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GEMP 3

PAEDIATRIC CLINICAL EXAMINATION (WEEK 1)

OBJECTIVES







1. History taking

2. Principles of examination and growth charts

3. Examination of the cardiovascular system

4. Examination of the respiratory system

5. Examination of the head, face, neck and skin

6. Examination of the abdomen

7. Examination of the nervous system

8. Examination of the newborn baby


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HISTORY

At the end of this session you should be able to:

1. List factors which promote and detract from effective communication with
parents and children of different ages.

2. Take a comprehensive history. This should include the following details:
a. Identifying data
b. Source of referral or source of information
c. Chief complaint
d. History of the present illness
e. Past medical history
general state of health
pregnancy
birth
feeding
previous illness, operations or injuries
immunisation
current medication
allergies
f. Growth and Development
physical growth
developmental history
g. Social history
h. Family history
i. Systems Review
e.g. CVS, respiratory, GIT
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CLASSIFICATION OF ERRORS IN PHYSICAL DIAGNOSIS
Technique
1. Poor ordering and organisation of the examination
2. Defective or no equipment
3. Improper manual technique and use of instruments
4. Performance of the examination when inappropriate (i.e. when required
patient cooperation or other prerequisites were not present)
5. Poor bedside etiquette leading to patient discomfort, embarrassment or
overt hostility.
Omission
1. Failure to perform part of the examination
Detection
1. Missing a sign that is present
2. Reporting detection of a sign that is not present
3. Reporting normal physiological or anatomical variation as normal
4. Misidentifying a sign after detection
Interpretation
1. Failure to understand the meaning in pathophysiologic terms of an
identified sign
2. Lack of knowledge or use of confirming signs
3. Lack of knowledge of the value of a sign in confirming or ruling out
a diagnostic entity
Recording
1. Forgetting a finding and not recording it
2. Illegible handwriting, obscure abbreviations, improper terminology, poor
grammar, and incomplete recording of findings
3. Recording a diagnosis and not the sign detected

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PRINCIPLES OF EXAMINATION AND GROWTH CHARTS

At the end of this session you should be able to:

1. Describe the purpose and technique/s of performing the following physical
assessment skills.
a. Inspection
b. Palpation
c. Percussion
d. Auscultation

2. List ways you would prepare the environment (surroundings) to facilitate the
examination.

3. Discuss some of the principles of examination, e.g.:
how to organise your examination, e.g. the importance of the history
in prioritising your examination.
performing the least distressing aspects of examination first and
likewise the most distressing last.
using a kind but firm approach.
allowing children to handle the equipment.
not leaving children unattended on an examining table or open cot.

4. Describe how you would approach the examination of, and the difficulties to
be anticipated in examining children of different age groups, viz.:
infants (first 12 months of life)
toddlers (1 to 3 years)
pre-school child (3 to 6 years)
school-aged child (6 to 12 years)
adolescents (12 years and older)

5. * Anthropometrical measurements
Demonstrate the correct technique of measuring of measuring the following
parameters in an infant and a child:
weight
length/height
head circumference

6. * Understand and discuss the following aspects of using growth charts:
a. The different types of charts available, e.g., height and weight-for-age,
growth velocity, etc.
b. What the percentiles indicate.
c. How to plot weight, height, and head circumference on the chart.
d. What "expected weight" or "the median means.
e. How you would decide if a child was malnourished.
f. The Wellcome classification of malnutrition.
h. The importance of serial measurements (monitoring).

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CARDIOVASCULAR SYSTEM

In the examination of the CVS the following specific manoeuvres are important for
detecting abnormalities of the CVS:

1. General appearance.
2. Inspection of the hands.
3. Palpation of radial, carotid, femoral and dorsalis pedis pulses for rate,
rhythm and quality.
4. Measurement of arterial blood pressure.
5. Determination of peripheral oedema.
6. Inspection of the neck veins.
7. Inspection, palpation and percussion of the precordium.
8. Auscultation of the heart.
9. Auscultation of the abdominal aorta, carotid, and femoral arteries.

OBJECTIVES

1. * At the end of this session you should be able to identify cyanosis and
clubbing and describe their significance.

2. Pulse
a. * Demonstrate how you would feel the pulse of a child.
b. * Describe how you would calculate the pulse rate.
c. * Palpate and comment on the character of all pulses
(including popliteal and posterior tibial).
d. * Know the normal pulse rate of a newborn baby, infant, pre-
school child, school-aged child and adolescent
e. List some factors that may influence the pulse rate.
f. List a few examples of abnormal pulse patterns.

3. Blood pressure
a. * Describe the different methods for determining blood pressure
in an infant or child, i.e.:
auscultation
palpation
flush method
Doppler
oscillometry ("Dinamap")
b. * Describe how you would select the appropriate method, site
and cuff size when measuring the blood pressure.
c. Recognize the normal blood pressure of a neonate, infant, child
and adolescent.
d. List factors that may influence the blood pressure.

