Core Note Pediatrics a Systematic Guide to Physical Diagnosis &

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B E S U F E K A D A D A N E
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A SYSTEMATIC GUIDE TO PHYSICAL DIAGNOSIS & HISTORY MANUEL
CORE NOTE https://t.me/core_note

CORE NOTE PEDIATRICS & CHILD HEALTH
CORE NOTE
A SYSTEMATIC GUIDE TO PHYSICAL DIAGNOSIS &
HISTORY MANUEL
INCLUDING HISTORY & PHYSICAL EXAMINATION WRITTEN EXAM CASES

AND WARD CASE FOR PEDITRICS & CHILD HEALTH.
Author & Graphics Designer
Besufekad Adane
FIRST EDITION
Copyright © 2014/2021
All rights reserved!
CORE NOTE- Pediatrics and Child Health Page 1
II
Advice for Clinical One Student‘s

Always you have to consider these points:-
 First of all must know your patient.

 How to take history & physical examination.
 Presentation of physical findings
 Investigation & mgt. Principles
 Take detail histories of your patient

 Learn by experience how to establish rapport with the patient.
 Examine your patients starting from G/A up to neurological
examination.
 Normal lab. Investigations values.

 Common chief complaints (that found in the ward or other than your case)
 Clinical Procedures (Chest tube insertion, NG-tube, LP. . . . . .)
 How to manage your patients

 Surgical procedures or other . . .
CORE NOTE
 WOG
CORE NOTE- Pediatrics and Child Health III 2

Page
NOTICE
This is one package from CORE-NOTE‘S. As we all know, Medicine is an ever-changing

science. As new research and clinical experience broaden our knowledge, changes always
happens. The author of this work have checked with sources believed to be reliable in their
efforts to provide information that is complete and generally in accord with the standards
accepted at the time of publication. However, in view of the possibility of human error or
changes in medical sciences, neither the authors nor any other party who has been involved in
the preparation of this work warrants that the information contained herein is in every respect
accurate or complete, and I disclaim all responsibility for any errors or omissions or for the
results obtained from use of the information contained in this work. Readers are encouraged to
confirm the information contained herein with other standard sources (like Harrison for internal
medicine, Nelson for Pediatrics, Schwartz and Baily for Surgery and Gabbe, Williams, Novak,
Current for Gynecology, also don‘t forget to check guidelines for specific different cases).
Readers are advised and encouraged to check the new edition of standard Books. This book aim
is to lesser the load of medical school to clinical year students. Strongly this book recommended
for Clincal One students.
Dr. B E S U F E K A D A D A N E , MD
CORE NOTE- Pediatrics and Child Health PageIV

3
I. Notice………………………………………………………………………………………………………………….ii
II. Acknowledgement…………………………………………………………………………………...............iv
1. PART ONE: Clinical History Format…………………………………………………………………………..
2. PART TWO: Physical Examination Format……………………………….………………………………..
2.1. HEENT ………………………………………………………………………………………………………………………………..
2.2. Lymhoglandular System Examination………………………………………………………………………………....
2.3. Respiratory system Examination………………………………………………………………………………………….
2.4. Cardiovascular System Examination…………………………………………………………………………………….
2.5. Abdominal Examination………………………………………………………………………………………………………
2.6. Genitourinary System………………………………………………………………………………………………………….
2.7. Integumentary System…………………………………………………………………………………………………………
2.8. Musculoskeletal System………………………………………………………………………………………………………
2.9. Nervous System Examination………………………………………………………………………………………….…..
3. PART THREE: Newborn History Taking & Physical Examination…………………………………

4. PART FOUR: Common chief complaints…………………………………………………………………….
4.1. Cough………………………………………………………………………………………………………………………………..
4.2. Diarrhea……………………………………………………………………………………………………………………………
4.3. Stridor……………………………………………………………………………………………………………………………..
4.4. Wheeze……………………………………………………………………………………………………………………………
4.5. Genelazid Body Swelling………………………………………………………………………………………………….
4.6. Abnormal Body movement……………………………………………………………………………………………..
4.7. Developmental Delay………………………………………………………………………………………………………
4.8. Approach to SAM Pt………………………………………………………………………………………………………..
4.9. Dermatology…………………………………………………………………………………………………………………..
5. PART FIVE: Miscellaneous Topics………………………………………………………………………………
6. PART SIX: Triads and Tips………………………………………………………………………………………….
7. PART SEVEN: Anthropometric Interpretation…………………………………………………………..
8. Reference of Lab. Values……………………………………………………………………………………………
CORE NOTE- Pediatrics and Child Health Page 4 V

I am happy to bring out this for you. I’m grateful for those who contribute and
encourage me much in this book by giving constructive comments. This is due to
constant help and support of family & friends
Especially, I would like to thank Dr. Sirak Minale and mini-family’s
―Your single comment is constructive for the

next revised edition‖
CORE NOTE- Pediatrics and Child Health PageVI

5

PART 1
General History
 Introduce yourself by name and anticipated function in relation to the family
and child
 During the interview, it is important to convey to the parent interest in the
child as well as the illness.
 Allow the parent to talk freely at first and to express concerns in his or her own
words.
 Look directly either at the parent or the child intermittently or not only at the
writing instruments.
 IDENTIFICATION
 Name of the baby
 Age (hours, days, weeks, months, years)
 Sex
 Academic status
 Address
 Parental Name & age
 Parental occupation
 Ethnicity/religion- but not helpful in our setup because we are intermixed.

 Hospital Name, Ward, Bed number

 Mode of arrival
 Referral source
 Source of history
 Presence/Absences of Translator
Sample
This is Chaltu Mohammed, a 57 day old female infant born from Aminat Aba-fuad
and Mohammed Aba-bulgu who came from Doyo Bikila kebele Jimma zone. Both
are farmers. She was admitted to JUMC pediatrics and child health department
Level one ward room number 12 bed number 3 on 13/05/15 E.C. She was
transferred from NICU ward after she came here via ambulance with a referral
paper from Shenen Gibe hospital. The source of history is her mother without
language barrier and it seems reliable.
 PREVIOUS ADMISSION
 Ex: He has no Hx of P/A
If the Pt. has P/A history:

 Mention after you write Identification if it has no relation with the current
compliant or case.
 If the previous admission is related to the current illness, details could be

mentioned in appropriate place in the history of present illness.
 If the P/A is a detailed one, it should be explained in the section of PMSHx
(past medical & surgical Hx) or if it is directly related to the current illness, it
should be moved to the HPI.

Components of P/A
1. Date, year
2. Name of hospital
3. Location of hospital
4. Disease of admission &
5. Duration of stay
6. Ix & Rx
7. Outcome
For Instance
P/A: 1 years back (on November 03, 2012 E.C), she was Jimma University Medical
Center, Jimma, Ethiopia with a complaint of meconium aspiration. Blood and urine
sample was taken. She stayed for 6 days in hospital. She was given an unspecified IV
medication & discharged symptoms improved with appointment to come back after
a month.
 CHIEF COMPLAINT/S
 A brief statement in parents‘ own words of their main reason for seeking
medical advice (including duration).
 A brief statement of the reason why the patient was brought to be
seen.

 Expanding the question of "Why did you bring him?" to "What concerns you?"
allows the informant to focus on the complaint more accurately.
Components of c/c
1. Symptoms (not signs)
2. Localization
3. Duration (time)
4. Tempo (progression),
Common Chief Compliant
 Cough  Urine color/amount change
 Fast/difficult breathing  Abdominal pain/distension/swelling
 Failure to suck  Limping
 Jaundice  Joint pain/swelling
 Diarrhoea  Throat pain/difficulty of swallowing
 Vomiting  Difficulty of using the extremity
 Fever /extremities
 Skin rashes/lesions  Failure to grow / develop developmental
 Earache/discharge milestones
 Loss of consciousness  Defect / malformation in body part
 Seizure  Bleeding from body parts
 Body swelling  Failure to initiate / sustain breathing Etc. . .
 Shortness of breath
 HISTORY OF PRESENT ILLNESS

 Elaboration of the chief complaint with regard to:

 Onset
 Mode of onset
 Duration
 Characteristics
 Frequency/course of illness (progression)
 Aggravating / relieving factor (if any???)
for instance
Elaborate (characterize) each symptom LIKE THIS: e.g.
Fever:
 intermittent (as in malaria, kalazar) or continuous (as in lobar pneumonia)
Cough:
 Character- hacking, brassy, barking, paroxysmal, on-and off type
 Associated with: whoop, post-tussive vomiting, inspiratory stridor,
expiratory wheeze
 Dry or productive: sputum (very rare in children < 7 yrs of age) - describe
color, amount, odour (offensive smell), position dependence
Diarrhoea:
 Duration, frequency, consistency (formed, soft, loose, watery), content (mucus,
blood, bilious, ingested matter)
o N.B. Diarrhoea is defined as increased total daily stool output
• (> 10 g/Kg/24 hrs for infants and young children
• Or > 200 g/24 hrs for older children and adults)
• Or 3 or more episodes of loose stool per day
• Or 1 or more episodes of watery stool per day. It is usually associated
with increased water content of stool.

Chronic diarrhoea is defined as diarrhoea lasting for > 14 days (> 2 wks).
Pain:
 Type – Intermittent (colicky) or continuous pain;
 Character/quality:
A. Aching
B. Burning
C. Crushing, crampy
D. Dull
E. Sharp (opposite of dull)
F. Pleuritic (chest pain synchronized with respiration, as in pneumonia)
G. Squeezing (as in ischemic heart disease, IHD) – for adult
 Location: e.g. pain location:
 exact site of pain
 radiation (areas of spread)
 extent & manner of radiation.
Pertinent positive & negative statements

Elaborate and characterized in detail . . . . . . all symptoms that the patient has.
 Associated symptoms
 Any treatment the patient received for the complaint (type, duration, outcome)
 Other possible causes (DDx)
 Predisposing factor
 Complications
 Known Personal or family hx of comorbidities (Cardiac illness, asthma, Renal
diseases . . . . . . .
 Inclusion of other important historical parts
Example for HPI

"The child was well until "X" number of days before this visit." This is followed by a
daily documentation of events leading up to the present time, including signs,
symptoms, and treatment, if any
 NUTRITIONAL HISTORY
 Breast feeding
 Time of initiation of breast feeding
 Duration of exclusive breast feeding
 Frequency of breast feeding
 Any pre-lacteal feeding
 Total duration of breast feeding
 Complementary feeding
 Time of initiation of complimentary feeding
 Type/composition, amount, frequency of complimentary feeding
 Mode of administration of complementary feeding ( cup, spoon, bottle, self-
feeding, sharing plate with others?)
 Current feeding
 Exposure to sun light (when started/ how often/ how/for how long/if not, why
not?)
(Especially Breast feeding hx and initiation of complementary feeding are important
in under 2 year‘s children)
 Current nutrition:
 Staple food, type of food; composition of food (e.g. milk - full strength (milk
alone) or half strength (water & milk 50 % each);
 Amount

 Frequency of meals per day

 Does the child finish his dish
 Does he share dishes with siblings
 DEVELOPMENTAL HISTORY
 Age specific developmental milestones
 All the four spheres of development:
 Gross motor
 Fine motor
 Language
 Cognition
Gross motor
 Head support-2months
 Brings hands at midline-3months
 Sits with support-5mos
 Sits without support-6mos
 Creeps-7mos
 Crawls-8mos
 Walks without support-12mos
 Runs-16mos Etc. . . . .
Fine motor
 Reaches for an object-4mos

 Palmar grasp disappears-4mos
 Transfers object from one hand to the other-5.5mos
 Turns page of a book-12mos Etc. . . . . .
Language
 Smiles in response to face/voice-1.5mos
 Monosyllabic bubbles-6mos (―eh, ah, oh‖)
 Says mama/dada-10mos (bubbling)
 Speaks real word-12mos
 Speaks 4 to 6 words-15mos
 Speaks 10 to 15 words-18mos
 Speaks two word sentences-19mos Etc. ......
Cognition
 Stares momentarily at spot where object disappeared-2mos
 Stares at own hand-4mos
 Uncovers a toy-8mos
 Handles spoon-24mos Etc. . . . . .

Summery in Developmental Milestones:

Age Developmental Milestones
1 Month Watches person; follows moving object,
2 months Smiles on social contact; listens to voice and
coos,
3 months Lifts head and chest, reaches toward and
misses objects,
4 months hands in midline; Stares at own hand, reaches
and grasps objects and brings them to mouth,
Laughs out loud;
5-6 months Rolls over
6-7 months Sits without support, Transfers object hand to
hand
8-9 months Crawls, pincer grasp
12 months Speaks first real word, A few words besides
―mama,‖ ―dada‖, releases object to other person
on request or gesture, Walks with one hand held
(48 wk); rises independently
15-18 months Scribbles, Builds tower of two cubes, Speaks 4–
20 words, comes when called, Runs stiffly
24-30 months Runs well, walks up and down stairs, one step at
a time, jumps, imitates horizontal
stroke(24mths), Refers to self by pronoun ―I‖;
knows full name(36mths),
36 months Rides tricycle; stands momentarily on one foot,
copies a circle, Knows age and sex; counts 3
objects correctly; repeats 3 numbers or a
sentence of 6 syllables
48 months Hops, copies cross and square; draws a man
with 2 to 4 parts besides head; names longer of
2 lines, Counts 4 pennies accurately;
60 months Draws triangle from copy; names heavier of 2
weights, Names 4 colors; repeats sentence of 10
syllables; counts 10 pennies correctly, asks
questions about meaning of words, Hops on one
foot, knows address and mothers name.

Developmental Millstone for Children with Down

syndrome
Self Help Skills

 Immunization history
 If immunization card available, see which vaccines are given
 If immunization card not available, ask if the child has received age
appropriate vaccination or not.
 If child didn‘t receive, ask why?
 Then classify the child as fully vaccinated/partially vaccinated/not vaccinated
at all
15 month | 6 | Measles 2nd Dose

 PERSONAL, FAMILY & SOCIAL HISTORY

 FAMILY HISTORY
 Family Size, Number of Siblings in the Family (age, sex, health status),
Birth order and their Health Status
 Any Death in the Family: cause and time of Death
 Presence of Family Diseases: like HTN, DM, Epilepsy, Genetic Disorders…
 Presence of Similar illnesses or communicable diseases in the Family.
 PERSONAL & SOCIAL HISTORY
 School attendance & performance
 Engagement in any activity (looking after cattle, fetching water, farming,
etc.)
 Housing condition
 Type of house
 Number of rooms
 Number of doors/windows
 Isolated kitchen or no
 Isolated room for cattle or no
 Water source
 Waste disposal system
 Parental Occupation, Marital Status, Monthly Income, Educational
Background
 PERINATAL HISTORY
 Ante-natal
 Natal
 Post-natal
 Gravidity & parity
 Gestational age
 Any previous bad obstetric Hx
 ANC follow up
 Number of visits
 Any Ix done
 Any Rx given
 Any vaccination
 Any medical disorder
 Duration of labor
 Duration of ROM
 Place of delivery
 Mode of delivery

 APGAR score
 Color of baby
 Birth weight
Review of Systems/Functional Inquiry

General: Constitutional Symptoms like: - recent changes in Weight, Night Sweats,
Weakness, fatigue, fever…
 HEENT:
 Head: Headache, head injury, dizziness,
 Ears: Hearing loss, tinnitus, vertigo, earaches, discharge.
 Eyes: pain, redness, excessive tearing, double vision, blurred vision.
 Nose: Frequent colds, nasal stuffiness, discharge, or itching, nosebleeds.
 Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums,
sore tongue, dry mouth, frequent sore throats, Difficulty of Swallowing,
hoarseness.
 Respiratory:
 Cough, sputum (color, quantity),
 Difficulty of Breathing, Chest Pain, Wheezing…
 Cardiovascular:
 Chest pain or discomfort,
 Palpitations,
 dyspnea, orthopnea, Paroxysmal nocturnal dyspnea,
 Edema,
 Cyanosis,
 Squating,
 Easy fatigability on Breast feeding.
 Gastrointestinal:
 Difficulty of swallowing,
 Loss of appetite,
 Nausea, & Vomiting,
 Change in bowel habits, constipation,
 Change in Color of Stool, diarrhea,
 Abdominal pain, abdominal Distension,
 Food intolerance,
 Excessive belching or passing of gas,
 Jaundice.
 Genitourinary:
 Frequency of urination,
 Polyuria,
 Nocturia,
 Urgency,
 Burning or pain on urination,
 Change in color of Urine,
 Incontinence
 Integumentary:
 Rashes,
 lumps,
 sores,
 itching,
 color change,
 changes in hair or nails.
 Musculoskeletal:
 Presence of any swelling,
 pain,
 weakness, or limitation of motion or activity,

 Deformity of Joint or Extremity.
 Central Nervous System:
 Fainting & seizures,
 headache,
 paralysis,
 numbness,
 Abnormal body movement.

PART 2
Physical Examination
 Examination of the infant and young child begins with observing him or her
and establishing rapport.
 The order of the examination should fit the age of the child and the
circumstances.
 Complete first those parts of the examination that require the child's
cooperation.
 Painful or disagreeable procedures should be deferred to the end of the
examination, and these should be explained to the child before proceeding.
 For the older child and adolescent, examination can begin with the head and
conclude with the nervous system examination.
 Examine painful body part at the end of the examination
GENERAL APPEARANCE
Four Components
1. Health Status (Sick looking or not?)
2. Mental Status

 Level consciousness: Conscious, alert, lethargic, comatose

 Behaviour/Mood: level of activities, reaction to stress, interaction with
others
• apathetic, irritable
 Orientation of the patient
3. Nutritional status: well-nourished, emaciated
4. Other Features in the face:
 Any dysmorphic feature
 Any obvious swelling (on the face) and color
 Hygiene
A. Health Status
 Well looking
 Acute sick looking
 Chronically sick looking
 Acute on chronic sick looking
How to Report?
 Well looking: when you look the pt. if he looks well conscious, cooperative
comfortable (not in pain) and healthy you can say well looking.
 Acute sick looking: Pain, bleeding, SOB and signs of CRD, Posture
(decorticate or decerebrate), Abnormal Body Mov.t & Loss of Consciousness.
1. Signs of Cardio-respiratory distress: SOB, stridor, on intranasal oxygen,
nasal flairing, intracoastal/subcoastal retractions, use of accessory muscle
(contraction of SCM or Trapezius muscle during breathing)
 Chronically sick looking: if the pt. wasted(emaciated body habitus/cachexia)
• Check the prominent zygoma
• Check ribs and arm

 Acute on chronic sick looking: when the pt. with pain and wasted
 Acute signs on chronic-sick looking patient.
VITAL SIGNS
 PR / HR
 By using fingers while the arm is pronated to relax the fascia at the cubital fossa
and thus to avoid the stretch of the brachial artery.
DIFFERENCE BETWEEN HEART RATE AND PULSE RATE
HEART Pulse
Is the speed of the heart
RATE measured by the number of rate Is the number of times the
blood flows from the
contractions of the heart capillaries that are caused
per minute (BPM). The due to the contractions in a
heart rate can vary minute. A pulse rate can
accounting to the body’s be accurately measured
physical needs from the earlobe.
/ .
- New-born 120-160
- Infants (1-12months): 80-140
- Toddler (1-3yrs): 80-130)
- Pre-Schooler (3-5yrs): 80-120
Source: from Paediatrics’ Guideline 2016

Source: from Nelson 21th Edition
How to Comment On the Pulse
Rhythm
a. Regular
b. Regularly irregular – ectopic beats,
c. Irregularly irregular – atrial fibrillation,
 Respiratory Rate
 Fast breathing
 Age < 2months ≥ 60‘

 Age 2-12months ≥50‘

 Age 12months-5yrs ≥40‘
 Age 5-8yrs ≥30‘
 Age ≥8yrs ≥24
 Blood Pressure:
 Begin routine BP measurement at 3 years of age, but we measure when
indicated (<3yr.)
- Use Correct cuff size depends on arm size.
Indications for Blood Pressure Evaluation
# Symptomatic Patients # Encephalopathy
 headaches  Vomiting
 dizziness  temperature elevation
 visual change  Ataxia
 seizures  Stupor
 acute seizures

# Chronic Conditions # Acute Conditions

 renal disease  Seizures
 cardiac disease  head injury
 growth failure  poisonings
 seizure disorder  urinary changes
How to take a BP
The child should be calm and still when you take his or her BP. Try to keep your
child from crying, because crying makes the blood pressure higher.
1. Remove all clothing from your child arm
2. Turn the valve on the bulb counterclockwise (to the left). Press all of the
air out of the cuff
3. Place the bottom edge of the cuff about 1 inch above your child’s elbow
4. Arm stretch & rest his arm on bed or table
5. Place the gauge at your eye level
6. Place earpieces of the stethoscope into your ears.

7. Have your child relax his arm & hand. Press your fingertips on the skin at
inner bend child’s elbow to find the child pulse.
8. Place the diaphragm of the stethoscope at the spot where you feel the pulse
9. Turn the valve on the bulb clockwise (to the right) until it will turn no
further.
10.Inflate the cuff rapidly (pump it up with air) by repeatedly squeezing the
bulb. Inflate the cuff to _____ mm. of mercury reading on the pressure
gauge.
11.Deflate the cuff slowly. To do this, slowly turn the valve counter clockwise
to release the air. Let the needle on the gauge move at an even rate of
about 2 mm. (one marking) per second.
12.As you deflate the cuff, these are the 2 sounds you will listen for: (1) clear,
faint tapping (first beat heard) and (2) last beat heard
13.If you take the blood pressure a second time to double-check your reading,
let your child's arm rest 2 minutes before inflating the cuff again.
Definition of Hypertension (1–18 years)
Changes in HTN categorization compared to the Report:
- BP >90th percentile now termed ‗elevated BP‘

- BP cut-points for Stage 1 and 2 HTN simplified
- BP cut-points for adolescents ≥13 years of age are the same as in new
AHA/ACC adult HTN guideline
TABLE: Updated Definitions of BP Categories and Stages

For Children Aged 1–13 yrs For Children Aged ≥13 yrs
Normal BP: <90th percentile Normal BP: <120/<80 mm Hg

Elevated BP: ≥90th percentile to <95th Elevated BP: 120/<80 to 129/<80 mm Hg

percentile or 120/80 mm Hg to <95th percentile
(whichever is lower)
Stage 1 HTN: ≥95th percentile to <95th Stage 1 HTN: 130/80 to 139/89 mm Hg
percentile + 12 mmHg, or 130/80 to 139/89 mm
Hg (whichever is lower)
Stage 2 HTN: ≥95th percentile + 12 mm Hg, or Stage 2 HTN: ≥140/90 mm Hg
≥140/90 mm Hg (whichever is lower)
Check the interpretation from CORE NOTE – Pediatrics HandBook
 Temperature
Normal - 36.5-37.4O Celsius
 LGF - 37.5-38.4O Celsius
 HGF -  38.5OC
Hypothermia - <36.4OC
 36-36.4 = mild hypothermia
 32-35.9 = moderate hypothermia
 <32 = sever hypothermia
NB: all patients came with High grade fever we should have to treat the patient
because fever can affect the respiratory rate of the patient.
Oxygen Saturation:
 Normal arterial O2 is to 100mmHg. Value under 60mmHg usually
indicate the need for supplemental O2
 Normal pulse oximetry readings usually range from 95%-100%. Values
under 90% are considered as low.
 Example:

 97% on 100% oxygen

 98% on room air.

ANTHROPOMETRY
 Weight (kg), circumference (cm) Height (cm), Head Circumference (cm), Chest
Circumference (cm). Compare these to standard growth charts
Estimation of wt. gain

Age Wt.(Kg)
At birth 3.25
3-12months
1-6yr Age(yr.) x 2 +8
7-12yr
Simple Weight Calculation

 4-5 months = 2 × birth weight
 1 year = 3 × birth weight
 2 years = 4 × birth weight
 7 years = 7 × birth weight
 10 years = 10 × birth weight.
Newborn
 10% birth weight lost initially in first 5-7 days
 Regains birth weight by 10 days then,
 1st three months—30 grams/day
 3-6 months—20 grams/day
 6-12 months—15 grams/day

 1-3 years—3 kg/year

 3-12 years—2 kg/year.
Height Estimation
Age cm.
At birth 50
At 1yr 75
2-12yr
BMI =
<18.5 Underweight Weight (kg)
18.5-24.9 Normal Height (m2)
25-29.9 Overweight
30-34.9 Class 1 obesity

35-39.9 Class 2 obesity
≥40 Class 3 /extreme /morbid obesity
Head Circumference
• The head circumference of infants should be measured during the first 2
years of life, but measurement can be useful at any age to assess growth of
the head.
• The average rate of head growth in a healthy premature infant is

 0.5 cm in the first 2 wk,

 0.75 cm in the 3rd wk,

 1.0 cm in the 4th wk and every week thereafter until the 40th wk
of development.
• Term infant: 44 cm at 6month, 47 at 1yr

 Head circumference at birth: 35 cm
 Chest circumference at birth: 30.5 to 33cm
- Increases:
 ≈2 cm /month during the 1st 3 months
 ½ cm/month during the next 9 months of age.
< -3SD Microcephaly
< -2SD Small head
- 2SD - +2SD Normal
> +2SD Large head
>3SD Macrocephaly
 MUAC (age 6mos to 5yrs or length > 65cm)
 <11.5cm = Severe malnutrition
 11.5-12.5 = Moderate malnutrition
 12.5-13.5 = Mild malnutrition
 >13.5cm = Normal
Record all of them
1 Wt ? WFA ?
2 Ht /L HFA ? ?
3 MUAC (6mo-5yr) WFH ? ?
4 HC (0-2 yr) HC/A ? ?
5 BMI (Kg/m2) ?

