs. It is sensible to commence with the history of the presenting observations because that is what the parents have come to talk about. In the newborn infant the history from the attending nurse and medical staff is important.5
Every endeavour should be made to ask appropriate questions and discuss relevant points in the history in order to identify the nature of the child's problems and come to a tentative diagnosis. Ask what the child is called at home and address the child with this name since otherwise he/she may be less forthcoming. Let the parents give the history in their own way and then ask specific questions. Ask, how severe are the symptoms; have the symptoms changed during the past days, weeks or months; has there been any change recently in the child's appetite, energy or activities; has the child been absent from school; has anyone who cares for the child been ill; has the child been thriving or losing weight; what change in behaviour has there been; has there been a change in appetite, in micturition or bowel habits. An articulate older child can describe feelings and symptoms more accurately, as the child's memory for the time and sequence of events may be more precise, than the parents.
 
Past Medical History
The past history is the documentation of significant events which have happened in the child's life and which may be of relevance in coming to a diagnosis. Therefore the doctor should try to obtain relevant information concerning the past from the family and any other sources that are available. It is useful if the events are recorded in the sequence of their occurrence. A careful history should contain details of pregnancy, delivery, neonatal period, early feeding, the child's achievement of developmental milestones and details of admissions to hospital, with date, place and reason for admission. A complete list of current medication including vitamins and other supplements should be obtained. An enquiry should be made of any drug or other sensitivity which should always be prominently recorded. Details of immunisation and all previous infectious diseases should be elicited.
 
Mother's Pregnancy, Labour, Delivery and the Neonatal Period
The younger the child, the more important is the information about the period of intrauterine life. The history of pregnancy includes obstetric complications during the pregnancy; history of illness, infection or injury and social habits, e.g. smoking of the mother are important. Drug or alcohol ingestion and poor diet during pregnancy may have an adverse effect on the fetus and lead to problems. The estimated length of gestation and the birth weight of the baby should be recorded. Details of any intrapartum or perinatal problems should be recorded.
 
Dietary History
The duration of breastfeeding should be recorded or the type of artificial feed and any weaning problems. The dietary history can be of major importance in paediatric history-taking. If the patient is not thriving or has vomiting, diarrhoea, constipation or anaemia then the physician must obtain a detailed dietary history. The dietary history should not only include solid foods but also the consumption of liquid foods and any other supplements such as vitamins. In this way the quality of the diet and the quantity of nutrients can be assessed and compared to the recommended intake. Any discrepancy between the actual and recommended intake may have a possible bearing on the diagnosis.
 
Developmental History
Inquiries about the age at which major developmental milestones in infancy and early childhood were achieved are necessary when faced with an infant or child who is suspected of developmental delay. On the other hand the child who is doing well at school and whose physical and social activities are normal, less emphasis on the minutiae of development is needed. Some parents are vague about the time of developmental achievements unless, very recently acquired but many have clear recall of the important events such as smiling, sitting and walking independently. It can be helpful to enquire whether this child's development paralleled that of other children.
 
Family and Social History
The health and educational progress of a child is directly related to the home and the environment. Medical, financial and social stresses within the family sometimes have a direct or indirect bearing on the child's presenting problem. It is therefore essential to know about the housing conditions and some information of parental income and working hours, as well as the child's performance in school and adjustment to playmates.
The family history should be thoroughly evaluated. The age and health of the close relatives are important to record. Heights and weights of parents and siblings may be of help especially when dealing with children of short stature, obesity, failure to thrive, or the infant with an enlarged head. Consanguinity is common in some 6cultures and offspring of consanguinous marriages have an increased chance of receiving the same recessive gene from each parent and thus developing a genetically determined disease. Therefore it is important to draw a family tree and to identify children at high risk of genetic disease, and to make appropriate referrals.
 
