Subject:Physical Diagnosis Topic: Pediatric History Taking Lecturer: Dr.Roberto Espos Date of Lecture: 07/01/2011 Transcriptionist: agaw-buhay Pages: 9 Objective in taking hx: y Have a dx gather hx ask questions: o Px cannot talk: basis of the question knowledge learned in med school o Growth and development Follows a cephalocaudal manner Pattern is uniform but has different velocity Have to know growth and developmental milestone range (to know normal and abnormal) y y The mark of an excellent physician is the proficiency with which he takes the history Performs the physical examination and then on the basis of the findings utilizes the laboratory accurately and cost-effectively, when necessary, to approach a final diagnosis and initiate effective therapy. An adequate history is essential for the physician to make a correct diagnosis. To obtain a complete history with data properly recorded chronologically and in appropriate detail is an art which is acquired only with patience and experience. Children are not miniature adults as such the history taking is in pediatric patients is unique and distinctive for the following reasons: 1. Content Variations: a. Prenatal and birth history b. Developmental history c. Social history of family environmental risks d. Immunization History e. Feeding History 2. Indirect source of clinical information commonly given by parents a. Parent s interpretation of clinical features may affect accuracy of data b. Reliability of parent s observation varies c. Parental behaviors/emotions are important y y y y y Failure to keep on track leads to error in diagnosis and unnecessary laboratory procedures DON T accept the diagnosis given by parents but pursue the clinical features that enable parents to reach such conclusion Keep an open mind and follow the scent (clue)like an expert detective Be flexible in your approach to obtain clinical data especially at the ER or during acute office visit Start interview with parents or guardians in a positive note since first contact is the most important connection. y y History y The historian should realize that the information in a pediatric history is usually obtained from a person other than the patient himself. Therefore, it is up to the historian to evaluate the accuracy ands relevance of the date given by the informant. I. General Data Name, age (birth date); sex; race (ethnicity); birthplace; religion; present address; number and date of hospital admissions; name of informant and relation to patient; reliability of informant should be stated; if possible qualify in percentage (%). This should be assessed at the end of history taking. Eg for Age: 10y/o px- Dx: RHD How to classify heart problems: 1. Congenital a. Cyanotic b. Acyanotic- due to shunting of bld from LV to RV (VSD, ASD, PDA) Common location of murmur- base of heart, 2nd-3rd ICS) 2. Acquired a. RHD- most common, 3-4y/o youngest Filipino dxd with RHD involves the mitral valve mitral stenosis murmur at apex of heart assessed by Jone s Criteria y Some basic concepts in obtaining a very good clinical history of the patient: y Go after the symptoms like a hound dog and pursue the symptom relentlessly 1 SY 2011-2012 - Reliability of the informant depends on the following factors: 1. Relationship of the informant to the patient 2. Number of hours informant stays with the patient 3. Educational attainment of the informant 4. Involvement of the informant in the care of the patient II. Chief Complaint - The answer to the question why was the patient brought to the hospital? expressed in a word or two without describing or qualifying the reply. - This may be a single symptoms or group of related symptoms - This should not include diagnostic terms or names of diseases - The duration of the symptoms may also be mentioned - For OPD patients, may write for follow-up. CP clearance, well baby care and immunization *Give the exact words of the informant whenever possible III. History of the Present Illness (HPI) Inquiry as to the HPI should be conducted as follows: A. The signs and symptoms should be described in chronological order o from the start of the illness, with appropriate paragraphing and underlining for emphasis so that the reader may obtain the maximum information in minimum reading time. (hpi: from prenatal to perinatal hx) Eg: Sepsis neonatorum- common cause: gram (-) E. coli a. Early onset-before 7days of life; usually maternal cause (through vertical transmission) b. Late onset- after 7days of life Use specific number of hours or days or weeks or months, not last Monday, or a few weeks ago for the time of onset. In case of chronic illness, state also