Measuring Height
Measuring Head Circumference
Measuring Weight
Measuring MUAC
Refer an anthropometric interpretation part for interpretation

HEENT
HEAD:
Look for
A. Shape & size of the head
 Look for:- Frontal boosing, Hydrocephalous, Micro/Macrocephaly
B. Hair –
 Look for: - amount, color, texture, distribution, pluckablity
C. Fontanelles –
1. Size
 Posterior fontanel (triangular shape) is (1x1 cm) closed at the age of
2 months / (6-8wk)
 Anterior fontanel (diamond shaped) is (2x2±1 cm), maximally
enlarged & closed at the age of 6 months &18 months respectively
2. Sunkening/bulging of fontanels
D. Sutures - diastases / over riding
Differential Diagnosis
BULGING ANTERIOR FONTANEL
 Physiological: Crying infant
 Drugs: Tetracycline, Vitamin A, Corticosteroid (following cessation) and
Nalidixic acid

 Hyperparathyroidism/Vitamin D dependent rickets/Congenital
hypophosphatasia
 Raised intracranial tension (meningitis, intracranial bleeding, tumor,
pseudotumor cerebri, etc.)
 Hydrocephalus
Frontal bossing
 Rickets
 Thalasemia major
 Congenital syphilis
 Achondroplasia
 Hurler‘s syndrome
Depressed Fontanel
 Dehydration
CRANIOTABES
Craniotabes refers to softened bones which can be indented like a ping-pong ball.
The sign should be elicited away from the suture line. It is normally elicitable in
preterm babies.
 Physiological
 Rickets
 Congenital syphilis
 Hydrocephalus
 Osteogenesis imperfect
 Lacunar skull
Microcephaly
 Severe malnutrition
 RVI
 TORCHS infection
 Hyperthyroidism
 Craniosynstosis
 Chromosomal abnormalities ( Patau or Edward syndrome)
 Zika virus
LARGE HEAD (MACROCEPHALY)
Megalencephaly:
 Hydrocephalus, Storage disorders, Achondroplasia, Gigantism,

Neurofibromatosis.
 Subdural hematoma
 Intracranial SOL
 Arachnoid Cyst
Skeletal disorders: Achondroplasia, Pyknodysostosis, Cleidocranial dysostosis,

Hurler‘s syndrome.

EYE EXAMINATION
c

EYE:
Look for
A. General
1. Slant of palpebral fissures
2. Strabismus, Proptosis, Ptosis.
3. Hypertelorism or telecanthus
4. Lid lag, exophthalmos (as in thyrotoxicosis)
5. Sunset eyes
 Hydrocephalus,
6. Periorbital swelling
 Nephrotic syndrome, kwashiorkor . . . .

7. Sunken eyes
 Dehydration, marasmus. . .
8. Excessive tearing / discharge
 Conjunctivitis, keratitis
B. Conjunctivae: Pink/pale Conjunctiva
C. Color of sclera: icteric sclera or non-icteric sclera

DDx
Ptosis:- is unilateral or bilateral drooping of eyelid
 Congenital
 Oculomotor palsy (ptosis with mydriasis)
 Horner‘s syndrome (ptosis, enophthalmos, miosis and lack of
sweating)
 Myasthenia gravis
 Botulism
 Local lesion like edema of eyelid.
CATARACT
 Prematurity
 Hereditary
 Chromosomal anomalies
 13, 18 and 21 Trisomy.
 Turner‘s syndrome.
 Developmental anomalies: Persistent strand of papillary membrane
 Intrauterine infections:
 Rubella.
 Metabolic causes:
 Galactosemia, Juvenile Diabetes Mellitus, Hypoparathyroidism,
Wilson‘s disease, Mucopolysaccharidosis.
 Miscellaneous: Steroids, Penetrating injury, Radiation

EAR, NOSECORE&NOTE
MOUTH/THROAT
PEDIATRICS & CHILD HEALTH
EXAMINATION

EAR:
Look for
Examination of the ear

Inspection
 Size & position of the ear
• Set of the Ear:- normal, low or high
 Inspect the pinna and the surrounding skin
• Skin color change
• Pinna abnormalities
• Swelling
 Foreign bodies
Palpation
 Hot, tender post-auricular swelling suggests mastoiditis
 Notice for tragus tenderness (tenderness on pulling the tragus suggests middle
ear infection) and mastoid tenderness
Otoscopic examination
 Hold the otoscope like a pen between thumb and index finger with ulnar
border of hand resting against the side of pt‗s head
 Retract the pinna backwards and upwards to straighten the external meatus into
line with the bony canal
 Light is reflected from intact tympanic membrane at lower end down ward and
forwards to its periphery
 Visualize for ear discharge, impacted wax, and membrane perforation

Age Signs That an Infant Can Hear

0–2 months Startle response and blink to a sudden noise
Calming down with soothing voice or music
2–3 months Change in body movements in response to sound
Change in facial expression to familiar sounds
3–4 months Turning eyes and head to sound
6–7 months Turning to listen to voices and conversation
DDx
LOW SET EARS
Imaginary line drawn between inner and outer canthi should bisect the ears into upper
one-third and lower two third portions.
 Normally 1/3rd of the ear comes above this line.
When less than 20% comes above this line, it is low set ear.
 Down syndrome
 Renal agenesis (Potter facies)
 Turner‘s syndrome
 Trisomy 17-18, 13-15
 Treacher-Collins syndrome
 Cri-du-chat syndrome
 Apert syndrome
Otalgia – earache or pain
Main causes of otalgia
Otological
 Acute suppurative otitis media/mastoiditis
 Acute otitis externa
 Barotrauma
 Herpes zoster (Ramsay-Hunt syndrome- shingles of the facial nerve)
 Viral Myringitis

 Malignant otitis externa (necrotizing otitis externa due to Pseudomonas

aeroginosa)
Non-otological
 Tonsillitis (Quinsy)
 Dental disease
 Temporo-mandibular joint disease
 Cervical spine disease
 Carcinoma of nasopharynx
Otorrhea – ear discharge
Main causes of otorrhea
 Acute/chronic suppurative otitis media
 Acute/chronic otitis externa
 Cerebrospinal leak in basal skull fracture
Profuse mucoid ear discharge with pulsation suggests acute otitis media with
perforated tympanic membrane

NOSE
Look for
 Nasal bridge, septum, polyp
 Discharge
 Active bleeding
 Sinus tenderness
Examination of the nose
 Inspect the nose from the front, side and back in a good light
• Examine the nasal vestibule and intranasal contents by gently pushing
the tip of the nose upwards with a finger, preferably using reflected
illumination from a hand mirror
 Inspect the anterior nasal cavity with nasal speculum or an otoscope
• Look for nasal blockage, granulation on the nasal septum, nasal polyps,
and nasal septum deviation and perforation
 Notice for the presence of sinus (maxillary or frontal) tenderness by firmly
pressing at the maxillary area (bony cheeks just below zygomatic bone) or just
below medial border of eye brow
 Presence of sinus tenderness with fever, headache and foul smelling nasal
discharge suggests Sinusitis
DDx
Nasal discharge
 Purulent discharge- infection in the nose/sinuses
 Mucoid discharge- allergic rhinitis
 Watery discharge- vasomotor rhinitis and cerebrospinal fluid (CSF) leak

Epistaxis
 Unilateral- local cause in the nasal passage
 Bilateral- systemic cause (thrombocytopenia, coagulopathy)
Smell disturbance
 Anosmia- loss of smell
 Reduced sense of smell or anosmia occurs in
- allergic rhinitis with nasal polyposis blocking nasal passage,
- viral infection,
- craniofacial trauma causing olfactory nerve damage
 Cacosmia is unpleasant smell caused by chronic anaerobic infection of the
nasal passages and sinuses (usually unnoticed by the patient)
Bear in Mind
 Both the ethmoidal and maxillary sinuses are present at birth, but only the
ethmoidal sinus is pneumatized
 The maxillary sinuses are not pneumatized until 4 yr of age
 The sphenoidal sinuses are present by 5 yr of age
 Frontal sinuses begin development at age 7–8 yr and are not completely
developed until adolescence

MOUTH/THORAT
Look for
 Lip ulcer, fissures and cracks
 Gum bleeding, lead line and ulcers
 Tooth caries, extractions and dentures
 Ulcers, patches, and masses in the bucal mucosa and palate
 Macroglossia
 Micrognathia
Examination
A. Tongue & buccal mucosa:
 dry or wet, tongue coating, fissure, atrophy,
 hairy white patches on sides of the tongue (leukoplakia);
 Oral thrush (candidiasis: clear with spatula; the base will be reddish
/erythematous),
 oral & dental hygiene
B. Lips:
 Color, fissure, ulceration, herpes infection
 Any anatomic defect (cleft lip or palate )
C. Teeth:
 Number of teeth erupted
 Any lost tooth
 dental caries (plaque), tooth decay, missing teeth, dentures, filling,
Spacing: dispersed or overlapping
D. Gums: ulceration, bleeding, hypertrophy, pus discharge /pyorrhoea/, lead line

E. Oral cavity & throat:

 Oral thrash / ulceration
 any mass, abnormal breath odor, salivation
F. Soft palate: ulceration, any tumor, Kaposi sarcoma, pigmentation
G. Tonsils: size, exudates, swelling, inflammation, erythema
DDx
Delayed dentition
 Rickets
 Hypothyroidism
 Hypopituitarism
 Down syndrome
 Constitutional delay
Macroglossia (big tongue)
 Cretinism
 Down syndrome
 Pompe disease
 Hurler‘s disease
MICROGNATHIA (HYPOPLASIA OF MANDIBLE)
 Pierre Robin syndrome
 Cri-du-chat syndrome
 Fetal alcohol syndrome
 Rubinstein-Taybi syndrome
 Trisomy – 13 and 18
 Treacher-Collins syndrome
 Pyknodystosis
ORAL THRUSH
 Fungal infection

 Steroids
 Antibiotics
 AIDS
 Hypoparathyroidism.
Abnormalities

YMHOGLANDULAR
Lymphoglandular System Examinations
EM
 LNs:
LN enlargement regional or generalized;
 Characterize the mass- (SSSOP WMT CCC)
 Site/exact location, Size & shape,
 Origin /fixation (edge),
 Pulsation/bruits,
 Warmness,
 Mobility/matting,
 Tenderness, color changes on skin,
 Consistency (soft, cystic, firm or hard),
 Surface/contour (nodular or smooth)
Regional sites:
 Sub-mental, submandibular, posterior auricular, occipital, anterior cervical
triangle, posterior cervical triangle, supra clavicular, axillary, Epitrochlear (as
in syphilis), inguinal region
 Glands
A. Lacrimal
B. Thyroid:
 INSPECTION: heat/cold intolerance (light /heavy clothing); enlarged
neck mass, movement with swallowing, with tongue protrusion

 PALPATION: characterize the mass using (SSSOP WMT CCC)

 AUSCULTATION: bruits

 Breast
 Shape
 Contour
 Discharge
 Ulcer
 Swelling/lump

 Testicles
 Size
 Position
 Any swelling
 Tenderness
Technique
 Inspect the scrotum, including:
 The skin - lift up the scrotum so that you can see its posterior
surface.
 The scrotal contours - note any swelling, lumps, or veins.

 Palpate each testis and epididymis between your thumb and first two fingers.
Note size, shape, consistency, and tenderness; feel for any nodules.
 Palpate each spermatic cord
 Transillumination in cases of scrotal swelling
Fig. Transilluminated hydrocele. Fig. varicocele
DDx
SHORT NECK
Ratio of neck length (distance between external occipital protuberance and the C7
spine) and height is approximately 1:13, if it is more than 1:13 it suggests short neck.
 Down syndrome
 Hypothyroidism
 Hurler‘s syndrome
 Klippel-Feil deformity
 Turner‘s syndrome (Webbed neck)
LYMPHADENOPATHY
 Generalized lymphadenopathy: Involvement of three or more non-contiguous
lymph node areas.

 Persistent generalized lymphadenopathy: Presence of enlarged lymph nodes

(>1 cm) in two or more extrainguinal sites for more than 3 months.
Significant lymphadenopathy (SLAP)

Can be defined as:
 Extra inguinal lymph nodes —1 cm in size
 Inguinal lymph nodes—1.5 cm in size
 Palpable lymph nodes at multiple sites
 Lymph nodes which are red/tender/matted/ulcerated
 Enlarged lymph nodes associated with a focus of infection
DDx for Lymphadenopathy

Inflammatory:
 Tuberculosis, syphilis, Actinomycosis, Cat scratch disease, Pyogenic lymph
node and filariasis
 Infectious mononucleosis (EBV, CMV)
 Persistent generalized lymphadenopathy (HIV infection): ≥ 2 extra-inguinal
significant (>1.5cm) lymphadenopathy persisting for > 3 months
 Secondary syphilis (Treponema pallidum)
 Toxoplasmosis (Toxoplasma gondii)
Hematological:
 Hodgkin‘s disease, non-Hodgkin‘s lymphoma, AIDS.
 Acute lymphoblastic leukemia
 Chronic lymphocytic leukemia
Immunological:
 Drug reaction, SLE and rheumatoid arthritis.

Posterior cervical or occipital lymphadenopathy may be caused by scalp

infection or dermatitis, roseola or rubella infection.
TECHNIQUE
Examination of epitrochlear lymph nodes
 Epitrochlear lymphnodes are located at medial side of arm just proximal to

medial epicondyle
 Support the patient‗s right arm with your right hand to examine the right
epitrochlear lymph node area, and the patient‗s left arm with your left
hand to examine the left epitrochlear lymph node area
 Palpate the right epitrochlear lymph node area with your 2 nd , 3 rd and
4 th fingers of left hand, and left epitrochlear lymph node area with your
2 nd , 3 rd and 4 th fingers of right hand
Examination of axillary lymph nodes
 Support the patient‗s right arm with your right hand to examine the right axilla,
and the patient‗s left arm with your left hand to examine the left axilla
 Palpate the patient‗s right axilla with your left hand, and the patient‗s left axilla
with your right hand
 Cup together the fingers of your hand and reach as higher you can toward the
apex of axillae, and milk down against the chest wall

Differential Diagnosis of Common Scrotal Swellings

Diagnosis Usual Age Transillum Scrotal Pain
(yr) ination Erythema
Epididymitis/ orchitis Any No Yes Severe,

increasing
Torsion of testis <20 No Yes Severe,

sudden
Testis tumor 15-35 No No Minimal or

absent
Hydrocele Any Yes No None
Spermatocele Any Yes No None
Hernia Any No No None to

moderate*
Varicocele >15 No No None

RESPIRATORY SYSTEM
VIVA/ORAL QUESTIONS:
 If you are asked to do respiratory system examination;
do both anterior & posterior chest
 But, if not do as ordered (posterior or anterior)
 Differential diagnosis for your findings
 Investigation
 Management principle for your likely diagnosis

Respiratory System Examinations
Types of respiration
 Orthopnea: dyspnea when lying down
 Platypnea: dyspnea when the upper body is upright (e. g., congenital
anomalies with right-to left shunting)
 Rapid shallow breathing
 Due to hypoxia in respiratory diseases
 Kussmaul respiration:
 abnormally deep and slow respirations in metabolic acidosis
(ketoacidosis, renal failure)
 Slow breathing
 Occurs in drug-induced respiratory depression
E.g. Barbiturate poisoning
 Sighing:
 Individual, deep respirations (normally occurs a few times per hour)
 Cheyne-Stokes respiration:
 Periodic variation of respiratory depth with respiratory pauses (brief
intervals of apnea)
 Biot respiration:

 Chaotic, irregular breathing (e.g. in processes affecting the medulla or

medication induced respiratory depression)
 Gasping:
 Rapid, shallow, snapping inspiratory movements interspersed with
apneic pauses (deep intoxications, agonal respiration)
 Paradoxical respiration
 The abdomen sucks inwards with inspiration due to diaphragmatic
paralysis (it normally pouches outwards due to diaphragmatic descent)
GENERAL EXAMINATION
 RR- rate, rhythm (regular, irregular), depth (shallow or deep breathing)
 Cyanosis (central cyanosis– lip and ventral tongue & peripheral cyanosis—
nail beds)
 Check audible Wheeze and Stridor (
 Clubbing of fingers (grade 1-4)
HOW TO DO . . . . . . .
CYANOSIS
 Look for the presence of central cyanosis (at lips and tongue) & peripheral
cyanosis (at leg & hand)
 Cyanosis in lips, tongue, and oral mucosa signals hypoxia. Pallor &
sweating (diaphoresis) are common in CHF
Central Cyanosis Peripheral Cyanosis
Mechanism Right to left shunts or lung disorders Peripheral stasis

Site Whole body Nail bed, nose tip, earlobe,
Extremities

Associations Clubbing -
Polycythemia
Extremities Warm Cold
CLUBBING
Definition
 Bulbous enlargement of soft parts of the terminal phalanges with both
transverse and longitudinal curving of the nails.
 Probably caused by interstitial edema and dilatation of the arterioles and
capillaries.
Causes
 Pulmonary: Bronchiectasis, lung abscess.
 Cardiac: Infective endocarditis, cyanotic congenital heart diseases.
 GIT: Inflammatory bowel disease, cirrhosis.
 Endocrine: Hyperthyroidism.
 Miscellaneous: Hereditary, idiopathic.
 Uni digital: Traumatic or tophi deposit in gout.
Clubbing grades

1 Nail bed fluctuation (softening)

2 Obliteration of the Lovibond’s angle (normal angle 160 O
increased to ≥ 180O) -drum stick appearance
3 Parrot beak appearance
4 Hypertrophic Osteoarthropathy (HOA)

Examination of the Chest

• POSITION
– Anterior chest –usually in lying position
– Posterior chest-in sitting position-patient‘s arms should be folded across
the chest /on the opposite shoulders.
• Follow
– Inspection
– Palpation
– Percussion
– Auscultation
INSPECTION:
1. Shape of the Chest (symmetry, asymmetry or deformity)
 Normally: round (elliptical)
2. Any scar on chest
3. Fracture (flail chest)
4. Chest movement;- (symmetrical/ asymmetrical)
 Normally: Symmetrical
 Abnormal (asymmetric): Causes: — Unilateral lagging – due to
pneumonic consolidation, pleural effusion, pneumothorax, atelectasis
(Collapse), pulmonary fibrosis.
5. Deformity:

o Pectus excavatum (funnel chest)— the lower part of the sternum is

displaced inwards & the lower ribs are prominent visible chest lag (assymetric
chest expansion)
o Pectus carinatum (pigeon breast) — protrusion of sternum and costal
cartilages anteriorly.
o Barrel Chest: the antero-posterior (AP) diameter may increase with aging or
in COPD
o Harrison‗s sulcus – see at rickets
Pectus carinatum
6. Noisy breathing— audible wheeze- (expiratory); stridor- (inspiratory)
7. Prominent veins: — mostly on the anterior chest due to superior vena caval
obstruction
8. Signs of Cardiovascular Respiratory Distress
 Nasal flaring, use of accessory muscles in the neck, SC/IC Retractions
Inspect the neck
 During inspiration, is there contraction of the accessory muscles, namely SCM
& scalene muscles, or supraclavicular retraction?
 During expiration, is there contration of intercostal abdominal oblique
muscles?

Signs of respiratory distress

 Is trachea midline?
 Tachypnea
 Flaring of ala nasae
 Use of accessory muscles of
respiration
 Intercostal retraction & Subcostal
retraction
 Chest indrawing
PALPATION: (3T+CE)  Cyanosis
1. Trachea
2. Tenderness
Components of Palpation
3. Tactile fremitus
4. Chest Expansions
Position of Trachea: (central, deviated to the rt. or lt.)

 Technique of examination:
 By placing the index & third finger at sterno-clavicular joint on clavicle
and feeling for its position with the middle finger.

 Normal: central to slightly shifted to the right.

 Abnormal
Towards side of lesion (Pull) Away from side of lesion (Push)
Loss of lung volume Space occupying lesions
- Lung fibrosis - Pleural effusion
- Collapse (atelectasis) - Pneumothorax
- Agenesis - Large mass lesions
- Surgical resection - Hemothorax
Mediastinal masses & thyroid tumors
Tenderness: don‘t forget to see pt‘s face while you examining.

 Normal: No tenderness
 Abnormal: Ddx: Costochondritis, Pleuritis (especially in thin pt), Rib fracture
Tactile fremitus: palpable vibrations (comparable, increased or

decreased) - :( for cooperative child (mostly >7yr. old)
 Normal: Comparable, Symmetrical
 Abnormal:
Increased Decreased
Consolidation Unilateral
- Pneumonia, TB. . . . Pneumothorax
Mass Pleural effusion
Bronchial obstruction
Atelectiasis
Bilateral
Emphysema COPD
Thick chest wall

Speech creates vibrations & when

one palpates the chest wall these
vibrations can be felt and are
termed tactile fremitus.
 Tactile fremitus provides

useful information about
the density of the
underlying lung tissue and
chest cavity.
 Feel the vibration with the
ball (bony part) of palm of
the hand.
Chest Expansion:
 Normally – Chest expands symmetrically
 Abnormalities: Unilateral reduction of chest expansion.
- Causes: pleural effusion, pneumothorax, collapse, consolidation and
fibrosis.
 Degree of Chest Expansion (measure with a tape; anteriorly & posteriorly),
chest lag, subcutaneous empysema, palpable crepitation (as in pneumonia, rib
fracture)

 Place your thumbs at

about the level of the 10th
ribs, with your fingers
loosely grasping and
parallel to the lateral rib
cage.
PERCUSSION:
 Helps you establish whether the underlying tissues are air-filled, fluid-filled, or
solid.
 Components
1. Percuss all over the chest –comparing both sides symmetrically
2. Diaphragmatic excursion
 Normal: Produces a resonant, higher-amplitude, lower-pitched note.
 Abnormal:
 Stony dull percussion, due to pleural effusion, lung mass….
 Relative dullness, due to pneumonia, collapse, fibrosis…..
 Hyperresonance, can be due to, pneumothorax, emphysema…..
Techniques: Start at clavicle because of lung apex –

1) Area of dullness
2) Abnormal percussion notes (dull, tympanitic, flat, hyper resonant),
3) Diaphragmatic excursion: excursion-normal -4-5cm--decreased in
emphysema and diaphragmatic excursion
AUSCULTATION:
1) Breath sounds
 Broncho-vesicular, Bronchial, Vesicular, Tracheal
2) Added sounds (rhonchi, crepitation, expiratory wheeze, inspiratory stridor,
pleural friction rub)
3) Air entry (good, decreased, absent)

4) Transmitted Sounds: Vocal resonance, bronchophony, egophony, whispered

pectoriloque
Bronchophony
 ask the pt to say repeatedly ―ninety-nine‖ ; louder & clearer sounds are heard on
the chest wall
 normally muffled and indistinct
Aegophony
 ask the pt to say ―ee-ee-ee‖ ; E-to-A change with nasal or bleating quality is heard
 normally hear a muffled long ―E‖ sound
Whispering pectoriloquy
 ask the pt to whisper ―one-two-three‖ ; louder & clearer whispered sounds are
heard
 normally heard faintly and indistinctly


CARDIOVASCULAR SYSTEM CORE NOTE PEDIATRICS & CHILD HEALTH
 If you are asked to do cardiovascular system
examination; do starting from general examination
 But, if not do as ordered (precordium)
 Investigation

Cardiovascular System Examinations
CARDIOVASCULAR Examination
The examination of the heart & vascular systems in infants and children is similar to
that in adults.
Components of CVS Examination
 General examination
 Arterial examination
 Venous examination
 Precordial examination
 General examination
 BP
 Finger nails:
 Cyanosis
 Digital clubbing
 Splinter haemorrhage
Cardiorespiratory distress
 Arterial examination
 Pulse ( rate, character, volume, radio-femoral delay)
• Temporal

• External maxillary (facial)