PHYSICAL EXAMINATION
The physical examination of the paediatric patient requires a careful and gentle approach. It should be carried out in an appropriate environment with a selection of books or toys around, which can be used to allay the apprehension and anxiety of the child. More can be learned by careful inspection than by any other single examination method. The baby should be examined in a warm environment in good light. Nappies must be removed to examine the baby fully. We look first at the baby as a whole noting especially the colour, posture and movements. Proceed to a more detailed examination starting at the head and working down to the feet “Top to Toe”.
It is important to realise that the child may be apprehensive with a stranger, especially when faced with the unfamiliar surroundings of a surgery or hospital outpatient department. It is essential that the doctor be truthful with the child regarding what is going to be done. The child should never be made to face sudden unexpected manouevres and should be allowed to play with objects such as the stethoscope. It may be useful to let him or her examine a toy animal or doll to facilitate gaining confidence. Infants and young children are often best examined on the mother's lap where they feel more secure. The doctor should ensure that his hands and instruments used to examine the child are suitably warmed. It is not always mandatory to remove all the child's clothes, although it is often essential in the examination of the acutely ill child. Procedures which may produce discomfort such as examination of the throat, ears or rectal examination should be left until towards the end of the examination. The order of the examination may be varied to suit the particular child's needs. Awareness of the normal variations at different ages is important.
A thorough physical examination is a powerful therapeutic tool especially if the problem is one primarily of inappropriate parental anxiety. Understandably parents do not usually accept reassurance if the doctor has not examined the child properly. Examination of the infant or child is often preceded by recording the patient's height, weight and head circumference on the growth chart. This may have been done by a nurse before the doctor sees the family. These measurements are plotted on graphs or charts which indicate the percentiles or standard deviations at the various ages throughout childhood. If these measurements are outwith the 3rd to 97th centile for children of that sex and age further study is indicated. If previous records of height, weight or head circumference are available for comparison with the current measurements this may provide considerable help towards diagnosis and management. Inquiry of parental height, weight or head size may also be important, e.g. familial macrocephaly or constitutional short stature.
 
General Inspection
The general appearance of the child may suggest a particular syndrome. Does the child look like the rest of the family? The facies may be characteristic in Down's Syndrome and other chromosomal disorders or in mucopolysaccharidoses. Peculiar odours from an infant may provide a clue to diagnosis of aminoacidurias, such as Maple Syrup disease (maple syrup like odour), Phenylketonuria (mousy odour), or Trimethylaminuria (fishy odour). A more detailed examination should then be performed. The most valuable of the doctor's senses are his eyes as more can be learned by careful inspection and also on watching the patient's reactions than any other single procedure.
 
Colour
Should be pink with the exception of the periphery which may be slightly blue. Congenital heart disease is only suggested if the baby has central cyanosis. A pale baby may be anaemic or ill and requires careful investigation to find the cause. A blue baby may have either a cardiac anomaly or respiratory problems and rarely methhae-moglobinaemia.
 
Posture and Movements
A term baby lies supine for the first day or two and has vigorous, often asymmetric movements of all limbs. In contrast a sick baby adopts the frog position with legs abducted, externally rotated and is inactive. Older infants and children should be observed for abnormal movements, posture and gait.
7
 
Skin
The skin is a major body organ which, because of the larger surface area in relationship to weight, of the young means that the skin is relatively more important in the immature. It forms a barrier against environmental attack and its structure and function reflects the general health of the child, i.e. in states of malnutrition and dehydration. The presence of any skin rash, its colour and whether there are present macules, papules, vesicles, bullae, petechiae or pustules should be recorded (see Box). The skin texture, elasticity, tone and subcutaneous thickness should be assessed by picking up the skin between the fingers. Pigmented naevi, strawberry naevi, haemangio-mata or lymphangiomata may be present and may vary in size and number. They may be absent or small at birth and grow in subsequent days or weeks.
 
Head
The head should be inspected for size, shape and symmetry. Measurement of the head circumference [occipital frontal circumference (OFC)] with a non-elastic tape by placing it to encircle the head just above the eyebrows around maximum protuberance of the occipital bone should be performed and charted. In the infant the skull should be palpated to determine the size and tension in the fontanelles and assess the skull sutures (Figure 1.1). Premature fusion of sutures suggests craniostenosis. In the neonate the posterior fontanelle may be very small and subsequently closes by three months of age but the anterior fontanelle is larger, only closing at around 18 months. A tense and bulging fontanelle suggests raised intracranial pressure and a deeply sunken one suggests dehydration.
Large fontanelles, separation of sutures, delayed closure of the fontanelles may be associated with raised intracranial pressure or other systemic disorders such as hypothyroidism and rickets.
zoom view
Fig. 1.1: Top of head – anterior fontanelle and cranial sutures
 
Ears
Position and configuration of the ears should be observed. Whilst abnormalities such as low setting of the ears is frequently associated with renal tract anomalies absence of an ear or non development of the auricle will require early referral to an otolaryngologist. It often requires the parent to hold the child on his or her lap and provide reassurance during the examination. Methods of doing this are illustrated in Figure 1.2. Parents are usually very competent in detecting hearing impairment. The exception to this is where the child is mentally retarded. All infants should be given a screening test for hearing at 6 months of age. Simple testing materials are required, e.g. a cup and spoon, high and low pitched rattles, devices to imitate bird or animal sounds, or even snapping of finger tips are usually effective if hearing is normal.
zoom view
Fig. 1.2: Method of restraining a child for examination of the ear
8
The sounds should be made quietly at a distance of 2 – 3 feet out of view of the child. By 6 months of age a child should be able to localise sound. To pass the screening test the child should turn and look directly at the source of the sound.
 
