Revalida Review 2022

Joanna Lissa F. Payuran-Gatchalian

Chief Resident
UST Department of Pediatrics
Outline
• History

• Physical Examination

• Formulating a diagnosis

• Common chief complaints encountered in the OPD

• Abdominal Pain

• Cough

• Edema

• Fever

• Headache

• Leg Pain

• Pallor

• Rash

• Seizure

• Tea Colored Urine

 REVALIDA TIP!

Memorize history and

physical examination

History and Physical Examination

History
• General Data - name, age (birth date), sex, race (ethnicity), birthplace, religion, present
address, number date of hospital admissions, name of informant and relation to patient,
reliability of informant
• Chief Complaint - “why was the patient brought to the hospital?”
• History of Present Illness - chronological order
• onset, intensity of symptoms, factors that aggravate/relieve symptoms, medications
including dose (mg/kg/dose or mg/kg/day), duration of treatment, outside medical
treatment, consultations and hospitalizations, associated symptoms (describe also as to
onset, course, chronology, intensity)
• pertinent negatives
History
• Review of systems - general, cutaneous, head, cardiovascular, respiratory, gastrointestinal, genitourinary,
endocrine, nervous/behavioral, musculoskeletal, hematopoietic, make sure it is age-appropriate

• Personal History
• Gestational, Birth, and Neonatal History - below 2 y/o, and if related to illness for >2y/o
• Feeding history - all ages
• infancy
• childhood
• adolescents)

• Developmental History - all ages (young children, middle childhood, adolescence)

History
• Developmental History - all ages

• young children (1-5 years old) - development using modified developmental

checklist, dental eruption, other behavioral problems
• middle childhood - inquire about school performance and sexual development
using Tanner’s Maturity Rating
• adolescence - HEADSSS, menstrual history and self breast examination for
females
History
• Past Illnesses - all ages (state age when contracted, severity, complications)

• Immunization History - types of immunization given, including age when given,

where given, any untoward reactions, COVID vaccination
• Family History - include family profile, familial illnesses or anomalies

• Socioeconomic History - living circumstances, economic circumstances

• Environmental History - exposure to cigarette, garbage disposal, sewage disposal,

water source, COVID 19 exposure
 Physical Examination
• General Survey - (SEVEN components: mental state or sensorium, level of activity,
presence of cardiorespiratory distress, ambulatory, nutritional state, state of hydration,
ill looking)
• Vital Signs - temperature, heart rate, respiratory rate, blood pressure if >3y/o

• Anthropometric data - weight, length/height (>2 y/o), head circumference, chest

circumference, abdominal circumference, arm span & U/L ratio for children with
growth disorders
 REVALIDA TIP!

plo t d o w n to th e m o nth s
 Physical Examination
• Skin - color, presence of rashes, birth marks, neurocutaneous lesions, skin turgor,
• Head - hair, shape, scalp, fontanels, sutures, presence of lice/nits
• Face - symmetry, facies, deformities
• Eyes - lids, conjunctivae, sclerae, pupils, edema
• Ears and mastoids - presence of discharge, erythema, skin tags, pits, sinus, tympanic membrane
• Nose and paranasal sinuses - alar flaring, patency of nostrils, nasal discharge, sinus tenderness
• Mouth - lips, gums, tongue, mucous membrane, dentition, palate, posterior pharyngeal wall,
tonsils
• Neck - venous engorgement, flexibility, rigidity, masses, lymph nodes
 Physical Examination
• Chest and Lungs - inspection (retractions, deformities), palpation, percussion,
auscultation
• Heart and Vascular System - precordium, visible pulsations, apex beat, thrills, heart
sounds, pulses
• Abdomen - inspection (striae, umbilicus, abdominal circumference), auscultation
(bowel sounds), percussion (liver span), palpation (splenic tip), psoas sign, obturator
sign,
• Inguinal Regions - swelling, lymph nodes

• Genitalia - penile length, prepuce, location of urethra, bilateral testes, labial adhesions
 Physical Examination
• Anus and rectum - patency, fissures, tags, hemorrhoids, digital rectal exam

• Extremities - clubbing, cyanosis, signs of joint inflammation, range of motion,

deformitites
• Spine - bend forward test

• Lymph Nodes - enlarged if >1cm for cervical lymph nodes, >1.5cm for inguinal nodes
Neurologic Examination
• Cerebrum

