List of practical skills (module 2)

1. Assessment of physical development of child with percentile range ( BMI)

2. Determination of rigidity of occipital muscles, Kerning’s, Brudzinsky upper and other lower
symptoms, Lessage’s symptom.
3. Determination elasticity of skin
4. Assessment of the temperature & humidity of skin
5. Determination of thickness of subcutaneous tissue
6. Determination of turgor of skin & subcutaneous tissue.
7. Assessment of rash on the skin primary lesions: macula, patch, papule, plaque, nodule,
tumor,
vesicle, bulla, pustule (choose);
8. Assessment of rash on the skin secondary: pigmentation, crust, fissure, erosion, ulcer, scar,
lichenification, vegetation (choose)
9. Hemorrhagic rash
10. Determination of presence of edema
11. Examination of lymphatic nodes
12. Assessment of muscular strength of fingers of hand, hands, forearms, arm, upper shoulders.
13. Assessment of muscular tone
14. Inspection on fontanels. Determination of size of fontanels.
15. Estimation of joints
16. Estimation of posture state:
17. Determination of respiratory rate
18. Superefficient palpation of chest:
19. Assessment of vocal fremitus:
20. Deep palpation of chest
21. Comparative percussion on anterior side of chest, apex of lung, , lateral, posterior side of
chest
( apex of lung, intrascapular area, below scapular )
22. Character of percussion sound in norm above different organs.
23. Topographic percussion upper body of lung in anterior, upper border of lung in posterior,
inferior
border of lung on medclavicularis line, axillaries, scapular lines
24. Determination of width of Kroning’s area
25. Determination excursion of lung
26. Auscultation of lung point of auscultation, character of breathing sound in norm .
27. Adventidional sound
28. Bronchophony
29. Palpation of apex beat
30. Assessment of pulse on radial artery rate , rhythm, size, tension, filling
31. Palpation of apex beat and assessment of it characteristic location, extension, height ;
force).
32. Determination of relative and absolute dullness of heart
33. Auscultation of heart: points of auscultation, characteristic of heart sound in norm,
34. Extra heart sound
35. Murmurs and their characteristic
36. Investigation of arterial pressure on cubital arteries
37. Inspection of oral cavity
38. Superficial palpation of abdomen
39. Palpation of colon
40. Checking of symptom of gallbladder disorders
41. Checking of symptom of pancreas disorders
42. Palpation of liver
43. Palpation of spleen
44. Mendel’s symptom
45. Determination of liver border with percussion
46. Determination of symptom of appendicitis
47. Checking of Pasternatsky symptom
48. Assessment of urinal test
49. Assessment of Zimnytsky test
50. Assessment of Nechyporenko test
51. Assessment of bacteriuria
52. Assessment of CBC
53. Assessment of biochemical investigation of liver function
54. Assessment of coprological test

1. Assessment of physical development of child with percentile range ( BMI)

Body mass index (BMI) is a person’s weight in kilograms divided by the square of height in
meters. It is an inexpensive and easy-to-perform method of screening for weight categories
that may lead to health problems.
For children and teens, BMI is age- and sex-specific and is often referred to as BMI-for-age. In
children, a high amount of body fat can lead to weight-related diseases and other health issues.
Being underweight can also put one at risk for health issues.
A high BMI can indicate high body fatness. BMI does not measure body fat directly, but BMI is
correlated with more direct measures of body fat.

After BMI is calculated for children, it is expressed as a percentile obtained from either a graph
or a percentile calculator. These percentiles express a child’s BMI relative to children who
participated in national surveys. Weight and height change during growth and development, as
does their relation to body fatness. Consequently, a child’s BMI must be interpreted relative to
other children of the same sex and age.

BMI percentiles show how a child's measurements compare with others the same gender and age. For
example, if a child has a BMI in the 60th percentile, 60% of the kids of the same gender and age who
were measured had a lower BMI. BMI is not a direct measure of body fat.
2. Determination of rigidity of occipital muscles, Kerning’s, Brudzinsky upper and other lower
symptoms, Lessage’s symptom.

Kernih's - an attempt to unbend the leg, bowed in the knee and talocrural joints at a right angle (the
child is on its back), turns out to be impossible (physiological state up to the age of 4-6 months).

Brudzinskyi's (physiological state up to the age of 3-4 months) – the upper one: during the passive head
bowing the quick leg bowing in the knee and talocrural joints is observed;
 middle: if to press the thoracic region of an ill child with the palm edge, its legs are bending; low. during
the passive leg bowing in the knee and talocrural joints the other leg is bowed too.

Lessage’s: the child pulls legs to the stomach when lifted.

3. Determination elasticity of skin

Skin elasticity can be checked with a simple examination called the Snap Test. With your forefinger and
thumb, pinch your under-eye skin. If it snaps back quickly, it indicates good elasticity. If it takes time to
get back to its original position, it indicates low skin elasticity.

The measurement of skin elasticity is based on the so-called suction method. A negative pressure is
produced in the measuring head, and the skin is drawn inside the instrument.