Eyes
These should be inspected for subconjuctival haemorrhages which are usually of little importance, for cataracts, for papilloedema and congenital abnormalities such as colobomata (Figs 1.3A and B). ‘Rocking’ the baby from the supine to vertical position often results in the eyes opening so they can be inspected. Squint is a condition in which early diagnosis and treatment is important. There are two simple tests which can be carried out to determine whether or not a squint is present.
zoom view
Figs 1.3A and B: A. Congenital cataract B. Papilloedema
  1. The position of the “corneal light reflection” should normally be in the centre of each pupil if the eyes are both aligned on a bright source of light, usually a pen torch. Should one eye be squinting then the reflection of the light from the cornea will not be centred in the pupil of that eye. It will be displaced outwards if the eye is convergent and inwards towards the nose if the eye is divergent. It may be displaced by such a large amount that it is seen over the iris or even over the sclera, where of course it may be rather more difficult to identify, but with such obvious squints the diagnosis is usually not in doubt.
  2. In the “cover test” one chooses an object of interest for the child, e.g. a brightly coloured toy with moving components. When the child is looking at the object of interest the eye thought to be straight is covered with an opaque card and the uncovered eye is observed to see whether it moves to take up fixation on the object of interest. If the child has a convergent squint then the eye will move laterally to take up fixation, and this is the usual situation since convergent squints are four times more common than divergent squints. If the eye were divergent it would move medially.
The commonest cause for apparent blindness in young children is developmental delay. Assessment of whether a young baby can see is notoriously difficult, Fixation should develop in the first week of life but an early negative response is of no value as the absence of convincing evidence of fixation is not synonymous with blindness. The failure to develop a fixation reflex results in ocular nystagmus, but these roving eye movements do not appear until the age of 3 months.
A misleading response may be obtained when a bright light stimulus is applied to a child preferably in a dimly lit room. The normal response is a blinking or “screwing up” the eyes and occasionally by withdrawing the head. This is a subcortical reflex response and may be present in babies despite them having cortical blindness. The absence of this response increases the probability of blindness.
 
Face
Abnormalities of facial development are usually obvious and an example is the infant with cleft lip. Associated with this there may be a cleft palate but full visual examination of the palate including the uvula is necessary to ensure that the palate is intact and there is not a submucous cleft of the soft palate or a posterior cleft. Submucous and soft palate clefts cannot be felt on palpation.9
 
Mouth
Inspection of the mouth should include visualisation of the palate, fauces and the dentition. A cleft lip is obvious but the palate must be visualised to exclude a cleft. The mouth is best opened by pressing down in the middle of the lower jaw. A baby is rarely born with teeth but if present these are almost always the lower central incisors. The soft palate should be inspected to exclude the possibility of a submucous cleft which could be suggested by a bifid uvula. Small fibromata are sometimes seen in the gums. They are white and seldom require treatment. These are normal. The lower jaw should be seen in profile as a receding chin (micrognathia) may be the cause of tongue swallowing or glossoptosis (Pierre Robin Syndrome) and it may be associated with a cleft palate.
 
Neck
Examination of the neck may reveal congenital goitre and midline cysts which may be thyroglossal or dermoid in origin. Lateral cysts which may be of branchial origin or sometimes there may be extensive swellings which may be cystic hygroma or lymphangiomata. In early infancy a sternomastoid tumour may be palpable in the mid region of the sternomastoid muscle. Associated with this there may be significant limitation of rotation and lateral flexion of the neck. Palpation along the clavicle will define any tenderness or swelling suggestive of recent or older fracture.
 
Chest
The shape, chest wall movement and the nature and rate of the breathing (30 to 40 per minute) as well as the presence of any indrawing of the sternum and rib cage should be noted. In a normal baby without respiratory or abdominal problems the abdomen moves freely during breathing and there is very little chest movement. Most of the movements of the breathing cycle are carried out by the movement of the diaphragm. The nipples and axilliary folds should be assessed to exclude conditions such as absent pectoral muscles.
 