• Carotid
• Brachial
• Radial
• Femoral
• Popliteal
• Posterior tibial
• Dorsal pedis
 BP
 Venous system examination
 JVP
 Hepato-jugular reflux
Internal jugular vein pulsation Carotid artery pulsation
 Rarely palpable  Palpable

 Two pulsations per heart beat  A single pulsation per heart beat
 Pulsation is eliminated by light pressure  Not eliminated by pressure
over the vein  Unchanged with position
 Level of pulsation changes with position,  Not affected by inspiration
dropping as the pt becomes more upright
 Level of pulsations usually descends with
inspiration
Causes of Kussmaul’s Sign

 Constrictive pericarditis
 Restrictive cardiomyopathy
 Right ventricle failure
Elevated venous pressure occurs in:

 Right ventricular failure

 Cardiac tamponade
 Tricuspid stenosis
 Superior vena cava obstruction
 Hyperkinetic circulatory state
 Increased blood volume
 Pulmonary diseases like asthma, emphysema.
Causes of fall in JVP
 Hypovolemia
 Shock
 Addison‘s disease
Precordium
INSPECTION:
- Precordial buldge,
- Active or quiet precordium,
- Apical impulse (location in no. of ICSs, or in distance from mid axillary line,
or from mid sternum line)
LOCATION OF APICAL IMPULSE
 Up to 4 years: Left 4th intercostal space lateral to midclavicular line

 4-8 years: Left 5th intercostal space lateral to midclavicular line

 8-12 years: Left 5th intercostal space medial to midclavicular line
PALPATION:
PMI - POINT OF MAXIMAL IMPULSE
(location, character- localized or diffuse, tapping or sustained);
 Location: normal- 4th/5th interspace along the left MCL or 7-9 cm to the left of
the midline.
 If displaced  shifted apex.
 Diameter/size:
 Localized- <2.5 cm and limited to a single interspace.
 Diffuse: > 2.5cm &/or felt in more than 1 interspace.
 Amplitude and duration:
 Tapping: small and brisk
 Hyperkinetic: vigorous but brisk.
 Sustained: with heave and in LVH
Displaced apical impulse
Cardiac:-
 LV-Dilation or hypertrophy (DCMP and Valvular lesion (MR)
Respiratory:
 Large Pleural Effusion
 Pneumothorax
 Lung fibrosis
 Atelectasis
PALPABLE (ACCENTUATED) HEART SOUND
P2 accentuated –
- Pulmonary Hypertension
- Dilated pulmonary artery
- ASD
HEAVE (APICAL & PARASTERNAL)
 Use the ulnar side of the palm.
 Apical area and Left parasternal area
DDX of Apical Heave
 LVH
 Pressure Overload eg: AS, HTN & Coarction of Aorta
 Volume overload eg: MR, AR, VSD, ASD, PDA
DDX of Parasternal Heave
 Pulmonary HTN
 PS, MS, TR
THRILL (PALPABLE HEART MURMUR) - SYSTOLIC,

DIASTOLIC OR BOTH)
Palpate over the valve areas with the ball of the palm.
 Mitral, tricuspid, pulmonic, and aortic.
Timing: systolic or diastolic
 Determined by simultaneous palpation of the carotid artery.
 Thrill coincident with carotid pulsation is systolic; otherwise it‘s diastolic.
DDX OF THRILLS
Is palpable when the murmur is grade 4
 Systolic Thrills
 MR and AS
 Diastolic Thrill

 AR and MS
PERCUSSION:
- To estimate cardiac size when the apical impulse isn‘t palpable.
- Cardiac outline (as in dextrocardia), dullness (as in pericardial
effusion)
AUSCULTATION:
Normal heart sounds (S1 & S2, added heart sounds)
 Both heart sounds heard in all auscultatory areas S1 and S2 are well heard.
Abnormality
 S1 loud at mitral area (ex. MS)  Loud S1
 S1 decreased in intensity  muffled
 P2 louder than A2  Accentuated P2
 A2 louder than P2  accentuated A2
 Murmur (type, quality, grade, radiation)

 Accentuation / muffling of heart sounds

 Gallope rhythm
1. THE AUSCULTATORY AREAS
A. Aortic area (A2) – right 2nd intercostal space
B. Pulmonic area (P2) – left 2nd intercostal space
C. Tricuspid area – 3rd / 4th intercostal space along left lateral border of the
sternum
D. Mitral area – apex of heart
2. THE STETHOSCOPE
 Use both the diaphragm and the bell.
 The diaphragm. The diaphragm is better for picking up the relatively
highpitched sounds of S1 and S2, the murmurs of aortic and mitral
regurgitation, and pericardial friction rubs. Listen throughout the precordium
with the diaphragm, pressing it firmly against the chest.
 The bell. The bell is more sensitive to the low-pitched sounds of S3 and S4 and
the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure
to produce an air seal with its full rim. Use the bell at the apex, then move
medially along the lower sternal border. Resting the heel of your hand on the
chest like a fulcrum may help you to maintain light pressure.
3. AUSCULTATORY SOUNDS
 S1 and S2: the first sounds to focus on.
 S1: due to closure of the AV valves
 S2: caused by closure of semilunar valves. A2 the aortic component and P2 the
pulmonic component.
 Additional heart sounds: S3 and S4 are both diastolic sounds. The presence of
an additional HS gives a gallop rhythm.

 Murmurs: sounds due to turbulent flow across valves.

STEPS OF AUSCULTATION
 Using the bell start from the aortic area and proceed to apical area.
 Then change to the diaphragm and proceed from the apex to the aortic area.
 Listen carefully and describe findings.
 Auscultate in the left lateral position with the bell for mitral diastolic murmur.
 Auscultate over the erbs point with the patient sitting leaning forward and at
end expiration for the diastolic murmur of AR.

Findings. . . .
Murmurs MURMURS
Are caused by audible vibrations that are due to increased turbulence from
accelerated blood flow through normal or abnormal orifices
Characteristics of Murmurs
 Intensity/grading: grade1-6
 Timing – Systolic, Diastolic or Continuous
 Location of maximal intensity
 Radiation: signify direction of blood flow
 Shape (Configuration): Decrescendo, Crescendo-decrescendo, Crescendo
 Pitch: high, medium or low
 Quality : Blowing, Harsh, Rumbling, Musical
Murmur Loudness Grading

1 Very faint, barely audible in a quiet room, heard only after careful
listening, may not be heard in all positions
2 Quiet murmur, clearly audible, audible with the stethoscope fully on

the chest, not loud
3 Moderately loud
4 Moderately loud plus thrill (palpable murmur)
5 Very loud plus thrill, audible with the stethoscope partly off the chest

6 Audible with the stethoscope just off the chest
Attributes of murmurs
Timing: systolic or diastolic. Palate the carotid artery to time a murmur or any added
sound.
 Systolic murmurs:
 Pan-systolic: starts with S1 and stops at S2, without a gap between murmur
and heart. S1 is muffled. Pathological EX. MR
 Mid-systolic: begins after S1 and stops before S2. usually flow murmurs.
 Diastolic murmurs:
 Early Diastolic Murmur starts right after S2, without a discernible gap, and
then usually fades before S1. ex AR
 A Mid-diastolic Murmur starts a short time after S2. It may fade away, or
merge into a late diastolic murmur. EX MS
 A late diastolic (presystolic) murmur starts late in diastole and typically
continues up to s1
 Continuous murmurs have both systolic and diastolic components
Systolic Diastolic
Pan-systolic Early Diastolic
 MR, TR and VSD  AR & PR
EJECTION SYSTLOLIC
Mid-Diastolic
 AS, PS & ASD
 MS, TS & Atrial Myxoma
Late Systolic
Continuous
 MVP
 PDA
 Arterio-venous fistula

How to Report Murmur. . . . .

Example: - Grade 4 Holo-systolic Murmur best heard at the apex which radiates to
the axilla, characterized by High pitched, Blowing in quality, plateau in
configuration
ACCENTUATION MANEUVERS
Accentuation of heart murmurs

Accentuation 1 2
A Patient Pt on left lateral Pt on sitting position, leaning

position position forward
B Maneuver -- after full expiration
C Site of at the apex of heart at 3rd/4th ICS left of the sternum

auscultation

D Part of listen with the bell Listen with the diaphragm

stethoscope to be of stethoscope
used
E Finding MDM of S3 gallop EDM of AR & pericardial

& MS friction rub
DDX for Valvular Heart Disease

Major Causes of Mitral  Rheumatic fever
Stenosis (MS)  Congenital (parachute valve, cor

triatriatum)
 Severe mitral annular calcification with
leaflet involvement
 SLE, RA
 Myxoma
 IE with large vegetations
Major Causes of Mitral Acute
Regurgitation (MR)  IE
 Papillary muscle rupture (post-MI)
 Chordal rupture/leaflet flail (MVP, IE)
 Blunt trauma
Chronic
Primary (affecting leaflets, chordae)
 Myxomatous (MVP, Barlow‘s, forme fruste)
 Rheumatic fever
 IE (healed)
 Congenital (cleft, AV canal)
 Radiation
Secondary (leaflets, chordae are ―innocent

bystanders‖)
 Ischemic cardiomyopathy
 Dilated cardiomyopathy
 HOCM (with SAM)
 AF with LA enlargement and annular dilation
(atrial functional MR)
Mitral annular calcification


Peripheral Signs of AR
1. Bounding peripheral pulses
2. Collapsing pulse or Large-volume pulse: rapid distension and quick
collapse
3. Corrigan’s sign: dancing carotid (water hammer pulse), exaggerated by
raising the arm
4. de Musset's sign: Head nodding
5. Mueller’s sign: Pulsating uvula
6. Becker's sign — Visible pulsations of the retinal arteries and pupils
7. Quincke's sign: Capillary pulsation in nail beds
8. Mayne's sign — More than a 15 mmHg decrease in diastolic blood pressure
with arm elevation from the value obtained with the arm in the standard
position
9. Rosenbach's sign — Systolic pulsations of the liver.
10.Gerhard's sign — Systolic pulsations of the spleen.
11.Hill’s sign: BP Lower extremity >BP Upper extremity by
 > 20 mm Hg - mild AR
 > 40 mm Hg – mod AR
 > 60 mm Hg – severe AR
INVESTIGATION
CBC: anemia, infection, inflammation (acute phase reactant - elevated platelet,
Leukocytosis)
Electrolytes: K+, Na+, Ca2+, phosphate
ESR/CRP: elevated in infective endocarditis, TB

CXR: Cardiomegaly, prominent pulmonary vessels, pulmonary edema & pleural

effusion
ECG:
 In MR: LA enlargement, LV hypertrophy, RV enlargement in some pt.
 In MS: the P wave usually suggests LA enlargement and QRS Complex is
usually normal
Echocardiogram (2D/Doppler): best diagnostic modality, TT-Echo, & TE-Echo
 Size of the chambers
 Ventricular wall thickness
 Regional wall motion abnormality: indicates myocardial infarction
 Valvular lesions
 Vegetation (infective endocarditis): Thickened calcified valve, fusion of leaflets
 Abscess
 Pericardial effusion
Ejection fraction

ABDOMINAL, IGS, GUS & MUS

EXAMINATION
 Don‘t forget introducing your self
 Do as ordered
 Investigation

Abdominal System
Prerequisites for Abdominal Examination

1. Good Light
2. Relaxed patient
3. Position: supine, arms at sides or folded across.
4. Full exposure from above the xiphoid process to symphysis pubis.
 Groin should be visible.
 Genitalia should be draped
Components of Abdominal examination
1. The Four Cardinal Steps.
 Can be done in two different orders.
A. B (Our Format)
 Inspection - Inspection

 Auscultation - Palpation
 Percussion - Percussion
 Palpation - Auscultation
2. Digital Rectal Examination (PR)
Do every steps of abdominal examination . . . .
Inspection:
1. Symmetry/Flank/Shape and Contour
 Normal: flat
 Abnormal: Scaphoid, Protuberant . . .
Scaphoid (Cachexia) Distended (6F’s) Protuberant
 Malnutrition Generalized  Pregnant

 Comorbidities  Fat
 Fetus, Flatus or
feces
Localized (bulge)
 Mass (tumor)
 Organomegally
2. Movement
 Normal: moves with respiration
- Rise – during inspiration
- Fall – during expiration
 Abnormal: silent
- Generalized peritonitis

- GBS – diaphragmatic paralysis
3. Peristaltic movement
 Normal: no peristaltic movement
 Abnormal: visible
- Eg. Pyloric Stenosis, Dynamic Bowel obstruction
4. Skin:
Striae mark, rash, surgical scare & skin lesion.
 Normal: depends on race and smooth
 Abnormal: hyper/hypo pigmented
- Scares: Old (White), New (Pink)
- Striae: White (Old), Pink (recent), Purple (Cushing syndrome)
5. Umbilicus
 Normal: Horizontal slut, slightly retracted & Inverted
 Abnormal: Everted & flat – due to distention
- Vertical Slut: Ovarian Ca, Pregnancy
- Horizontal Slut: Ascites
6. Visible Vein
 Normal: not visible
 Abnormal: visible
- Portal HTN:- direction of blood flow
 Upward- above the umbilicus
 Downward:- below the umbilicus
- Inferior Veina-cava Obstruction-

 Upward- all are upward
7. Hernia: ask the pt. to cough

 Look: Epigastric, Umbilicus, femoral (lingual) & Surgical Site
8. Visible pulsation:
 Pulsating liver suggests tricuspid regurgitation
Auscultation:
1) Bowel Sound
 On auscultation, the presence of high pitch localized bowel sound or
absent bowel sound suggests intestinal obstruction/ilius
 Areas of auscultation: Illocecal Junction
- Normal 5-32/min
2) Bruit: a harsh or musical intermittent auscultatory sound,

especially an abnormal one
 Area to auscultate:
 Aorta
 Renal artery
 Iliac artery
 Femoral artery
3) Friction rub
Palpation
On palpation, assess for tenderness, mass, enlargement of spleen and liver

1. Prerequisites for Palpation.
 Patient should have empty bladder.
 Warm your Hands Before palpation.
 Avoid long finger nails.
2. Rules of Palpation.
 Approach slowly & avoid unexpected movement.
 Ask the patient to point areas of pain & examine this area at last.
 Watch patient‘s face closely for sign of Tenderness.
 Distract the patient with conversation
3. Steps
1. Superficial (light) Palpation
2. Deep Palpation
 Abdominal mass/Organomegally??
- Chxize.- Site, Size, Shape, surface (smooth, rough), consistency (soft,
firm, hard), boarder (margin), mobility (attachment)
3. Liver Palpation: measure liver below costal margin
 Normally – Liver is firm, smooth surfaced & edge is palpable.

- Normal variation – enlarged Right Lobe (Reidel lobe)

 Abnormal: causes of palpable tender liver
 Hepatitis
 Liver abscess
 Congested liver – due to RHF. . .etc.
4. Spleen Palpation
 Normal: not palpable
 Splenomegaly: enlargement of spleen.
 Spleen should enlarge 2-3x to be palpable.
 It enlarges downward & towards umbilicus.
 Enlargement confirmed by:-
 If can‘t go above it & If medial notch is palpable.
5. Bimanual Palpation
 Kidney Palpation
 Normally not palpable
 Abnormal: Causes of enlargement – Cysts, Tumors or
Hydronephrosis.
 .Assessing Kidney tenderness.
 causes of (+) CVAT
 Pyelonephritis, renal stone
6. Ballot-able Organ (Identifying an organ or mass in ascetic abdomen)
 Nodular liver suggests cirrhosis or tumor

How to differentiate Spleen from Left Kidney

Spleen Left Kidney
 Palpable along line growth  Not

(towards the umbilicus)
 Can‘t go above it  Can go above it
 Finger can‘t probe between  Finger can probe between left

spleen & costal margin. kidney & costal margin
 Notch palpable  Not
 Dull to percussion  Tympanic in percussion
Percussion
 Normally: Tympanitic all over b/c of gas in GIT.
 Abnormal findings.
 Dull percussion Note in: - Enlarged mass or organ (Organomegally) &
Intra-peritoneal Fluid.
 Hypertympanitic: - in intestinal obstruction.

1. Check fluid collection:-

 Shifting Dullness
 Fluid thrill
2. Total Liver Span
Physical assessment of Hepatomegaly in children

Age Acceptable Span (cm)
Pre-term infants 4-5

Healthy term infants 5-6.5

1-5 6-7
5-10 7-9
10-16 8-10
3. Splenic Percussion
1. Traube’s semilunar space
Borders: superiorly (left 6th rib), laterally (left mid-axillary line/left anterior
axillary line), inferiorly (left costal margin)
Patient’s position: supine with left arm slightly abducted
Percussion: from medial to lateral
Interpretation: resonance is the normal finding and dullness shows
splenomegaly (Pleural effusion or mass in stomach may cause dullness in
Traube’s space)
2. Castell’s method
Patient’s position: supine
Percussion: in the lowest intercostal space in the anterior axillary line (8th
or 9th)
o Interpretation: resonant on expiration or full inspiration is the normal
finding and dullness on full inspiration shows splenomegaly

Check the URL Link: . . . . .
https://youtu.be/5YVkGfoY5pM
3. Nixon’s method

o Patient’s position: right lateral decubitus (spleen comes to lie above colon
and stomach)
Percuss: midway along the left costal margin and proceed in a line
perpendicular to left costal margin
Interpretation: upper limit of dullness >8cm above costal margin shows
splenomegaly
 Percussion helps to differentiate whether swelling is due to gas ( tympanic) or

fluid or solid[dull note)
 Absence of dullness does not rule out presence ascites.

 WHY? - minimum of 1500ml of ascitic fluid required for detection by

P/E but US can detect as little as 100 ml of ascitic fluid.
 On palpation, assess for tenderness, mass enlargement of spleen, and liver
 Nodular liver suggests cirrhosis or tumor
 Pulsating liver suggests tricuspid regurgitation
COMMON EXAM QUESTIONS

 How do you differentiate between a liver, spleen and kidney?
 Why is it a liver?
 Why is it a spleen?
These are straightforward but commonly asked questions that are often answered badly. If you find
organomegaly it is important that you assess its character carefully and make it clear to the examiner using
the criteria below that you are demonstrating a liver, spleen or kidney.
Liver
 Right hypochondrium
 Cannot get above it
 Moves with respiration
 Dull to percussion
Spleen
 Left hypochondrium
 Cannot get above it
 Moves with respiration
 Dull to percussion
 Has a notch
Kidney
 Can get above it
 Doesn‘t move with respiration
 Resonant
 Ballotable

Genitourinary System
Look For:-
 Bladder distension
 CVAT (Costo-vertebral Angle Tenderness)
 Suprapubic tenderness
 Urethral opening (epispadias, hypospadias)
 Testicles in the scrotum or no
A) Distal end of penil shaft (B and C), midshaft

(D) Scortum (E) perineum
 Scrotal swelling
 Urethral discharge

 Vaginal discharge / bleeding

 Vulvar erythema / ulceration
Examination
The Penis
Inspection
 The skin
 The prepuce (foreskin).
 The glans. Look for any ulcers, scars, nodules, or signs of inflammation.
Palpation
The Scrotum and Its Contents
INSPECTION
 Inspect the scrotum, including:
 The skin. Lift up the scrotum so that you can see its posterior surface.
 The scrotal contours. Note any swelling, lumps, or veins.
PALPATION
 Palpate each testis and epididymis between your thumb and first twof fingers.
 Note size, shape, consistency, and tenderness; feel for any nodules.
 Pressure on the testis normally produces a deep visceral pain

Check CORE NOTE Gyn/Obs for female reproductive examination


Integumentary System
 Skin, Hair, Nails
Components
 Inspection
 Palpation
4 cardinal features in describing skin lesion:
1. Type (primary or secondary)
2. Shape and Color (round, raised, oval, and hypo or hyper-pigmented)
3. Arrangement (Are the lesions scattered diffusely, well circumscribed or
confluent?solitary, grouped, multiple )

4. Distribution (extremities, abdomen, face, . . . . . . .)
Findings
 Palmar pallor ( some / sever )
 Site of Pallor: Pallor is seen at the following sites:
 Lower palpebral conjunctiva (upper palpebral conjunctive may be
scarred due to trachoma making assessment difficult)
 Dorsum of the tongue
 Palmar or plantar creases
 Nails
 Rash ( characteristic , distribution, color)

 Any skin lesion (characteristic, distribution)

 Edema ( grade, pitting / non-pitting)
 Nail disfiguring
 Skin pinch ( fast, slow, very slow)
 Check baggy pants
Skin: -Check texture, pigmentation, lesions, turgour

-Lesions should be described according to their site and appearance as:
 Macule: a small spot not raised above the surface
 Papule: same size as macule, raised above the surface, less than 5mm in
diameter
 Nodule: papule 5-40 mm in diameter
 Mass or tumor: nodule more than 4 cm in diameter
 Vesicle : a papule filled with fluid, usually clear and watery
 Pustule: vesicle containing pus
 Wheal: elevated, indurated papule or nodule, usually with white center and
erythematorus flare around the elevated area (often associated with allergic
conditions).
 Desquamation: fine or extensive flakiness (peeling of finger tips in scarlet
fever, flaky paint dermatosis in kwashiorkor).
 Wound: laceration or contusion secondary to trauma
 Ulcer: superficial or deep necrotic areas.

 Hemorrhage: purpura, petechiae, ecchymosis, hematoma

Hair:
 distribution, color, texture
Nails:
 deformity, splinter hemorrhages, capillary refill, clubbing, etc
Scalp
 Seborrheic dermatitis
 Tinea capitis
 Alopecia areata
 Psoriasis
 Nevus sebaceous
Face
 Contact dermatitis
 Perioral dermatitis
 Pityriasis alba
 Acne
 Photosensitivity disorders
Trunk
 Tinea corporis
 Tinea versicolor
 Pityriasis rosea
 Psoriasis
Extremities
 Psoriasis (also scalp and nails)
 Scabies (also groin and waistline)
 Erythema nodosum
 Erythema multiforme

Nails
 Psoriasis
 Alopecia areata
 Twenty nail dystrophy
 Lichen planus
 Ingrown toenail
Oral
 Lichen planus
 Mucocele
 Stevens–Johnson syndrome
Genital/groin
 Lichen sclerosus
 Condyloma acuminate
Maculopapular Rash

Musculoskeletal System
Technique
 Look  Inspection
 Feel  Palpation
 Assessment of joint range of motion & stability
 Move
 Gait assessment in ambulatory children
 Measure
Look
 Expose both sides
 Adequate light
Inspection
 Look for asymmetry
 Any deformity ( kyphosis, scoliosis, lordosis)
 Joint swelling & Bruising /discoloration
 Gibbus deformity
 Any wound ( site, size, type of discharge)
 Any abnormal movement
 Muscle bulk ( any visible wasting )
 Look for Shortening of a limb.
NB. Specific to the site of interest

Feel
 Temperature – with ur back of hand
 Sensation
 Tenderness at joint areas
 Bony tenderness
 Dryness or wetness
 Muscle bulk
 Pulse
 Capillary refill
o > 2 second – prolonged or abnormal
 Signs of rickets: craniotabes, caput quadratum, rachitic rosary, Harrison‘s
groove, widening at the wrist joints, double malleoi, chest deformity, bowing
of the legs etc.
 Look for the presence of edema: pedal, pre – tibia, sacral. Pitting, non-pitting
Move (range of motion)
 Active vs passive
Active
 Ask the pt to move the normal one first, and then the affected site
 Watch for
• decreased or increased movement of the joint compared to the normal
one
• pain with movement
• abnormal movement
o Listen for crepitus or ―popping‖
Passive
 Move the joints passively, comparing the end points to the active

 Again note
 Any decreased or increased movement
 Pain with the movement
 Crepitus or ―popping‖
Measure
 Apparent length
o From xiphisternum or umbilicus to medial malleolus
 Real length
o From greater trochanter of the femur up to the medial malleolus
 True length
o Between two bony prominences



NEUROLOGICAL EXAMINATION CORE NOTE PEDIATRICS & CHILD HEALTH
Nervous System
 Do as ordered (Cranial nerves or motor, . . . .)
 Investigation

NERVOUS
General
1. Mental Status
2. Cranial Nerves
3. Motor System
a. Body position
b. Fasiculations: Spontaneous, induced.
c. Involuntary mov`t
d. Muscle characteristics
i. Bulk: normal, atrophy, hypertrophy or psudohypertrophy
ii. Tone
iii. Strength
e. Coordination
i. RAM
ii. Point to point mov`t
iii. Gait &Stance
4. Reflexes
5. Sensory:
What are we checking and how?