An optical measuring system consisting of a light source and light receptor measures the light intensity,
which varies in accordance with the degree of skin penetration.

The two parameters measured are firmness and elasticity. Firmness is measured in terms of the
resistance that the skin displays against being drawn in by the negative pressure.

Elasticity is measured in terms of the time taken for the skin to return to its original state.

4. Assessment of temperature and humidity of skin

Skin temprature

hyperemia- physiological -climate eposure to sun and pathological- allergy fever

Inspect palm and soles

Humidity - increased moisture – autonomic dysfunction ,thyroid problems

Dryness- dehydration hypothyroidism, diabetes

Normal skin moist and warm.

Color of skin. Possible changes: paleness (true and false one), cyanosis (local and generalized one),
icterus (physiological icterus of newborns and pathologic one), hyperemia (physiological, developing
under the influence of either high or low temperatures, in psychical excitement or mechanic irritation of
skin, and pathologic); bronze color (adrenal glands chronic insufficiency). Primary: appear on visually
unchanged skin. They are:

5. Determination of thickness of subcutaneous tissue

(Ultrasound (US) provides the most accurate technique for thickness measurements of subcutaneous
adipose tissue (SAT) layers. This method was recently standardised using eight sites to capture SAT
patterning and allows distinguishing between fat and embedded fibrous structures.)
6. Determination of turgor of skin & subcutaneous tissue.
Skin turgor refers to the elasticity of your skin. When you pinch the skin on your arm, for
example, it should spring back into place with a second or two. Having poor skin turgor means it
takes longer for your skin to return to its usual position. It's often used as a way to check for
dehydration.

To check for skin turgor, the health care provider grasps the skin between two fingers so that it is
tented up. Commonly on the lower arm or abdomen is checked. The skin is held for a few seconds then
released. Skin with normal turgor snaps rapidly back to its normal position.

Most cases of poor skin turgor just require rehydration. Mild dehydration usually resolves after you
drink some water. However, more severe cases may need intravenous fluids. Some children find it easier
to tolerate nasogastric fluid therapy, which delivers fluids though a tube that goes through your nose.

Elasticity of skin is detected on back of the hand, anterior surface of the chest over ribs, in elbow bend.
Skin moisture is evaluated by stroking of skin with doctor’s fingers on symmetric parts of the body.
Normal skin is elastic, moderately moist and of normal temperature.
determination of thickness, of subcutaneous tissue, skin demography subcutaneous adipose tissue is
the most marked on face, extremities, chest and back. In this regions fatty layer reaches its maximal
development to 6-th week of life whereas on the abdomen – to 4 – 6-th months. In case of disease its
disappearing has an opposite direction: first of all from the abdomen, than – from extremities and trunk
and at last term – from face.

Fatty tissue distribution type depends on sexual specificity. Its accumulation in boys tends to a visceral
type (deposition of fat in the abdominal cavity, inside inner organs and in vessels’ tunics). In girls fat
deposition in lower segments of body, especially around the ties, prevails.

7. Assessment of rash on the skin primary lesions: macula, patch, papule, plaque,
nodule, tumor,vesicle, bulla, pustule (choose);
Primary: appear on visually unchanged skin. They are:

Nodule (nodulus): a non-cavernous element located in derma. Maybe of non-inflammation (atheroma,

lipoma) and inflammation (strophulus, leprosy, furuncle, carbuncle, erythema nodosum) genesis.

Bulb (urtica): a non-cavernous element (stands between cavernous and non-cavernous ones), forms as a
result of temporary surface blood vessels widening and liquid blood components release. Examples:
nettle rash, insects bites, nettle burns, allergic dermatosis.

Pustule (pustula): a non-cavity element with purulent content located in epidermis, derma or
subcutaneous layer. May be connected (osteofolliculitis, folliculitis, acne, and hydradenitis) and
disconnected (impetigo) with skin appendages; deep and superficial.

8. Assessment of rash on the skin secondary: pigmentation, crust, fissure, erosion,

ulcer, scar, lichenification, vegetation (choose)
Secondary: a stage of primary and secondary elements development.

Secondary pigmentation: skin colour change on the place of a previously existing

element.

• Crust – These are secondary elements, which are formed as a result of

drying up of different primary cavitary elements - vesicles, pustules, blisters, ulcers,

erosion, cracks, tubercles, and gum. Crust can have different color by their

etiological structure – serous – Crusta serosa, sanguine – Crusta hemorrhagica,

purulent – Crusta purulenta, seropurulent, etc.

• Erosion - is a superficial skin defect at the level of the epidermis with the

juicy bottom, and also on mucous membrana of oral cavity. Occurs as a result of
the opening of cavity elements (bubbles, blisters, abscesses). After healing, it does

not leave scars.

• Excoriatio is damage to the upper layers of the dermis, but it is deeper,

arising as a resulting of mechanical injury of skin (cracking, itching, bulla`s

scratching, eczema, etc.). Can leave сicatrix. Surface scratches heal without a trace.