Cardiovascular
Examination of the cardiovascular system of infants and children is carried out in a similar manner to that of adults. The examiner should always feel for femoral pulses and ascertain whether there is any radio-femoral or brachio-femoral delay as this would suggest the possibility of coarctation of the aorta. The most important factor in recording the blood pressure of children is to use a cuff of the correct size. The cuff should cover at least two thirds of the upper arm. If the cuff size is less than this a falsely high blood pressure reading may be obtained. In small infants relatively accurate systolic and diastolic pressures as well as mean arterial pressures can be obtained by use of the doppler method. The apex should be visible and palpable and the position noted. The precordial areas should be palpated for the presence of thrills. If the apex beat is not obvious look for it on the right side of the chest as there could be dextrocardia or a left-sided congenital diaphragmatic hernia with the heart pushed to the right or collapse of the right lung. All areas should be auscultated while the baby is quiet Systolic murmurs may be very harsh and can be confused with breath sounds.
 
Lungs
Small children frequently cry when the chest is percussed and when a cold stethoscope is applied. If the mother holds the child over her shoulder and soothes him it is often easier to perform a thorough chest examination. Light percussion can be more valuable than auscultation in some situations but the basic signs are similar to those found in an adult. Breath sounds are usually harsh, high pitched and rapid. Any adventitious sounds present are pathological. Percussion of the chest may be helpful to pick up the presence of a pleural effusion (stony dull), collapse, consolidation of a lung (dull) or a pneumothorax (hyper-resonant). These pathological states are usually associated with an increase in the respiratory rate, as well as clinical signs of respiratory distress.
 
Abdomen
In the infant the abdomen and umbilicus are inspected and attention should be paid to the presence of either a scaphoid abdomen which in a neonate may be one of the signs of diaphragmatic hernia or duodenal atresia or a distended abdomen which suggests intestinal obstruction especially if visible peristalsis can be seen. Peristalsis from left to right suggests a high intestinal obstruction whereas one from the right to the left would be more in keeping with low intestinal obstruction. Any asymmetry of the abdomen may indicate the presence of an underlying mass. Abdominal movement should be assessed and abdominal palpation should be performed with warm hands.
Palpation of the abdomen should include palpation for the liver, the edge of which is normally felt in the newborn baby, the spleen which can only be felt if it is pathological and the kidneys which can be felt in the first 24 hours with the fingers and thumb palpating in the renal angle and abdomen on each side. The lower abdomen should be palpated for the bladder and an enlargement can be confirmed by percussion from a resonant zone, progressing to a dull zone. In the baby with abdominal distension where there is suspicion of 10perforation and free gas in the abdomen, the loss of superficial liver dullness on percussion may be the only physical sign present early on. Areas of tenderness can be elicited by watching the baby's reaction to gentle palpation of the abdomen. There may be areas of erythema, cellulitis, oedema of the abdominal wall and on deeper palpation crepitus can occasionally be felt from pneumatosis intestinalis (intramural gas in the wall of the bowel).
Auscultation of the abdomen in the younger patients gives rather different signs than in the adult. The infant even in the presence of peritonitis may have some bowel sounds present. However, in the presence of ileus or peritonitis breath sounds become conducted down over the abdomen to the suprapubic area and in even more severe disorders the heart sounds similarly can be heard extending down over the abdomen to the suprapubic area.
Perineal examination is important in both sexes. Examination of the anus should never be omitted. Occasionally the anus is ectopic, e.g. placed more anteriorly than it should be, stenotic or even absent. The rectal examination is an invasive procedure and should be carried out in a comfortable warm environment, preferably with the child in the left lateral position and the mother holding the hand of the child at the top end of the bed.
The testes in boys born at term should be in the scrotum. The prepuce cannot be and should not be retracted. It is several months or years before the prepuce can be retracted and stretching is both harmful and unnecessary. In girls the labia should be separated and genitalia examined
The presence of a swelling in the scrotum or high in the groin may suggest torsion of a testis and requires urgent attention. The testis which cannot be palpated in the scrotum and cannot be manipulated into the sac, indicates the presence of an undescended testis which will need to be explored and corrected before the age of 2 years. A swelling in the scrotum which has a blueish hue to it suggests the presence of a hydrocele due to a patent processus vaginalis and one can get above such a swelling in most children. Palpation of the scrotum is initially for testes but if gonads are not present then palpation in the inguinal, femoral and perineal regions to determine presence of undescended or ectopic testes should be carried out.
Conditions such as hypospadias, epispadias, labial adhesions or imperforate hymen should be diagnosed on inspection.
 