• Sensorium

• Speech

• Cranial Nerves

• Motor T I P!
RE VA L I D A
• Cerebellar

• Sensory
Be age-specific!
• Reflexes

• Autonomic Nervous System

• Signs of meningeal irritation

 Steps in Diagnosis
1. Summarize Salient Features

e.g. “Again, we are presented with a 2 month old male who was previously well,
presenting with 3 day history of low grade fever, weight loss, irritability, accompanied by
cough and poor feeding. He came in at the ER in respiratory distress (manifested by
tachypnea, alar flaring, IC and SC retractions) and on auscultation had bilateral fine
crackles”

2. Choose the presenting manifestation

 Steps in Diagnosis
2.1 A pathognomonic sign or laboratory finding

e.g. Koplik’s spots in measles, Gottron’s papules/rash in juvenile dermatomyositis,

blood culture isolate of Salmonella typhi in typhoid fever, CSF culture of Mycobacterium
tuberculosis in TB meningitis, (+) gene xpert in MTB, BMA findings of >25% blasts in acute
leukemia

2.2 Presenting manifestation pointing to a definite organ or system

e.g. RUQ pain & (+) Murphy’s sign = gallbladder disease (cholecystitis), fever,
headache, vomiting, seizures, (+) Brudzinski, (+) Kernig’s = CNS (meningitis), fever, cough,
dyspnea, tachypnea, retractions and fine crackles = respiratory (pneumonia)
 Steps in Diagnosis
2.3 Presenting manifestation that point to a group of diseases or disorders

e.g. diarrhea of < 2 weeks = acute diarrhea, bloody diarrhea with tenesmus =
dysentery, types of rashes

2.4 Presenting manifestation whose mechanism is well understood

e.g. anemia, edema, hyperbilirubinemia/jaundice

2.5 Presenting manifestation pointing to the least number of diseases

e.g. risus sardonicus = seen in tetanus or strychnine poisoning

 Steps in Diagnosis
3. Establish the clinical diagnosis - the one that will explain most, if not all of the
patient’s clinical manifestation becomes the clinical diagnosis; necessary diagnostic
tests are requested to support the initial clinical diagnosis

4. Discover unexplained data - should be used as another presenting manifestation

5. If the diagnostic tests confirm the clinical diagnosis, this becomes theREworking
VALIDA TIP!
diagnosis

6. At the end of the hospitalization, the final diagnosis must be given It is important to
have an organized
thought process.
Common Chief Complaints in the OPD
ABDOMINAL PAIN
Abdominal Pain
• History - dependent on both the ability and willingness of child to communicate, and
the skill of the parent or guardian as observer
• presence of anorexia - ask about food intake, time last food was eaten

• time of onset of pain

• location of pain

• character of pain

• child activity level

Abdominal Pain
• gastrointestinal symptoms

• vomiting - intestinal disease such as ileus, gastroenteritis, or acute problems of

the GI tract that warrant surgery, vomiting in relation to pain (pan before
vomiting ~ acute surgical lesions or vomiting before pain ~ gastroenteritis),
appearance of vomited material
• diarrhea - intestinal disease, usually large volume

• constipation

• associated symptoms - headache, sore throat (flu)

• family history and personal medical history

Abdominal Pain
• Physical Examination

• General Survey, vital signs, anthropometrics

• Ask for fever, tachycardia, tachypnea, hypotension

• Examination of the head, neck, chest, extremities

• Decreased breath sounds in lower lobe

• Abdominal examination - performed systematically IAPePa

• bowel sounds are usually nonspecific (hyperactive in gastroenteritis, normal in early appendicitis)

• palpation begun as far away from the area of pain, ask about guarding, rigidity, rebound pain

• Rectal Examination
Abdominal Pain
• Laboratory Evaluation

• Complete Blood Count

• Urinalysis

• Other: serum electrolytes, amylase, lipase, liver function studies

• Imaging Evaluation
• Plain film of the abdomen
• Ultrasound

• Contrast Studies
• CT Scan
Common Chief Complaints in the OPD
COUGH
 Cough
• History - most important body of information about a child’s cough

• demographics - age

• characteristic of cough - acute, recurrent, chronic

• associated symptoms - wheeze, stridor

• family and patient’s medical history - asthma, chronic cough

 Cough
• Physical Examination

• General survey, vital signs, anthropometrics (wasted?)