Mental Status
 What?
 Level of alertness, awareness
 Degree of interaction
 Orientation
 Following commands
 Older children: naming objects, simple calculations, extinction, neglect,
fund of knowledge
 Difference from baseline
 How?
Glasgow Coma Scale (GCS)

Modified Glasgow Coma Scale for Children Score
Eye opening
 Directed(e.g. follows mothers face) 1
 Non Directed 0
Best Verbal Response
 Appropriate cry 2
 Moan or inappropriate cry 1
 None 0
Best Motor Response
 Localizes painful stimuli 2
 Withdraws limb from pain 1
 Nonspecific or absent response 0
Total 0-5
Score Best Motor Response Modified Glasgow Coma

Scale for Infants
6 Follows commands Normal spontaneous movements
5 Localizes pain Withdraws to touch(Localizes
pain)
4 Withdraws to pain Withdraws to pain

3 Abnormal flexion Abnormal flexion

2 Abnormal extension Abnormal extension
1 None None
Score Best Verbal Response Modified Glasgow Coma
Scale for Infants
5 Oriented Coos, babbles,Smilesw
4 Confused Irritable, Cries but consolable
3 Inappropriate words Cries to pain, persistent in
appropriate crying,
Screaming
2 Nonspecific sounds Moans to pain
1 None None
Score Eye opening Modified Glasgow Coma
Scale for Infants
4 Spontaneous Spontaneous
3 To speech To speech
2 To pain To pain
1 None None
Total 3-15 3-15

B. Orientation
 Asking to state his or her name, location,& time (day & date)
 Time is usually the first to be affected
Language, Speech
 Language

 Comprehension
 Spontaneous, fluent
 Appropriate content
 Other things you can check: repetition, naming objects, reading, writing
 Speech
 Prosody
 Volume
 Rate
 Dysarthria
Memory: be analyzed according to 3 main time scales:
o Immediate memory tested by having the patient repeat the list of three
items immediately
o Short-term memory assessed by asking the patient to recall the same
three items 5 and 15 min later
o Long-term memory [YEARS] evaluated by how well the patient is able
to provide a coherent chronologic history of his or her illness or personal
events
Cranial nerves (1-12)

The nucleus of each CN is:
General Function
 CN-1, 2Cerebral hemisphere/cortex
 Pure sensory  1, 2, 8
 CN- 3, 4Midbrain
 Pure motor  3, 4, 6, 11, 12
 CN 5, 6, 7, 8 Pons Brain stem
 Mixed  5, 7, 9, 10
 CN-9, 10, 11, 12Medulla
1. I (olfactory):
 Check for smell, each nostril in turn, with coffee or lemon
2. II (optic):
 Visual acuity
 Snellen chart (6meter or 20 feets), If not use your finger from 2meter

 Visual fields
 Color visionIshihara test
 Ophthalmoscopic examination. (Examine the fundus e.g. disc margins, venous
pulsations, chorioretinities etc).
3. III (oculomotor), IV (trochlear), and VI (abducens):
 Check extra-ocular muscles (AII3SO4LR6)
 Check for mono ocular & binocular diplopia
 Examine for squinting (Having eyes half closed in order to see better)
 Look for nystagmus and identify the type
 Observe the position of lids(e.g. ptosis)
 Examine the pupils for size, position and reaction to light and accommodation.
4. V (trigeminal):
 Test the jaw jerk, Test corneal reflex with a wisp of cotton,
 Test for all other sensation in the face
5. VII (facial):
 Check for any asymmetry in facial movement
 Wrinkle forehead, frown, smile, raise eyebrows, strength of eyelid muscles
 Test for taste in the anterior 2/3 of the tongue with sugar, salt, lemon
 Observe if the patient can produce tears
6. VIII (acoustic):
 Cochlear portion - Hearing, lateralization, air and bone conduction, tinnitus.
 Vestibular - Caloric tests.
7. IX (glossopharyngeal), X (vagus):
 Ask if the patient can salivate, Test phonation, coughing, swallowing, Note for
drooling of saliva, check for gag refax.
8. XI (accessory):
 Strength of trapezius and sternocleidomastoid muscles.
 Test the power of shrugging the shoulders and of turning the head to one side
against resistance
9. XII (hypoglossal):
 Note for wasting, fasciculations, weakness on protrusion of the tongue towards
the weak side.
 Ask the patient to push the tongue into the check and apply resistance over the
same check. This will help you to assess the power of the tongue
Motor Examination
1. Posture /anatomical position/; internal or external rotation of limbs;
2. Muscle bulk (atrophy, hypertrophy);
3. Fasciculation (spontaneous, induced); involuntary /abnormal body
movement;
4. Muscle tone (hypotonic/flaccid; hypertonic/spastic): – rigidity (clasp
knife, cog wheel, or lead pipe rigidity);
5. Muscle power (grade 0-5)
DTR & Superficial Reflexes
Muscle Power Grading

5 Pt raises limb against full resistance
4 Raise againist gravity plus some resistance
3 Raise againist gravity

2 Side to side movement of limbs
1 Flickering of fingers/ toes
0 No movement at all
Tone & power reporting

Tone: resistance to passive stretch:-
 Normal (Normotonic),
 Decreased (hypotonic / flaccid), or
 Increased (hypertonic): [spastic, rigid (cogwheel or lead pipe), paratonia
A. Spasticity:
 Resistance determined by the angle and velocity of motion;
corticospinal tract disease.
 Clasp knife ??
B. Rigidity :
 Similar resistance in all angles of motion; extrapyramidal disease),
 Cogwheel rigidity, in which passive motion elicits jerky interruptions
in resistance, is seen in parkinsonism.
C. Paratonia :
 Fluctuating changes in resistance; frontal lobe pathways or normal
difficulty in relaxing
LL (lower limb) UL (upper limb)
Motor function LLL RLL LUL RUL

Tone Hypotonic Norm-otonic Hypo Normo

Tonic Tonic
Power 0/5 5/5 0/5 5/5
Superficial Reflexes:
1) Corneal (R & L) CN V, VII
2) Abdominal (absent in infants) T9 –T12
3) Cremasteric (only in boys) L1, L2
4) Plantar L5, S1, S2
Deep Reflexes (deep tendon reflexes)

 Grades 1-4
DTR- grading Ankle reflex- grading

1 Diminished 1 normal
2 Normal 2 brisky
3 Brisky
4 Brisky + clonus
 Clonus: ankle, knee

NB. D. Reflexes: if absent repeat while distracting the child’s attention. Don’t forget
to examine bilaterally.
Muscle Nerve roots

Upper limb 1) Biceps C5, C6
2) Triceps C6, C7
3) BR C6, C7,
(Brachioradialis) C8
Lower limb 4) Knee L3, L4
5) Ankle S1, S2


Sensory Examination
1) Posterior column functions:
 Position (on toes, fingers);
 Vibration (with tuning fork on bony prominences – ankle, tibial tuberosity,
ASIS /anterior superior iliac spine/, radio ulnar prominences, olecranon,
mastoid process etc.); touch sensation
2) Spinothalamic tract function:
 Superficial pain; deep pain; To ; touch sensation
3) Cerebellar sensation
 Coordination:
 Finger to nose test (pt‘s index finger moving from examiner‘s finger to pt‘s
nose, with the pt‘s eyes closed);
 Heel to shin test; rapidly alternating movement (knee pat/pronation &
supination test)
4) Cortical sensation (sensory cortex function):
 Two points discrimination
 Use an opened paper clip to touch the patient's finger pads in two places
simultaneously
 Alternate irregularly with one point touch
 Ask the patient to identify "one" or "two."
 Find the minimal distance at which the patient can discriminate
 Stereognosis
 Place a familiar object in the patient's hand (coin, paper clip, pencil etc.)
 Ask the patient to tell you what it is
 Graphistesia

 With the blunt end of a pen or pencil, draw a large number in the
patient's palm
 Ask the patient to identify the number
Meningeal signs
Nuchal rigidity/neck stiffness
 The examiner passively flexes patient‘s neck towards the chest, and the
maneuver reproduces pain and resistance to neck flexion
Brudzinski’s 1 sign (pt raises knee with neck exam.)
Kernig’s sign
 Place patient supine with hip flexed at 90 degrees. Attempt to extend the leg at
the knee. The test is positive when there is resistance to extension at the knee to
>1350 or pain in the lower back or posterior thigh
Brudzinski’s 2 sign (pt raises knee with Kernig’s exam.)

NEWBORN
HISTORY AND PHYSICAL EXAMINATION

History and Physical Examination

Identification:
• Age (in hours for the first 72 hrs., after that use days)
• Gender of neonate; birth order; Twin A or twin B
• Mother – name, age, Occupation
• Date of admission; ward; bed number
• Source of hx (historian) – name, age,
• Occupation, relationship to the neonate
• Referral – diagnostic impression, treatment given;
C/c:
Mostly presenting compliant: like failure to suck, fever, breathing difficulty (fast
breathing), abnormal body movement, yellowish discoloration of skin and eye.
HPI
Detailed hx of current & past pregnancies:
 Age; obstetric hx (gravidity, parity, abortion, LNMP, how many children does
she have)
 Blood type, Sero-status, VDRL/RPR (date and results).
Maternal Health:
 Previous complications of pregnancy, labor, delivery.
 Type of contraception used, if any. Was present pregnancy planned, wanted
and supported?
Pregnancy:
 If she have ANC follow up – ask for; Location of ANC follow up and number
of visits,

 Complications of pregnancy: Special test, ultrasound exams.

 Medications - drug, dose, route, length of therapy, indication, when used
during pregnancy.
Labor and Delivery:
• Labor spontaneous or induced?
• Complications of labor
• Fetal monitoring? Fetal distress?
• Rupture of membranes: artificial or spontaneous, hours before delivery,
character of fluid.
• Medications - including analgesia and anesthesia: drug, dose, route,
time prior to delivery
• Duration of labor
• Mode of Delivery (Vaginal (SVD) or C-section delivery)
• Fetal presentation and position
 Forceps used? If so, state type and indication
• APGAR score: 1 min/5 min (Specify points lost at each)

• Resuscitation: none; bulb suction; free flowing oxygen; bag and mask;
intubation, drugs used (dose and route)
Nutritional History of the mother.
Ask the current copliant and try to write it in detail
Peritent Negative Statement
Family:
• Relationship of neonate's mother and father (single, married, divorced, live
apart, no contact maintained, etc.)
• Education and occupation of the parents
• Any significant illnesses (physical, mental, growth failure) in the family?
• Family size
• Family income (approximate)

 The initial examination of a new-born infant should be performed as soon as
possible after delivery to detect abnormalities and to establish a baseline for
subsequent examination.
 Infants should have temperature, pulse, respiratory rate, color, type of
respiration, tone, activity, and level of consciousness monitored every 30 min
after birth for 2 hr or until stabilized.
 For high-risk deliveries, this examination should take place in the delivery
room and focus on congenital anomalies and pathophysiologic problems that
may interfere with normal cardiopulmonary and metabolic adaptation to
extrauterine life.
 After a stable delivery room course, a 2nd and more detailed examination
should be performed within 24 hr of birth.
 If an infant remains in the hospital longer than 48 hr, a discharge examination
should be performed within 24 hr of discharge.
 The pulse (normal, 120–160 beats/min), respiratory rate (normal, 30–60
breaths/min), temperature, weight, length, head circumference, and dimensions
of any visible or palpable structural abnormality should be recorded.
 Blood pressure is determined if a neonate appears ill or has a heart murmur.
 Examining a newborn requires patience, gentleness, and procedural flexibility.
 Thus, if the infant is quiet and relaxed at the beginning of the examination,
palpation of the abdomen or auscultation of the heart should be performed 1st
before other, more disturbing manipulations are attempted.

General: Describe resting posture, activity, gross abnormality, color (pink,

cyanotic/acrocyanotic, pale mottled)
Gestational age assessment: (Ballard Score)

Vital Signs: T ___ PR______RR______BP______

Pulse rate according to age
Age Normal Average
Range (beats/min)
0 (at birth) 70-190 125

1-11 mo 80-160 120
2 yr 80-130 110
Anthropometry: -Weight ___ gm (% of Colorado Intrauterine Growth Curve)

 Length ___cm (% of Intrauterine Growth Curve)
 Head Circumference ___cm (% " " ―)
 Chest Circumference ___cm (% " " ―)
CLASSIFICATION BY BIRTH WEIGHT AND GESTATIONAL AGE
Birth Weight
Classification Weight
 Extremely low birth weight <1000 grams
 Very low birth weight <1500 grams
 Low birth weight <2500 grams
 Normal birth weight 2500 grams
Gestational Age
Classification Gestational Age
 Preterm < 37 wks (<259th day)
 Term 37–42 wks

 Postterm > 42 wks (>294th day)

New born classifications
Small for gestationalage SGA <10th
Aprpriate for gestationalage AGA 10-95th
Large for gestational age LGA >95th
HEENT:
Head:
 General shape, molding, caput, cephalohematome
 Examine Sutures (overriding, separated), craniotabes.
 Fontanel - anterior, posterior (presence, size, flat/full).
 Texture of hair.

Eyes:
 Edema, conjunctival or anterior chamber hemorrhage, discharge. Size of eye;
cornea, iris normal? Lens clear? Red reflex present? Retina visualized?
 Newborns and young infants may look at your face and follow a bright light if
you catch them while alert. Normal visual milestones are as follows:

 Leukocoria is a white papillary reflex (instead of the normal red

papillary reflex). It can be a sign of a rare tumor called retinoblastoma.
 Nystagmus, strabismus
Nose:
 Internal and external nares patent?
 Septum midline?
 Drainage present?
Ears:
 Cartilaginous development of the ear lobe,
 position of ears,
 shape of auricle (normal/abnormal),
 preauricular sinus or skin tags.
 External auditory canal patent.
Mouth and Throat:
 Palate (intact, narrow or high arched),
 Epstein's pearls,
 Mucosal cysts, teeth, tongue (size, position),
 Frenulum, uvula, Micrognathia.
Lymphoglandular System:
 Masses (thyroid, sternocleidomastoid, etc.),
 Cysts, sinus tracts, movement,
 Lymph nodes,
 Breasts.
Respiratory System: -
 Symmetry and Shape,

 Retractions, flaring, grunting,

 tachypnea,
 auscultation (rales, rhonchi, wheezes)
CVS:
 Peripheral pulses - femoral, brachial, radial (amplitude, equality,
simultaneous),
 Peripheral perfusion (capillary filling time)
 PMI, rhythm, rate (tachycardia, bradycardia), S1, S2 (amplitude equal? S2
split?)
 Murmur (quality, intensity, duration, relation to cardiac cycle, radiation,
location of maximum intensity.
Gastrointestinal System:
 Shape, muscle tone,
 number of umbilical vessels,
 Hernia/diastases.
 If palpable, note size and consistency of liver,
 Spleen, kidney, or other masses.
 Inguinal adenopathy?
Per rectal exam (PR): patency, anal wink, abnormal stooling
Genitourinary System:
 Female- size of clitoris and labia, masses in labia, hymenal
tags, discharge.
 Male - urethral meatus patency and position,
 Chordee,

 Testicular descent and scrotal development (i.e., rugae only on inferior

aspect, or surface completely covered with rugae and pendulous in
appearance).
 Hernia or hydrocele.
Musculoskeletal system:
 Symmetry,
 Do Ortolani maneuver to check for congenital hip dislocation, position
of hands and feet.
 Number, shape, length of digits, palmar creases normal?
 Subcutaneous tissue normal?
 Spine: Sinus tracts,
 Sacral dimple, scoliosis, spinal defects, meningomyelocoeles.
Integumentary system:
 Texture, lanugo, vernix, meconium staining, icterus, hemangioma, nevi, rash,
excoriation, petechiae, bruises.
Central Nervous System:

 Observation is the key to the neurological evaluation of the neonate. Much
information can be gained by observing spontaneous movements and activity
without touching the baby.
 It is important to recognize that the normal infant‘s alertness will vary,
depending particularly on the time of the last feeding, environmental stimuli
and gestational age.
Cranial Nerves in Newborns and Infants
Strategies to assess Newborn and Infant

 Cranial Nerves:

 Motor Examination:
• Tone and posture:
 Note the posture of the infant at rest, is this normal for age?
• Motility and power:
 the quality, quantity and symmetry of movement
are important.
Primitive Neonatal Reflexes


Chief Complaints
Chief Complaints
1 Cough
Cough is one of the most common presenting symptoms in children.
 Acute(less than 2 weeks) - pneumonia, bronchiolitis, croup, FBA
 Chronic(more than 2 weeks) - TB, asthma, pertussis, lung abscess,
bronchiectasis, FBA, CHF
History: ASK?
 Onset: When did the cough starts? Was it gradual onset or rapid?
 Duration: Acute or Chronic. How long has it been present? Is it first
occurrence or recurrent?
 Type/Character
• Dry or productive (if there is sputum) –Ask the amount, color & odor of the
sputum
 Aggravating & Reliving Factor
 Time of the day the cough worsens
• For instance: Bronchial Asthma (worsen during night and early morning)
 Pets or animals contact
 Triggers asthma
 Type of exposure that triggers the cough
 Seasonal aero allergens
 Noxious odor (perfumes)
 Presence of danger signs like child not able to drink or vomits everything, has
convulsions or is lethargic or unconscious.
Rule In & Rule Out

 DDx
 Pneumonia –cough with fast breathing, fever, grunting, head nodding,
living condition, recurrence
• Fever: most of the time it can be continuous.
 Pertussis- post-tussive vomiting, whooping cough, central cyanosis, no
fever, contact hx, vaccination hx DPT-85%, paroxysmal(the child is
normal between episodes of coughing)
• Post-tussive vomiting:
 Croup - Harsh barking cough, stridor, hoarseness of voice
 Common Cold or Influenza, Sinusitis: fever, headache, chills & rigor
 Foreign Body Aspiration:- chocking episode, Commonly in children 6
months to 3 years of age
• Ask History of choking
 foreign objects in airway
 TB – Nonspecific symptoms (night sweats, appetite and wt. loss, fever),
contact history, vaccination, Immunodeficiency (malnutrition, RVI)
 Asthma- nocturnal cough, seasonal exacerbation, family hx of atopy,
self hx of allergy, rx response within minutes, wheezing.
 CHF –SOB, Orthopnea, PND(ask for >5year pediatric group),
• fast breathing, feeding interruption, body swelling, diaphoresis
during breast feeding, cough (<5 year age pediatrics group)
 Lung abscess and bronchiectasis- previous URTI, foul smelling sputum,
and blood tingled sputum.
Assess the. . .

Risk factors
• Low socioeconomic status (overcrowding )
• Un-immunization
• Congenital heart disease
• Bronchopulmonary dysplasia:
• Asthma
• Male sex:
• Immunodeficiency disorders(Congenital and acquired)
• Malnutrition, including Vitamin A and D deficiencies
• Sickle cell disease
• Neuromuscular disorders, especially those associated with a depressed
consciousness
 Duchenne muscular dystrophy (DMD)
 Myasthenia gravis
 Peripheral neuropathy
• Some gastrointestinal disorders (Eg, gastroesophageal reflux,
tracheoesophageal fistula)
• Cigarette smoking (the adolescent or mother of the infant)
• Alcohol and other substances of abuse
• Cystic fibrosis
***Nutritional and Immunization History must be
Including in the HPI part.
Housing and living condition also included in the HPI part.
G/A: In the young infants,

 ASL /respiratory distress and presence of cyanosis/
 Respiratory distress
• Tachypnea,
• Hypoxemia (usually oxygen saturation <94 to 96 percent in room
air), and increased work of breathing:
• Intercostal, subcostal, or suprasternal retractions;
• Nasal flaring;
• Grunting;
• Use of accessory muscles
More specific than fever or cough for lower respiratory tract infection (LRTI)
Vital Sign
BP: use American Pediatrics Association for BP based on age, Ht
PR:
RR: make a count for a full minute when the child is calm
 Age <2 months old: ≥ 60 breaths
 Age 2–11 months: ≥ 50 breaths
 Age 1–5 years: ≥ 40 breaths
If the breathing rate is 60 or more repeat counting the breathing rate in young
infants for a full minute.
TO: fever (nonspecific and invariably present)
Respiratory Examination
Inspection:
• lower chest wall in-drawing ( it occurs when the lower chest wall goes in
when the child breathes in)
• Visible distended veins on the neck
Palpation:
• Trachea shifted from midline
• Decreased tactile fremitus (pleural effusion)

Percussion:
• signs of pleural effusion (stony dullness) or pneumothorax (hyper resonance)
Auscultation:
• coarse crackles, bronchial breath sounds, decreased or absent air entry
(Consolidated lung parenchyma)
Cardiovascular Examination
 Raised jugular venous pressure (JVP)
 gallop rhythm / murmur of heart on auscultation
 distant heart sound
Abdominal Examination
 Enlarged liver and spleen.
 Abdominal masses other than liver or spleen
 Sign of fluid in the peritoneum (ascites)
Integumentary System
 Sever palmar pallor
 Rashes (petechiae, ecchymosis)
 Clubbing of finger nails
MSS
 Peripheral edema
Investigations
 Pulse oximetry–to guide when to start and stop oxygen therapy
 Complete blood count
 Chest X-ray: in children with very severe pneumonia, or severe pneumonia
not responding to treatment or with complications, unclear diagnosis or
associated with HIV
AFB
 Sputum (for children old enough to expectorate) or
 gastric aspirate(for younger children)

C/C: cough of 4 days duration

HPI:
This is a 5 y.o male preschool who was relatively healthy 7 days back at which time
he started to develop sneezing and runny nose, three days later he stated experiencing
intermittent non barking cough(to r/o croup) and fast breathing that begun
insidiously. He also has high grade intermittent fever. The following day shortness
of breath and grunting started to occur.
He was fully vaccinated (being not vaccinated is a risk factor)
He lives with his parent in a family 7 in a house with 2 rooms having one door and 2
windows. (Overcrowding is a risk)
Otherwise,
 He has no hx of chocking and gagging before the onset of the cough; to r/o
foreign body aspiration
 No hx of wheezing and family hx of asthma; to r/o asthma
 No hx of body swelling or sudden awakening from sleep; to r/o congestive
heart failure
 No hx of hoarseness of voice during cough; to r/o tracheobronchitis
 No hx of ear discharge; to r/o otitis media
 No hx of red throat and difficulty of swallowing: to r/o tonsillopharyngitis
 No hx of headache, loss of consciousness; to r/o complication –meningitis
 No hx vomiting and diarrhea (systemic infections)
DX: pneumonia

2 Stridor –
 Is noisy breathing that occurs due to obstructed air flow through a
narrowed airway
 Cardinal sign of URT obstruction in children
 Can be
• Inspiratory
 At or above the vocal cords
 Due to the collapse of the soft tissue with negative pressure during
inspiration
• Expiratory
 Due decreased airway caliber with expiration
 Emanates from intrathoracic trachea and bronchi
• Biphasic
 Indicates unchanging airway caliber due to a fixed lesion
 Characteristics of mid-tracheal lesions

 Diphtheria croup, laryngeal papilloma, viral croup, epiglottitis, peritonsillar

abscess, retropharyngeal abscess.
DDx
New born Older infants & children
 Choanal atresia  Macroglossia

 Pierre robin sequence  Angioedema
 Treacher Collins syndrome  Adenotonsillar hypertrophy
 Cystic hygroma  Croup
 Laryngomalecia  Bacterial trachieties
 Subglottic stenosis  Acute epiglotities
 Laryngeal web, cysts  Retropharyngeal abscess
 Tracheomalecia  Laryngeal papilloma
 Vascular ring  Foreign body
 Caustic ingestion
 Inhalational burn
 Anterior mediastinal mass
Investigations
 WBC count with differentials
 Lateral neck x-ray
 Neck x-ray (anterio-posterior view)
 Chest x-ray

3 WHEEZE
 High pitched sounds with hissing or shrill quality
 Usually maximal during expiration and is accompanied by prolonged expiration
 Can be diffused, scattered or localized & unilateral or bilateral
Why mainly on expiration?
- b/c during expiration the volume of the thoracic cavity decreases, creating
positive pressures within the thorax.
A- Single(non-recurrent) B-Chronic(recurrent)
• Acute bronchiolitis(commonest cause • Bronchial asthma(commonest cause of
of wheezes in infancy) wheezes in children)
• Sever bronchopneumonia • Recurrent aspiration(GERD, tracheo
• Foreign body inhalation(sudden onset osophageal fistula)
& chocking) • Foreign body inhalation(unremoved)
• Organo-phosphorous • Chronic infection(immunodeficiency)
poisoning(exposure, chest secretion, • Bronchopulmonary dysplasia
diarrhea, pinpoint pupils& coma) • Interstitial pneumonia(expiratory
wheezes)
Identification
a) Age
- Most infants and young children with recurrent wheezing have asthma
however, a wide variety of congenital and acquired conditions can cause
narrowing of the extrathoracic or intrathoracic airways, and may present with
wheezing.