Limbs
Upper and lower limbs are examined in detail. Hands and feet should be examined for signs and those experienced in dermatoglyphics may define a finger print pattern which is consistent in various syndromes. The presence of a simian palmar crease may suggest trisomy 21 (Down's Syndrome) and thumb clenching with neurological disease. The feet, ankles and knees should be examined for the range of movement in the joints and tone of the muscles. The femoral head may be outside the acetabulum at birth in true dislocation of the hip or it may be dislocated over the posterior lip of the acetabulum by manipulation, in which case the hip is described as unstable, dislocatable or lax. There are conditions in which the acetabulum is hypoplastic and shallow and the femoral head itself is distorted. Congenital dislocation of the hip is more common after breech deliveries in girls and in certain parts of the world. All newborn infants should be screened shortly after birth. The infant is placed supine with the legs towards the examiner and each hip is examined separately. The knee and hip of the baby are flexed to 90% and the hip fully abducted by placing the middle finger over the greater trochanter and the thumb on the inner side of the thigh opposite the position of the lesser trochanter. When the thigh is in the mid-abducted position, forward pressure is exerted behind the greater trochanter by the middle finger. The other hand holds the opposite femur and pelvis steady. A dislocated femoral head is felt to slip over the acetabular ridge and back into the acetabulum as a definite movement. This part of the test is called the Ortolani manouvre. The second part of the test is the Barlow procedure. With the infant still on his back and the legs and hands in the same position the hip is brought into the position of mid-abduction with the thumb exerting gentle pressure laterally and posteriorly; at the same time the palm exerts posterior and medial pressure. If a hip is dislocatable the femur can be felt to dislocate over the posterior lip of the acetabulum. There is need for caution in performing this test and no force should be employed. Caution is particularly required in infants born with neural tube defects and paralysis of the lower limbs.
The knees, ankles and feet should be examined. Dorsiflexion of the feet should allow the lateral border to come in contact with the peroneal compartment of the leg. Failure indicates a degree of talipes – equino-varus (TEV) which is of concern to the parents although with simple physiotherapy there are seldom longterm problems in the absence of underlying neurological abnormality.
 
Spine
With the baby held face-downwards fingers should be run along the spine excluding spinal defects such as spina bifida occulta and noting the presence of the common post-anal dimple, a tuft of hair, a pad of fat and haemangioma. A Mongolian blue spot is commonly seen over the sacrum in Asian babies. The presence of a posterior coccygeal dimple or a sacral pit is common in babies and is due to tethering of the skin to the coccyx. 11When one stretches the skin and the base of the pit can be seen then nothing needs to be done about it. Very rarely there is communication with the spinal canal which could be the source of infection and cause meningitis.
 
Stool and Urine Examination
Examination of a stool which is preferably fresh is often informative. The colour, consistency and smell are noted as well as the presence of blood or mucus. Urine examination is also important in children since symptoms related to the urinary tract may be non-specific.
 
Neurological Examination
The neurological examination of the young infant and child is different from that routinely carried out in the adult. Muscle tone and strength are important parts of the examination. In infants muscle tone may be influenced by the child's state of relaxation. An agitated hungry infant may appear to be hypertonic but when examined in a cheerful post-prandial state the tone reverts to being normal. The examination of the neurological system cannot be complete without the evaluation of the child's development level relating to gross motor, fine motor and vision, hearing and speech and social skills. All older children should be observed for gait to detect abnormal co-ordination and balance
Older children may be tested for sense of touch and proprioception as in adults. Tests of sensation as well as motor power must be performed in the paediatric patient but are difficult to assess in the very young child. The normal newborn has a large number of primitive reflexes (Moro, asymmetric tonic neck, glabellar tap, sucking and rooting process). The Moro-reflex is a mass reflex which is present in the early weeks after birth. Its absence suggests cerebral damage. It consists of throwing out of the arms followed by bringing them together in an embracing movement. It can be demonstrated by making a loud noise near the child. The sucking reflex is present at birth in the normal baby as is the swallowing reflex. If the angle of the baby's mouth is touched by the finger or teat the baby will turn his head towards it and search for it. It is looking for its mother's nipple and is known as the rooting or searching reflex.
The grasp reflex is illustrated by gently stroking the back of the hand so that the fingers extend and on placing a finger on the palm of the baby it takes a firm grip. Similar reflexes are present in the toes. If the baby is held up under the arms so that his feet are touching a firm surface he will raise one leg and hesitatingly put it down in front of the other leg, taking giant strides forwards. This is the primitive walking reflex.
Tendon reflexes such as the biceps and knee jerks are easily obtainable but the ankle and triceps jerks are not readily elicited. Important as an indication of nervous system malfunction are muscle tone, posture, movement and the primitive reflexes of the newborn that have been described. Plantar reflex is usually extensor and is of little diagnostic importance in the first year. Delay in disappearance of the primitive reflexes suggests cerebral damage.
 