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4. * Demonstrate how to assess for the presence of oedema in a child.
5. * Demonstrate the anatomy of the internal jugular vein and the method
for measuring the jugular venous pressure (JVP).
6. * Demonstrate how to palpate for the apex beat, a parasternal heave,
the 2nd heart sound and a thrill. You should be able to describe the
significance of each of these manoeuvres.
7. * Demonstrate:
How you would use a stethoscope to auscultate the heart.
Areas of the precordium that are auscultated.
8. Describe the normal heart sounds.
9. List the important characteristics to be mentioned when describing any
murmur.
10. List differences between children and adults in their anatomy,
physiology and findings on clinical examination as regards the
cardiovascular system.

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RESPIRATORY SYSTEM

Manoeuvres in the routine physical examination of importance to the pulmonary
system include:

1. Observation of general appearance and vital signs.
2. Inspection of the hands, nails, skin and mucous membranes.
3. Inspection of the nose.
4. Observation of breathing.
5. Inspection of the chest.
6. Palpation of the neck and chest.
7. Percussion and auscultation of the chest.

OBJECTIVES

At the end of this session you should be able to:

1. * Demonstrate how you would determine an infant/child's respiratory
rate using:
observation
palpation (placing fingers just below the xiphoid
process)
auscultation (listening to breath sound)
2. Recognize variations in the respiratory rate at different ages [Table 3].
3. List a few conditions that influence the respiratory rate.
4. Briefly describe a few altered (abnormal) breathing patterns.
5. Explain why infants breathe at a faster rate.
6. * Identify the signs of respiratory distress in a child.
7. * Demonstrate how you would measure chest expansion, feel for an
apex beat, identify the tracheal position and feel for vocal fremitus.
8. * Demonstrate the correct percussion technique.
9. Describe the different types of breath sounds (vesicular and
bronchial).
10. Describe the different types of pathological sounds, e.g., crackles,
wheezes, stridor, pleural rub and their significance.
11. * Demonstrate the correct technique of chest auscultation.
12. Describe differences between children and adults as regards the
anatomy, physiology, and clinical examination of the respiratory
system.

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HEAD AND NECK

In this tutorial, aspects of the examination of the skull, face, eyes, ears, nose,
throat, and neck will be covered. Some features of the examination of the skin will
also be covered.

Examination manoeuvres included in routine exam of the eye:
Test of visual acuity.
Detailed inspection of the external eye.
Pupillary reaction to light testing.
Testing of extra ocular movements, e.g. corneal light reflex (to
determine strabismus).
Ophthalmoscopic examination of the cornea, lens and retina.

Examination of the ear includes:
Inspection of the auricle.
Palpation of the pinna and tragus.
Otoscopic examination of the external auditory canal and tympanic
membrane.
Hearing testing with voice, noises or tuning fork.

Examination of the nose involves:
Inspection of the external nares, septum, and the visible portion of the
turbinates.

Structures assessed when examining the mouth and throat:
Lips and configuration of the mouth.
Buccal mucosa.
Teeth and gums.
Tongue.
Hard and soft palate.
Tonsils and oropharynx.

Examination of the head involves assessing:
Skull size, shape, and symmetry.
Fontanelles and sutures.
Head control.

In the routine physical examination of the neck, the following manoeuvres apply:
Inspection of the neck.
Palpation of submental, submandibular, anterior cervical,
supraclavicular, posterior cervical and posterior occipital node groups.
Bimanual palpation of the thyroid.
Range-of-motion testing.

Examination of the skin:
Complete inspection of the nails, hair and skin is part of any routine
physical examination. Careful examination of the mucous membranes
of the mouth and the skin surrounding the genital and anal margins
are also essential.

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OBJECTIVES

At the end of the session you should be able to fulfil the following objectives:

EYES

1. Able to identify abnormalities of:
the position and placement of the eye
the eyebrows and eyelids
conjunctivae, pupils and irises (no details required)
2. Demonstrate how you would test for strabismus (squint).
3. Demonstrate how you would check for nystagmus.
4. Demonstrate how you would check a child's field of vision.
5. Describe how you would test the visual acuity of a child using the
Snellen chart, the Snellen E chart and Allen cards.
6. Describe how you would perform an ophthalmoscopic examination.


EARS

1. Identify the structures of the pinna (e.g. tragus, helix)
2. * Demonstrate how you would you position (restrain) a child during
otoscopic examination.
3. * Demonstrate how to hold and use the otoscope.
4. * Demonstrate how you would hold a child's ear (depending on his/her
age) during otoscopic examination.
5. Describe/draw the usual landmarks of the tympanic membrane.
6. Demonstrate how you would assess (screen) the hearing acuity of an
infant, pre-school child and school-aged child (or adolescent).
7. Demonstrate the use of a tuning fork.


