Chapter 6

1. Chapter 6 Examination and Assessment of the Pediatric Patient

2. Introduction • Obtaining a complete history on a pediatric patient not only is necessary, but also leads to the correct diagnosis in the vast majority of children. • The history usually is learned from the parent, the older child, or the caretaker of a sick child. • After learning the fundamentals of obtaining and recording historic data, the nuances associated with the giving of information must be interpreted.

3. Introduction • During the interview, it is important to convey to the parent interest in the child as well as the illness. • The parent is allowed to talk freely at first and to express concerns in his or her own words. • The interviewer should look directly either at the parent or the child intermittently and not only at the writing instruments. • Careful observation during the interview frequently uncovers stresses and concerns that otherwise are not apparent.

4. General Information • Identifying data include the date, name, age and birth date, sex, race, relationship of the child and informant, and some indication of the mental state or reliability of the informant. • It frequently is helpful to include the ethnic or racial background, address, and telephone numbers of the informants.

5. Patient History • The history for a new patient can be divided into: • Chief complaint or primary concern • History of the present illness (HPI) • Past medical history (PMH) • Review of symptoms (ROS) • Family history (FH) • Social and environmental histories

6. Patient History (cont.) • Chief complaint • Current signs and symptoms • Typically assessed by a parent or caregiver • Includes cough/fever/chest pain… • Given in the informant's or patient's own words, the chief complaint is a brief statement of the reason why the patient was brought to be seen. It is not unusual that the stated complaint is not the true reason the child was brought for attention. Expanding the question of "Why did you bring him?" to "What concerns you?" allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying.

7. Patient History (cont.) • History of Present Illness • Present illness are recorded in chronologic order. • "The child was well until "X" number of days before this visit.“ • Statements should be recorded in number of days before the visit or dates, but not in days of the week, because chronology will be difficult to retrieve even a short time later if days of the week are used. If the child is taking medicine, the amount being taken, the name of the medicine, the frequency of administration, and how well and how long it has been or is being taken are needed. • For the well child, a simple statement such as "No complaints" or "No illness" suffices. A question about school attendance may be pertinent. If the past medical history is significant to the current illness, a brief summary is included. If information is obtained from old records, it should be noted here or may be recorded in the past medical history.

8. Past Medical History • A. Antenatal:  Health of mother during pregnancy.  Medical supervision, drugs, diet, infections such as rubella, etc., other illnesses, vomiting, toxemia, other complications; Rh typing and serology, pelvimetry, medications, x-ray procedure, maternal bleeding, mother's previous pregnancy history. • B.  Natal:  Duration of pregnancy, birth weight, kind and duration of labor, type of delivery, presentation, sedation and anesthesia (if known), state of infant at birth, resuscitation required, onset of respiration, first cry. • C. Neonatal:  APGAR score; color, cyanosis, pallor, jaundice, cry, twitchings, excessive mucus, paralysis, convulsions, fever, hemorrhage, congenital abnormalities, birth injury.  Difficulty in sucking, rashes, excessive weight loss, feeding difficulties.  You might discover a problem area by asking if baby went home from hospital with his mother.

9. Growth and Development: Mother and Mental Development • a. First raised head, rolled over, sat alone, pulled up, walked with help, walked alone, talked (meaningful words; sentences) • b. Urinary continence during night; during day. • c.  Control of feces. • d.  Comparison of development with that of siblings and parents. • e.  School grade, quality of work.

10. Growth and Development: Nutrition • 1. Breast or Formula:  Type, duration, major formula changes, time of weaning, difficulties.  Be specific about how much milk or formula the baby receives. • 2. Vitamin Supplements:  Type, when started, amount, duration. • 3.  "Solid" Foods:  When introduced, how taken, types. • 4.  Appetite:  Food likes and dislikes, idiosyncrasies or allergies, reaction of child to eating.  An idea of child's usual daily intake is important.

11. Past Illnesses • A comment should first be made relative to the child's previous general health, then the specific areas listed below should be explored. • 1. Infections: Age, types, number, severity. • 2. Contagious Diseases:  Age, complications following measles, rubella, chickenpox, mumps, pertussis, diphtheria, scarlet fever. • 3. Past Hospitalizations: including operations, age. • 4. Allergies, with specific attention to drug allergies - detail type of reaction. • 5. Medications patient is currently taking.