- Wheezing that appears at birth or soon afterward should prompt an evaluation

for congenital airway abnormalities such as tracheomalacia, complete rings, or
vascular abnormalities or compression
- Infection-induced wheezing in children younger than 2 years is associated
with RSV, especially in infants with passive exposure to smoke, and with
rhinovirus in children older than 2 years.
History of Present Illness

a) how was the onset? Was it sudden?
▪ If the onset is Sudden
• foreign body aspiration not seen by the parents and don‘t forget to ask
history of choking
b) Ask the duration of the symptom? Also whether the symptom is for the first
time or have previous episodes?
 This helps us differentiate acute from chronic/persistent wheeze
c) Does the patient have history of cyanosis? Or shortness of breath?
 Cyanosis and SOB are seen with severe hypoxemia and acute respiratory
distress.
d) Is baby able to communicate?
 Inability to communicate indicates airway obstruction and impending acute
respiratory failure.
e) Does patient have easy emesis, go to sleep immediately after drinking? Or if
an infant, drink large quantities milk daily?
 Gastroesophageal reflux, even when occult, can cause wheezing.
f) Did patient aspirate a foreign body?
g) Any preceding upper respiratory symptoms and fever?

 Wheezing caused by viral bronchiolitis is usually preceded by upper

respiratory symptoms and fever, often worsens within the first few days of
onset, and tends to improve slowly thereafter.
Discussion on Ddx of Wheeze

 Congenital anomalies
 Malecia of the larynx, trachea and/or bronchi
• Symptoms since birth
• Relief of symptoms in prone position
 Tracheoesophageal fistula (H – type)
• Recurrent pneumonia
• Risk factors during pregnancy like polyhydramnios
 Vascular ring
• Symptoms since birth
• Noisy breathing, Tachypnea, opisthotonic position
 Bronchial asthma
• Diffused, bilateral wheeze
• Afebrile
• Recurrent symptoms
• Response to bronchodilators
 Infections
 Bronchiolities
• Diffused or scattered, bilateral wheeze
• Febrile
• First episode of wheeze during infancy
• Poor /no response to bronchodilators
 Pneumonia

• Sign of consolidation
• Scattered, unilateral wheeze
• Coarse crepitation
 Endobronchial TB
• Contact hx to a known TB pt
• Hilar adenopathy on CXR
• Foreign body
• Chocking episode hx
• Localized, uni or bilateral
• Afebrile
• No response to bronchodilators
 Miscellaneous
 Pulmonary edema
• Bilateral or unilateral wheeze
• Signs of CHF
• Auscultory cardiac findings
• Bilateral postero- basal rales
 GERD
• Vomiting since early infancy
• Failure to thrive
 Mediastinal mass/tumor
• Mediastinal widening on CXR
• Other systemic signs
Investigations
 WBC with differentials
 CXR

 Hyperinflation (asthma)
 Foreign body
 Cardiomegaly
 Mediastinal mass
 Consolidation / pulmonary edema
 Pulmonary function test
 PPD test – bronchial TB
 Esophagogram - Vascular ring, GERD


C/C: Cough and wheeze of 3 days duration

HPI:
He was relatively healthy 3 days back at which time he started to experience an intermittent dry cough which
worsens at night time and sometimes early in the morning but it is not associated with feeding (r/o: Gastro
esophageal reflux). His mother also noticed a noisy breathing like a wheeze which is not associated with
runny nose, sneezing and nasal stiffness (r/o: common cold). She denies that he has any prior wheezing
episodes. Associated with this, he also has history of difficulty of breathing and difficulty of keeping up with
his friends at school during different physical activities and playing. For these reasons, he discontinued to
attend school for 2 days. Yesterday, his symptoms worsened during day time while playing and jumping
around the house with his brother and had a difficulty of catching his breath and continuous cough. Then his
mother rushed him to this hospital emergency department and he was given a drug which is inhaled through
his mouth. After few minutes he became well. He has a past history of food allergy for peanut butter and a
skin allergy. He is fully vaccinated. (RF for pneumonia, some etiology of acute bronchiolitis).
He was first exclusively breastfed for 6 months and had been breastfeeding for 2 years. (RF for acute
bronchiolitis).
He lives in a total family size of 5. He has one big brother aged 8 years, one younger sister aged 3 years, and
his both parent. All of them are healthy. They live in a house with 3 rooms, 2 of them have a single window
in each while the other has 2 Windows and 2 doors which is separated from the kitchen and toilet. They have
no any animal in the house. (RF for acute bronchiolitis, pneumonia).
He started to sit unsupported at age of 8 months and walk steadily unsupported at age of 1 and half years. At
age of 4, he started to run up and downstairs, to dress and undress himself without help and to
speak fully understandable sentences. (if failure to thrive- CF, immunodeficiency).
He was born by spontaneous vaginal delivery as his other siblings at gestational age of 39 weeks with a birth
weight of 2.5 kg with no neonatal and maternal complications. (congenital abnormalities or
bronchopulmonary dysplasia)
Otherwise,
 He has no history of previous asthma diagnosis and treatment

 He has no history of second hand tobacco and other smoke exposure. (Bronchiolitis,
asthma)

 He has no history of clear nasal discharge, sneezing (Bronchiolitis, transient asthma,

pneumonia)
 He has no history of fever. (Bronchiolitis, pneumonia)
 He has no history of choking (foreign body aspiration)
 He has no history of difficulty of swallowing and any neurogenic disease. (Swallowing
disorders)
 He has no history of recurrent upper respiratory tract infection and poor weight gain.
(immunodeficiency, ciliary kinetic disorders)
 He has no history of food regurgitation or vomiting (Gastroesophageal reflux)
 He has no history of difficulty of making a sound and throat thightness. (Vocal cod
dysfunction)
 He has no history of prior surgery like lung transplantation. (Bronchiolitis obliterans)
 He has no personal and family history of cardiac disease (r/o congenital heart disease),
asthma, immunodeficiency, TB, renal disease and RVI

4 Diarrhea
Is abnormal frequency and liquidity of fecal discharges. WHO defines diarrhea as
passage of loose stool  three times per day.
 Infection is a leading cause of acute diarrhea, whereas Inflammatory
Bowel Syndrome is the leading cause of chronic diarrhea
History
HPI:
 Onset: When did it start?
 Duration: Since how many days has this been happening?
 Frequency: How many times does it make you go to the toilet? (How many
times you child go to toilet in a day?)
 Character – Persistent or Intermittent
 Appearance: content (mucus or blood), lose or formed, color, odor?
- Presence of blood in stools (Bloody diarrhea may suggest
specific infectious agents, inflammatory bowel disease, bowel ischemia (or
necrotizing enterocolitis) or cow‘s milk protein allergy.)
- Is it extremely foul-smelling or contain oil droplets (malabsorption)?
Viral or bacterial infections and parasitic infection can cause foul
smelling stool or diarrhea. Giardiasis, Rotavirus,
 Associated symptom (Ask?)
 If there is vomiting- duration, frequency, relation with food, nature, quantity,
color and blood in vomiting

 If fever- duration, low or high grade

 Weight loss
 Cough (for URTI), rash (for measles), and urinary complaints (for UTI).
 What is the child’s current urine output (oliguria or anuria suggests a large
volume deficit)?
 Abdominal pain or distention
 Any history of seizure
Asses the Risk Factors

 Past history of diarrhea
 Treatment given previously – (C. difficle enterocolitis by clindamycin)
 Feeding hx (breast feeding)
 Family history (other person in the family with the same sx)
 Food poisoning.
 Tenesmus: Painful spasm of the anal sphincter along with an urgent desire to
defecate without the significant production of faeces; associated with irritable
bowel syndrome
 Vaccination hx.
 Hx of contact with measles or TB patient
 Social and family hx
 Assess dehydration status (no, some-irritable, thirsty, severe)
Etiology
– Rota virus, enterovirus, v.cholera, shigella, e.coli, salmonella, c.jejuni, ameba,
giardia, ascaris
• Acute – AGE, Cholera (profuse rise water appearance, effortless, watery
diarrhea followed by vomiting and severe dehydration), shigella(loose, mucus,

pus, and blood, fever, abd pain, tenesmus), salmonella, pseudomembraneous

colitis.
• Chronic - PEM, IDA, parasites (Giardia (chronic relapsing diarrhea, watery
stool, malodor, diffuse abdominal pain), hookworm, tapeworm), AIDS
enteropathy
- Ameba – cause acute dysentery or chronic non dysentery diarrhea. Watery,
blood and mucus, abdomial pain and tenesmus.
Table: DDx of the child presenting with diarrhea

Diagnosis Discussion
Acute (watery) diarrhea More than 3 stools per day
No blood in stools
Cholera Diarrhea with severe dehydration during
Cholera outbreak
Positive stool culture for V. cholera O1 or O139
Dysentery Blood in stool (seen or reported)

Persistent diarrhea Diarrhea lasting 14 days or longer
Diarrhea with severe malnutrition Any diarrhea with signs of severe malnutrition
Diarrhea associated with recent antibiotic use Recent course of broad-spectrum antibiotics
Intussusceptions Blood in stool

Abdominal mass (check with rectal examination)
Attacks of crying with pallor in infant
1. Watery diarrhea:
A. Diarrhea of enterotoxigenic pathway
B. Osmotic diarrhea
C. Motility diarrhea
D. Secretory diarrhea
2. Gastroenteritis with hemolytic anemia:
A. Viral infections(diarrhea & post viral autoimmune hemolysis)

B. E.coli infection (diarrhea with hemolytic uremic syndrome)
Check for vital signs: also helps for follow up
Look for:
 Signs of dehydration:
 Restlessness or irritability
 Lethargy/reduced level of consciousness
 Sunken eyes
 Skin pinch returns slowly or very slowly
 Thirsty/drinks eagerly, or drinking poorly or not able to drink
 Signs of shock
 Capillary refill

 Mental status
Clinical Dehydration Scale
0=No dehydration 1–4 = Some dehydration 5–8 = Moderate/severe

dehydration
*Goldman RN, Friedman JN, Parkin PC. Validation of the Clinical Dehydration Scale for children with acute
gastroenteritis. Pediatrics. 2008; 122 (3): 545-549
Loss of nutrients
Hypoglycemia
Convulsions, mental changes
Loss of bicarbonate
Vomiting & retching
Deep respiration
Decreased myocardial contractility
Potassium loss

Abdominal distension
Paralytic ileus
Investigations of diarrhea
• Stool examination (microscopy)
o leukocyte(>10/hpf)- invasive bacteria
o RBC, ova , tophozoite, ocyts
o Culture and sensitivity- persistent diarrhea
• Blood test
 CBC
 Serum electrolyte
 BUN Creatinine
• Stool culture
• Stool microscope
• Arterial blood gas analysis
Management
The 3 essential elements in the management of all children with diarrhea are
 Rehydration therapy,
 Zinc supplementation
 Counseling for continued feeding and prevention.
Acute diarrhea
A 13-month-old child has had a 3-day history of green watery stools. She has also
been vomiting for 1 day. Physical examination reveals a febrile, irritable baby with
dry mucous membranes and sunken eyes.
Table: Classification of dehydration in children with diarrhea

Classification Signs or symptoms Treatment

Severe Two or more of the following  Give fluid for severe
dehydration signs: dehydration (
 Lethargy/unconsciousness
(see Diarrhoea
 Sunken eyes
 Unable to drink or drinks
poorly Treatment Plan C in in
 Skin pinch goes back very
slowly section)
( ≥ 2 seconds )
Some Two or more of the following  Give fluid and food for some
dehydration signs: dehydration (see dehydration. -
Diarrhea)
Treatment Plan B
 Restlessness, irritability
 Sunken eyes
 After rehydration, advise
 Drinks eagerly, thirsty, may
mother
not be reliable sign for
on home treatment and when
young infants
to return immediately
 Skin pinch goes back slowly
 Follow up in 5 days if not
improving
No  Not enough signs to  Give fluid and food to treat
dehydration classify assome or diarrhoea at home (see
severe dehydration Diarrhoea Treatment Plan A)
 Advice the mother on when
to return immediately
 Follow up in 5 days if not
improving.
Assessing dehydration
For all children with diarrhoea, hydration status should be assessed and classified as
severe dehydration, some dehydration or no dehydration and appropriate
treatment given.
Severe Dehydration
Children with severe dehydration require rapid IV rehydration with close
monitoring, which is followed by oral rehydration once the child starts to improve
sufficiently.
Diagnosis

If any two of the following signs are present in a child with diarrhea, severe
dehydration should be diagnosed:
 Lethargy or unconsciousness
 Sunken eyes
 Skin pinch goes back very slowly (2 seconds or more)
 Not able to drink or drinks poorly.
1. REHYDRATION THERAPY: FLUID AND

ELECTROLYTES
— Fluid management consists of two phases: replacement and maintenance.
 Replacement therapy
 is to replenish deficits in water and electrolytes lost. Continued until all signs
and symptoms of diarrhea are absent and the patient has urinated; ideally this
is achieved during the first four hours of therapy.
 Maintenance therapy counters ongoing losses of water and electrolytes; this

phase is continued until all symptoms resolve.
 The approach to fluid and electrolyte management depends on the degree of

dehydration:
NO SIGNS OF DEHYDRATION

 Do not require a replacement phase and can begin maintenance therapy.

usually do not require hospital admission
 Ideally ORS is administered for maintenance fluids to counter ongoing fluid
and electrolyte losses.
SOME DEHYDRATION
Replacement therapy with ORS in a supervised setting. If ongoing stool losses
(Measured) are profound, these losses can be added to the initial amount of fluids
given over the first four-hour period.
 Ideally stool output is measured by collecting stool using a cholera cot.
Alternatively, stool output can have estimated as 10 to 20 mL/kg of body
weight for each diarrheal stool.
Maintenance fluids begins once dehydration has been corrected,
SEVERE DEHYDRATION
 Manage urgently with IV fluids in a hospital setting.
 The goal of rehydration with intravenous fluids is to stabilize the circulation
immediately.
 For developing settings:
 the WHO recommends that a bolus of isotonic crystalloid fluid of 30
mL/kg given over 30 minutes (or one hour in infants <12 months)
 Followed by additional isotonic fluids to correct the bulk of the
remaining fluid deficit, by giving 70 mL/kg of isotonic crystalloid over
2.5 hours (or 5 hours for infants).
NB: Crystalloid fluids such as Ringers’ Lactate solution or normal saline are used.
Colloids, blood products, or hypotonic fluids can be harmful and should NOT be
administered since these may cause fluid shifts which exacerbate fluid loss in the
cellular compartment.
Rehydration for Malnourished children - refer

on SAM management
2. NUTRITION — the goal of nutritional management for patients without

malnutrition is to encourage sufficient feeding both during and after the diarrheal
illness episode to prevent development of malnutrition and chronic enteropathy.
 FOR INFANTS WITH DIARRHEA, once rehydration is completed:

 Breastfeed or,
 If they are not breastfed, encourage them to continue to take undiluted
formula at least every three hours, in addition to ORS.
 FOR CHILDREN WITH DIARRHEA, encourage them to take solid foods
immediately after initial dehydration is corrected.
 AS LONG AS DIARRHEA PERSISTS, foods high in energy content and
micronutrients should be offered at frequent intervals (at least six meals a
day).
 AFTER DIARRHEA RESOLVES, at least one extra meal per day
should be continued for a minimum of two weeks, or until the patient regains
normal weight-for-height.
 In children with severe malnutrition, refer on SAM management.
VITAMINS AND MINERALS:
3. ZINC SUPPLEMENTATION
 Several studies have demonstrated that zinc supplementation reduces the

severity and duration of diarrhea and reduces the incidence of subsequent
episodes of diarrhea for several months.
 Based on these studies, the WHO recommends zinc for children under 5 years
of age with diarrhea
 10 mg/day for under 6 months
 20 mg/day for 10 days for 6 months to 5 years
4. OTHERS
 VITAMIN A SUPPLEMENT —
 Because children with diarrhea in developing countries are at high risk of

vitamin A deficiency.
 If patients with signs of xerophthalmia, severe malnutrition, or a history of
measles (a three dose series of repeated treatments)
 Antibiotics — are not indicated for most children with acute watery diarrhea;
suspected cholera is an important exception in which antibiotic therapy is useful.
Dysentery treatment
 Includes correction of fluid and electrolyte losses, appropriate nutritional care,
and treatment of the underlying cause of illness.
 The management of fluids and nutrition is as described in the preceding
sections.
 Empiric antibiotic therapy for acute bloody diarrhea should be targeted
against Shigella species. It reduces the duration of fever and diarrhea,
decreases the duration of bacterial shedding, and the risk of life threatening
complications of
infection (bacteremia).
NB
Sodium loss
 Fluid loss in acute watery diarrhea can be isonatremic, hyponatremic, or

hypernatremic.
 Corrected by ORS gradually (has advantage of reducing the risk of the
neurologic complications due to rapid shifts in osmolarity that may occur
with IV fluids)
Potassium loss
 Stool potassium losses commonly result in hypokalemia.

 Manifests with muscle weakness, paralytic ileus or arrhythmia.
 replaced using ORS
PREVENTION — WHO recommendations to prevent diarrhea include:
 Exclusive breastfeeding until age six months, and continued breastfeeding with
complementary foods until 2 years of age.
 The consumption of safe food and water. Boiling water.
 Handwashing after defecating, disposing of a child's stool, and before
preparing meals.
 The use of latrines; these should be located more than 10 meters and downhill
from drinking water sources.
 Immunizations — WHO strongly recommended rotavirus vaccine in countries
where diarrheal deaths account for ≥10 percent of mortality among children
aged <5.

C/c: diarrhea and vomiting of 4 days duration

HPI:
This a 9 and ½ month male infant. He was relatively healthy 4 days back until he developed
vomiting and diarrhea of 4 days duration. The vomiting is non-projectile, non-blood tingled, non-
foul smelling, and bilious with 3-4 episodes per day. The diarrhea is watery, non- blood tingled and
yellowish to brown in color with 4-5 episodes per day. Associated to this he has lost his appetite. In
addition, the pt has hx of sunken eye ball(dehydration) which is first noticed by his mother 3 days
back. His mother also complains that he has hx of fever 0f 2 days duration. (sign of infection) For
the above complaints he was taken to yabu local health center where he was given ORS and
referred to JMC for better management.
Otherwise
 he has no hx of change in urine output dehydration
 has no hx of use drugs (antibiotics clostridium deficil)
 has no hx of generalized body swelling (SAM hygiene RF for AGE) - there is no cholera
outbreak in the society
He has been on exclusively breast fed for 6 months. He was fed 6-8 x per day. At 6 th month he
started a complementary feeding with a diluted cow milk, gruel made of barley, potato and fruits
like banana, mango and orange. While he started the complimentary food the feeding was with
bottle. (SAM and BOTTLE feeding hygiene RF for AGE) His mother claims that she washes her
hand and food preparing materials before she cooks food. (personal hygiene hygiene RF for AGE
He has been exposed to sun light starting from the age of 1 month, necked and without lubricating
agent. His father is a farmer and his mother is a house wife. They produce about 85 Kesha of coffee
per year. They live in a house of 3 room and 3 windows with a kitchen and latrine separated from
the main house. The latrine is 10 m away from the main house. (poverty and environmental hygiene
RF for AGE)

5 Generalized Body Swelling

DDx
Generalized Swelling:
• SAM (sever acute malnutrition)-Edematous Malnutrition
• CHF 2O CHD
• CHF 2O RVHD & Infective Endocarditis
• Nephrotic Syndrome
• Nephritic Syndrome
• Acute Liver Failure (Due to drug toxicity, hepatitis, . . .)
• Protein losing Enteropathy
• TB pericarditis
• Polycystic Kidney Disease
• Hemolytic Uremic Syndrome
Localized Swelling:
 inflammation,
 lymph edema,
 DVT,
 Malignancy
 Angioneurotic edema
 Urticaria
 Cellulitis
 Filariasis.
HPI:
 Duration
 Mode of onset- sudden (may be angioedema), gradual (renal or cardiac)
- When was the first occurrence
 How patient first recognize swelling eg. Child unable to wear
his shoes or his clothes becomes tight.
 Pattern of the swelling:
- If from face downward may suggest renal diseases,

because in renal cases normal CVP but increased hydrostatic pressure and low
plasma oncotic pressure results in excess interstitial fluid in loose connective
tissue area; the eyelid.
- If from leg upwards may suggest cardiac diseases or SAM, because in
cardiac disease increased CVP results resistance to venous return resulting
peripheral congestion in the lower limb venous
system which ascends against gravity.
- If from abdomen downward to legs may suggest liver diseases, because
Liver disease cause portal hypertension resulting ascites.
- Weight gain: usually precedes overt GBS, patient may complain of difficulty
putting shoes and cloths particularly in the evening (why?)
 Diurnal variation- renal (first in the morning)
Associated sxs
 Cough
 Breathlessness(if it is cardiac cause)
 Jaundice
 Urinary Compliant (like urgency, frequency)
Rule in and Rule Out

SAM: ask nutritional hx in detail???
• Diarrhea Hx, Vomiting & nausea Hx
• Weight loss and appetite loss
Hepatic sxs (hep B vaccination)
Renal sxs (Urinary Compliant)
TB (Contact hx)
Nutritional, Immunization, developmental Hx must be included in HPI.

Edema grading
Grade 1 On both feet & ankles
Mild edema
Grade 2 On both feet & lower legs; hands &
Moderate edema forearms; Pretibial edema
Grade 3 Sacral edema, Generalized edema

Severe edema affecting feet & legs; hands &
forearms; face & eyes; ascites

6 Vomiting

 ONSET: When did vomiting starts?

 DURATION: Since how many days has this been happing?
 FREQUENCY: How many times do you vomit in day?
 DIURNAL Variation: Is vomiting worse in the mornings? (Ex. GERD . . . )
 CHARACTER: Persistent or intermittent
 Is vomiting effortless/painless?
 APPERANCE: Color-greenish tinged, blood tinged, any food in vomit?
 Is copious and watery?
 Is it projectile?
 Do you feel better after vomiting?
Associated with fever, abdominal pain, altered sensorium, and confusion?

7 Fever
Fever of short duration (less than one week):
1. Fever with focus (localizing signs):
 Diagnosis is established by clinical findings
 Re-examination after 24 to 48 hours is essential as the focus may be not
evident.
Mild focal infections Serious focal infections
Respiratory: Pneumonia: respiratory distress,

 tonsillitis , bronchial breathing & crepitations
 sinusitis Peritonitis: abdominal distension &
 nasopharyngitis , diffuse tenderness
 otitis media& bronchiolitis Pyelonephritis: loin pain &
Gastrointestinal : tenderness
 G.E.(vomiting & diarrhea) Meningitis :convulsions, neck
Urinary : retraction, increased intracranial
 Cystitis (dysuria,frequency) tension
Skin: abscess Arthritis or osteomyelitis: hotness
,redness ,tenderness & swelling
2. Fever without focus (simple fever):
Viremia Bacteremia Septicemia
Mild to moderate fever. More than 39.4° C High fever or hyperpyrexia
Fair general condtion. (high fever ). Very bad general condition
(look toxic &very ill).
Bad general
condition (look Other findings: pallor, cold
sick). extremities, mottled skin,
persistent vomiting & may
be disturbed
consciousness
Treatment : Broad spectrum Urgent hospitalization
antipyretics antibiotics
N.B.: -
 Otitis media is very common in infants & children so, should examine the ear.

 vomiting is not a localized sign as it accompanies infections of many systems
Fever of long duration (more than 10-14 days) (prolonged fever)

Infections(most common) Rheumatic Malignancy
diseases
Bacterial: Systemic lupus Leukemia
 Systemic: TB, Brucellosis, Juvenile Neuroblastoma
salmonellosis rheumatoid lymphoma
 Localized: Pyelonephritis, endocarditis arthritis
, abscess e.g liver, pelvic & perinephric Rheumatic
Viral: fever
 Hepatitis ,cytomegalovirus,
infectious mononeucleosis .
Parasitic:
 Malaria, toxoplasmosis, visceral
larva
migrans.
N.B.:-fever of unknown origin:
1) History of prolonged fever
2) Fever is documented in the hospital
3) History ,examination & routine investigations failed to reveal a cause
History
 How long has the child been febrile?
 Are there any localizing symptoms?
An infection in certain systems will advertise itself:
• Cough or coryza: suggest respiratory tract infection.
• Vomiting and diarrhoea: suggest gastrointestinal tract infection,
although vomiting alone is non-specific.
• A painful limb: suggests infection of the bones or joints.
• Lower abdominal pain: suggests urine infection but lobar pneumonia
can also present this way.

• Headache, photophobia and neck pain: suggest meningism.