• Check for signs of distress, cyanosis (both central and peripheral)

• Chest

• Inspection - AP diameter, presence of retractions (intercostal, subcostal, suprasternal,

supraclavicular)
• Palpation - trachea (shifting), chest expansion, tactile fremitus

• Percussion - dullness over areas of consolidation

• Auscultation - stridor (croup, laryngomalacia), crackles, rhonchi, wheeze (asthma)

 Cough
• Diagnostic Studies

• Radiography - chest radiograph

• Hematology - complete blood count

• bacteriology/virology - SARSCOV2 RT PCR, Gene Xpert

 Cough
• Differential Diagnosis and Treatment

• Infection - most common cause of acute cough in all age groups, some chronic
cough
• Infection in infants - viral upper respiratory infections, croup, viral bronchiolitis
(RSV or human metapneumovirus, and viral pneumonia) -> may predispose to
bacterial superinfection
• symptoms: stuffy nose with nasal discharge, sore throat, sneezing, constitutional
signs like fever, irritability, myalgia, headache, cough
• croup (laryngotracheobronchitis) - 1st 2 yrs of life, “barking” cough and stridor,
colds, low-grade fever, resolves within 1-2 days
 Cough
• Differential Diagnosis and Treatment

• Bronchiolitis - RSV, parainfluenza, influenza, human metapneumovirus, adenovirus, enterovirus,

rhinovirus, seen in >4 y/o, “cold-like” symptoms, hyperinflated chest, crackles, wheezing. Tx: O2
and IVF

• Viral pneumonia - can be similar to bronchiolitis w/ cough, tachypnea. Poor feeding, cough,
cyanosis, fever, apnea, rhinorrhea, retractions, crackles, cough. ESR and WBC not usually elevated.
Tx: supportive

• Pertussis - “whooping cough”, common to those who are underimmunized or not

immunized. Tx: supportive
• Bacterial pneumonia - less common but can cause severe illness, cough, respiratory
distress, and fever, abnormal Xray, elevated WBC Tx: Antibiotics effective against
pneumococci, group A streptococci, and if w/ severe illness, S. aureus
 Cough
• Tuberculosis - must be considered in children with chronic
cough (~2 weeks), living in endemic areas, or has been exposed
to an adult with active TB. Dx: PPD, Xray
 Cough
• Asthma - cough is the most prominent manifestation, wheezing may be absent
 Cough
• Aspiration - acute, recurrent, or chronic cough

• Foreign Body - abrupt onset, especially among toddlers, sx: cough, wheeze,

• Gastroesophageal Reflux - common cause of cough in all age groups, “spit ups”

• Anatomic Abnormalities - vascular rings and slings, pulmonary sequestration,

congenital pulmonary airway malformation, congenital emphysema,
tracheoesophageal fistula, hemangiomas, enlarged lymph nodes, bronchial stenosis,
bronchogenic cysts
Common Chief Complaints in the OPD
EDEMA
Edema
• History - onset of edema, location, associated symptoms like bubbly urine, ascites,
personal medical history, family history
• nephrotic syndrome - proteinuria, hypoalbuminemia, edema, and hyperlipidemia

• Physical Examination - general survey, vital signs, anthropometrics

Edema
• Minimal Change Disease - most common cause of nephrotic syndrome in children;
may present w/ swollen or puffy eyes upon awakening, increasing abdominal girth,
pedal or leg edema or swelling in other sites like the scrotum or vulva
• hallmark - total clearing of proteinuria with steroid therapy

• microscopic hematuria and hypertension may be present in up to 20% of cases

• Dx: urinalysis, serum BUN, creatinine, albumin, cholesterol, complements (normal)

and lupus antibody titers
• Tx: prednisone 60mg/m2/day or 2mg/kg/day max of 60mg for 4-6 weeks
Common Chief Complaints in the OPD
FEVER
 Fever
• History - may reveal a potential source for infection; onset and duration of fever,
degree of temperature, medications given, environmental exposures, associated
symptoms, ill contacts, recent immunizations and recent travel, COVID exposure,
COVID vaccination
• Physical Examination - look for the source of fever