A GUIDE TO EXAMINATION OF A CHILD-PATIENT
 
Checklist of Bodily Systems
GENERAL EXAMINATION
  • Is the child unwell, breathless or distressed?
  • Level of consciousness
  • Is the child cyanosed, pale or jaundiced (in carotinaemia the sclerae are not yellow)?
  • ENT examination: child's ears, nose and throat
  • Is the child dehydrated? – skin turgor, sunken eyes, sunken fontenelle
  • Nutritional state
  • Peripheral perfusion: capillary refill time-should occur within 2 secs
  • Does the child have any dysmorphic features, i.e. an obvious syndrome?
  • Check blood pressure, temperature and pulses, i.e. radial and femoral
  • Hands: for clubbing (look at all fingers), peripheral cyanosis, absent nails (ectodermal dysplasia), pitted nails (psoriasis), splinter haemorrhages
  • Height, weight and head circumference (OFC): plot these on a percentile chart
  • Rash: generalised or localised, bruises, petechiae, purpura, birth marks (learn dermatological termi-nology – (see Box on Page 7)
  • Abnormal pigmentation: café au lait spots, Mongolian blue spots
  • Palpate for lymph nodes in the neck (from behind), axillae, groins any subcutaneous nodules
  • Teeth: any dental caries, a torn lip frenulum (physical abuse)
  • Genitalia: injuries to genitalia or anus – sexual abuse
 
Head
  • Shape: normal, small (microcephaly, large (macro-ceohaly), plagiocephaly, brachycephaly, oxycephaly (turricephaly). Feel the sutures. Is there evidence of craniostenosis?
  • Hair: alopecia, seborrhoea of the scalp
  • Eyes: subconjunctival haemorrhage, ptosis, proptosis, squint, nystagmus, cataract, aniridia, optic fundi
  • Mouth: thrush, fauces, tonsils, teeth, palate12
  • Ears: normal, low-set, shape, pre-auricular skin tags
  • Anterior fontenelle: diamond shaped, open, closed, sunken, bulging, tense
  • Head circumference: measure the child's OFC and plot it on a growth chart (if not done under general examination)
 
Neck
Short, webbed (Turner syndrome), torticollis
Thyroid: enlarged, bruit
Swellings:
  1. Midline: thyroglossal cyst, goitre (Figs 1.4A and B)
  2. Lateral: lymph nodes, branchial cyst, cystic hygroma, sternomastoid tumour
zoom view
Fig. 1.4A and B: Goitre in Hashimotos thyroiditis – A. AP neck and B. lateral view neck
 
RESPIRATORY SYSTEM
 
Inspection
  • Use of accessory muscles of resp iration
  • Intercostal recession, any stridor, audible wheeze
  • Shape: normal, pectus carinatum (undue prominence of the sternum-pigeon chest,
  • Pectus excavatum (funnel chest), Harrison's sulci, hyperinflation (increased A-P diameter)
  • Count the respiratory rate
  • Scars of past surgery (look at the front and the back of the chest)
 
Palpation
  • Chest wall movement: Is it symmetrical?
  • Feel the trachea: central or deviated
  • Tactile vocal fremitus (over 5 years of age–ask the child to say 99)
 
Percussion
  • Percuss all areas: normal, resonant, hyper-resonant, dull (collapse, consolidation), stony dull (pleural effusion)
 
Auscultation
  • Air entry, vesicular (normal), absent breath sounds (pleural effusion), bronchial (consolidation)
  • Added sounds: wheeze, inspiratory or expiratory, crackles (fine versus coarse), pleural friction rub
  • Vocal resonance
 
CARDIOVASCULAR SYSTEM
 
Inspection
  • Are there features of Down's (ASD, VSD), Turner's (coarctation of the aorta), or Marfan's (aortic incompetence)
  • Cyanosis: peripheral, central
  • Hands: clubbing, splinter haemorrhages (endocarditis)
  • Oedema: praecordium, ankles, sacrum
  • Praecordium for scars of past surgery
 