Younger children (<2 years of age) might not localize symptoms and fever might be
the only symptom.
Has there been recent travel?
Is the child systemically unwell?
 G/A: Lethargy or irritability, ASL, CSL, Acute on Chronic Sick looking
 V/S: Persistent tachycardia.
HINTS AND TIPS
Assume sepsis in all febrile infants aged <3 months until proved otherwise
Are there local signs of infection?
 Look for abulging fontanelle in meningitis.
 Tonsillitis, otitis media, pneumonia, meningitis and septic arthritis can all be
revealed on examination
 a rash might be diagnostic.
 Look for abulging fontanelle in meningitis.
Investigations
Markers of inflammation:
 CBC: -white cell count (raised or low in overwhelming sepsis), differential
(neutrophil predominance in bacterial infection)
 C-reactive
HINTS AND TIPS
A seriously ill child might initially have normal blood inflammatory markers
Microbiological examination
 Blood Culture & Urine Culture

Imaging: CXR: is useful if there is no clear focus but is not required if a clinical diagnosis
of an uncomplicated pneumonia has been made.

8 Abnormal Body
Movement
DDX
CNS infections
• TB Meningitis
• Complicated Meningitis: ask sx of meningitis
• Encephalitis
• Brain abscess
• Syphilis(tertiary)
Metabolic
 Hypoglycemia
 Hypocalcaemia
 Hypomagnesaemia
 Hyper/Hyponatremia
Other
 Epilepsy
 Pediatric Stroke
 Head Trauma
 TIA
 Sydenham Chorea: unilateral dancing like movement
• Triads: Emotional liability, chorea, Hypotonia
 Salmonella typhi
 Brain Tumor

History
 Age
• Febrile Seizure (6mo-5yr.)
• Neonatal Seizure
HPI
ProdromalAura phaseIctal phasePostictal phase
CHARACTERIZATION (during ictal period)
 Onset
 Duration
 Mode of onset and its progression
 Frequency
 Time of occurrence
 State of consciousness(retained or impaired)
 Generalized or focal onset
 If it is focal asses from which part does it starts (whether from face or
extremity)

 Aura: - sensory experiences reported by the patient not observed externally

 It could be visual, olfactory, auditory, déjà vu, tingling, chest tightness,
epigastric pain, feeling of fear, apnea (for neonates), Epigastric discomfort
or pain
 Child behavior before the event like cyanosis
 Loss of sphincter control (bladder)
 Vocalization
 Posture of the patient
 Automatism: -automatic semi-purposeful movements.

 Example: chewing, salivation, dilation of pupils, flushing, lip smacking,
picking at clothes.
 Postictal state
 Sleep, headache, hemi paresis, aphasia.
 Presence of fever, vomiting. . . . . .

Precipitated factors
 Poor adherence
 Sudden withdrawal of drugs(Toxins or dugs)
 Acute infections
 Alcohol intake/ withdrawal(adolescent)
 Dehydration
 Emotional stress
 Fever
 Infection ,
 Head trauma
 Hypoxia,
 Cardiac arrhythmias
 Sleep deprivation

DETERMINIG THE TYPE OF ABNORMAL BODY MOVEMENT

 Seizure
 Sydenham chorea
 Spasm
 Tremor
 Paroxysmal vertigo
 Syncope Seizure mimicking events
 Psychogenic seizures
IDENTIFYING THE UNDERLYING ENTITY

 History of personality change or symptoms of increased intracranial pressure
can suggest an intracranial tumor.
 History of cognitive regression can suggest a degenerative or metabolic
disease.
 Certain medications such as stimulants or antihistamines can precipitate
seizures.
 Any evidence of active CNS infection.
 Any history of trauma.
RISK FACTOR FOR THE UNDERLYING CAUSE
PREVIOUS SIMILAR ATTACK: Past Hx of seizure disorder & use of
anticonvulsants
Ask Poisoning hx
FAMILY HISTORY
IMMUNIZATION HISTORY

DETAILED PRENATAL HISTORY (Asphyxia, Jaundice, Meningitis)(for <2

year
DETAILED DEVELOPMENTAL HISTORY
 Developmental delay can suggest etiologic congenital or perinatal brain
dysfunction.
The physical, ophthalmologic, and neurologic examination provides information

about the presence of
 1) Increased ICP
 2) Neuro-cutaneous syndromes
 3) Structural brain abnormalities
• Brain malformations , injuries , infections , tumors
V/S
 BP, TO
Anthropometry
 HC, length, weight
HEENT
 Fundoscopy
 Papilledema , retinal hemmorrhages ,
 coloboma , chorioretinitis , macular changes
LGS: LN enlargement
Respiratory & CVS
 symptoms of heart failure: for cardiogenic stroke
Abdominal
 Unusual facial features & hepatosplenomegaly
 Metabolic or storage diseases
IGS
 Skin lesions
 Shagreen patch (Tuberous sclerosis)
 multiple cafeau-lait spots

 Neurocutaneous disorder may be indicated by the presence of

vitiliginous ash leaf–type lesions using an ultraviolet light (Wood lamp)
Neurological
 Localizing neurologic signs
Investigation
 RBS
 BF
 Serum electrolytes
 LP
 CBC
 U/A
 MRI
 EEG

Management Principles
 ABC of life
 Position the pt. (recovery postion)
 Give AED

9 Neonatal Convulsion
Common causes Less common causes
• Hypoxic ischemic encephalopathy (most • Kernicterus
common) • Congenital brain anomalies
• Intracranial hemorrhage (intra-ventricular,
• Metabolic hyponatremia,
subdural, epidural)
• Meningitis, septicemia & TORCH infections pyridoxine(B6) dependency
• Metabolic: & hypomagnesemia
 hypoglycemia,
 hypocalcaemia
 hypomagnesaemia
N.B.: more than one cause may exist on the same case (e.g sepsis+hypoglycemia)
AGES 1-4 DAYS AGES 4-14 DAYS
Hypoxic-ischemic encephalopathy Infection
Drug withdrawal, maternal drug use of narcotic or • Meningitis (bacterial)
barbiturates • Encephalitis (enteroviral, herpes simplex)
Drug toxicity: lidocaine, penicillin Metabolic disorders
Intraventricular hemorrhage • Hypocalcemia related to diet, milk formula
Acute metabolic disorders • Hypoglycemia, persistent
• Hypocalcemia • Inherited disorders of metabolism
• Sepsis • Galactosemia
• Maternal hyperthyroidism, or • Fructosemia
hypoparathyroidism • Leucine sensitivity
• Hypoglycemia • Hyperinsulinemic hypoglycemia,
• Perinatal insults, prematurity, small for hyperinsulinism, hyperammonemia syndrome
gestational age • Anterior pituitary hypoplasia, pancreatic islet
• Maternal diabetes cell tumor
• Hyperinsulinemic hypoglycemia • Beckwith syndrome
• Hypomagnesemia Drug withdrawal, maternal drug use of narcotics
• Hyponatremia or hypernatremia or barbiturates
• Iatrogenic or inappropriate antidiuretic hormone Benign neonatal convulsions, familial and
secretion nonfamilial
Inborn errors of metabolism Kernicterus, hyperbilirubinemia
• Galactosemia Developmental delay, epilepsy, neonatal
• Hyperglycinemia diabetes syndrome
• Urea cycle disorders
Pyridoxine dependency and pyridoxal-5-phosphate
dependency (must be considered at any age)

AGES 2-8 WK
Infection
• Herpes simplex or enteroviral encephalitis
• Bacterial meningitis
Head injury
• Subdural hematoma
• Child abuse
Inherited disorders of metabolism
 Aminoacidurias
 Urea cycle defects
 Organic acidurias
 Neonatal adrenoleukodystrophy
Malformations of cortical development
 Lissencephaly
 Focal cortical dysplasia
 Tuberous sclerosis
 Sturge-Weber syndrome

10 Neonatal respiratory
distress
Pulmonary Extrapulmonary
• Respiratory distress syndrome Respiratory
• Meconium aspiration syndrome • Airway :
• Transient tachypnea of newborn  Choanal atresia (bilateral)
• Pneumonia(intrauterine  Laryngomalacia
aspiration of milk or secretion)  Trachea-esophageal fistula
• Pulmonary air leak:  Pierre-robin syndrome
 pnumothorax (micrognathia- glossoptosis)
 Pneumomediastinum • Chest wall:
 Pneumopericardium  Neonatal myasthenia
• Pulmonary haemorrhge  Thoracic dystrophy
• Congenital lobar emphysema Cardiac
• Diaphragmatic • Congenital heart disease with heart failure
• Persistent fetal circulation
Central (cerebral irritation)
• Cerebral hypoxia
• Intracranial hemorrhage
• Meningitis
• Narcosis: maternal drugs
Metabolic
• Acidosis
• Hypothermia
• Hyperthermia
• hypoglycemia


11 Neonatal Jaundice


12 Pleural effusion
 Is collection of fluid in the pleural space, rare <2yr. can be unilateral or
bilateral
 Simple fluid = hydrothorax
 Blood = Hemothorax
 Lymph = chylothorax
 Pus = empyema
 Can be exudative or transudative
 To differenciate the two, we use ―Lights criteria‖
Signs
 Trachea - deviated away from a massive effusion
 Reduced chest expansion
 Stony dullness
 Absent air entry
 Creptation over the fluid (not always)
Light Criteria
Exudative – if full fill one of the following Lights criteria

 Pleural protein-to-serum protein ratio > 0.5
 Pleural LDH-to-serum LDH ratio >0.6 or
 Pleural LDH is above 2/3 of upper normal serum level
Transudative – if not full fill any of the above parameters
DDx for Exudative Vs Transudative

Exudative Transudative
 Bacterial Pneumonia  Congestive heart failure
 TB Pleurisy  Hypoalbuminemia from PLE
 Metastatic cancer  Nephrotic syndrome
 Lymphoma  Constrictive pericardities
 Empyema  Hypothyroidism
 Pulmonary infarction  Meig‘s syndrome, …
 Traumatic effusion
 Connective tissue diseases (RA,SLE)
 Acute pancreatitis
 Drugs (cytotoxins, hydralazine...)
Bilateral pleural effusion

 CHF
 Nephrotic syndrome
 Pulmonary infarction
 Lupus
 Rheumatoid Arthritis
 Malignancy
 TB
Investigations
 CBC
 CXR

• May not be visible if the amount is <250 ml

• Expected to be seen
 Blunted/ obliterated costophrenic angle
 Radio-opaque density extending from the base
 Meniscus sign at upper surface
 Mediastinal shift away from the effusion – if huge effusion
Pleural fluid analysis

Appearance
Hemorrhagic Chylous
 Trauma  Malignancy
 Malignancy  Trauma to lymphatic
 Pulmonary infarction vessels
 TB  TB
 Spontaneous pneumothorax  Thrombosis of the left
subclavian vein
Cloudy – bacterial infection, TB, _____ _
 Turbidity
 Cell count
 LDH level
 Protein level
 Glucose level
 Gram stain
Diagnostic Thoracentesis should be performed if
 Not bilateral or comparable in size (CXC)
 If pt. febrile
 If pt. has pleuritic chest pain

 If the effusion is refractory to therapy(no response to diuretics)

Therapeutic thoracenetesis
 Located pleural fluid
 Pleural fluid PH<7.2
 Pleural fluid glucose < 60mg/dl(<3mmol/l)
 Positive gram stain or culture
 Presence of gross pus in pleural space
 Blood culture
 Ultrasound
 Aids in identification of loculated effusion
 Aids in differentiation of fluid from fibrosis
 Aids in identification of thoracentesis site
 CT scan
Aids in differentiation of
 Consolidation vs effusion
 Cystic vs solid lesions
 Peripheral lung abscess vs loculated empyema
Aids in identification of
 Necrotic areas
 Pleural thickening, nodules, masses
 Extent of tumour
 Pleural biopsy and cytology
Closed pleural biopsy
CT guided cutting needle biopsy
Video assisted thoracoscopic (VATS) pleural biopsy
Pleural fluid analysis Transudate Exudates

Appearance Clear Cloudy or purulent

Cell count (per mm3) < 1000 Often > 50,000
Cell type Lymphocytes, monocytes Neutrophils
Lactate dehydrogenase < 200 U/L >1000 U/L
Pleural fluid : serum LDH < 0.6 >0.6
Protein > 3 g Unusual Common
Pleural fluid : serum < 0.5 >0.5
protein
Glucose Normal Low (<40mg/dl)
PH Normal <7.10
Gram stain Negative <1/3 of cases +ve
Mgt principle
 Large bore needle insertion
 At 2nd ICS over the MCL for small fluid
 Chest tube insertion
 At 5 ICS over the MAL
 Antibiotics
Common VIVA Questions

 Why pleural effusion is common in the right pleura?
 Ddx for unilateral vs bilateral crepitation
13 Pneumothorax
Accumulation of air in the pleural cavity due to
 Leakage of air from the lung or chest wall punctures into the pleural space
Signs
 Tachypnea
 Trachea deviates away from
 Subcutaneous crepitation
 Reduced chest expansion
 Reduced tactile fremitus
 Hyperresonance
 Greatly reduced or absent air entry
 Distended neck vein
Investigations
CXR
o Expected to be seen
 Hypo dense (extremely dark) on the affected side
 Visceral pleural edge is visible
 Absent bronchovascular markings peripherally
 Loss of lung volume on the affected side
 Mediastinal shift to opposite side
 Tracheal shift to opposite side
Pulmonary function test
Mgt principle
1. Immediate decompression
 Thoracocentesis
 Large bore needle
 Chest tube insertion

14 Developmental Delay
 Developmental Delay is when your child does not reach their developmental
milestones at the expected times.
Five developmental disabilities

 Autism spectrum disorder (ASD)
 Cerebral palsy (CP)
 Intellectual disability (ID)
 Attention deficit hyperactivity disorder (ADHD)
 Learning disabilities.

Intellectual disability (ID) refers to a group of disorders that have in common

deficits of adaptive and intellectual function and an age of onset before maturity is
reached.
 The most common developmental disability is intellectual disability.

Cerebral palsy is the second most common developmental disability, followed
by autism spectrum disorder.
Global developmental delay (GDD)

 GDD is a diagnosis given to children <5 yr of age who display significant
delay (>2 SD) in acquiring early childhood developmental milestones in 2 or
more domains of development
―What Are The Signs Of Global Developmental Delay? ‖

The most common signs of GDD include:
 The child is unable to sit on the floor without support by 8 months;
 The child is unable to crawl by 12 months;
 The child has poor social skills/ judgment;
 The child is unable to roll over by 6 months;
 The child has communication problems
 The child has fine/ gross motor difficulties

 The child shows aggressive behavior as a coping skill
In some children GDD is suspected soon after birth because of feeding difficulties or
muscle-tone. In others it is suspected later when learning or behavior difficulties
occur at school.
Fine or gross motor Delay

1. Floppy or loose trunk and limbs.
2. Stiff arms and legs
3. Limited movement in arms and legs.
4. Inability to sit without support by 9 months old.
5. Dominance of involuntary reflexes over voluntary movements.
Language Delay
Causes for language delay
 Mental Retardation
 Hearing loss

 Maturation delay (developmental languge delay)

 Expressive languge disorder (developmental expressive aphasia)
 Bilingualism
 Psychosocial deprivation
 Autism
 Elective mutism
 Receptive aphasia
 Cerebral palsy
Cognitive Delay
Causes of cognitive delays
 A wide range of different learning disabilities.

 Exposure to alcohol or toxins before birth or afterward,

• Including lead poisoning.
 Institutionalization or neglect during infancy or early childhood
Red Flags
Red flags are early warning signs and symptoms that something is or may be wrong.
AGE WARNING SIGNS
1 month Does not regard face, no eye contact, no smile, poor suck, floppy
2 months Does not look at you with both eyes at least for a few moments, and
does not follow with eyes if you move your face slowly from side to
side
3months Does not respond to sound by quieting
4months Does not hold head steady for a few moments when you sit him up,
does not grasp rattle that you put into his palm
5months Does not raise head and support weight on arms when in prone
position
6 months Cannot reach for objects with both hands, Floppy, no response to
sound, Poor social response to people
9 months Unable to sit unsupported , hand preference, fisting, persistence of

primitive reflexes
12months Unable to bear weight on legs
15 months Does not walk alone, is not using at least one word meaningfully
18 months Does not use at least 3 words, and does not point to what he wants


15 FAILURE TO THRIVE
Persistent weight below 3rd percentile or falling off the growth curve
 FTT Causes
 Non organic
 Organic
A. FTT-Non organic causes
 Feeding Problem-insufficient breast milk or poor technique
 Maternal Stress-malnourished, Tense
 Financial difficulties
 Lack of stimulation & undernutrition
 Munchausen‘s syndrome by proxy

B. FTT-organic causes
1. Inability to feed
 Mechanical Problem-cleft palate
 Lack of coordination-cerebral palsy
2. Poor retention of food
 Vomiting
 Gastro-esophageal reflux
3. Illness induced anorexia
 Cystic fibrosis
 Renal failure
 Congenital heart disease
4. Malabsorption
 Celiac disease
 Cystic fibrosis
 Cow milk protein intolerance
5. Increased energy requirement
 Cystic fibrosis
 Malignancies
6. Metabolic
 Hypothyroidism
 Amino acid & organic acid disorder, IEM
7. Infection
 TB,HIV
 UTI
 Intestinal parasites
 Gastro enteritis(chronic)
8. Mixed
 Chromosomal disorder
 Syndromes
 Immunodeficiency
 Resp. failure

Failure to Thrive
History
 Family history
 Birth Hx
 Feeding Hx
 Maternal anxiety
 Detail of vomiting, diarrhea, stool color,
 Travel-foreign, domestic ect.
Physical Exam
 Growth Chart-Wt, Ht. & HC

 Development Assessment
 Wasting of buttock & thigh
 Dysphorphism
 Pallor
 Cleft palate
 Heart murmur, cracks
FTT- Investigations
 CBC, CRP
 RFT
 LFT, ferritin.
 Immunoglobulins
 Anti-endomysial & antigliadin
 Urine
 Stool
 Chest X-ray-sweat test
FTT-Management
 Non organic-multidisciplinary
 Organic-dietician, admission in ward?
FTT-Key Points

 Consistent Wt below 3rd percentile and falling off the growth

curve are both evidence of FTT
 Most cases are non-organic
 Any organic system may be implicated in organic FTT
 Think broadly for differential diagnosis
FTT-Take home message

Failure to thrive is a sign Not a diagnosis

16 Rickets
Rickets is a metabolic disorder characterized by defective mineralization of growing
bone & despite normal collagen matrix. It results from various causes which include
 deficiency of vitamin D,
 its abnormal metabolism or the abnormal metabolism or excretion of inorganic
phosphate and/or calcium.
Osteomalacia is the defective mineralization of the mature bone and is seen in adults.
Osteoporosis is the reduction of bone mass per unit volume and it usually occurs in
old age.
HISTORY
Age
 Age of onset of rickets will depend upon the cause of deficiency.
 Vitamin D-deficiency rickets is common in the age group of 6 months to 2
years, when the bonesare growing rapidly.
Familial disorders such as 1-a-hydroxylase deficiency present at an early age.
Complaints
 Failure to thrive
 Bony deformities
 Generalized muscular hypotonia
History of Present Illness
 H/o delayed dentition
 H/o muscle Wl':akness (generalised muscular hypotonia)
 H/o tetanic convulsions, carpopedal spasm, laryngeal spasm (in rickets
associated with hypocalcaemia)
 H/o frequent incidences of fractures, recent onset bony deformities of spine
(kyphosis, scoliosis), bowing of legs, knock-knees, rib-cage anomalies such as
costochondral beading, pectus carinatum, and Harri.son's sul.cus

Etiological History
1. Nutrition
 Diet-adequate or inadequate
 Dietary milk fortified with vitamin D or not
 Animal products used in the food or not
2. Malabsorption-History suggestive of malabsorption syndromes
 Symptoms suggestive of fat soluble vitamin deficiencies ( night blindness in
vitamin A deficiency, petechiae and purpura in vitamin K deficiency, ataxia
and tremora in vitamin E deficiency)
 Abdominal pain
 Distension
 Steatorrhoea
3. Expoaure to sunlight-adequate or inadequate
4. Renal rickets
 H/o oliguria, polyuri.a, polydipsia, hematuria., dysuria, failure to gain weight.
renal colic (occurs in RTA ), vomiting, lethargy, growth retardation
 H/o constipation, diarrhoea, vomiting (renal failure, renal tubular acidosis)
5. Hepatic rickets (chronic liver disease) history of fever, jaundice, gastrointestinal
bleeds (haematemesis/melena/haematochezia), neonatal hepatitis, itching (due to bile
salts), purpura (due to liver failure)
6. Drugs
 Anticonvulsanb-phenytoin/phenobarbitone
 Steroids
 Outdated tetracyclines and heavy metals (predispose to Fanconi's syndrome)
7. Miscellaneous
 H/o pain in abdomen-renal colic, lead poisoning, obstructive uropathy

 H/o convulsion (glycogen storage disease, galactosaemia, Lowe's syndrome,
cystinosis, renal osteodystrophy)
 H/o fatigue, weight loss, bone pain (oncogenic rickets)
 H/o alopecia (vitamin D-dependent rickets [VDDR] type II)
Past History
 H/o recurrent respiratory tract infections (cystic fibrosis, hypotonia of muscles
in hypocalcaemic rickets)
 H/o jaundice (may be due to liver failure)
 H/o steatorrhoea (obstructive jaundice)
 H/o worm infestation (worms can enter the biliary tract and cause obstruction
to the bile flow)
 H/o pica (common in worm infestations)
 H/o drug intake-anticonvul.sants, steroid (antagonist to vitamin D), outdated
tetracyclines (Fanconi's syndrome)
 H/o recovery from protein energy malnutrition
Antenatal History
 Maternal age at conception
 H/o maternal osteomalacia/matemal malnutrition (congenital rickets)
 Calcium supplementation during pregnancy
 Interval between two successiw pregnancies (shorter interval will predispose to
maternal malnutrition)
 Fever with rash (intrauterine infection), painful swelling behind the ears
(postauricular lymphadenopathy in rubella)
 Drug intake (anticonvulsants), irradiation
Birth History

 Gestational age (full term/preterm)-prematurity is associated with osteopenia.

