Pedia Examination - CE

Framework

• WIPER

  • Wash hands
  • Introduce
  • Right side of bed
  • Explain Procedure
  • Permission for examination from both parties
  • Position (may not be significant in neonates) & Exposure
  • Vitals & growth parameters (mention)

• Preliminary examination

  • General Appearance (child, comfortable, comatose, connected device)
  • General examination (Vitals, hand/arm/axilla, hair, face, neck, chest, abd,leg)

• Focused Examination + (correct technique)

  • Specific System Exam - IPPA
    • Inspection
    • Palpation
    • Percussion
    • Auscultation

• Describe correct physical findings

The child is a patient, ask his name, what is his problem, stand on his level, distract with toy if needed, smile, talk to him, be gentle, explain what you would do, thank child.

WIPER

Exposure | position | privacy | Ask for vitals 

• W ash hands (before and after)
• I ntroduce yourself to the patient and seek his or her consent both parties
• P osition the patient correctly.Z
• E xpose the patient as needed (e.g. ‘Please take off your shirt for me now, if that is all right’)
• R ight side of the bed
• Vital signs & Growth parameters (mention with introductionZ) + Body Proportions

usual presentation in General exam case with dysmorphic features - commonly case Down syndrome | could be entrance to CVS, GIT exam for general if otherwise.

Intro

Greet, Introduce (5th year med), assure privacy (curtain, nurse), explain procedure, position (mention good position - supine semisitting) & exposure (from midchest to midthigh - cover genatelia)

In the end thank the patient document.

General Appearance

Mention initially the four - then focus on ABCDEFG… Condition + Position (mention current position) + Connection + Dysmorphic features

Well, lying comfortable in bed, connected to iv line, no dysmorphic features.

A - 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. Be as descriptive as possible in this section so that your patient “can be picked out of a crowd.”

• Alertness / Activity

• Abnormal position in the bed. Distressed or not

• Appropriate size regarding weight and height for his age, just by observation.

• Any specific medications or devices surrounding the patient.

• Any dysmorphic features.

• Conscious, alert, looks around.

• Abnormal position

• Hypotonia = Frog position

• Scissor legs

• Irritated? Lying on one side?

B - Body Build

• Cachexic?
• BMI? Check weight/chart
• Moving limbs spontaneously

C - Cardio

• Pale / Cyanotic
• Yawning
• Petechiae
• Jaundice
• Plethoric clathoric??? pinkish??? /purplish (related to polycythemia)
• Infant diabetes

D - Distress Respiratory Distress

• Tachypnea
• Audible wheeze / stridor / grunting / inability to talk
• Accessory muscle use
• Cyanosis
• Drowsy = severe respiratory distress
• Prefers sitting position (8m can easily sit, whereas 6m will compensate by turning around bed, and 4m by crying, cyanosis)
• Nasopharynx (?)
• Silent chest

Deformities

• …

Dysmorphic Features look in face, all limbs, arms legs proportion, chest, back, feet, arms etc… should be done in all steps, mention in every part when in related general examination not done together at same time.

• Deep nasal bridge

• Thin lips

• Low-set ears

• Hypotelorism (?)

• Hypertelorism (?)

• Large mandible, ears, nose

• Frontal bossing

• Cleft Palate/Lip (male/female ratio)

• Microcephaly

• Macrocephaly

• Turners, Noonan, down syndrome

• Midline defects: Hypopituitarism - cleft lip & palate, central incisors, Umbilical Hernai, micropenis

• Down syndrome characteristics

  • Round face and flat nasal bridge
  • Upslanted palpebral fissures
  • Epicanthic folds (a fold of skin running across the inner edge of the palpebral fissure)
  • Brushfield spots in iris (pigmented spots)
  • Small mouth and protruding tongue
  • Small ears (75%)Flat occiput and third fontanelle