Fissure (rhagades- superficial, fissure- deep) - usually formed in the folds

of the skin in the area of inguinal and axillary cavities, in the corners of the mouth,

between the fingers, behind the ears, etc. with inflammatory infiltration, dryness,

hyperkeratosis. Surface cracks heal without trace. Deep cracks leave scars on the

body.

• Ulcer - is a deep defect of the skin, subcutaneous tissue, sometimes down to

the deep organs. It can sometimes develop as a result of tissue necrosis. Occurs

after the collapse of tubercles, nodes and always leaves behind a scar. The shapes

and edges of the ulcer are different. Cicatrix is formed after the ulcer course, which

is the main distinctive attribute of ulcer from erosion sometimes very similar to it.

• Scar (cicatrix) is the presence of a coarse-fibred connective tissue formation

as a result of a deep skin defects. The surface and shape of the scars are different.

There are flat, hypertrophic, keloid and atrophic scars. There are scars, for example,

after deep burns, ulcers, after surgery, etc.

• Pigmentation - is the increased formation of melanin pigment in certain

areas of the skin. Occurs sometimes after the primary elements of the rash

(tubercles, nodules, vesicles, abscesses). Sometimes hyperpigmentation can also be

a result of secondary elements of the rash (ulcer, erosion).

• Lichenification - is dense, rather dry, thickened skin with non- standard

external structure. It is rough shagreen (shagreen leather), hyperpigmented skin.

Lichenification develops after chronic inflammation, usually accompanied by

itching (neurodermatitis, chronic eczema).

 • Vegetation - growth of skin in the form of villi and papilla at the bottom of

continuing primary or secondary inflammatory character rashes. Similar to cockish

comb (cock`s comb). Vegetation can be:

- gray, dry, moderately dense, covered with a thick horny layer

- pink or red, which releases serous or bloody fluid

- soft - a sign of the erosion of vegetation

- - hyperemic around, serous-purulent secretion, painful – these are sign of

infected vegetation. An example is a vegetative vesicle, sharpened warts,

at ulcerative processes.

9. Hemorrhagic rash
Petechiae are flat and look like pinpoint-sized red, brown, or purple dots. Clumps of them on your skin
look like a rash. But unlike many rashes, when you press on the spots they don't turn white.

Petechiae usually occur on the arms, legs, stomach, and buttocks. They don't itch

Petechiae are formed when tiny blood vessels called capillaries break open. When these blood vessels
break, blood leaks into your skin. Infections and reactions to medications are two common causes of
petechiae.

10. Determination of presence of edema

What are the signs and symptoms of Pediatric Edema?

● Increased abdominal size.

● Skin that appears shiny.
● Skin that retains a dimple (known as “pitting”) after being pressed for several seconds.
● Stretched skin.
● Swelling or puffiness of the tissue directly under the skin.

To determine the extent of the pitting edema, your doctor will push on your skin, measure the depth of
the indention, and record how long it takes for your skin to rebound back to its original position. They
will then grade it on a scale from 1-4.

Depending on the cause, treatments can include:

● elevating the swollen limb

● venous vascular procedures
● compression stockings if the cause is chronic and your doctor recommends them
● diuretics if the cause is due to congestive heart failure, liver, or kidney disease

11. Examination of lymphatic nodes

A physical exam is performed on your child. The healthcare provider will check the nodes in the neck,
behind the ears, under the arms, and in the groin. These nodes can often be felt from outside the body
when they are swollen. If an infection is suspected, the healthcare provider may order more tests as
needed.
lymph node examination is performed with circular motion, identifying pain, and swollen ganglia or
induration. For the anterior cervical lymph node exam, palpate the lymph nodes in the neck using
circular motion over the underlying tissues in each area.

Lymph nodes reach the largest total lymph node mass at the age of about 8–12 years and start to get
reduced with atrophy after adolescence. In young children, 2 cm in the neck, 1 cm in the axilla and 1.5
cm in the inguinal region are considered normal values and they do not require investigation.

12. Assessment of muscular strength of fingers of hand, hands, forearms, arm, upper
shoulders.
Muscular strength investigation is of great diagnostic importance in muscular system evaluation. It is
possible to do by trying to take off a toy from the child’s hands in younger children; elder children are
asked to make resistance when a doctor tries to extend an extremity. Conclusion about muscular
strength may be also composed on the basis of observing the child getting up from a pot, chair, floor,
walking, stepping over, going upstairs and downstairs, walking on heels or tiptoes, holding hands on a
head, etc.
13. Assessment of muscular tone
Muscle tone is assessed by asking the patient to relax completely while the examiner moves each joint
through the full range of flexion and extension. Patients vary in their ability to relax.

Signs and symptoms of low muscle tone

● seem limp when you lift them.

● have increased flexibility in their joints.
● have poor posture.
● get tired easily (have low endurance) because of the extra effort they have to put in to activate
their muscles or maintain their posture.
● not have much strength in their muscles.