the date and age at onset. * If the patient is a newborn and/or the present problems are related to the prenatal and perinatal period, the maternal and birth history should be incorporated in the HPI. o B. Elaborate on the symptoms as to: 1. Onset (acute or chronic) 2. Intensity of symptoms: how severe the pain is and whether it interferes with activity, its quality, location, duration, extent, severity and frequency 3. Factors that aggravate/relieve the main symptoms 4. Medication (generic and brand names) including actual dose (in mg/kg/day or mg/kg/dose) and duration of treatment *Brand name of the drugs should be written in parenthesis * Include any outside medical treatment, consultations or hospitalization. Find out where the child is getting their medical care prior to visit and the reason for change 5. Associated symptoms must be described as to: onset, course chronology, intensity Terms: y Recurrence- primary problem was gone but followed by a 2nd attack (eg: malaria, flu) y Relapse- a dse that always remits (basta hindi gumagaling!!!) eg: asthma, leukemia y Complication- a dse/ condition that arised as a consequence of another dse. (eg: measles after 17yrs: subacute sclerosing panencephalitis) * If the history suggests a particular disease, inquired about signs and symptoms characteristic of this disease. Pertinent negatives are of value in the differential diagnosis. Re-admissions: if previously admitted to this hospital or had Out-Patient Department. Previous hospital admissions appear related to the HPI, summarize the pertinent information (including pertinent laboratory date, final diagnosis) y Interval history which describes the course of illness since the last hospital admissions related to the present illness and then elaborate of the present symptom/s and it associated manifestations on this admission. These will all now constitute the HPI. Previous admissions not related to the HPI are placed under Past Illnesses. Important formulas: 1. # of teeth = age (mos) -6 o 1st tooth- 6-7mos : mandibular central incisor) 2. Gastric capacity = age (mos) + 2 or 3 y Review of Systems 1. Elaboration of data in systems not covered in the history of the present illnesses. This will help uncover symptoms in other organs or systems that may be related to the present illness * Ask only symptoms applicable to the age of the patient 2. General: Weight loss/gain; activity level appetite; delay in growth a. Cutaneous: rash, pigmentation; hair loss; acne; pruritus 2 IV. b. Head: (include eyes, ears, nose, mouth and throat): headache; dizziness; visual difficulties; lacrimation; hearing; aural discharge; nasal discharge; epistaxis; toothache; salivation; sore throat c. Cardiovascular: orthopnea; cyanosis; easy fatigability; fainting spells; etc. d. Respiratory: chest pain; cough; difficulty of breathing e. Gastrointestinal: vomiting, bowel movements-diarrhea, constipation; encopresis; passage of worms; abdominal pain; jaundice; food intolerance; pica f. Genitourinary: color of urine; burning sensation; frequency; discharge; enuresis, edema of hands and feet; I prepubertal female: ask about discharge and itching; in pubertal and adolescent female get history of menstrual periods (onset, frequency, regularity, pain), date of last period g. Endocrine: breast asymmetry, pain or discharge; palpitations; cold/heat intolerance; polyuria, polydipsia, polyphagia h. Nervous/Behavioral: tremors, sleep problems; convulsions; weakness or paralysis; mental deterioration; personality or behavioral changes; memory loss; eating problems,school failures; mood changes; temper outburst; hallucinations i. Musculoskeletal: pain in bone, joint of muscle; swelling in bone, joint or muscle; limitation of motion; stiffness, limping j. Hematopoietic: pallor; bleeding manifestations; easy bruisability V. Personal History a. Gestational History: age of mother during pregnancy, her parity, health, nutrition, infections, intake of drugs, roentgen exposure, etc.; duration of gestation (when pertinent, especially in infants) b. Birth: term or premature or post mature; manner of delivery; persons who attended the delivery; birth weight (especially in infants, or when pertinent). c. Neonatal History: APGAR SCORE: spontaneous respiration or required resuscitation; cyanosis, pallor, cry; jaundice (age of onset); convulsions; hemorrhage; respiratory or feeding difficulties, congenital abnormalities, birth injury (especially in infants, or when pertinent). y APGAR Score: o Appearance, Pulse, Grimace, Activity, Respiration o perfect score: 10 o <7- asphyxiated *The gestational birth and neonatal histories should be included only in patients <2 y/o and if related to the illness for children >2 y/o. d. Feeding history: Infancy (<2 y/o): I. Type of feeding: breastfeeding: exclusive or mixed; how many times per day, how long each breast; if not breastfeeding, give reason: formula used, dilution and amount given per day, bottle feeding or cup feeding; * breast milk- 20cal/oz (best milk) * S26- infant formula (Wyeth); 1scoop: 2oz of water * Midjohnson- 1scoop: 1oz of water * Enfalac- (Abbott) * each infant formula has different dilution factor ***until dito lng ung diniscuss ni doc, so intindihin nyo nlng ung the rest n nklgy s ppt nya . ito un, ung nxt slides ..