• Eyes - include visual acuity, EOMs, inspection of external structures

• Ears, Nose, Throat - palpate sinuses, inspect nares, tympanic membrane, mouth,
teeth gums,
• Neck - adenopathy or thyroid enlargement
 Fever
• Heart, Lungs, and Abdomen - murmur (~endocarditis), friction rub (JIA, SLE,
rheumatic fever, malignancy), hepatosplenomegaly, abdominal tenderness, rectal
examination, pelvic examination
• Musculoskeletal examination - active and passive ROM, warmth, tenderness,
swelling (JIA, osteomyelitis, malignancy), myalgia (influenza, dermatomyositis)
• Skin - rashes, skin lesions, evanescent rash (JIA), heliotrope rash (dermatomyositis),
butterfly rash (SLE), polymorphous rash (Kawasaki),
 Fever
• Differential Diagnosis

• most common - self limited viral infection

• UTI - most common serious bacterial infection in children less than 36 months of
age who present with fever without source. Dx: urinalysis, urine culture
• Occult bacteremia - positive blood culture in a febrile patient
 Fever
• Diagnostic Testing

• <1 month, 1-3 months, 3-36 months

• Complete Blood Count

• Markers of inflammation

• PCR

• Blood Cultures

• Urinalysis and Urine Culture

• Lumbar Puncture - <28 days, or if dx is sepsis, meningitis, encephalitis

• Chest Xray

• Fecalysis, Stool Cultures - acute diarrhea and fever

Common Chief Complaints in the OPD
HEADACHE
Headache
• History - laterality, location, timing, frequency, duration, quality, severity, associated
symptoms and alleviating and aggravating factors
• thunderclap headache - sudden onset, maximum severity within seconds, described
as the “worst headache they ever had” (subarachnoid hemorrhage, arterial
dissection, venous sinus thrombosis)
Headache
• Physical Examination

• General survey, vital signs, anthropometrics

• Complete Neurologic Exam!

RE VA L I D A T I P!

Don’t forget to do
funduscopy
Common Chief Complaints in the OPD
LEG PAIN
 Leg Pain
• History - pain location, pain character, pain acuity, signs of inflammation, disability,
medical history, medications, family history, social history, constitutional symptoms,
skin changes (erythema marginatum, malar rash, heliotrope rash, gottron papules)
• Physical Examination - general survey, vital signs, anthropometrics

• observe ambulation, examine all joints, observe for skin changes

Articular - prolonged stiffness in the AM >1 hr; pain and stiffness ease through the day, presence of pain, warmth, swelling, erythema, limited ROM
 Leg Pain
• Laboratory Studies

• CBC w/ differential count (acute infection or leukemia)

• elevated WBC (septic arthritis or osteomyelitis, systemic JIA)

• moderate normocytic anemia, mild thrombocytosis

• ESR - elevated in the setting of inflammation and leukemia

• urinalysis - to screen for glomerulonephritis (vasculitis/SLE)

• ANA - screening for SLE; RF - not diagnostic

• C3, C4 - SLE
 Leg Pain
• Diagnostic Imaging

• Radiographs - potential infections, trauma, leukemia, or solid bone tumors

• MRI - sensitive test for osteomyelitis and avascular necrosis

• Bone Scan - can help distinguish arthritis from osteomyelitis, fractures, tumors

• Ultrasound - hip for transient synovitis

• 2D Echo - Rheumatic Fever

• Joint Fluid Aspiration - Indications: 1) infectious arthritis, 2) hemarthrosis, 3) crystal

diseases such as gout or pseudogout
Common Chief Complaints in the OPD
PALLOR
Pallor
• History - family history, dietary history, breastfeeding, iron supplementation, neonatal
hyperbilirubinemia
• Physical Examination - general survey, vital signs, anthropometrics

• isolated pallor vs (+) bruising, petechiae, lymphadenopathy, hepatosplenomegaly, or

abdominal mass; pallor of the face, nail beds, tongue, palms, and palmar creases as
well as conjunctival pallor; prominent cheekbones, dental malocclusion, frontal
bossing (chronic hemolytic anemias e.g. thalassemia major), splenomegaly
(hemolytic anemia, leukemia)
Common Chief Complaints in the OPD
RASH
 Rash
• History - features of rash, when it occurred in relation to fever, its evolution, or
progression, anatomic distribution, pruritic or painful; immunization
• Physical Examination - general survey, vital signs, anthropometrics, assess degree of
toxicity
Common Chief Complaints in the OPD
SEIZURE
Seizure
• History - description of event or events from beginning to end