Feature/Condition	Turner Syndrome	Edwards Syndrome	Down Syndrome
Digits and Palmar Crease	Short, broad hands with nail dysplasia or hypoplastic nails	Clenched hands with overlapping fingers and nail hypoplasia	Single palmar crease, clinodactyly, short, broad hands
Face	Low-set, posteriorly rotated ears, micrognathia	Micrognathia, low-set ears, prominent occiput	Flat facial profile, flat nasal bridge, upward slanting palpebral fissures, epicanthal folds, low-set small ears, smooth philtrum, microstomia with protruded tongue
Neck	Webbed neck, low posterior hairline	Short neck	Short neck with excess skin at the nape
Chest	Shield chest (broad with widely spaced nipples)	Prominent sternum, narrow chest	Normal or mild structural deformities
Abdomen	-	-	Umbilical hernia common
Feet	Lymphedema of feet (at birth), broad through childhood	Rocker-bottom feet	Sandal gap (wide gap between first and second toes)
Limbs	Short stature	Limited hip abduction, joint contractures	Hypotonia, joint hyper-flexibility
Genitalia	Streak ovaries, delayed or absent puberty, underdeveloped genitalia	Often undescended testes, ambiguous genitalia	-

Multidisciplinary Approach

• Caring Multidisciplinary Team: Ensure follow-ups with cardiology, neurology, etc.
• Heart Defects Expected for Each Syndrome:
  1. Turner Syndrome:
     • Bicuspid Aortic Valve
     • Coarctation of the Aorta
     • Aortic Dissection
  2. Edwards Syndrome (Trisomy 18):
     • Ventricular Septal Defect (VSD)
     • Patent Ductus Arteriosus (PDA)
     • Pulmonary Valve Stenosis
     • Atrial Septal Defect (ASD)
  3. Down Syndrome (Trisomy 21):
     • Atrioventricular Septal Defect (AVSD)
     • Atrial Septal Defect (ASD)
     • Patent Ductus Arteriosus (PDA)
     • Tetralogy of Fallot

Systemic Defects

• Turner Syndrome:

  • Cardiovascular: Coarctation of the aorta
  • Reproductive: Gonadal dysgenesis (streak ovaries)
  • Renal: Horseshoe kidney
  • Endocrine: Hypothyroidism

• Edwards Syndrome (Trisomy 18):

  • Cardiovascular: Ventricular septal defect (VSD)
  • Musculoskeletal: Rocker-bottom feet
  • Gastrointestinal: Omphalocele
  • Neurological: Microcephaly

• Down Syndrome (Trisomy 21):

  • Cardiovascular: Atrioventricular septal defect (AVSD)
  • Gastrointestinal: Duodenal atresia
  • Neurological: Intellectual disability
  • Endocrine: Hypothyroidism

Differential Diagnoses

• For Down Syndrome:

  • Zellweger syndrome
  • Other trisomies (if female, consider Turner)
  • Noonan syndrome (due to flat nasal bridge and low-set ears)
  • Williams syndrome (if asked more)
  • Confirmation: Karyotyping via blood sample (WBCs, not RBCs) or amniocentesis during pregnancy if ultrasound shows abnormalities.

• For Turner Syndrome:

  • Noonan syndrome (very close resemblance)
  • Noonatello
  • Swyer syndrome

Dehydration

• Dry lips/mucous membranes, no tears or saliva
• Skin turgor delay
• Eye dehydration/anemic
• Peripheral/central cyanosis

Disability

• Walk, gait, blindness, deafness

E - Environment

• Connected devices, supportive devices

F - Vitals

• BP
• PR
• RR
• Oral temp
• O2 saturation

G- Growth chart / Growth parameters:

• Head Circumference,
• Length/Height, Weight
• BMI - related to age
• weight to height below 2 years

plot in centile chart depending on sex/age/length/height compare with moms and dads height for expected projection with growth chart of patient.

General Examination

Hands

Position

• Plantar, both arms look at once
• Flapping tremor
• Clubbing (window test)

Dorsal

• Leukonychia / koilonychia
• Skin turgor
• Muscle wasting
• Extra digits (polydactyly/syndactyly) - C-shaped edge
• Tripod hand - Down syndrome (short broad hand)

Palmar

• Capillary refill
• Pallor
• Creases – single palmar crease - Down syndrome
• Hypothenar, thenar muscle wasting
• palmar erythema Resp | hypothenar Git
• Flapping tremors

Arm

Eczema

• Cheeks
• Extensors of the arm

Scratch Marks

• Liver disease
• Fat Vitamin Deficiency

Neurocutaneous Stigmata

• Café-au-lait spots (five with >1.5 cm for further investigation)
  • Familial/neurofibromatosis
  • Pre/post-pubertal identifications (pre is with >1.5 cm)