(Resting muscle tone is important for maintaining normal posture, and provides support for the joints to
stabilize their position and help prevent sudden changes in the position. Muscle tone is increased in
upper motor neuron lesions, for example in cerebral cortical damage that occurs in cerebrovascular
accident.)

14. Inspection on fontanels. Determination of size of fontanels.

When assessing the fontanelles, use the flat pads of your fingers to palpate (gently feel) the surface of
the head. Ensure you make note of any retraction or bulging, as the normal fontanelle feels firm and flat
(not sunken or bulging).

15. Estimation of joints

Inspect the position of the joint at rest, its surface anatomy, contours, color, scar, size and muscle bulk,
and limb length.

Feel: Palpate for skin warmth, joint swelling, and tenderness. Swelling includes any increase in joint size
that alters the normal surface markings of the joint.

For example: In the feet, squeeze the row of metatarsophalangeal joints, assessing for the presence of
pain or tenderness. Palpate the small joints of the feet, assessing for the presence of tenderness, bony
or soft tissue swelling, or joint effusion.

16. Estimation of posture state:

Postural assessment entails observation of static posture for alignment and visual and palpable
assessment of paired anatomic landmarks for symmetry. • The patient is instructed to stand still, with
feet shoulder-width apart, face forward, and arms relaxed to the sides.
Adam's test: forward bend test for scoliosis screening. The patient stands and bends forward at the
waist. The examiner assesses for back symmetry from behind and beside the patient. Any back or rib
cage abnormalities, such as a rib hump (arrows), may be a sign of scoliosis.

17. Determination of respiratory rate

To find your child's breathing rate: When your baby is sleeping, count the number of times their
stomach rises and falls in 60 seconds. One rise and fall equals one breath.
18. Superefficient palpation of chest:
19. Assessment of vocal fremitus:
Vocal fremitus is a vibration transmitted through the body. It refers to the assessment of the lungs by
either the vibration intensity felt on the chest wall (tactile fremitus) and/or heard by a stethoscope on
the chest wall with certain spoken words (vocal resonance).

This is usually assessed by asking a patient to repeat a word such as "ninety-nine," while the healthcare
provider feels the chest wall.
20. Deep palpation of chest

● Palpate the apex beat

Palpate the apex beat with your fingers placed horizontally across the chest.

● Assess chest expansion

1. Place your hands on the child’s chest, inferior to the nipples.

2. Wrap your fingers around either side of the chest.

3. Bring your thumbs together in the midline, so that they touch.

4. Observe the movement of your thumbs (in healthy individuals they should move symmetrically
upwards/outwards during inspiration and symmetrically downwards/inwards during expiration).
21. Comparative percussion on anterior side of chest, apex of lung, , lateral, posterior side of
chest

Percussion of the chest involves listening to the volume and pitch of percussion notes across the chest
to identify underlying pathology. Correct technique is essential to generating effective percussion notes.

Warn the child before beginning percussion – ‘I’m going to play your chest like a drum!’

Perform percussion gently, comparing one side to the other.

Percussion is often not performed on younger children.

Percussion technique

1. Place your non-dominant hand on the child’s chest wall.

2. Position your middle finger over the area you want to percuss, firmly pressed against the chest wall.

3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s
middle finger using a swinging movement of the wrist.

4. The striking finger should be removed quickly, otherwise, you may muffle the resulting percussion
note.

Areas to percuss

Supraclavicular region: lung apices

Infraclavicular region

Chest wall: percuss over 3-4 locations bilaterally

Axilla
Comparative percussion is percussion of the symmetrical points of the chest

for determination of character of percutory sound, its symmetry. In comparative percussing the chest,
the anterior lung is percussed from apex to base, usually with the child in the supine or sitting position.
Each side of the chest is percussed in sequence in order to compare the sounds. At normally the sounds
should be same.

The task of comparative percussion is to compare percussion sounds over the lungs on the opposite
parts of the chest, and also on neighboring areas on the one side.

The technique of comparative percussion. The patient should be in a comfortable posture and
relaxed. The best position is standing or sitting. Patients with grave diseases should be percussed in
the lying posture. The room should be warm and protected from external noise.

Percussion consists of setting up vibrations in the chest wall by means of a sharp tap. The middle
finger of the left hand (pleximeter finger) is placed in close contact with the chest wall in the
intercostals space. A firm sharp tap is then made by the middle finger of the right hand (plexor finger)
kept at right angles to the pleximeter finger. Loud percussion (with a normal force of taping) is used.

All areas of the chest are percussed, that is, the front, both axillary regions, and back.

In anterior percussion, place pleximeter finger parallel to the clavicle in the right, in the left
suprascapular regions, and then along midclavicular line. On the left side percussion is carried out only
to the 3rd interspace, because underlying heart below this level changes percussion sound.
22. Character of percussion sound in norm above different organs.

The main types of sounds obtained by percussion: normal resonance, increase

of resonance – hyperresonance (tympanic) and decrease of resonance – dullness (dull, flatness, flat,
stone dull).