FACE, NOSE AND ORAL CAVITY

1. Identify any abnormalities of the face or mouth (no details required).
2. * Demonstrate how you would examine a child's mouth.
3. Identify common abnormalities of the teeth and gums (e.g., caries).
4. Briefly describe the normal schedule of eruption of the primary and
secondary dentition.
5. * Demonstrate how you would examine the tonsils, including the proper
use of a tongue depressor or spatula when indicated.
6. Assess the quality of a child's voice or cry, and his/her speech.

SKULL

1. * Measure the head circumference.
2. * Identify the anterior and posterior fontanelles.
3. * Identify an abnormally shaped head (no details).


NECK

1. * Demonstrate the palpation of the trachea.
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2. * Demonstrate how you would palpate the thyroid gland.
3. * Demonstrate the position of lymph nodes in the neck.


SKIN

1. * Demonstrate how to assess tissue turgor.
2. Identify common abnormalities of the nails (no details).
3. Identify abnormalities of hair texture and distribution (no details).
4. Identify common skin lesions (e.g. birthmarks [naevi], scabies, and
impetigo).


TEMPERATURE

1. * Demonstrate how you would measure the temperature of an infant or
child, considering the site to be used i.e. axillary, oral or rectal.
2. Describe why rectal temperatures are not routinely taken at our
institution.
3. Recognise the limits of normal body temperature in a child.
4. List some factors that may influence body temperature.

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ABDOMEN

Physical examination manoeuvres of importance in the routine evaluation of the
abdomen include:

1. Inspection of general appearance, skin and sclera.
2. Inspection of the mouth.
3. Inspection of the abdomen and genitalia.
4. Auscultation of the abdomen.
5. Percussion.
6. Palpation of the abdominal organs _ liver, spleen kidneys, bladder.
7. Palpation for an inguinal hernia.
8. Palpation of testes and scrotum.
9. Palpation of lymph nodes.

OBJECTIVES

At the end of this session you should be able to:

1. * Demonstrate the correct technique for palpating the liver, spleen,
kidneys, and bladder.
2. Describe what features characterize each of these (e.g. why is it a
spleen and not a kidney?).
3. Describe at what ages each of these organs are normally palpable.
4. * Demonstrate how you would assess a child for the presence of ascites.
5. * Demonstrate the examination of the penis and scrotum.
6. Demonstrate how you would diagnose an inguinal hernia.
7. Describe how you would perform a rectal examination (this procedure
is not to be done by GEMP 3 students).
8. Briefly describe the stages in the normal pubertal development of male
and female genitalia and secondary sexual characteristics.

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NERVOUS SYSTEM

A methodical approach to the examination of the CNS is important. Physical signs are
missed not because of incompetence but because of a lack of a full examination.

The examination of the CNS should include the following:
1. Mental status, behaviour, speech and hearing.
2. Head and cranial nerves.
3. Motor system - posture, muscle mass, tone, power and movements.
4. Reflexes - deep tendon, plantar, superficial and primitive
5. Sensory system - especially touch and pain.
6. Cerebellar system.
7. Gait.
8. Testing for neck stiffness and meningism.

OBJECTIVES

At the end of this session you should be able to:

1. * Elicit all the deep tendon reflexes, by correctly positioning the limb
being tested and by the proper handling of a patellar hammer.
2. * Identify abnormal muscle tone in a child.
3. * Recognise muscle wasting/atrophy.
4. * Identify an abnormal gait in a child.
5 Demonstrate how to test each cranial nerve's function.
6. Demonstrate a few ways of testing for cerebellar function.
7. Demonstrate how you would check for meningism.

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NEONATE

The examination of the newborn, usually occurs on more than one occasion after
birth, and has the following purpose:
1. To assess the baby's general condition.
2. To estimate the baby's gestational age.
3. To establish if the transition to extra-uterine life has been successfully
accomplished.
4. To detect major and minor congenital abnormalities.

The examination should be thorough and methodical and evaluate all the different
systems. Particular attention needs to be directed to the examination of the palate,
hips, back, anus and neurological system.

OBJECTIVES

At the end of this session you should be able to:

1. Define a term, pre-term (premature), and post-term pregnancy.
2. Define LBW (low birth weight).
3. Define SGA (small for gestational age), AGA (appropriate for
gestational age) and LGA (large for gestational age) and describe a
few criteria used to determine the gestational age of a baby.
4. List the criteria used to determine an Apgar score.
5. * Identify fontanelles and know their normal time of closure.
6. * Demonstrate the Moro, grasp, suck and rooting reflexes.
7. Demonstrate how you would examine a newborn baby's hips.


DEFINITIONS USED IN NEONATOLOGY
Low birth weight A baby weighing less than 2 500g.
Pre-term Born before 37 completed weeks of gestation.
Term Born between 37 and 42 completed weeks of gestation.
Post-term Born after 42 completed weeks of gestation.
Small for gestational A baby whose birth weight is below the 10
th

age (SGA) age percentile for gestational age (plot on charge).
Large for gestational A baby whose birth weight is above the 90th
age (LGA) age percentile for gestational age (plot on chart).
Neonatal period 0-28th day of life.
Perinatal period From 28th week of gestation to 7th day of life.