Peripheral Pulse examination - in cvs gen ex,

Ask instructor to do, if applicable. #CC …

• Rate
• Rhythm – variation of pulse rate with respiration is normal (‘sinus arrhythmia’) •
• Volume and character – small in circulatory insufficiency or aortic stenosis; increased in high- output states (stress, anaemia, hyperthyroidism); collapsing in patent ductus arteriosus, aortic regurgitation
• Blood pressure – at end of examination
• Sync delays (Radial femoral most accurate)

Head

Jaundice, Pallor Periorbital edemas | cleft palate, dental hygiene, central cyanosis

Size, shape, circumference, asymmetry, cephalhematoma, bosses, craniotabes, control, molding, bruit, fontanel (size, tension, number, abnormally late or early closure), sutures, dilated veins, scalp, hair (texture, distribution, parasites), face, transillumination.

• Shape, scars, hair distribution

• Macrocephaly - hydrocephalus or rickets

• Microcephaly

  • Symmetrical (infectious CMV/Rubella, chromosome deficiency)
  • Asymmetric (premature fissure closure)
    • Tower head
    • Oxycephaly (premature closure of all sutures)
    • Irregular shape plagiocephaly (?)
    • Frontal closure should be at 18 months; if early, may protrude eye, over-ridging - refer to neurosurgeon and plastic surgeon.
    • Posterior fontanelle (what month?)

• Anterior fontanelle bulging

  • Presentation? If pulsatile, better prognosis

• Eye down, up, down to check pallor jaundice

• Nose - bleeding, allergic rhinitis, clots, polyps, deviated septum

• Hydrocephalus VP shunt

Hair

• Hairless with eyelash and eyebrow - alopecia totalis
• Hairless completely - alopecia universalis
• Fragile hair - vitamin deficiency, scurvy, malnutrition, abnormal
• Normal shape of head is diamond-shaped
• Increased size may indicate increased intracranial pressure, meningitis

Mouth

• Dental caries, commonly in synthetic milk powders happen due to not rinsing mouth before sleeping. Advice is given to wash mouth prior to sleep to prevent them and advise parents to brush with their kids until age of 9 to know good habit of brushing teeth to prevent further complications or infection spreading to blood = sepsis

Eyes

• Light reflex

Ears

• Check for any wax - removal done by specialist, not parents

Neck

• Lymph Nodes (LN’s)

Chest & Abdomen

• Deformities, scars

Back

• Tufts of hair
• Scars
• Myelomeningocele - surgery
• Ash leaf spot - whitish spot - tuberous sclerosis? + neurofibromatosis
• Shagreen patches - orange peel texture - tuberous sclerosis
• Café-au-lait spots, neurofibromatosis
• Swellings - meningocele
• Etc…

Lower limb

• Lower limb edema
• Hypotonia (wide legs) (typically in down syndrome)
• Sacral edema
• Sandal sign indicating…
• Rocker bottom feet

May indicate GI / Nephrotic / CVS causes for baby

Chest/Abdomen/Heart Examination

Done Combined for neonates

Inspection

• Midline scars, lobectomy, splenectomy
• Deformity, umbilical hernia, vein distention
• Umbilicus inverted/everted?
• NG tube? (complication of ulcer and blockage and others…)
• Café-au-lait spots
• Respiratory distress (remove shirt to fully inspect all accessory muscles associated with respiratory distress)
• Recession if abnormal breathing

Palpation

• Apex beat
• Deep & Superficial (Liver span differs by age between female and male)

Percussion

Done rarely, unless there is abnormality

• Fluid thrill, shifting dullness, span

Auscultation

• Bowel sound
• Renal bruit - renal thrombosis

Complete with examining all arteries & CNS exam

CNS

Should be quick

GCS

• Is patient following you with his eyes, responds to your command or movement, engaging with surrounding.

Power Grading

• Raise legs/arm against gravity = 3
• Pushing feet then child pushes against you = 5

If there is neuro abnormality, refer to neurologist for further assessment.

Other Notes

• “I would like to do ENT exam at end, to not irritate child”
• If child is sleeping, do auscultation first then go through other series of steps
• Causes of anterior fontanelle bulging (???)
• organomegaly commonly comes in exam also GIT exam