● Normal resonance is heard over all the lobes of the lungs that are not adjacent
to other organs.

● Dullness is heard beginning at the fifth interspace in the right midclavicular

line.

● Percussing downward to the end of the liver, a flat sound is heard because the liver no longer
overlies the air-filled lung.
● Cardiac dullness is felt over the left sternal border from the second to the fifth interspace
medially to the midclavicular line.
 ● Below the fifth interspace on the left side, tympany results from the air-filled stomach.
Deviations from these expected sounds are always recorded and reported.
● The pathological dullness is heard in cause of pneumonia, hydro-,
hemothorax, pulmonary edema, lung or mediastinal tumor.

● The bandbox (tympanic or hyperresonance) is heard in cause of: emphysema

of lungs, cavern of lung, abscess of lung, pneumothorax, bronchial asthma, asthmatic bronchitis.

23. Topographic percussion upper body of lung in anterior, upper border of lung in posterior,
inferior

Topographic percussion has following potential uses:

● determination of the upper borders (apices) of the lungs;

● determination of the lower borders of the lungs;
● determination of the excursion of the lower borders of the
lungs.

● Determine the upper borders of the lungs both anteriorly and

posteriorly. To assess location of the lung apex anteriorly, place pleximeter finger parallel to the clavicle
and move it gradually upwards and medially to dullness on the right side then on left one (Fig. 5).
Normally the upper level of the lung apices is 3-4 cm above clavicle.

● In order to determine the upper borders of the lungs apices posteriorly, place pleximeter finger
parallel to the scapular spine and move it gradually upwards to the point located 3-4 cm laterally
to the spinous process of the 7th cervical vertebra (C7). Normally, the upper level of the lungs
apices is about at the level of the C7.
The upper borders of the lungs can vary depending on the amount of air in the apices. In increased
airiness of the pulmonary tissue (emphysema, attack of the bronchial asthma) the apices increased inn
size and move upwards. In decreased airiness of the pulmonary tissue (presence of connective tissue in
the lungs as a result of inflammation in tuberculosis or pneumonia) the apices decreased inn size and
move downwards.

● In order to determine the lower lungs borders percussion is carried out along topographic lines.
First determine the lower border of the right lung anteriorly from second interspace along
parasternal and midclavicular lines (Fig. 6). Lateral percussion starts from the axillary fossa along
anterior axillary, midaxillary, and posterior axillary lines (Fig. 2.28). The patient should put his
hands behind the back of the head.
24. Determination of width of Kroning’s area
The width of Krenig’s area is a width of vesicular resonance over the surface
of the lung occupying the area from the clavicle to the scapular spine. Normally it is
about 3 – 5 cm.

25. Determination excursion of lung

Chest excursion in this study is defined as that circumferential measurement at the xiphoid level from
full forced expiration to absolute maximum inspiration. This differs from chest expansion which occurs
during inspiration and chest retraction which occurs during full forced expiration.
26. Auscultation of lung point of auscultation, character of breathing sound in norm

● Start by showing the child your stethoscope and demonstrate it on your own chest and/or on
one of their toys to familiarise them with this piece of equipment.

● Suggest listening to their chest, making sure the stethoscope diaphragm isn’t cold prior to it
making contact with the child.

● When auscultating the chest, it is important that you have a systematic approach that allows
you to compare each area on both the left and the right as you progress.

Technique

1. Ask the child to take ‘big breaths’ – some abnormal sounds may be inaudible if taking shallow breaths.

2. Position the diaphragm of the stethoscope over each of the relevant locations on the chest wall to
ensure all lung regions have been assessed and listen to the breathing sounds during inspiration and
expiration. Assess the quality and volume of breath sounds and note any added sounds.
3. Auscultate each side of the chest at each location to allow for direct comparison and increased
sensitivity at detecting local abnormalities.

27. Adventidional sound

• Crackles are small clicking, bubbling, or rattling sounds in the lungs. Rales result
from the passage of air through fluid or moisture. They are more pronounced when
the child takes a deep breath.
• Crepitation is a fine bubbling or crackling sound heard on auscultation, produced by
the presence of a very thin secretion in the alveolus, pathognomonic sing of
pneumonia. Heard over the lungs at peak of inspiration, when air reaches alveolus,
expands and the wall of alveolus separate.
• Rhonchi are sounds that resemble snoring. Rhonchi are continuous, since sound
being forced past an obstruction. They occur when air is blocked or becomes rough
through the large airways.
• Wheezes are continuous, high-pitched, musical, predominantly expiratory sounds
that are produced by air flowing through narrowed bronchi, causing fluttering and
resonance of the bronchial walls. Thus, they are caused by pathology leading to the
narrowing of bronchi, most commonly COPD, asthma, and bronchitis.
• pleural friction rub is a loud, dry, creaking or grating sound indicative of pleural
irritation. It is produced by the rubbing together of inflamed and roughened pleural
surfaces during respiration
28. Bronchophony
Bronchophony are also part of auscultation of the lungs. The resonant sound that is heard with the
stethoscope when the patient is asked to repeat “ninety nine” or “oneone-one”. Normally voice sounds
or vocal resonance is heard, but the syllables are indistinct. Sound depends on the loudness and the
depth of the patients voice and the conductivity of the lungs. Consolidation of the lung tissue produces
three types of abnormal voice sounds – whispers pectoriloquy, bronchophony and egophony. Egophony
is present when e sounds like a. Whispering pectoriloquy produces clearer sounding whispered words.