Palpation
  • Pulses: radial/brachial/femoral – radio-femoral delay (synchrony of the two pulses), rate
  • Character of pulse-collapsing, volume
  • Heart rate-rhythm
  • Apex beat: position (normal position in children 4th–5th left intercostal space in the mid-clavicular line), beware of dextrocardia
  • Palpate for a parasternal heave and for precordial thrills13
 
PERCUSSION OF THE HEART IS NOT NORMALLY UNDERTAKEN IN CHILDREN
 
Auscultation
  • Listen to all four valve areas (apex, lower L sternal edge, upper L sternal edge, upper R sternal edge
  • Quality of heart sounds
  • Additional sounds, i.e. clicks, murmur (timing of the murmur)
  • Blood pressure – use a cuff that covers at least 2/3rd of the upper arm or use Doppler
 
GASTROINTESTINAL SYSTEM
 
Inspection
  • General distension
  • Superficial veins-direction of flow, striae, umbilicus
  • Masses, scars, visible peristalsis
 
Palpation and Percussion
  • First lightly palpate the entire abdomen, keep looking at the child's face all the time
  • Localised tenderness, rebound tenderness, rigidity
  • Masses
  • Ascites-percuss for the shifting dullness
  • Spleen, liver, kidneys
  • Hernial orifices
  • Genitalia (testes), anus (site)
 
Auscultation
Bowel sounds: absence implies ileus
 
NERVOUS SYSTEM
  • Level of consciousness
  • Right or left handed
  • Orientation, memory (past – present)
  • Speech
  • Posture
 
Cranial Nerve
1st
Smell-ability of each nostril to different smells
2nd
Visual acuity, visual fields, pupils (size, shape, reaction to light and consensual);
Fundoscopy – papilloedema, optic atrophy, cataract
3rd
Palsy-unilateral ptosis, fixed dilated pupil, eye down and out
4th
Palsy-diplopia on looking down and away from the affected side
5th
Palsy-motor – jaw deviates to the side of lesion
Sensory – corneal reflex lost
6th
Palsy – convergent squint
7th
Facial nerve lesions: weakness
Only the lower 2/3rd is affected in UMN lesions, but all of one side of the face in LMN lesions. Ask the child to screw-up eyes, raise eyebrows, blow out cheeks, show teeth
8th
Hearing, balance and posture
9th and 10th
Gag reflex – look at palatal movement
11th
Trapezii – shrug your shoulders
12th
Tongue movement – deviates to the side of lesion
 
Cerebellar Function
  • Jerk nystagmus (worse on gaze away from midline)
  • Truncal ataxia (if worse when eyes closed then lesion is of dorsal columns; not cerebellum)
  • Intention tremor – Ask the child to pick up a small object and watch for tremor
  • Past pointing – Ask the child to cover one eye with one hand and with the index finger of the other hand ask him to touch his nose and then touch your finger
  • Gait – Ask the child to walk normally and then walk heel – toe look for ataxic gait
 
LOCOMOTOR SYSTEM
 
Arms
  • Tone, muscle bulk, muscle power – oppose each movement
  • Joints: hands – swollen/tender MCP/PIP joints, test joints for hypermobility
  • Reflexes: biceps (C5,6) and triceps (C7,8) – compare both sides
  • Hand: ask child to squeeze your fingers/spread fingers,
  • Coordination: finger-nose touching
  • Sensation: test light touch
 
Legs
  • Tone, quadriceps/gastrocnemius bulk
  • Power – oppose each movement
  • Coordination – rub heel up and down shin (“heel – shin test”)
  • Joints: swollen, tender, patella tap test (effusion in knee)
  • Reflexes: knee (L3,4) ankle (S1,2), plantar reflex – the plantar is normally up-going in infants until they begin to walk
  • Feet: any deformity: are arches high or low?
 
Sensation
  • Joint position sense
  • Fine touch discrimination
 
Gait
Ask the child to walk normally across room14
 
Gower's Sign
Ask the child to stand from supine. A child will normally sit up from lying and then stand. In Duchenne muscular dystrophy, the child will have to roll over onto their front and then climb up their legs.
 
DEVELOPMENTAL ASSESSMENT
This should be carried out under four headings: gross motor, fine motor and vision, hearing and speech and social behaviour. These milestones are based for a child who is aged 6 weeks to 5 years.
 
Birth to 6 weeks
 
Gross Motor
Marked head lag at birth on pulling to sit. By 6 weeks moderate head lag on pull to sit prone, brings chin momentarily off couch.
 
Fine Motor and Vision
Can see at birth. By 6 weeks, can fix and follow across to 90°.
 
Hearing and Speech
Can hear at birth. Startles and quietens to a soothing voice.
 