12. Immunizations and Tests • Be familiar with departmental recommendations for immunizations.  List date and type of immunization as well as any complications or reactions. • Accidents and Injuries (include ingestions): Nature, severity, sequelae. • Behavioral History • 1. Does child manifest any unusual behavior such as thumb sucking, excessive masturbation, severe and frequent temper tantrums, negativism, etc.? • 2. Sleep disturbances. • 3. Phobias. • 4. Pica (ingestions of substances other than food). • 5. Abnormal bowel habits, ex. - stool holding. • 6. Bed wetting (applicable only to child out of diapers).

13. Family History • A.  Father and mother (age and condition of health).  What sort of people do the parents characterize themselves as being? • B. Marital relationships.  Little information should be sought at first interview; most information will be obtained indirectly. • C. Siblings.  Age, condition of health, significant previous illnesses and problems. • D. Stillbirths, miscarriages, abortions; age at death and cause of death of immediate members of family. • E. Tuberculosis, allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular diseases, kidney disease, rheumatic fever, neoplastic diseases, congenital abnormalities, cancer, convulsive disorders, others. • F. Health of contacts.

14. System Review • A system review will serve several purposes.  It will often bring out symptoms or signs missed in collection of data about the present illness.  • It might direct the interviewer into questioning about other systems that have some indirect bearing on the present illness (ex. - eczema in a child with asthma).  • Finally, it serves as a screening device for uncovering symptoms, past or present, which were omitted in the earlier part of the interview. 

15. System Review • A. Skin:  Ask about rashes, hives, problems with hair, skin texture or color, etc. • B. Eyes:  Have the child's eyes ever been crossed?  Any foreign body or infection, glasses for any reason. • C. Ears, Nose and Throat:  Frequent colds, sore throat, sneezing, stuffy nose, discharge, post-nasal drip, mouth breathing, snoring, otitis, hearing, adenitis. • D. Teeth:  Age of eruption of deciduous and permanent; number at one year; comparison with siblings. • E. Cardiorespiratory:  Frequency and nature of disturbances.  Dyspnea, chest pain, cough, sputum, wheeze, expectoration, cyanosis, edema, syncope, tachycardia. • F. Gastrointestinal:  Vomiting, diarrhea, constipation, type of stools, abdominal pain or discomfort, jaundice.

16. System Review • G. Genitourinary:  Enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of stream, vaginal discharge, menstrual history, bladder control, abnormalities of penis or testes. • H. Neuromuscular:  Headache, nervousness, dizziness, tingling, convulsions, habit spasms, ataxia, muscle or joint pains, postural deformities, exercise tolerance, gait. • I. Endocrine:  Disturbances of growth, excessive fluid intake, polyphagia, goiter, thyroid disease. • J. Special senses. • K. General:  Unusual weight gain or loss, fatigue, temperature sensitivity, mentality.  Pattern of growth (record previous heights and weights on appropriate graphs).  Time and pattern of pubescence.

17. Physical Exam Approaching the Child • Adequate time should be spent in becoming acquainted with the child and allowing him/her to become acquainted with the examiner.  • The child should be treated as an individual whose feelings and sensibilities are well developed, and the examiner's conduct should be appropriate to the age of the child.  A friendly manner, quiet voice, and a slow and easy approach will help to facilitate the examination.

18. Physical Exam Observation of the Patient • Although the very young child may not be able to speak, one still may receive much information from him/her by being observant and receptive.  • The total evaluation of the child should include impressions obtained from the time the child first enters until s/he leaves; it should not be based solely on the period during which the patient is on the examining table.  • In general, more information is obtained by careful inspection than from any of the other methods of examination.

19. General Physical Examination Vital Signs and Measurements • Temperature, pulse rate, and respiratory rate (TPR); blood pressure (the cuff should cover 2/3 of the upper arm), weight, height, and head circumference.  • The weight should be recorded at each visit; the height should be determined at monthly intervals during the first year, at 3-month intervals in the second year, and twice a year thereafter.  • The height, weight, and circumference of the child should be compared with standard charts and the approximate percentiles recorded.  Multiple measurements at intervals are of much greater value than single ones since they give information regarding the pattern of growth that cannot be determined by single measurements.

20. General Physical Examination General Appearance Does the child appear well or ill?  Degree of prostration; degree of cooperation; state of comfort, nutrition, and consciousness; abnormalities, gait, posture, and coordination; estimate of intelligence; reaction to parents, physician, and examination; nature of cry and degree of activity, facies and facial expression.