Preterm babies are more prone to develop rickets as they require more vitamins
for catch-up growth
Neonatal History
 Low birth weight
 Breathing difficulties
 Birth asphyxia
 Neonatal convulsiom
 Respiratory di.stress syndrome
 Kernicterus
Growth and Development History
 Short stature-the height or length is shorter than that expected for age
 The motor milestones may be delayed due to hypotonia of the muscle
Physical EXAMINATION
General Examination
 Consciousness
 Undernourished/wasted (nutritional deficiency)
 Diaproportionate short stature-the ratio between the upper segment and the
lower segment will be abnormal (Table 6.1)
 Hypotonia-ligament5 are lax 50 that the joint can be bent to any position than
in normal children
Head-to-Toe Examination
The skeletal manifestations in the head-to-toe examination are as follows:
1. Head

 Craniotabes-softening of skull bones (earliest). It occurs due to softening of the

outer table of the skull bones and is better appreciated in the occipital region
 Frontal and parietal bossing-giving box like appearance of head known as hot
cross bun appearance or caput quadratum. It occurs due to deposition of excess
osteoid and non -calcified cartilage over frontal and parietal region Prominent
occipital protuberance (renal rickets)
 Delayed closure of fontanelt-anterior fontanelle remains wide open and its
closure is delayed. Posterior fontanel which usually doses within a few weeks
after birth may also remain open
 Cranial sutures are widened
 Alopecia (VDDR type II)
2. Dentition
 Delayed eruption of teeth
 Premature fall of deciduous teeth
 Defects in structure of teeth-enamel defects (hypoplasia) in permanent teeth,
pulp defects (hypophosphataemic rickets), intraglobular dentine
 Caries tooth (VDDR type I and hypophosphataemic rickets)
3. Chest
 Harrison's sulcus (horizontal groove along the attachment of diaphragm, due to
constant pulling of the soft lower ribs by the diaphragm)
 Pectus carinatum or pigeon chest (forward projection of the sternum)
 Pectus excavatum
 Rachitic rosary-costochondral junctions are enlarged and beaded (smooth
angle compared to sharp angle in scurvy)
 Soft rib cage due to softening of n'bs (predisposes to decreased chest
movements and thereby atelectasis)

4. Spine
 Kyphosis (rachitic cat back)-it occurs in children above 2 years of age due to
softening of vertebra
 Scoliosis
 Lordosis
5. Extremities
 Muscle weakness-the child is unable to stand till 3 years despite adequate
weight and height due to proximal muscle weakness
 Lower limb deformities become more pronounced once the c.hild starts
walking
 Curvature or angulations at the junction of the lower and the middle thirds of
the forearms and the legs. This is due to the softening of the bones
 Anterolateral bowing of tibia at the junction of middle and lower one-third
 Widening of epiphysis of wrists and ankles
 Double medial malleolus (marfan sign)- tibial malleolus gives an impression of
double epiphysis

 Genu recurvatum-posterior angulation at the knee joints seen due to

hyperextenslbility of the knee joint)
 Genu varum. (bowlegs)-the knees are bowed outside so the intercondylar
distance is increased to more than 5 cm
 Genu valgum (knock-knees)-the knees are dose to each other, but the
intennalleolar distance is increased (> 10 cm)
 Genu valgum or varum can be differentiated clinically from tibial
varum/valgum by the following method-on full flexion of knee, genu
valgum/varum will disappear but tibial varum/valgum will remain the same. If
the deformity does not disappear but reduces, then the valgum/varum is the
result of both components; knee joint and tibial shaft.
6. Hip and Pelvis

 Coxa vara deformity-reduction in femoral neck. shaft angle
 Tiradiate pelvis--pelvic entrance is narrowed due to forward projection of
promontory. Pelvic outlet will be narrowed due to forward displacement of the
sacrum and coccyx

7. Joints and ligament&-the ligaments are lax & the limbs can be bent more than the
usual (acrobatic rickets).
Bear In Mind
Some of the according to the age of onset are as follows:
1. During first year
 Cranium-.Craniotabes, wide sutures, frontal bossing
 Wrist-widened
 Ribs-rachitic rosary, Harrison's sulcus
 Teeth-delay in eruption, enamel hypoplasia
 Muscle weakness-unable to stand till 3 years despite adequate weight and height (motor
milestone delay)
 Recurrent respiratory infection-pneumonia
 Tetany (or) stridor-in hypocalcaemia
2. After l year
 Long bones deformities (due to rapid growth and weak epiphyseal plate-legs have most
deformities)
 Genu varum/valgurn/recurvatum Cox.a vara

 Rachitic saber shin

 Up to 4 years of age they resolve with treatment
3. Late onset in childhood-long bone. Are straight, but knee epiphyses become angulated

17 SAM Pt.
General appearance
 Level of consciousness
 Health status (acute, healthy, chronic)
 Old man appearance or cachexic
 Emaciated
 Edematous
Vital signs
 Bradycardia or Tachycardia
 Tachypnea
 Hypo or hyperthermia
Head
 Hair color & distribution
 Alopecia, pluckablity or brittle hair
 Craniotabes
 Caput quadratum
 Frontal bossing
 Fontanel size, closure & surface
 Sutures – closed or not
Eye
 Sunkening of eyeball
 Pale conjunctiva
 Bitot‘s spot
 Icteric sclera

 Periorbital edema
 Discharge
Mouth and throat
 Bucal mucosa (pink, pale, wet, dry )
 Tongue atrophy
 Angular cheilities/ stomatitis
 Dentition
 Gum bleeding & swelling
 Oral ulcers, OHL, candidiasis
Respiratory system
 Costochondral beading
 Harrison groove
 Pigeon chest deformity
CVS
 Pounding pulse
 S3 gallop
Abdomen
 Distended abdomen - because of distended stomach and intestinal loops
 Hepatomegaly – due to severe fatty infiltration (fatty liver)
Integumentary system
 Palmar & plantar pallor
 Wet, dry, pink , pale, … skin
 Warm or cold extremities
 Skin rash (hyper or hypo pigmentation)
 Aka Kwash-dermatosis
 Often involves the perineum, groin, limbs, ears, & armpits

 Has 3 grades
 Grade I(Mild)– discoloration or a few rough patches of skin
 Grade II (Moderate) –multiple patchy on arms &/ or legs
 Grade III (Severe) – flaky paint appearance of skin, fissures
Musculoskeletal system
 Wrist widening
 Double malleoli
 Bow leg
 Joint swelling
 Pitting leg or sacral edema (GBS)
o Grading …. See ―edema‖
CNS
 Mental status
 Conscious
 Apathetic
 Irritable or cry easily
 Expression of misery and sadness
 Lethargic, comatose – DHN, shock
Investigations
 RBS
 CBC
- Hct or Hb
 Blood film
 Peripheral morphology
 PICT
 Stool microscopy
 U/A & culture

 CXR
 Tests for TB
 Serum albumin
 Reduced in kuash pts
 Serum electrolytes
 K+& Mg2+ increases
 Na+ decrease
 RFT
Complications
 Hypoglycemia (< 54 mg/dl)
 Dehydration
 Severe anemia (Hgb < 4 g/dl or Hct < 12%)
 Hypothermia (Tº< 35 ºc)
 Heart failure
 Infection
 Septic shock
 Electrolyte disturbance
Management principles
 Tx. of compications
 Dietary tx
 Routine medication
 Follow up

18 SCABIES
It is an infestation of the skin by the mite Sarcoptes scabiei.
Transmitted by
 Physical contact with an affected individual I.e is affected by the extent and
duration of contact
 Rarely byfomites b/c the isolated mite dies within 2-3 day
 Classic scabies — The prominent clinical feature of classic scabies is pruritus.
Severe and usually worse at night.
 Typical cutaneous findings are multiple small, erythematous papules, often
excoriated. Burrows may be visible as 2 to 15 mm, thin, gray, red, or brown,
serpiginous lines. Burrows are a characteristic finding but often are not visible
due to excoriation or secondary infection. Miniature wheals, vesicles, pustules,
and, rarely, bullae also may be present.
-The distribution of the cutaneous findings includes the sides and webs of the fingers,
wrists, axillae, areolae, and genitalia are among the common sites of involvement.

- Crusted scabies, a less common variant that primarily occurs in the setting of
reduced cellular immunity such as in acquired immunodeficiency syndrome (AIDS),
leprosy, and lymphoma. This variant may also occur in older adults, patients with
Down syndrome and long-term users of topical corticosteroids. Crusted scabies is
associated with a heavy mite burden
Clinical manifestation
 intensive pruritus particularly at night
 Red papules (1-2mm) -----first sign
 Thread like burrow------classic lesion
i.e. may not be seen in infants (bullae and pustules are common)
Management
- Classic scabies — Topical permethrin and oral ivermectin are the most common
first-line treatments. Benzyl benzoate, topical sulfur, crotamiton, lindane, and
topical ivermectin are examples of other treatments.
Complications(If left untreated)

 Secondary Infection
 Eczematous Dermatitis
 Impetigo
 Folliculitis
 Cellulitis
 Glomerulonephritis…
 Latent Period Of 1 Month Follows Initial Infestation

19 Tineacapitis
 Is dermatophytic infection of the scalp most often caused by
Trichophytontonsurans, occasionally by Microspordium
Epidimology
Common in black children age 4-14 yr.
If the patient is above age of 14 with the same compliant, We should consider
Seborric Dermatitis.
Clinical manifestation- varies with the infecting organism
Endothrix infection
 Caused by T.tonsurans
 An infection within the hair shaft characterized by ―black-dot ringworm‖
 Initially many small circular patches of alopecia in which hairs are broken off
close to hair follicle
 diffuse scaring with minimal hair loss;resemble seborrhic dermatitis,psoriasis,
atopic dermatitis
 Kerions(elevated boggy granulomatous mass caused by sever inflammation)
which are often studded with pustules
 fever ,pain,lymphadenopathy & permanent scarring &alopecia
 chronic alopecia
Ectothrix infection
 Caused by some other types of Trichophyton infections
 Spores are are distributed in sheath like fashion around the hair shaft

 M.audoini
Initially a small papule at the base of hair follicle,spreads peripherially,forming an
erythematous &scaly circular plaque(ring worm)
 Numerous patches of alopecia
 Severe pruritus
 Favus
 Chronic form of tineacapitis which is rare
 Caused by T.schoenleinii
 Starts as yellowish red papule at the opening of hair follicles, the papules
expand and coalesce to form cup shaped yellowish, crusted papule that
fluoresce dull green under wood lump
Method of transmission
 mostly by contact with infected hair, combs, hats &seats
 may also be air born with in the immediate environment (school mate &house
hold members)
 zoophilic; cats and dogs<<<<< M.canis
Differential diagnosis
 Seborrhic dermatitis
 Psoriasis
 Alopecia areata
 Dystrophic hair disorders
Diagnosis
 Wood lamp
 Microscopic examination with KOH preparation
 Culture
Treatment
 Oral grisofulvin
 Terbinafine
 selenium sulfate, zinc,
pyrithione or ketoconazole for patient and potential carrier

20 DKA Management Protocol
Bolus fluid 10 - 20 ml /kg 0.9 % N/S to be given Regular insulin 0.5 unit/kg ½ IV/IM & ½ sc first
over 1-2 hour depending on the degree of DKA. dose then 0.5 unit/kg every 6 hourly
Rehydration therapy to be given over 48 hrs.

General Resuscitation Measures (Follow the pediatrics Advanced life support)

A= If comatose inert NGT and maintain the airway
B=Give oxygen by face mask for patients with severe circulatory impairment or shock
C=Insert IV cannula and take blood sample and if the child is in shock give 20 ml/kg of 0.9 % normal
saline to the maximum of 30 ml/kg depending on the response of the child over 30 minutes
Examination
 Perform a clinical evaluation to confirm the diagnosis and take weight for calculation
 Vital signs
 Assess the degree of dehydration
 Look for signs of cerebral edema
 Neurological assessment using GCS
 Documentation of fluid balance and lab results
Investigation
 Collect blood sample to do – RBS, Ketone, electrolytes (K +), CBC
 Urine analysis – Check glucose, ketones and WBC
 Blood gas analysis – PH, Bicarbonate
 ECG-T waves
 Blood or urine culture if there is sign of infection
Principles of DKA Mxt Goals of DKA Mxt

1. Expand intravascular volume  Correct acidosis and reverse ketosis
2. Rehydration therapy  Correct dehydration
3. Potassium replacement therapy  Restore blood glucose to near normal
4. Insulin therapy  Monitor for complications of DKA and

its treatment
5. Avoid /Treat complications (
Hypoglycemia, Cerebral edema and  Identify and treat any precipitating
Hypokalemia ) event
6. Treat precipitating factors
7. Monitoring

DKA patient management sheet

Name--------------------------------Age-----------Weight----------Date----------------
% of dehydration-----------------Type of Resuscitation fluid-----------------------
Fluid Requirement (expand intravascular volume + Rehydration therapy)

Expand intravascular volume: bolus fluid 10 - 20 ml /kg 0.9 % N/S to be given over 1-2 hour depending on the
degree of DKA. It can be repeated if necessary.
Rehydration therapy calculated as: Maintenance fluid for 48 hours + Deficit fluid calculated as 85 ml/kg and
subtract the Bolus fluid = --------ml/ 48 hr= with potassium 40 mmol in 1000 ml of normal saline.
K + Replacement therapy is required regardless of the serum potassium concentration.
Make sure that the child is passing urine before initiation of KCL.
Keep mannitol at the bed side (dose for cerebral edema 0.5-1 gm/kg IV over 20 min).
INSULIN (Blue colored texts- current practice in Ethiopia)

 Start insulin infusion 1-2 hours after starting fluid management (Intravascular volume
expansion) with regular insulin 0.1 u/kg/hour (e.g. dilute 50 units Regular [soluble]
insulin in 50 ml N/S, 1 unit = 1 ml) IV infusion. Low dose IV insulin administration is
the standard of care
 In circumstances where continuous IV administration of insulin is not possible regular

insulinSC or IMwith a dose: 0.1 unit/kg / every1-2 hours can be given( other
developing countries experience)
 Current practice in Ethiopia is to start with regular insulin with a dose of 0.5 u/kg every
6 hourly (½ IV/IM and ½ sc for the first dose) then continue with 0.5 u/kg sc every 6
hourly.
 Don‘t omit insulin is the key- If there is a rapid decline of glucose > 90 mg/dl /hour,
you can decrease the dose of insulin by 50% (give 0.05 u/kg/hr insulin infusion or 0.25
u /kg every 6 hourly until the serum glucose is stabilized) and you can change the fluid
to ½ N/S in 10 % D/W. Consider adding glucose even before plasma glucose has
decreased to 250 mg - 300 mg/dl.
 Continue the management until the child is out of DKA (PH> 7.3 or bicarbonate >15
mmol/l). In our case until the urine ketone is free.

 In patients with insulin infusion to prevent rebound hyperglycaemia the first SC

injection should be given 1-2 hours (with Regular insulin) before stopping the insulin
infusion to allow sufficient time for the insulin to be absorbed. In our case you can
adjust the time for the initiation of standing dose, until that give ½ of the every six hour
regular insulin dose.
 Potassium -Can be given as potassium phosphate or acetate or chloride with a rate of

0.5 mmol/kg/hr (20-80 mmol/l of fluid)
 Acidosis -bicarbonate administration is not routine, only indicated if there is only

severe life threatening acidosis PH < 6.9
 Oral fluids- can be introduced when there is marked clinical improvement and no
vomiting (mild acidosis or ketosis can be there)
DKA FLOW SHEET

Date Time BP PR RR RBS Urine Urine Electrolyte Neurologic Insulin Fluid
/hr glucose ketene K + status dose input
/hr every every (GCS)
2 hourly (2-4 hrs) hourly


Miscellaneous Topics
Common Procedures in Pediatrics
Topics
1. Lumber Puncture . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .
2. NG-Tube . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Thoracotomy (Chest Tube) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Intraosseous Line . . . .. . . .. . . . .. . . . . .. . . . .. . . .. . .. . . .. . . . .. . .. . . . .. . . .
5. CPAP …………………………………………………………………………..
*******
6. Triads of pediatrics . . . . . . . . . . . . . . . . .. . . … . .. . . . . .. . . .. . .. . . . . . . .
7. Important Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .
8. Baseline Investigations……………………………………………………

1) Lumber Puncture
Other names Spinal puncture, Thecal puncture, Rachiocentesis, Spinal tap,
Ventricular puncture, Cisternal puncture, Cerebrospinal fluid culture.
Lumbar puncture (spinal tap) is performed in your lower back, in the lumbar
region.
 During lumbar puncture, a needle is inserted between two lumbar bones
(vertebrae) to remove a sample of cerebrospinal fluid — the fluid that
surrounds your brain and spinal cord to protect them from injury.
Lumbar punctures are commonly performed in the pediatric emergency department. There is no
standard, recommended, optimal position for children who are undergoing the procedure.
Indication
Diagnostic
 Meningitis (bacterial, fungal, tuberculous, viral, carcinomatosis,
lymphomatosis or aseptic)
 Early subarachnoid hemorrhage
 Pseudotumor cerebri
 Multiple Sclerosis
 Guillain-Barre Syndrome
 Possible Lupus Cerebritis, CNS Vasculitis, Acute demylinating disorders

Therapeutic
 Spinal anesthesia
 Treatment of Pseudotumor Cerebri
 Intrathecal administration of chemotherapy
 Intrathecal administration of antibiotics
 Injection of contrast media for myelography or for cisternography
Contraindication
Absolute contraindications for lumbar puncture are
 the presence of infected skin over the needle entry site and the presence of
unequal pressures between the supratentorial and infratentorial compartments.
The latter is usually inferred from the following characteristic findings on
computed tomography (CT) of the brain:
 Midline shift
 Loss of suprachiasmatic and basilar cisterns
 Posterior fossa mass
 Loss of the superior cerebellar cistern
 Loss of the quadrigeminal plate cistern
Relative contraindications for lumbar puncture include the following:
 Increased intracranial pressure (ICP)
 Coagulopathy
 Brain abscess
Equipment
 Sterile gloves & gown
 1% lidocain solution
 22G or 25G needle
 5ml disposable syringe

 Povidone-iodine prep
 Sterile drape
 Spinal needle with Stylet
 22G, 3.5 inch spinal needle for adults
 22G, 2.5 inch spinal needle for children
 22G, 1.5 inch spinal needle for infants and new borns
 Manometer with 3-way stopcock
 4 labeled sterile specimen containers
 Sterile bandage
Procedure
 First the patient is usually placed in a left (or right) lateral position with their
neck bent in full flexion and knees bent in full flexion up to their chest or
sitting up postion.
 Draw an imaginary line between the top of the iliac crests. This intersects the
spine at approximately the L3-4 interspace (mark this if necessary).
 Wash hands and aseptically put on sterile gloves.
 Prepare the skin with povidone-iodine or chlorhexidine and set up sterile
drapes.
 Allow adequate time for the skin preparation to dry.

 Take the tops off the tubes, ensuring that they remain sterile.
 Infiltrate the skin with 1% lignocaine using a 22G needle.
 Withdraw stylet and check for fluid return.

 Attach end of stopcock with manometer to read the opening pressure (opening
pressure can only be checked in lateral decubitus position).
 Collect 1-2 ml of CSF in each of the four labeled sterile tubes.
 Replace the stylet and withdraw the spinal needle.
 Clean off povidone-iodine prop solution.
 Apply a sterile band air over the puncture site.

Complications
 Post-LP headache
 Infection (Injection site Infection)
 Bleeding
 Cerebral herniation
 Minor neurologic symptoms such as radicular pain or numbness
 Late onset of epidermoid tumors of the thecal sac
 Back pain
VIVA Questions
Q: What is post-LP headache? How to manage it?
A: Headache usually occurs if LP is done in normal intracranial tension. It results
from low intracranial tension as a result of withdrawal of CSF, which causes traction
on the meningeal blood vessel, resulting in headache.
Treatment is as follows:
• Increased fluid intake.
• The patient should lie flat for 8–24 hours.
• Foot end should be raised and the head pillow should be removed.
• Analgesics.
Interpretation
Cause Appearance PMN lymphocytes protein Glucose

leukocytes
Pyogenic Yellowish, Markedly Slightly Markedly Very
bacterial turbid increase increased or increase decreased
meningitis normal
Viral Clear fluid Slightly Markedly Slightly Normal or
increase or increase increase or mildly
normal normal decreased
TB. Yellowish Slightly Increased Markedly Decreased
Meningitis and viscous increase or increased
normal


2) N G tube
 Insertion of a plastic tube through the nose past the throat into the stomach.
Indications
Diagnostic
1. UGI bleeding
2. Aspiration of gastric content for dx
3. Identification of esophagus & stomach on chest radiograph.
4. Radiologic contrast to GIT.
Therapeutics
1. Gastric decompression, (including maintenance of a decompressed state after
endotracheal intubation, often via oropharynx)
2. Feeding (enteral nutrition)
3. Administration of medications
4. fluid and electrolyte therapy
5. Bowel irrigation (stomach lavage)
6. Aspiration of gastric content from recent ingestion of toxic material.
 Contraindication
 Absolute

 Basilar skull fracture (fear of intracranial placement of the tube)

 Recent nasal, esophageal or gastric surgery
 Relative
 Esophageal stricture
 Esophageal varices
 Bleeding diathesis
 Hx of caustic/acid ingestion or esophagus burns.
 Equipment’s
1. NG tube (for adult pt.)- 16-18 Fr.
2. NG tube(for pediatric pt.) - 16+(age/2) French
3. Viscous lidocaine 2%
4. Oral analgesic spray (benzocaine spray or other)
5. Syringe, 10mL
6. Glass of water with straw
7. Water based lubricant
8. Suction tubing and container.
 Size
 ([16+age/2]) French
 Insertion
 Fowler's position--Sniff and swallow—anesthetize
 Measure-tip of the nose-ear-xiphoid (Infant till the umbilicus)
 Check for placement

 Auscultation for air over the epigastrium
 Aspiration of gastric contentsif you see greenish gray colored
fluidit means correct insertion.
 Get glass of water-put the tip in water-bubble—Lungs
 Radiography
Detail Procedure
 Introduce yourself to the patient and clarify the patient’s identity. Explain the
procedure to the patient and gain informed consent to continue.
 Gather equipment
 Don non-sterile gloves
 If possible, sit patient upright for optimal neck/stomach alignment
 Examine nostrils for deformity/obstructions to determine best side for
insertion
 Measure tubing from bridge of nose to earlobe, then to the point halfway
between the end of the sternum and the navel
 Mark measured length with a marker or note the distance
 Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This
procedure is very uncomfortable for many patients, so a squirt of Xylocaine
jelly in the nostril, and a spray of Xylocaine to the back of the throat will help
alleviate the discomfort.
 Pass tube via either nare posteriorly, past the pharynx into the esophagus and
then the stomach.
 Instruct the patient to swallow (you may offer ice chips/water) and advance
the tube as the patient swallows. Swallowing of small sips of water may
enhance passage of tube into esophagus.
 If resistance is met, rotate tube slowly with downward advancement toward
closes ear. Do not force.
 Withdraw tube immediately if changes occur in patient's respiratory status, if
tube coils in mouth, if the patient begins to cough or turns pretty colour
 Advance tube until mark is reached
 Check for placement by attaching syringe to free end of the tube, aspirate
sample of gastric contents. Do not inject an air bolus, as the best practice is to

test the pH of the aspirated contents to ensure that the contents are acidic.
The pH should be below 6. Obtain an x-ray to verify placement before
instilling any feedings/medications or if you have concerns about the
placement of the tube.
 Secure tube with tape or commercially prepared tube holder
 If for suction, remove syringe from free end of tube; connect to suction; set
machine on type of suction and pressure as prescribed.
 Care
o Secure the tube--keep it out of patient's vision
o Meet the patients comfort needs
 Complications
o Nasotracheal intubation (malposition)
o Esophageal perforation
o Esophagitits, sinusitis
o Pulmonary aspiration
o GI bleeding
o Intracranial placement of the tube.

3) Thoracotomy Chest Tube ( )

 It is a tube placed through the chest wall into the pleural space to drain an air
or fluid collection from the pleural space and can be used to instill
medication.
 Parts
 Tube (multiple holes, radio opaque lines-for radiological evidence)
 Bottle(air or fluid in, air out)
 Indications
 Fluid in the pleura space; site 5th ICS in MAL (safe triangle = lateral border
of pec. Major, mid-axillary line (medial border of latisimus dorsi), 6th ICS);
wider tube(can drain both fluid & air)
 Hemothorax
 Hemopneumothorax
 Large Pneumothorax
 Tension Pneumothorax after needle decompression.
 Empyema
 Malignant pleural effusion
 Chylothorax
 Following thoracic surgery or upper abdominal surgery

 Air in the pleura space, site 2nd ICS in MCL; narrower tube
 Pneumothorax
 Tension pneumothorax
 Broncho- pleural fistula
 Pleurodesis: installation of sclerosing agents
 Size of tube
 Depends on the indication
 Trauma: 36fr
 Hemothorax : 32fr
 Pneumothorax: < 24fr FR= 3*(mm)
Table 1.1: Chest Tube Size for Age
A Adult/teen male 28-40 Fr
B Adult/teen female 26-36 Fr
C Children 18-22 Fr
D Newborn 12-14 Fr

 CONTRAINDICATION
There are no absolute contraindications for drainage by means of a chest tube
except when a lung is completely adherent to the chest wall throughout the hemothorax.
Relative contraindications include:

o Patients taking anticoagulant medication

o Patients with a coagulopathy
o Skin infection over the chest tube insertion site
o Transudative pleural effusion… (Secondary to liver failure or CHF because it can
resolve with diuretics only)
 Care
 Asepsis
 Oscillation on coughing – working
 DDx for non-oscillation
 Clogged, clot, misplaced, malposition, kinked, full bottle
 Gentle insertion
 Prevent air entry under saline sealed bottle
 Latency in initial drainage ask the pt. to cough
 Initial drainage could range from 500 -1000ml (if above 1000ml –
expansion edema)
 Removal
 Symptom resolved
 Drainage (˂ 200ml/24hr) of serous fluid (no pus, no blood)
 Control x-ray showed expansion of lung
 Clump for 24hrs before removal – no reappearance of dyspnea
 Procedure: Clump the tube → disconnect from water seal →
remove stich → mobilize gently → remove the ICT rapidly at the end
of expiration(+ve intrathoracic pressure is created) → cover the
wound area with pressure bandage for 5-7days

 Complications
 Malposition
 Infection
 Organ injury (bronchopleural fistula – continuous bubbling in the
underwater seal sys)
 Subcutaneous emphysema
 Re-expansion pulmonary edema
 NB. The under seal bottle must be

 Shouldn’t be shaken. Should be stable
 Adequately filled with fluid
 Kept below the level of pt.’s chest
 Changed when the bottle becomes full, when transportation is needed


4) Intraosseous line
 Insertion of needle into intraosseous or marrow space for administration of
drugs, fluids of blood products
Indications
 Need for emergency access, usually in a child less than 3 years
old, when other attempts from peripheral venous access have failed.
Contraindications:
 Injury to the extremity of interest
 Avoid placing the needle distal to a fracture site
 Anesthesia
 none
Equipment
 16- or 18- gauge bone marrow aspiration or intraosseous infusion needle
Positioning
 Supine
Technique
Complications and management