29. Palpation of apex beat

30. Assessment of pulse on radial artery rate , rhythm, size, tension, filling
31. Palpation of apex beat and assessment of it characteristic location,
extension, height ; force).
32. Determination of relative and absolute dullness of heart
33. Auscultation of heart: points of auscultation, characteristic of heart sound
in norm,
Characteristic I & II sound in all point of auscultation (in normally clear and rhythmic) Splitting
of heart sound, clicks, snaps, Characteristic of murmurs
34. Extra heart sound

35. Murmurs and their characteristic

36. Investigation of arterial pressure on cubital arteries

37. Inspection of oral cavity

The oral cavity in infants is small, the tongue is relatively thick and large, the lips are like a
trunk, the round muscle of the lips is well developed. The soft palate is located horizontally,
and the hard palate is broad and flat. Mucosa is fine, dry and well vascularized. The sucking
fat in the cheeks fills the mouth and helps to maintain negative pressure. The teeth are
absent.

38. Superficial palpation of abdomen

Superficial palpation. Palpation is carried out starting from the right iliac region in a
clockwise direction. Except when the pain is located on the right - in this case, palpation
begins on the left. Painfulness may indicate a pathology of a particular organ. Tension of the
abdominal wall (normally the abdominal wall is soft) usually occurs in pancreatitis,
appendicitis. Abdominal distension (tympanic) is a sign of meteorism. The enlargement of
internal organs may also be found during superficial palpation.

39. Palpation of colon

Sigmoid colon is palpated with the right hand (the left hand supporting the trunk in lumbar
area). In norm it is painless and has a smooth surface; the width is about 1-2 cm, soft,
mobile, murmurs are absent. Painfulness can be a sign of sigmoiditis, and its thickening —
a sign of colitis. The cecum (blind gut) is palpated in the right iliac area with the right hand.
In norm cecum is painless; its size is 3-3,5 cm, it is rather dense, its surface is smooth and
slightly moves. During pressing murmurs can be heard. Painfulness and absence of normal
mobility are the signs of its changing or inflammatory process. The ascending part of the
large intestine — transverse colon — is located above the umbilicus or 1-2 cm lower, it
moves upwards and downwards, soft, without murmurs, painless, with the thickness of 2-
2,5 cm. The descending colon is about 25 cm in length and passes down the left side of the
abdomen to the inlet of the lesser pelvis, where it becomes the sigmoid colon.

40. Checking of symptom of gallbladder disorders

Kerh’s point (the site of gallbladder projection) situated 1 cm below the place of crossing of
the right midclavicular line and the coastal arch. Pressing Kerh's point is painless in norm.
Painfulness determined during inhalation is called a positive Kerh’s symptom. --Lepine’s
sign is considered to be positive if pain is felt at percussion in specified Kehr’s point with
the third finger. --Ortner's sign is conducted by percussing the area of the coastal arches (at
first left and then right) with the hand. It is considered to be positive if pain appears on the
right (especially during inhalation). --Mussy’s sign (phrenicus symptom) is positive if pain
appears at pressing with a finger the site between the crura of the right
sternocleidomastoid muscle (n. phrenicus). --Murphy’s sign is useful for differentiating
pain in the right upper quadrant. Typically, it is positive in cholecystitis, but negative in
pyelonephritis, choledocholithiasis, and ascending cholangitis. The body is embraced with
the left hand in the area of the right flank and right
hypocostal area so that the thumb is placed down the Kehr’s point. During exhalation the
thumb is immediately immersed deeply inside. The child inhales after that. It is positive if
during inhalation pain appears in the Kehr’s point. --Boas’s sign is hyperesthesia (increased
or altered sensitivity) below the right scapula that can be a symptom in acute cholecystitis.
Pain during pressing the right side of the spine at the VIII thoracic vertebra indicates the
pathology of the gallbladder. Pain during the pressing the process transversus of the X-XII
thoracic vertebrae on the left is a symptom of the ulcer on the lesser curvature of the
stomach, on the right – a symptom of ulcer of the pyloric part and duodenum.

41. Checking of symptom of pancreas disorders

Desjardin’s point (1) is a point on the abdomen 5 to 7 cm from the umbilicus, on a line
joining it to the right axilla; it lies over the head of the pancreas. Painfulness in this point
corresponds to the head of the pancreas.
Mayo-Robson’s point (3) is situated on the junction of the medium and upper third of
bisector of the left squares. Painfulness in this point corresponds to the pancreas tail. The
Shaffar area (2) - the projection of the pancreatic head - is defined as follows. If we draw
the bisector of the angle formed by the front median line and the horizontal line drawn
through the navel, this zone is located at a distance of 3-5 cm from the navel between the
bisector of the angle and in front of the median line.