21. General Physical Examination Skin • Color (cyanosis, jaundice, pallor, erythema), texture, eruptions, hydration, edema, hemorrhagic manifestations, scars, dilated vessels and direction of blood flow, hemangiomas, cafe-au-lait areas and nevi, Mongolian (blue-black) spots, pigmentation, turgor, elasticity, and subcutaneous nodules.  • Striaeand wrinkling may indicate rapid weight gain or loss.  Sensitivity, hair distribution and character, and desquamation.

22. General Physical Examination • A. Loss of turgor, especially of the calf muscles and skin over abdomen, is evidence of dehydration. • B. The soles and palms are often bluish and cold in early infancy; this is of no significance. • C. The degree of anemia cannot be determined reliably by inspection, since pallor (even in the newborn) may be normal and not due to anemia. • D. To demonstrate pitting edema in a child it may be necessary to exert prolonged pressure. • E. A few small pigmented nevi are commonly found, particularly in older children. • F. Spider nevi occur in about 1/6 children under 5 years of age and almost ½ of older children. • G. "Mongolian spots" (large, flat black or blue-black areas) are frequently present over the lower back and buttocks; they have no pathologic significance. • H. Cyanosis will not be evident unless at least 5 gm of reduced hemoglobin are present; therefore, it develops less easily in an anemic child. • I. Carotenemic pigmentation is usually most prominent over the palms and soles and around the nose, and spares the conjunctivas.

24. General Physical Examination Thorax • Shape and symmetry, veins, retractions and pulsations, Harrison's groove, flaring of ribs, pigeon breast, funnel shape, size and position of nipples, breasts, length of sternum, intercostal and substernal retraction, asymmetry, scapulas, clavicles. • *Practical notes: • At puberty, in normal children, one breast usually begins to develop before the other.  In both sexes tenderness of the breasts is relatively common.  Gynecomastia is not uncommon in the male.

26. General Physical Examination Lungs • Type of breathing, dyspnea, prolongation of expiration, cough, expansion, fremitus, flatness or dullness to percussion, resonance, breath and voice sounds, rales, wheezing. • *Practical notes: • A. Breath sounds in infants and children normally are more intense and more bronchial, and expiration is more prolonged, than in adults. • B. Most of the young child's respiratory movement is produced by abdominal movement; there is very little intercostal motion. • C. If one places the stethoscope over the mouth and subtracts the sounds heard by this route from the sounds heard through the chest wall, the difference usually represents the amount produced intrathoracically.

27. General Physical Examination Heart • Location and intensity of apex beat, precordial bulging, pulsation of vessels, thrills, size, shape, auscultation (rate, rhythm, force, quality of sounds - compare with pulse as to rate and rhythm; friction rub-variation with pressure), murmurs (location, position in cycle, intensity, pitch, effect of change of position, transmission, effect of exercise). • *Practical notes: • A. Many children normally have sinus arrhythmia.  The child should be asked to take a deep breath to determine its effect on the rhythm. • B. Extrasystoles are not uncommon in childhood. • C. The heart should be examined with the child recumbent.

29. Pediatric Assessment Triangle • Appearance • Awake • Aware • Upright • Work of breathing • Retractions • Noises • Skin circulation

30. Appearance • Tone • Interactiveness • Consolability • Look/Gaze • Speech/Cry

31. Appearance • Appearance reflects adequacy of ventilation, oxygenation, brain perfusion, body homeostasis, and central nervous system (CNS) function. • The “tickles” (TICLS) mnemonic helps to recall observations that give a general impression of appearance. • Tone: Is there normal motor movement? Is the infant/child limp and listless, or moving vigorously? • Interactiveness: Is the patient alert? Irritable? Lethargic? Does the patient respond appropriately to the environment? • Consolability: Is the patient easily comforted/consoled? Is he/she agitated and inconsolable? • Look/Gaze: Does the patient fix on a face or object, or is the patient glassy-eyed, with a “nobody-home” stare? • Speech/Cry: Is the cry/speech weak, muffled, hoarse? An infant with poor brain perfusion, CNS infection, or brain injury often will have a high-pitched or cephalic cry. • Appearance is very dependent on the child’s developmental age.