Social Behaviour
Stops crying when picked up. By 6 weeks, smiling to familiar noises and faces.
 
3 to 6 Months
 
Gross Motor
By 3 months, on ventral suspension brings head above level of back. Prone lifts head and upper chest off couch. By 6 months, sits with support or tripod sits. Beginning to weight bear. Rises to stand when supported.
 
Fine motor and Vision
By 3 months, holds hands loosely open and has hand regard. By 6 months, reaches for toys with palmar grasp. Transfers hand-to-hand and hand-to-mouth.
 
Hearing and Speech
Can laugh, gurgle and coo. Starts to babble around 6 months. Will turn when called.
 
Social Behaviour
Holds on to bottle or feeding cup when fed. Frolics when played with. Examines and plays with hands and places feet in mouth.
 
6 to 9 months
 
Gross Motor
By 6 months can roll from front to back. Sits unsupported with a straight back. Begins to pivot around on arms and legs into the crawling position.
 
Fine Motor and Vision
Small objects picked up between index finger and thumb in a pincer grasp. Transfers from hand to hand.
 
Hearing and Speech
By 9 months, shouts to gain attention. Vocalises non-specific syllables such as “dada” and “mama”.
 
Social Behaviour
Turns when talked to. Resists when objects taken away. Tries to reach for objects out of reach. Likes to feed with fingers.
 
9 to 12 Months
 
Gross Motor
By 9–10 months most infants are crawling. 10% normal infants never crawl, but move around by rolling, padding or bottom shuffling. These children are often late walkers and may not walk alone until 2 years. By 9–12 months, begins to pull to standing and cruise.
 
Fine Motor and Vision
Will bang two cubes together. Looks for fallen objects.
 
Hearing and Speech
By 9–12 months, usually have 1 or 2 recognisable words in addition to “mama” and “dada”.
 
Social Behaviour
Enjoys imitative games such as clapping hands and waving goodbye. Shy with strangers until the end of the first year.15
 
12 – 18 Months
 
Gross Motor
By 12 months, can walk with hands held and begins to stand alone.
By 18 months, climbs onto chair and up stairs. Holds on to toys while walking.
 
Fine Motor and Vision
Pincer grip refined. Tiny objects can be picked up delicately. Points at objects with index finger. Can be persuaded to give objects to another on request. Builds a tower of two or three bricks.
 
Hearing and Speech
Vocabulary of several words. Comprehension is more advanced than speech at this age. Enjoys looking at pictures on a book and points and babbles while doing this.
 
Social Behaviour
By 12 months indicates wants, usually by pointing. Drinks from a cup and helps to feed themselves. Begins to help with dressing. Learns to throw. Enjoys simple games such as peek-a-boo.
 
2 Years
 
Gross Motor
Can walk, run, squat and climb stairs two feet per step.
 
Fine Motor and Vision
Builds tower of six or seven cubes. Spontaneous scribbling. Hand preference. Holds pencil with thumb and first two fingers. Imitates vertical lines.
 
Hearing and Speech
Uses 50 or more recognisable words and understands many more. Forms simple sentences. Carries out simple instructions.
 
Social Behaviour
Feeds with a spoon, drinks from a cup. Usually dry through day (variable). Demands mother's attention. Tantrums when frustrated. Instant gratification.
 
3 Years
 
Gross Motor
Climbs stairs one foot per step. Pedals a tricycle. Kicks a ball.
 
Fine Motor and Vision
Copies a circle, imitates a cross. Builds a tower of nine cubes. Threads beads.
 
Hearing and Speech
Speaks in sentences and may know a few colours. Recites nursery rhymes. Counts to 10.
 
Social Behaviour
Eats with fork and spoon. Dry through night. Likes to help in adult activities. Vivid imaginary play. Joins in play with others.
 
4 Years
 
Gross Motor
Walks up and down stairs one foot per step. May hop.
 
Fine Motor and Vision
Copies cross (also V T H O). Draws a man with head, legs and trunks. Picks up very small objects and threads beads. Knows four primary colours.
 
Hearing and Speech
Intelligible speech. Knows name, address and usually age.
Listens to and tells stories. Enjoys jokes.
 
Social Behaviour
May wash, dress, undress, but not yet manage laces. Understand taking turns, as well as sharing. Appreciates past, present and future time.
 
5 Years
 
Gross Motor
Catches a ball.
 
Fine Motor and Vision
Draws triangle and detailed man.
 
Hearing and Speech
Clear speech.
 
Social Behaviour
Comforts others, group play.