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Clinical Notes of Pediatrics] 2013 First Edition [CLINICAL NOTES OF PEDIATRICS] History, Physical Examination & Previous OSCE Topics Bedoor H. Al-Qadrah بسم هللا الرحمن الرحيم والصﻻة والسﻻم على أشرف اﻷنبياء والمرسلين نبينا محمد وآله وصحبه آجمعين . أساس كل عمل فكره .. تولد يتيمه .. ﻻ ينميها إﻻ العمل المستمر واﻹخﻻص في تنفيذها .. وﻻ يقويها إﻻ إبتغاء مرضاة هللا في ذلك فبفضل من هللا ومنته وحده .. تم اﻹنتهاء من إعداد هذه المذكره المختصه بالجانب العملي لتخصص طب اﻷطفال والهدف اﻷساسي منها إفادة طلبة الطب والمتخرجين حديثا وﻷن تخصص طب اﻷطفال كبير وشاسع .. ويصعب حصره في عدد محدود من الصفحات تم التركيز في هذا العمل على أهم المواضيع الشائعه وأيضا ما قد تم وضعه في إختبارات اﻷوسكي في السنوات السابقه إختبارات اﻷوسكي في دورة طب اﻷطفال تتكون من أخذ التاريخ المرضي و عمل فحص جسدي للمريض باﻹضافه إلى مناقشه مواضيع عامه في تخصص طب اﻷطفال وهو الجانب اﻷكبر في اﻷوسكي لذلك تم تقسيم المذكره إلى عدة أجزاء مختص كل منها بنظام معين لجسم اﻹنسان ويندرج تحته: History + Physical Examination + Important Topics (Previous OSCE Topics) وتم إعداد المواضيع على هيئة سؤال وجواب لتسهيل أكثر في المذاكره وفي تطبيقها عمليا وﻷننا في النهاية بشر .. نخطئ ونصيب .. سيتم تجديد هذه المذكره بين فترة وأخرى حتى تفيد مستخدميها بشكل أفضل وهذا هو الهدف لذلك في حالة وجود أي مﻻحظات أو إقتراحات يرجى إرسالها عبر هذا اﻹيميل: [email protected] في النهاية .. ﻻ أبتغي من هذا العمل إﻻ الدعاء بالخير في ظهر الغيب لي ولمن هم أغلى من روحي أمي وأبي سائلة هللا عز وجل أن يبارك في هذا العمل لكل من يستخدمه ويرزقه أعلى الدرجات أختكم ... بدور حسن القدره طالبة طب – السنة الخامسه جامعة الملك سعود 2013-09-08 2 Contents GENERAL HISTORY & PHYSICAL EXAMINATION ................... 4 NEONATOLOGY .................................................................................... 14 CARDIOVASCULAR SYSTEM ........................................................... 30 RESPIRATORY SYSTEM .................................................................... 38 GASTROINTESTINAL SYSTEM ....................................................... 55 GENITOURINARY SYSTEM .............................................................. 76 NERVOUS SYSTEM .............................................................................. 87 MUSCULOSKELETAL SYSTEM .................................................... 114 ENDOCRINE SYSTEM ...................................................................... 127 DERMATOLOGY & HEMATOLOGICAL SYSTEM.................. 145 REFERENCES ...................................................................................... 164 3 General history & physical examination [CHAPTER 1] Chapter 1 GENERAL HISTORY & PHYSICAL EXAMINATION General history Developmental milestones Vaccination Physical growth Genetic syndromes General physical examination 4 General history & physical examination [CHAPTER 1] General History Identifying data: o name o nationality o age o significant medical conditions o sex o informant (mother, father or other) - Chief complaint: o reason that the child is seeking medical care (use their own words) o Duration of the symptoms History of present illness: Describe the course of the patient’s illness (in chronological order) including: o Onset o Relieving and Exacerbating factors o Course o Diurnal or seasonal variation o Duration o Relation to food or exercise o Site o School missing related to the complaint o Frequency o Any associated symptoms o Severity Past medical History: o medical problems o previous medications o Hospitalizations o Any known drug or food allergies? o Operations - Current medication: o Names o Dosages and Frequencies Pregnancy and Neonatal History: o Mother’s illness during pregnancy (nature of illness-which trimester) o Mother’s medication o Exposure of the mother to radiation or smoking during pregnancy o Fetal movement o Length of gestation o Mode of delivery, any fetal distress o Birth weight, height and head circumference o APGAR score o Any neonatal disease or admission to NICU and why? Nutrition: o Breast or battle fed, type of formula & how was it prepared, frequency, amount & duration, reasons for any changes in formula o total daily intake o any difficulties or change in feeding habits o time of weaning o timing of introduction of solids and cereals, any problems created by specific types o appetite o Did the mother took the vit's+ minerals+folic acid during pregnancy? o Did the mother start feeding immediately after the delivery or delayed? o Is he/she the 1st baby or not? 5 General history & physical examination [CHAPTER 1] o Is he/she taking regular family food? (For adult children) o Who's taking care of the baby? Immunizations: o Up to date? What was the last vaccine he/she received, when? o Check immunization card o If there is failure in taking the vaccine ask for the reasons o History of complications