32. Work of Breathing • Abnormal airway sounds • Abnormal positioning • Retractions • Nasal flaring • Head bobbing

33. WOB • Work of breathing is a quick observational indicator of the adequacy of oxygenation and ventilation. • Observe the patient carefully before laying on hands. Listen for audible sounds, and look for signs of increased effort to breathe. • Abnormal airway sounds include: • Stridor, muffled speech, hoarse voice, and snoring all reflect upper airway obstruction. • Grunting is caused by an effort to exhale on a closed glottis to keep alveoli from collapsing, and suggests lower airway disease. • Wheezing is caused by lower airway partial obstruction as heard with asthma or bronchiolitis. • The position that a patient with increased work of breathing takes is revealing. Tripoding is seen in patients trying to maximize use of accessory muscles to improve ventilation. The “sniffing” position is seen with severe upper airway obstruction as an attempt to line up the axes of the airway to improve air flow. • Look carefully for retractions in the intercostal and supraclavicular areas. • Nasal flaring and head bobbing are signs of severe respiratory distress.

34. Circulation to Skin • Pallor • Mottling • Cyanosis

35. The skin is an organ that has easily seen visual responses to both early and late shock, as well as respiratory failure. Taking time to observe skin color and signs is time well spent! • Pallor cannot be ignored. In the trauma patient, it can be a sign of significant occult internal bleeding and need for immediate fluid/blood resuscitation. In the patient with septic or hypovolemic shock, it suggests the need for rapid fluid resuscitation. Children have excellent catecholamine responses to shock, and this can be easily seen as pallor when assessing the PAT. • Mottling occurs when the skin starts to lose microvascular integrity. Areas of vasodilatation interspersed with vasoconstriction will give a patchy network of pallor, erythema, and/or cyanosis that is referred to as mottling. This is a pre-morbid condition, and late sign of shock. In small infants, mottling should not be confused with cutis marmorata, or irregular marbled skin often seen in a cool ambient environment. • Cyanosis reflects poor tissue oxygenation, and can be seen with respiratory failure or cardiorespiratory compromise.

36. General Approach • Pediatric Assessment Triangle (PAT) • Hands-on assessment of ABCDEs • Pediatric differences

37. Airway • Airway opening maneuvers: • Head tilt-chin lift, jaw thrust • Suction: • Often dramatic improvement in infants • Age-specific obstructed airway support: • <1 year: Back blow/chest thrust • >1 year: Abdominal thrust • Advanced airway techniques

38. Breathing: Auscultation • Midaxillary line, above sternal notch • Stridor: Upper airway obstruction • Wheezing: Lower airway obstruction • Grunting: Poor oxygenation; pneumonia, drowning, pulmonary contusion • Crackles: Fluid, mucus, blood in airway • Decreased / absent breath sounds: Obstruction

39. Vital Signs by Age • Slow or fast respirations are worrisome

40. Circulation • Pulse: Central, peripheral pulse quality • Skin temp: “Reverse thermometer” sign • Capillary refill: ≤ 2 sec, warm finger, 5 sec • B/P: Minimum = 70 + (2 X age in years)

41. Respirations Abnormal respirations are a common sign of illness or injury. Count respirations for 30 seconds. In children less than 3 years, count the rise and fall of the abdomen. Note effort of breathing. Listen for noises.

42. Pulse In infants, feel over the brachial or femoral area. In older children, use the carotid artery. Count for at least 1 minute. Note strength of the pulse.

43. Blood Pressure • Use a cuff that covers two thirds of the upper arm. • If scene conditions make it difficult to measure blood pressure accurately, do not waste time trying.

44. Skin Signs • Feel for temperature and moisture. • Estimate capillary refill.

45. Disability (and Dextrose) • AVPU scale: • Alert • Verbal: Responds to verbal commands • Painful: Responds to painful stimulus • Unresponsive • (Pediatric) Glasgow Coma Scale • Check Dextrose (glucose) if impaired

46. Exposure / Environment • Full Exposure Necessary • Evaluate physiologic function • Identify anatomic abnormalities • Maintain warm ambient environment • Minimize heat loss • Monitor temperature • Warm IV fluids

47. Reassess • General impression (PAT) • ABCDE • Continually reassess ABCs for response to therapy

48. The Bottom Line • Begin with PAT, then ABCDEs. • Form a general impression to guide priorities. • Treat respiratory distress, failure, and shock as they are recognized. • Focused history and detailed PE. • Reassessment throughout ED stay.

49. Airway / Breathing

50. Objectives • Compare anatomic, physiologic differences b/w adult & pediatric airway • Distinguish respiratory distress from failure • Describe clinical features of upper and lower airway obstruction and diseases of the lung