42. Palpation of liver

The finger of the right hand is placed at the level of the right midclavicular line almost
perpendicularly to the margin of the liver, 3-5 cm, sometimes 7-8 cm, below the right costal
arch. Bimanual palpation is used. The right hand is directed down, deep into the abdominal
cavity, moving closer and closer to the costal arch until the feeling of the margin of the liver.
In norm it is 0,5-3 cm lower the inferior margin of the right costal arch up to 5-7 years of
age. It does not protrude from under the coastal arch in older children. The liver is soft,
painless, its margin is sharpened in norm. The wall of the healthy liver is smooth

43. Palpation of spleen

Palpate either in supine or right lateral position • In right lateral position palpate spleen
with right hand with the left fund encircling the left lower ribs and pushing forwards. • To
avoid missing large spleen it is recommended to start palpating from the right iliac fossa,
the direction of enlargement of spleen being that way.

44. Mendel’s symptom

Mendel’s symptom is determined by slight percussion of epigastric zone. If pain appears,
the symptom is positive that can be the sign of such disorders as gastric ulcer, duodenitis,
duodenal ulcer

45. Determination of liver border with percussion

First, the lower border of liver is determined along the right midclavicular line by
percussion from below upwards, where a point is put down (A). Then the upper border of
the liver is determined (dull sound) by percussion from above downwards, beginning with
the 3th – 4th intercostal intervals along the right midclavicular line – second point is
marked (Б). The distance between these points is the first parameter of sizes of the liver
(I). The distance between the upper and inferior liver on midclavicular line. A horizontal
line is visually drawn from the second point (Б) – the place of its crossing with the front
forward median line is third point (B). After that relatively silent percussion is carried out
along the front median line from the umbilicus upwards up to the decrease of resonance –
the fourth point (Г). The distance between C and D is the second parameter of the sizes of
the liver (II). The distance between the upper and inferior borders of liver on front median
line.The percussion is carried out along the bisector of the angle between median line and
horizontal line (point B and Г till obtaining the dull sound, the fifth point is already marked
(Д). The distance between the received fifth and third points is the last parameter of the
liver sizes (III). The point Д may be determined by percussion along the left costal arch
upwards from level of the VIII-IX ribs up to the decrease of resonance.

46. Determination of symptom of appendicitis

The sign of appendicitis. Shchotkin-Blumberg’s symptom. The usual slow pressing on
abdominal wall can cause a bigger or smaller pain. Positive pain is an acutely increased
pain when taking away the hand suddenly, and means peritonitis, acute appendicitis.
Negative symptom means that intensity of pain does not change when the hand is taken
away. Rovsing’s symptom is a sign of appendicitis. If palpation of the left lower quadrant of
a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to
have a positive Rovsing's sign and may have appendicitis. In acute appendicitis, palpation
in the left iliac fossa may produce pain in the right iliac fossa. The pain arises almost at
pressing of the right iliac area, and increases at rising up the straightened right leg

47. Checking of Pasternatsky symptom

This is a slight beating percussion. A doctor places the palm on the loins in the projection of
kidney( it is the angle between XII rib and periphery edge of the long back muscles Then
doctor makes 2-3 slight beatings. The absence of the pain means that Pasternatsky’s sign is
negative, presence of pain – positive. It possible in patients with pyelonephritis,
glomerulonephritis.
48. Assessment of urinal test
49. Assessment of Zimnytsky test
Zimnitsky`s test determines the functional ability of kidneys to osmotic concentration and
osmotic dilution.
1. Daily volume of urine is determined ( in normal it is 2/3 -2/4 of volume of the taken
liquid or can be counted with using formula V=600 + 100 x (n-1), n- age. 2. The ratio
between day time ( first 4 portion) and night time (last 4 portions) diuresis that the index
of rhythm of kidneys activity during the day ( in normal 2:1) 3. Parameters of specific
gravity ( relative of density) the portions of urine an their change throughout the day –
maximal is the index of ability of kidneys to concentrate urine, and minimal –to dilute. The
normal parameters of specific gravity depend of age
Normally the difference between the maximal and minimal figures should not be less than
7. Hyposthenuria – low specific gravity in all portions (for example 1002- 1010) shows that
concentration kidneys function is decreased (renal insufficiency; period of disappearance
of edema, diabetes insipidus). Isosthenuria – variation of gravity very low (2-5 units). It
stays at the level of 1010 - 1012, that corresponds to the density of blood plasma. It shows
that the dilution and concentration function of kidneys are decreased (a serious form of the
disease – renal failure). Hypersthenuria – high specific gravity – 1025-1030 (a sign osmotic
dilution kidney function is decreased (chronic glomerulonephritis, diabetes mellitus).
Functional renal tests is performed for determination glomerular filtration and tubules
reabsorption - ( level of urea, creatinine, rest nitrogen in blood) Filtration clearance based
on endogenic creatinine (amount of plasma in millimeters, which can be completely
purified of the substance to the found within 1 minute). Electrolytes blood level
(assessment of the level of sodium and potassium in the blood serum) Level of total protein
and fraction of blood CBC (for evaluated of level of hemoglobin, white blood cells,
neutrophils, ESR).

