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Pediatric History and Physical Examination Hiba Abujaradeh Introduction Obtaining the Child's History Interview is a very personal conversation with a parent, caretaker, and child/ adolescent .during which private concerns and feelings are shared Communication Strategies Careful listening Strategies to Build a Rapport with the Family Make a self- introduction )Explain the purpose of the interview (NCP Provide privacy and remove as many distractions as possible during the interview Direct the focus of the interview with open-ended questions. Use close-ended questions or directing statement to clarify information Ask one question at a time Involve the child in the interview by asking age appropriate questions Be honest with the child when answering questions or when giving information about what .will happen. Children need to learn they can trust their nurse Careful Listening Complete attention is necessary to "hear" and accurately interpret information the parents and child give during the nursing history pay attention to the parent's attitude or tone of voice when the child's problems are discussed the tone of voice can reveal anxiety, anger, or lack of concern Observe the parent's nonverbal behavior (posture, gestures, body movements, eye contact, )and facial expression )History taking Outline (Subjective Data Identifying data/ Chief Complain Present illness Past Medical History Birth history, childhood illnesses, immunizations, hospitalizations and surgeries, allergies, and medications Family Medical History Social History Habits/ Activities of daily living (Nutrition, dental, sleep, elimination pattern (toilet training), )safety/ injury prevention, activity and exercise, Discipline )cognitive/ perception ( value and believe, pain Developmental behavior )Review of Systems (ROS Case Study Group work Read the case study and find Identifying data Chief complain Past medical history )Family medical history (draw a genogram Social history Habits/ Activities of daily living Mile stones that Maria achieved ROS Physical examination Sequence of the examination The sequence of children examination follows head-to-toe direction. The main function of such systemic approach is to provide a general guidelines for assessment of each body area .to minimize omitting segments of the examination Holding toddler for mouth exam Pediatric physical Examination Outline Physical Growth measurement Physiologic measurements General appearance Skin - head and neck -eyes – ears- nose, mouth and throat - lungs-heart – abdomen genitalia- back and extremities - neurologic assessment CDC Growth Charts :The available clinical charts include the following :Infants, birth to 36 months Length-for-age and Weight-for-age percentiles Head circumference-for-age and Weight-for-length percentiles Children and adolescents, 2 to 20 years Stature-for-age and Weight-for-age percentiles BMI-for-age percentiles Preschoolers, 2 to 5 years Weight-for-stature www.cdc.gov ??Is Ameena growing normally .Ameena is nine-month-old girl .Ameena’s length= 69 cm, weight =9 kg, and Head circumference = 45 cm The mother asks you if Ameena’s length, weight, and head circumference are normal for her age or not?? Explain ??Is Ahmad growing Normally Ahmad is 5-year-old boy Height = 112 cm Weight = 23 kg ?Find Ahmad’s BMI and if he is growing normally Physiological parameters Temperature: can be easily measured at several body sites via oral, rectal , axillary, ear canal .or skin Substitutes for the no-longer-used mercury glass thermometer are electronic thermometers, infrared ear-based thermometers, chemical indicator thermometers, skin plastic strips, and .digital thermometers All of which offer advantages: rapid temp taking, minimal intrusion, and reduced cross .contamination Recommendation based on research vary *From 2-3 min for oral. Normal 37.0c )min for rectal. 1 degree higher than oral (subtract 2-1 )min for an axillary reading. 0.5 degree lower than oral (add 7-5 Physiological parameters Respiration count in the same manner as for the adult patient .In infant observe abdominal movements because respiration are primarily diaphragmatic Count respiration for 1 full min for accuracy :Pulse .Can be taken radially in children older than 2 years In infant and young children the apical impulse (heard through a stethoscope) is more reliable Count the pulse for 1 full minute in infant and young children because of possible . irregularities in rhythm .For greater accuracy, measure the apical rate while the child is a sleep Compare brachial and femoral pulses at least once during infancy to check for coarctation of .aorta :Blood pressure Measure using noninvasive method BP should be measured annually in children 3 years of age through adolescence .Use an appropriate cuff size Position limb at level of heart Rapidly inflate cuff to about 20 mm hg above blood pressure baseline .BP is classified by systolic BP and diastolic BP percentiles for age/sex/height ???Is my child BP Normal Nagham is 4-year-old girl with a height of 103 cm and BP of 100/65. Nagham’s mom ask you ?if her child BP is normal :Nagham BP According to BP levels for girls by age and height percentile normal BP is between 52/92 -71/110 This means that Nagham has Normal BP )Pain (the fifth vital signs- Subjective )Pain (the fifth vital signs- objective Skin )Skin Color (Mongolian spot, erythema toxicum, acrocynosis, jaundice Texture Thickness )Hair (lanugo Palpate the skull for patent sutures, fontanels (anterior closed at 12-18m, posterior closed at .2nd- 3rd m), fracture and swelling .Observe the face for symmetry, movement and general appearance Inspect the neck for size and palpate it for associated structures: normally short with .skinfolds between the head and shoulders during infancy, it lengthens during next 3-4 years Eyes : red reflex. Absence of red reflex can indicate retinoblastoma :Ears Ear abnormalities are commonly associated with renal anomalies. Low set ear can be associated with down syndrome :Examination of the tympanic membrane Pull pinna down and backward in children younger than 3 years old and Up and backward in .children older than 3 years old Nose, mouth, and throat: Encouraging opening the mouth to Inspect the teeth, gum, tongue, .hard and soft palate and tonsils .Examine paranasal sinuses: only the maxillary and ethmoid sinuses are present at birth Chest Inspect the chest for size, shape, symmetry, movement, breast development and the presence of bony landmarks formed by ribs and sternum During infancy the chest normal to be rounded (By 2 years of age the lateral diameter is )greater than the anteroposterior diameter .Costal angle 45-50 degree .Assess breathing sound Child rib cage Auscultate the breathing sound Heart :Position : Use palpation to determine the location of the apical pulse .Just lateral to the left MCL and fourth ICS in children younger than 7 years of age .At the left MCL and fifth ICS in children older than 7 years of age .Auscultate origin and differentiating of heart sound Infant apical pulse Child apical pulse Direction of heart sounds for anatomic valve sites and areas (circled) for auscultation Assess heart sound Abdomen .Examination orders: inspection, auscultation, percussion and palpation .)Inspect for abdominal hernia (umbilical, internal or external inguinal canal, femoral hernia Male genitalia: examine the penis, glans and shaft, urethral meatus (hypospadias), scrotum .)(undescended tests .)Female genitalia: examine for external structure (ambiguous genitalia Infant's Abdominal palpation Umbilical hernia Back and extremities .)Spine: examine for curvature (scoliosis .Inspect the back for any tufts of hair .Inspect the extremity for symmetry of length and size )Count the fingers and toes to be certain of normal number ( polydactyly, synductyly Back and extremities .Joints: palpate for heat, tenderness, swelling, and range of motion .Note symmetry and quality of muscle development, tone, and strength Spina bifida THANK YOU