Continuous Positive Airway

Pressure (CPAP)
In premature infants with respiratory distress CPAP expands collapsed alveoli,
splints the airway, reduces work of breathing and improves the pattern and regularity
of respiration
Indications:
 To put the neonate on CPAP the presence of good respiratory effort is the
prime requirement.
 Recently delivered preterm infant with minimal respiratory distress and low
supplemental oxygen requirement (to prevent atelectasis)
 Respiratory distress and requirement of FiO2 above 0.30
 Recurrent apneas not responding to medical management
 Post extubation from mechanical ventilation
 Term neonates with respiratory distress and saturations less than 88% on hood
oxygen
 Initial stabilization in the delivery room for spontaneously breathing,
extremely preterm infants (25 to 28 weeks' gestation)
 Initial management of premature infants with moderate respiratory distress
NB: Preterm infants with RDS who require FiO2 above 0.4 on CPAP should be
intubated, ventilated, and given surfactant replacement therapy.
Aims of CPAP
1. Reduce respiratory distress
2. Improve oxygenation by improved alveolar gas exchange by recruiting
collapsed and poorly ventilated alveoli

3. Improve hypercarbia
4. Reduce time spent in oxygen
5. To avoid fatigue in infants
6. To avoid invasive ventilation
7. Reduce hospital inpatient stay
Biochemical aims of CPAP
1. To maintain pH 7.35-7.45
2. To maintain saturations > 95%, PCO2 <6.0 KPa
3. To prevent hypoxia and hypercarbia
Contraindications for use of CPAP

Consider the need for intubation and/or mechanical ventilation as evidenced in the
presence of:
 Severe cardiovascular instability and impending arrest
 Upper airway abnormalities that make CPAP ineffective or potentially
dangerous (e.g. Choanal atresia, cleft palate, tracheoesophageal fistula)
 Pneumothorax
 Older infants do not tolerate the application of CPAP devices well, resulting in
restlessness and a labile oxygen requirement.
 PH <7.2 or SpO2 <88% in maximal oxygen therapy may be an indication for
ventilation, but CPAP may be tried initially if the child is stable.
When to start
 If the preterm newborn has respiratory distress with Downe score (see table )is
more than or equal to 4 CPAP must be started, earliest initiation is
recommended in preterm infants with signs of RDS
 In preterm newborns who were initiated on CPAP at delivery room CPAP
must be continued in the NICU till baby had Downe score less than 4

 In late preterm and term newborns oxygen requirement greater than 30 % or

0.5 L/min to maintain SpO2 more than 90%
How to start CPAP
• Initial flow 10L/min= FIO2 of 57.5 %
 5 L/min air
 5 L/min oxygen
 Increase or decrease FIO2 based on patient saturation
 Initial CPAP depth
• RAM cannula is available start at 6 cm H20 and increase to 10
• Hudson prongs start at 5 cm of H2O and increase to 10
Monitoring on CPAP
• Continuously monitor SPO2 and heart rate if possible RR
• Every 2-4 hour monitor and document
• Vital signs (temp, RR, HR)
• Downes‘ score
• Securing and position of nasal prongs
• Condition of nares, nasal septum and skin – check for pressure points
Signs of improvement
• Oxygen saturations increasing – oxygen requirement decreasing
• Signs of respiratory distress improving
• Downes‘ score decreasing
• Baby appears more comfortable
Table Downes’ score for assessment of Respiratory Distress
Downes’ score 0 1 2
Reparatory <60Breaths per min 60-80 >80
rate

Retractions None Mild Severe

Cyanosis None Cyanosis relieved by Cyanosis not relieved
oxygen by
oxygen
Grunting None Audible with Audible with ear
stethoscope
Air entry Good bilaterally Mildly decreased Markedly decreased
Complications of CPAP
 Abdominal distension increasing risk of aspiration.
 False pressure readings due to obstruction of nasal prongs, poor fixation,
kinking, blockage from mucous plugging or increased resistance created by
turbulent air flow through the prongs, artificially maintaining air pressure.
 Inadequate gas flow causing fluctuating baseline pressures, resulting in
increased respiratory effort by the infant.
 Excessive flow preventing incomplete exhalation inadvertently increasing
positive end expiratory pressure (PEEP) levels resulting in over-distension.
 Impedance of pulmonary blood flow, increase in pulmonary vascular
resistance & decrease in cardiac output.
 Nasal irritation, septal distortion, pressure necrosis, nasal mucosal damage
secondary to inadequate humidification or poor fixation of nasal prongs.
 Skin irritation of the head and neck from improperly secured bonnets.
 Lung over-distension causing air leak syndromes i.e. Pneumothorax.
 Equipment failure including leaks, tubing blockages, alarm failures, incorrect
calibration.
 Blockage of nasopharyngeal area and vocal cords with thick secretions.


BASELINE AND DIAGNOSTIC

INVESTIGATIONS
1. RESPIRATORY SYSTEM
→Baseline investigations
 CBC
 ESR or CRP
→ Diagnostic investigations
 Chest x-ray, U/S
 Chest CT
 AFB smear and culture of body secretions, TST (for TB)
 Pleural fluid analysis (pleural effusion, empyema)
2. CARDIOVASCULAR SYSTEM
 CBC
 ESR/ CRP
 RFT and LFT (when required)
 Blood culture (IE)
 ASO titer/Anti-DNase B (RHD)
 UA (when required)
→ Diagnostic investigations
 Chest x-ray
 Echocardiography
 ECG
3. GASTROINTESTINAL SYSTEM

→ Baseline investigations
 CBC
 ESR
 RFT (when required)
→Diagnostic investigations
 Stool exam (GE)
 Liver enzymes & LFT
 Imaging (Abdominal U/S, x-ray, CT)
 Serology (HBV, HCV)
 Ba swallow or enema
 Biopsy (mass)
4. NEPHROLOGY
→ Baseline investigations
 CBC
 ESR
 U/A & culture
 RFT
 Serology (serum C3, C4 level, serum antibody- GN)
 Imaging
 Biopsy (mass, GN)
5. NEUROLOGY
 CBC
 Serum electrolyte
 Serum glucose
 UA (when required)
 Toxicology screening (urine and serum)
 CSF analysis and culture (meningitis)
 Blood culture (meningitis)
 Brain U/S, CT, MRI, Skull X-Ray
 Stool exam (polio)
 EEG (seizure)
 Nerve conduction Study
 Electromyography
 Muscle, nerve biopsy
6. HEMATOLOGY
→Workup for Anemia
 CBC & RBC indices
 Peripheral morphology
 Reticulocyte count (↑in hemolysis & blood loss, ↓in malignancies)
 Stool exam (hook worm)
→Work up for Hematologic malignancies
 CBC
 peripheral morphology
 Bone marrow aspiration & biopsy
 IHC
 Flow cytometry
 LN biopsy
 CSF analysis, CXR, CT (staging)

 Serum electrolyte (TLS)
7. MALNUTRITION
→Work up:
 CBC
 Stool Examination
 RBS
 U/A including microscopic examination
 PICT
 B/F
 Serum electrolyte
 Serum albumin
 Wrist x-ray (Ricketts)
 Investigate for infection and sepsis:
 Blood Culture
 Investigate for TB
 RFT (if required)
8. INFECTIOUS DISEASES
→Work up for Malaria:
 CBC
 Blood film
 Rapid diagnostic test (RDT)
 Serology (Antibody detection)- Positive test indicates past infection, not useful
for treatment decisions
 RFT
→Work up for Leishmaniasis
 CBC
 Rk-39
 Serology (antileishmanial antibodies-VL)
 Tissue specimen
 Culture (tissue, blood)
9. ENDOCRINOLOGY
→Work up for DM
 RBS= >200mg/dl or
 FBS= >126mg/dl or
 2hr plasma glucose during OGTT >=200mg/dl
 HbA1c= > 6.5%
→Work up for disorders of thyroid gland
 TSH level
 T3/FT3, T4/FT4 levels
 Thyroid scan
 Serum thyroglobulin
 Imaging (U/S)
 FNAC
→Work up for disorders of adrenal gland
 24 hr urine Cortisol, midnight salivary cortisol
 Dexamethasone suppression test
 ACTH level
 Serum metanephrines (pheochromocytoma)
 Serum androgen levels (CAH, Addison‘s disease)
 Imaging (CT)
 Serology, Serum electrolytes, blood glucose
Maintenance Fluid Preparation

Fluid therapy (Maintenance)
For Example:
Case 1
A 5-year-old pre-school child presents to your office complaining of diarrhea of 2
days duration. He has also a history of loss of appetite of the same day duration. He is
currently 23kg. Put him in maintenance fluid?
Answer:
Req. - 23Kg.
- Normal saline
- DW, D5
- 40% Dextrose
1560 ml/kg over 24 hr. Put him for 12 hr. =780ml/kg over 12hr
Preparation of the therapy
1/3rd NS and 2/3rd 10% dextrose
 To prepare the 1/3rd NS = Multiply 780ml/kg by 1/3rd NS
 780ml/kg x 1/3rd NS = 260
 To prepare the 2/3rd 10% dextrose 780ml/kg – 260ml/kgNS =
560ml/kg

 85%(from DW) + 15% (from 40% dextrose)

 85% x 520 = 442
 15% x 520 = 78
 Finally, 260 NS, 442 DW and 78ml of 40% dextrose
Table 2: Preparations for 10% dextrose
Mixture Gives
12.5 ml of 40% dextrose + 37.5 ml of Distilled 50ml of 10% Dextrose
water
7.5 ml of 40% dextrose + 42.5 ml of 5% dextrose
10 ml of 50% dextrose + 40 ml Distilled water
6 ml of 50% dextrose + 44 ml of 5% dextrose

1. TRIADS IN PEDIATRICS
 CHF in infants  Congenital toxoplasmosis
1. Tachypnea 1. Chorioretinities
2. Cardiomegaly 2. Hydrocephalus
3. Hepatomegaly 3. Intracranial calcification
 Epiglottitis  Congenital rubella
1. Drooling 1. Microcephaly
2. Dysphagia 2. PDA
3. Dyspnea 3. Cataract
 Croup  Meningitis
1. Barking cough 1. fever
2. Hoarseness of voice 2. neck stiffness
3. Stridor 3. Headache
 Infectious mononucleosis  Meningitis in children
1. fever 1. fever
2. Pharyngitis 2. neck stiffness
3. Lymphadenopathy 3. Vomiting
 Congenital syphilis  Raised ICP (Cushing triad)
1. Skin rash 1. Bradycardia
2. Hepato-splenomegaly 2. Hypertension
3. Lymphadenopathy 3. Irregular breathing pattern
 Pneumonia  Sydenham chorea
1. Cough 1. Chorea
2. Fast breathing 2. Hypotonia
3. Fever 3. Emotional liability

 Measles
1. Fever
2. Maculopapular rash
3. One of the 3‘C‘ s
a. Conjunctivitis
b. Cough
c. Coryza
 Triple Test (for diagnosis of downs syndrome) Down's Syndrome
1 Estimation of hcg,
2 Estriol,
3 AFP
 Kwashiorkor
1 Growth Retardation
2 Mental Change
3 Edema
 GBS Neonatal Sepsis:
1 Newborn sepsis
2 within hours of birth
3 Bilateral diffuse pneumonia
 Danger of Warmer
1 Hyperthermia
2 Mask Serious Infection
3 Dehydration
Tips
1. Under five mortality causes in Ethiopia
 Pneumonia

 Diarrheal disease
 Perinatal causes
 Malaria
 Measles
2. Top five causes of neonatal mortality in Ethiopia

 Prematurity
 Neonatal sepsis
 Perinatal asphyxia
 Neonatal tetanus
 Bleeding disorder

Assessment and Plan:

(The Process of Clinical Reasoning):
Assessment:
 List the abnormalities (pertinent positives) of history and physical exam
and tie them together in a diagnostic formulation.
 If there are several different problem areas, discuss them in sequence
and number them to keep them straight.
 Include a differential diagnosis
PLANS:
 Plans for each problem should be divided into:
1. A diagnostic plan (Diagnostic tests that are planned should each
be connected to the diagnosis being evaluated by that test)
2. a treatment plan (Treatment should include all medications,
surgery, physical therapy or other treatments being directed
towards the problems at hand).
3. A patient education plan.

Writing the Progress Note

The SOAP note format
 Subjective,
 Objective,
 Assessment, and
 Plan
 Progress notes are your record of the patient's progress - they are
intended to be the record of what you thought and did and to be a mode
of communication between you and other providers
 Subjective: deals with how the patient or parent feels - the status of
important symptoms like pain or dizziness, mother's perception of the
patient's energy level, and the like.
 Objective: is the data you have collected such as vital signs, test
results, changes in objective physical findings, and recommendations by
consultants. New labs and xrays
 Assessment: is the section in which you make sense of the subjective
and objective information you have collected. Is the patient responding
to therapy? Is the diagnosis still not clear? This is where the academic
discussion occurs.
 Plan: describes what you will do about the assessment, if anything. It
should be very specific so that anyone could write orders from it. This
may also describe contingency plans - what you plan to do if a test
comes back one way vs. another.

Order Sheet
The physician order sheet is a direction directed at medical personnel available to
follow up on the procedure given by the person authorized to write on the order
sheet.
 The content of this sheet must be carried out and followed in accordance with the
written details.
 Problem): a matter or situation or a diagnosis that leads the patient for
admission. Write all diagnosis of the pt. like this
- P1: SAM (non-edematous)
- P2:
- P3 . . . . .
 Condition): the current condition of the patient
- Stable
- Subcritical
- Critical
 Activity):
- Bed rest or ambulating
 Diet):
- Salt free
- High protein
- F75 or f100
 Ix (Investigations): write the investigation that ordered for your pt.
 Rx (Treatments): Briefly describe treatment provided during hospitalization,
including surgical procedures and antibiotic therapy
 Signature and Physician name

Discharge Note:
• The discharge note should be written in the patient‘s
chart prior to discharge.
• It includes:
 Date/time:
 Diagnoses:
 Treatment: Briefly describe treatment provided during hospitalization,
including surgical procedures and antibiotic therapy.
 Studies Performed: Electrocardiograms, CT scans.
 Discharge Medications and Follow-up Arrangements

Procedure Note:
• A procedure note should be written in the chart after a procedure is performed (e.g.,
lumbar puncture).
• It includes:
 Date and time:
 Procedure:
 Indications:
 Patient Consent: Document that the indications, risks and alternatives to the
procedure were explained to the parents (and patient if applicable). Note that
the parents and the patient were given the opportunity to ask questions and that
the parents consented to the procedure in writing.
 Lab tests: Relevant labs, such as the CBC
 Anesthesia: Local with 2% lidocaine
 Description of Procedure: Briefly describe the procedure, including sterile
prep, anesthesia method, patient position, devices used, anatomic location of
procedure, and outcome. Complications and Estimated Blood Loss (EBL):
 Disposition: Describe how the patient tolerated the procedure.
 Specimens: Describe any specimens obtained and labs tests which were
ordered

HIGH-RISK BABIES
 Very low birth weight
 Neurological disorders
 Perinatal asphyxia
 Intraventricular hemorrhage
 Meningitis
 Persistent seizure
 Neurological abnormality on discharge.
 Ventilated neonates
 Neonatal sepsis
 Hyperbilirubinemia requiring exchange transfusion.


Anthropometry Interpretation
Growth Indicators
Z-Score
Length/Hei Weight Weight for BMI for Age
ght for age for age length/height
Above 3 See note 1 Obese Obese
Above 2 Overweight Overweight

Above 1 See Note 2 Possible risk of Possible risk of

Overweight (See Overweight (See note 3)
note 3)
0 (median)
Below -1
Below -2 Stunted
Underweight Wasted Wasted
(See note 4)
Below -3 Severely Severely
stunted (See Underweight Severely Wasted Severely wasted
note 4 (see note 5
Note
1. A child in this range is very tall. Tallness ia rarely a problem, unless it is so excessive that
may indicate an endocrine disorder such as a growth-hormone producing tumor. Refer a
child in this range for assessment if you suspect an endocrine disorder (e.g If parents of
normal height have a child who is excessively tall for his or her age)
2. A child whose weight for-age fall in this range may have a growth problem, but this is
better assessed from weight for length/height or BMI-for-age
3. A plotted point above 1 shows possible risk. A trend towards the 2 -z-score line shows
definite risk.
4. It is possible for a stunted or severely stunted child to become overweight
5. This is refered to as very low weight in | MC | training modules . (Integrated Management
of Childhood illness, in-service training WHO, Geneva, 1997)
WEIGHT FOR AGE: Weight-for-age reference data are not available beyond age
10 because this indicator does not distinguish between height and body mass in an
age period where many children are experiencing the pubertal growth spurt and may
appear as having excess weight (by weight-for-age) when in fact they are just tall.

Mid-Upper Arm Circumference


Blood Pressure
 Begin routine BP measurement at 3 years of age, but we measure when
indicated (<3yr.)

5th Centile – 0 – 1 month 60mmHg SBP

1 month – 1 year - 70mmHg SBP
1 year – 10 year – 70 + Age x 2 (lower range)
- 90 + Age x 2 (upper range)
DBP = (Age x 2) + 55 (for 1 – 6 year)
= (Age x 2) + 60 (for 7year)
Definition of Hypertension (1–18 years)
Changes in HTN categorization compared to the Report:
- BP >90th percentile now termed ‗elevated BP‘

- BP cut-points for Stage 1 and 2 HTN simplified
- BP cut-points for adolescents ≥13 years of age are the same as in new
AHA/ACC adult HTN guideline
TABLE: Updated Definitions of BP Categories and Stages

For Children Aged 1–13 yrs For Children Aged ≥13 yrs
Normal BP: <90th percentile Normal BP: <120/<80 mm Hg
Elevated BP: ≥90th percentile to <95th Elevated BP: 120/<80 to 129/<80 mm Hg
percentile or 120/80 mm Hg to <95th
percentile (whichever is lower)
Stage 1 HTN: ≥95th percentile to <95th Stage 1 HTN: 130/80 to 139/89 mm Hg
percentile + 12 mmHg, or 130/80 to 139/89
mm Hg (whichever is lower)

Stage 2 HTN: ≥95th percentile + 12 mm Hg, Stage 2 HTN: ≥140/90 mm Hg

or ≥140/90 mm Hg (whichever is lower)


Reference Intervals for Laboratory Tests and

Procedures
Table 6 – 1 Laboratory Profile as a Review of System

Laboratory Screening
Screening profiles (Table 726-4) are used as part of a complete review of systems, to establish a baseline
value, or to facilitate patient care in specific circumstances, such as
1. When a patient clearly has an illness, but a specific diagnosis remains elusive;
2. When a patient requires intensive care;
3. For post-marketing surveillance and evaluation of a new drug; and
4. When a drug is used that is known to have systemic adverse effects. Laboratory screening
tests should be used in a targeted manner to supplement, not supplant, a complete history
and physical examination.
WHO CRITERIA FOR DIAGNOSIS OF ANEMIA

 Children 6 months to 6 years: Hb <11 gm/dl
 Children 6-14 years: Hb <12 gm/dl
 Mild anemia: Hb >10 g/dl
 Moderate anemia: Hb 7-10 g/dl
 Severe anemia: Hb <7 g/dl

 For SAM pt. Hb <4 g/dl
 For Malaria Hb <5g/dl
* Below 2 wk 13 g/dL, upto 6 month, 9.5 g/dL. 6 months-12 yrs 11g/dL. above 12
yrs 12 g /dL
Clinical grading of anemia

Grade Clinical parameters
 Mild: Pallor of conjunctiva and/or mucus membrane
 Moderate: Above plus pallor of skin
 Severe: Above plus pallor of palmar creases

URINALYSIS, NORMAL VALUES

1. Appearance: ―Yellow, clear,‖ or ―straw-colored, clear‖
2. Specific Gravity
a. Neonate: 1.012
b. Infant: 1.002–1.006
c. Child and Adult: 1.001–1.035 (with normal fluid intake 1.016–1.022)
3. pH
a. Newborn/Neonate: 5–7
b. Child and Adult: 4.6–8.0
4. Negative for: Bilirubin, blood, acetone, glucose, protein, nitrite, leukocyte

esterase, reducing substances
5. Trace: Urobilinogen
6. RBC: Male 0–3/hpf, female 0–5/hpf
7. WBC: 0–4/hpf
8. Epithelial Cells: Occasional
9. Hyaline Casts: Occasional
10.Bacteria: None
11.Crystals: Some limited crystals based on urine pH (see below)
Ketones
Detects primarily acetone and acetoacetic acid and not β-hydroxybutyric acid.
Positive: Starvation, high-fat diet, DKA, vomiting, diarrhea, hyperthyroidism,
pregnancy, febrile states (especially in children)
Casts:

The presence of casts in a urine localizes some or all of the disease process to the
kidney itself.
 Hyaline Casts. (Acceptable unless they are ―numerous‖), benign
hypertension, nephrotic syndrome, after exercise
 RBC Casts. Acute glomerulonephritis, lupus nephritis, SBE, Goodpasture‘s
disease, after a streptococcal infection, vasculitis, malignant hypertension
 WBC Casts. Pyelonephritis
 Epithelial (Tubular) Casts. Tubular damage, nephrotoxin, virus
 Granular Casts. Breakdown of cellular casts, leads to waxy casts; ―dirty
brown granular casts‖ typical for ATN
 Waxy Casts. (End stage of granular cast). Severe chronic renal disease,
amyloidosis
 Fatty Casts. Nephrotic syndrome, diabetes mellitus, damaged renal tubular
epithelial cells
 Broad Casts. Chronic renal disease

Proteinuria Interpretation Ketone Interpretation

Dipstick Plasma Protein (Mg/dl) Ketone Interpretation
Protein
(-) Normal Negative No change
Trace 10-29mg/dl + Pinkish ring
+1 30-100mg/dl ++ Red ring
+2 100-300mg/dl +++ Deep purple ring
+3 300-1000mg/dl
+4 >1000mg/dl

Table 6 -3 | Reference Intervals







CSF-Analysis


for Young Infants and Children.























Antibiotics for Patients with SAM


R.From core note
* * * * * * * * * * * * * * * * * *
Gynecology and Obstetrics
Surgery
Pediatrics
History Format For ALL

Exam Book
Surgery Short

Surgery Short
Internal Medicine
CORE NOTE
Prepared By: Dr. Besufekad Adane

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CORE NOTE https://t.me/core_note

INCLUDING HISTORY & PHYSICAL EXAMINATION WRITTEN EXAM CASES

Author & Graphics Designer

CORE NOTE- Pediatrics and Child Health Page 1

Advice for Clinical One Student‘s

 First of all must know your patient.

 Take detail histories of your patient

 Normal lab. Investigations values.

 How to manage your patients

CORE NOTE- Pediatrics and Child Health III 2

This is one package from CORE-NOTE‘S. As we all know, Medicine is an ever-changing

CORE NOTE- Pediatrics and Child Health PageIV

3. PART THREE: Newborn History Taking & Physical Examination…………………………………

CORE NOTE- Pediatrics and Child Health Page 4 V

Especially, I would like to thank Dr. Sirak Minale and mini-family’s

―Your single comment is constructive for the

CORE NOTE- Pediatrics and Child Health PageVI

CORE NOTE- Pediatrics and Child Health Page 6

CORE NOTE- Pediatrics and Child Health Page 7

 Hospital Name, Ward, Bed number

If the Pt. has P/A history:

 If the previous admission is related to the current illness, details could be

CORE NOTE- Pediatrics and Child Health Page 8

CORE NOTE- Pediatrics and Child Health Page 9

 HISTORY OF PRESENT ILLNESS

 Elaboration of the chief complaint with regard to:

CORE NOTE- Pediatrics and Child Health Page 11

Pertinent positive & negative statements

CORE NOTE- Pediatrics and Child Health Page 12

CORE NOTE- Pediatrics and Child Health Page 13

 Frequency of meals per day

 Reaches for an object-4mos

CORE NOTE- Pediatrics and Child Health Page 15

Summery in Developmental Milestones:

CORE NOTE- Pediatrics and Child Health Page 16

Developmental Millstone for Children with Down

Self Help Skills

CORE NOTE- Pediatrics and Child Health Page 17

15 month | 6 | Measles 2nd Dose

CORE NOTE- Pediatrics and Child Health Page 18

 PERSONAL, FAMILY & SOCIAL HISTORY

CORE NOTE- Pediatrics and Child Health Page 20

Review of Systems/Functional Inquiry

 Difficulty of Breathing, Chest Pain, Wheezing…

 weakness, or limitation of motion or activity,

CORE NOTE- Pediatrics and Child Health Page 23

CORE NOTE- Pediatrics and Child Health Page 24

 Level consciousness: Conscious, alert, lethargic, comatose

• Check ribs and arm

CORE NOTE- Pediatrics and Child Health Page 26

Source: from Nelson 21th Edition

How to Comment On the Pulse

CORE NOTE- Pediatrics and Child Health Page 27

 Age 2-12months ≥50‘

CORE NOTE- Pediatrics and Child Health Page 28

# Chronic Conditions # Acute Conditions

CORE NOTE- Pediatrics and Child Health Page 29

Definition of Hypertension (1–18 years)

Core Note Pediatrics a Systematic Guide to Physical Diagnosis &

Core Note Pediatrics a Systematic Guide to Physical Diagnosis &

Core Note Pediatrics a Systematic Guide to Physical Diagnosis &