50. Assessment of Nechyporenko test

test The urinalysis by Nechiporenko is detection the amount blood cells (and cylinders) in
1 ml of urine. According this method: the child collects a middle portion of the first morning
urine, not less than 10 ml in a clean vessel. The normal parameters are: leucocytes – not
more than 4000; erythrocytes-not more 1000, hyaline cylinders not more 250.

51. Assessment of bacteriuria

The presence of pathogenic bacteria in urine is a diagnostic sing of inflammatory process in
kidneys and urinary tracts. The urine is collected in a sterile vessel. It is necessary to wash
the child well before collecting the urine. It is desirable to take the midstream or end
portion of urine as the first part washes the external genital organs which always contain
various flora. After collecting the urine the container should be closed tightly. Minimum
amount of the collected urine is 1 ml and time from taking urine till giving to the
bacteriological laboratory should not exceed 2 hours. Result comes in 3-7 days. Diagnostic
evaluation:
- increasing the microbial number more than 50000 in 1 ml is irrefutable singe of
inflammation of kidneys and urinary tract - the result of 10000-50000 bacteria in 1 ml of
urine in the first analysis is sing for suspecting true bacteriuria (need repeated) - if result is
less than 10000 or negative – is normal

52. Assessment of CBC

Level of total protein and fraction of blood CBC (for evaluated of level of hemoglobin, white
blood cells, neutrophils, ESR).

53. Assessment of biochemical investigation of liver function

Biochemical blood test to determine liver function - cytolysis syndrome: an increase in the
content of ALT (alanine aminotransferase), AST (aspartate aminotransferase); - cholestasis
syndrome: an increase in the content of total bilirubin, cholesterol, γ-glutamyl
transpeptidase, usually observed with jaundice; - mesenchymal inflammation syndrome:
an increase in the content of immunoglobulins, an increase of thymol, a decrease in the
sublimate test; - syndrome of hepatic cell insufficiency: decrease in prothrombin index,
serum albumin concentration, cholesterol, total bilirubin; it is found in severe forms of
HCV. Violation of the synthetic function of the liver is manifested by a decrease in the
content of albumin, prothrombin, proconvertin and other coagulation factors, cholesterol,
phospholipids, lipoproteins

54. Assessment of coprological test

Macroscopic examination is used to detect abnormalities based on the shape, texture, color,
smell, presence of mucus, pus or blood in the feces. Chemical examination reveals the
presence of stercobilin, bilirubin, ammonia. Microscopic examination is used to assess the
degree of digestion of food, the presence of connective tissue, muscle fibers, neutral fat,
fatty acids, residues of fatty foods, indigestible cellulose, digestive cellulose, starch, mucus,
leukocytes, red blood cells, epithelium, protozoa, and worm eggs.

55 - assessment of biochemical investigation of renal function

Zimnitsky`s test determines the functional ability of kidneys to osmotic concentration and
osmotic dilution. 1. Daily volume of urine is determined ( in normal it is 2/3 -2/4 of volume
of the taken liquid or can be counted with using formula V=600 + 100 x (n-1), n- age. 2.
The ratio between day time ( first 4 portion) and night time (last 4 portions) diuresis that
the index of rhythm of kidneys activity during the day ( in normal 2:1) 3. Parameters of
specific gravity ( relative of density) the portions of urine an their change throughout the
day – maximal is the index of ability of kidneys to concentrate urine, and minimal –to
dilute. The normal parameters of specific gravity depend of age
Normally the difference between the maximal and minimal figures should not be less than
7. Hyposthenuria – low specific gravity in all portions (for example 1002- 1010) shows that
concentration kidneys function is decreased (renal insufficiency; period of disappearance
of edema, diabetes insipidus). Isosthenuria – variation of gravity very low (2-5 units). It
stays at the level of 1010 - 1012, that corresponds to the density of blood plasma. It shows
that the dilution and concentration function of kidneys are decreased (a serious form of the
disease – renal failure). Hypersthenuria – high specific gravity – 1025-1030 (a sign osmotic
dilution kidney function is decreased (chronic glomerulonephritis, diabetes mellitus).
Functional renal tests is performed for determination glomerular filtration and tubules
reabsorption - ( level of urea, creatinine, rest nitrogen in blood) Filtration clearance based
on endogenic creatinine (amount of plasma in millimeters, which can be completely
purified of the substance to the found within 1 minute). Electrolytes blood level
(assessment of the level of sodium and potassium in the blood serum) Level of total protein
and fraction of blood CBC (for evaluated of level of hemoglobin, white blood cells,
neutrophils, ESR)