• Was this the first time? Single type or multiple events? Was the child previously
well? Any abnormal tone or movements? Is the child unresponsive or unconscious?
How long did the event last? Any associated symptoms like fever, headache,
vomiting? Any history of trauma?
• Gestational, Neonatal, birth history; Developmental history; Family history
Seizure
• Physical Examination - general survey, vital signs, anthropometrics !HC

• Elevated BP ~ pain, anxiety, increased ICP, hypertensive encephalopathy

• Hypotension - syncopal events, sepsis

• Check for dysmorphic features, cutaneous findings (cafe au lait spots)

• ophthalmologic exam - look for papilledema, assess EOMs

• muscle strength, tone - weakness vs hypotonia or ataxia

• nuchal rigidity, Kernig’s, Brudzinski

Seizure
• Red Flags

• Increased ICP or large intracranial mass

• hypertension, bradycardia

• CNIII or CNVI palsy, anisocoria, ptosis, diplopia

• papilledema, severe vomiting
• bulging fontanel
• ongoing status epilepticus

• stroke or complicated migraine - focal weakness or numbness

• meningitis - fever, nuchal rigidity, bulging fontanel
Seizure
• Febrile Seizure - bet 6-60 months with a temperature of 38C or higher

• Simple Febrile Seizure - generalized, usually tonic-clonic, assoc w/ fever, lasting

max of 15 min, and not recurrent within a 24 hr period
• Complex Febrile Seizure - more prolonged (>15 min), and/or focal, and/or recurs
within 24 hrs
• Evaluation

• Lumbar puncture - option in a child 6-12 mos who is deficient in HiB and strep
immunizations; option for children pretreated w/ antibiotics
Common Chief Complaints in the OPD
TEA COLORED URINE
 Tea Colored Urine
• Gross hematuria - blood in the urine visible to the naked eye; frankly bloody urine
(nonglomerular, lower urinary tract), brown/cola/tea-colored (glomerular source)
• History - pain with onset of hematuria ~ lower urinary tract source; irritative
symptoms e.g. dysuria, urgency, frequency ~ bladder; dysuria, abdominal pain, fever
(UTI); severe episodic, colicky flank or abdominal pain (urolithiasis); recent history of
pharyngitis, streptococcal skin infection, other febrile illnesses (PSGN); abdominal
pain, diarrhea, rash, arthralgia (HSP); painless, concurrent respiratory illness (IgA
nephropathy)
 Tea Colored Urine
• Physical Examination - general survey, vital signs, anthropometrics

• look for evidence of systemic disease, and for potential sequelae

• Hypertension - acute GN, CKD

• edema - underlying parenchymal disease

• poor growth - chronic renal disease

• pallor, fever, rashes, musculoskeletal findings - systemic vasculitis w/ renal

involvement (HSP, SLE, or ANCA-associated)
• Abdominal exam - abdominal or flank masses
 Tea Colored Urine
• Post-infectious Glomerulonephritis - gross hematuria occurring 5 days to 4 weeks
after a febrile illness
• hematuria, oliguria, edema, hypertension

• self-limited disease

• Dx: clinical, UA of glomerular hematuria, ASO, C3 (low but returns to normal by 6-

8 weeks vs LN, MPGN)
• Tx: directed towards hypertension
 Tea Colored Urine
• IgA Nephropathy - recurrent episodes of painless, gross hematuria

• triggered bu URTI

• Dx: confirmed by biopsy

• benign pattern

• Tx: supportive, steroids for patients with more severe form

 RE VAL I D A T I P!

Pray hard.
Sleep early.
Eat breakfast.
Drink coffee.

d a nd c o n f ide nc e a r e
Presence of min
important.

I S, b a tc h 2 02 2!
YOU GOT TH
Thank you for listening!
joannapayurangatchalian@gmail.com

Resources:
1. Nelson’s Pediatric Symptom-Based Diagnosis
2. Nelson’s Pediatric Textbook (21st Ed)
3. Batch 2020 Trans