noticed after the vaccines (Rash, fever, convulsion) Developmental History: o Age of attainment of important milestones (you have to ask about the proper milestones for the age, see page9). If the patient is "preterm baby" use the corrected age o relationships with siblings, peers & adults o School grade and performance, any specific problems o behavioral problems (e.g. enuresis, temper tantrums, thumb sucking, pica, nightmares etc.) N.B. if mother has other children; compare his or her development with his or her other siblings Family History: o Age of parents, condition of health & any chronic or inherited disease among them o consanguinity o which region the parents originally came from o medical problem in 1st degree relatives including the patient’s disorder (e.g. DM, HTN, seizures, cancer, heart disease, stroke, allergy & asthma etc.) o neonatal deaths o previous abortions Social History: o parents’ education, occupation and income of the family o marital state (mention if the husband having another wife) o Number of siblings & age range (any sibling from previous or another marriage) o daycare o living situation o Housing (type of accommodation) o Parents’ smoking habit ( if yes, is the smoker smoking around the kids or outside the house?) o contact with animal o recent travels o Safety: child car seats, smoke detector, bicycle helmets … Review of systems: General: overall health, weight loss, behavioral change, fever, fatigue, feeding & appetite Skin: rashes, moles, bruising, lumps, hair/nail changes. Eyes: visual problems, eye pain or discharge Ear, nose, throat: frequency of colds, pharyngitis, otitis media Cardiovascular: chest pain, breathlessness, cyanosis, syncope, sweaty on feeding Respiratory: cough, shortness of breath, wheezing, runny nose, hemoptysis Gastrointestinal: nausea/vomiting, diarrhea or constipation, abdominal pain, jaundice Genitourinary: frequency, dysuria, nocturia/enuresis, hematuria, polyuria, incontinence, vaginal discharge, age of menarche Musculoskeletal: weakness, joint pain, gait abnormality, scoliosis Neurological: headache, seizures Endocrine: growth delay, polyphagia, excessive thirst/fluid intake, menses duration, amount of flow 6 General history & physical examination [CHAPTER 1] General physical examination Differences in Performing A Pediatric Physical Examination Compared to an Adult: I. General Approach: A. Gather as much data as possible by observation first B. Position of child: parent’s lap vs. exam table C. Stay at the child’s level as much as possible. Do not tower!! D. Order of exam: least distressing to most distressing E. Rapport with child o Include child - explain to the child’s level o Distraction is a valuable tool F. Examine painful area last-get general impression of overall attitude G. Be honest. If something is going to hurt, tell them that in a calm fashion. Don’t lies or you lose credibility! H. Understand developmental stages’ impact on child’s response. For example, stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult. II. Vital signs: A. Normals differ from adults, and vary according to age B. Temperature o Tympanic vs. oral vs. axillary vs. rectal C. Heart rate o Auscultate or palpate apical pulse or palpate femoral pulse in infant o Palpate antecubital or radial pulse in older child D. Respiratory rate -Observe for a minute. Infants normally have periodic breathing so that observing for only 15 seconds will result in a skewed number. E. Blood pressure o Appropriate size cuff - 2/3 width of upper arm o Site F. Growth parameters - must plot on appropriate growth curve o Weight o Height/length o OFC: Across frontal-occipital prominence so greatest diameter (Occipital Frontal Circumference) Vital Sign Infant Child Pre-Teen/Teen 0 to 12 months 1 to 11 years 12 and up Heart Rate 100 to 160 beats per minute (bpm) 70 to 120 bpm 60 to 100 bpm 0 to 6 months 1 to 5 years 30 to 60 breaths per minute (bpm) 20 to 30 (bpm) 1 Respiration (breaths) 12 to 18 bpm 6 to 12 months 6 to 11 years 24 to 30 bpm 12 to 20 bpm 0 to 6 months Blood Pressure 65 to 90/45 to 65 millimeters of mercury (mm Hg) 110 to 135/65 to 90 to 110/55 to 75 mm Hg (systolic/diastolic) 6 to 12 months 85 mm Hg 80 to 100/55 to 65 mm Hg All ages All ages All ages 98.6 F 98.6 F Temperature 98.6 F (normal range is 97.4 F to (normal range is (normal range is 97.4 F to 99.6 F) 99.6 F) 97.4 F to 99.6 F) 7 General history & physical examination [CHAPTER 1] III. Unique findings in pediatric patients (See outline below) Outline of a Pediatric Physical Examination I. Vitals: o See the table in page 7 II. General: o Statement about striking and/or important features. Nutritional status, level of consciousness, toxic or distressed, cyanosis, cooperation, hydration,
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