>>>>>>>> II. Complementary foods: age introduced, foods initially and subsequently introduced, consistency of food (pureed, soft, lumpy, table foods); frequency of feeding per day III. Usual food intake for breakfast, lunch dinner, snacks (am, pm); iv. Assess if the five basic food groups (cereals,/ rice, fruits, vegetables (leafy, nonleafy & yellow vegetable, meat/fish/chicken, beans/egg, milk, oil/sugar) are eaten daily; IV. Compute for actual caloric intake (ACI) and compared with Recommended Energy & Nutrient Intake (RENI) or compare both the amount and quality of food intake with the food guide pyramid; V. Food intolerance; VI. Multivitamin and iron supplements: dosage, frequency; VII. Caregiver: mother, household help grandparents, sibling Childhood and Adolescent (2-20 years): Omit early feeding history unless it is pertinent to the present illness Assess: I. appetite: good appetite, picky eater; II.Usual food intake and amount per day for breakfast, lunch, dinner, snacks (am, pm) III. Assess if the five basic food groups (cereals, rice, fruits, vegetables (leafy, nonleafy & yellow vegetable), meat, fish, 3 chicken, beans, egg, milk, fats, sugar are eaten daily; IV. Compute for the actual caloric intake (ACI) and compare ACI with the Recommended Energy Nutrient Intake (RENI) or compare both the amount & quality of food intake with the food guide pyramid; V. Food likes or dislikes; feeding difficulties VI. Multivitamins & iron supplements: dosage & frequency e. Development/ Behavioral History 1. Young Children (1-5 years): Inquire about the I. Development using the Modified Developmental checklist II. Dental eruption III. Other behavioral problems: urinary continence, during day and night; toilet training, started and completed; temper tantrums; head banging; phobias; pica; night terrors; sleep disturbances. *If there are indications of Developmental Delay, DO Denver Developmental Screening Test II (DDST). 2. Middle Childhood (6-11 years); - Inquire about school performance, and sexual development using Tanner s Maturity Rating 3. Adolescence (10-20 years) - Inquire about: i. HEADSSS: Home Education, Eating behavior or habits, Activities, Drugs, Sexual, Suicidal ideations; ii. Sexual Development using the Tanner Sexual Maturity Rating (SMR); iii. For female: Include Menstrual History 4. Childhood and Adolescent (2-20 years) - Compute for the actual caloric intake (ACI) and compare ACI with the Recommended Energy Nutrient Intake (RENI) or compare both the amount & quality of food intake with the food guide pyramid; - Food likes or dislikes; feeding difficulties - Multivitamins & iron supplements: dosage & frequency. f. Past Illnesses: (state age when contracted; severity; complications 1. contagious diseases; measles, varicella, mumps, pertussis, etc. * Describe the clinical course of the illness 2. other medical illnesses: hospitalized? If so, where and for how long? 3. Operations: surgical condition, type and place of operation 4. allergy, eczema, asthma, food or drug sensitivities, etc. 5. injuries: include effects if any (verify accuracy of diagnosis by inquiring into signs, symptoms, course of illness) VI. Immunization History and Tuberculin Test Types of immunizations given, including ages when given, place (health center, doctor s clinic, etc) where given and untoward reactions VII. Family History y Parents: age , occupation, state of physical and mental health; if not living- age of death, cause and nature of symptoms, history of consanguinity y Siblings: number, ages, state of health; if not living age of death and cause y Familial illness or anomalies: tuberculosis (state contact with patient); diabetes mellitus, syphilis, cancer, epilepsy, rheumatic fever, allergy hereditary hematological disorders, mental retardation, congenital defects, etc. (verify accuracy of diagnosis by inquiring into signs, symptoms, course, sequelae and treatment given); presence of illness similar to patient s illness in other members of the family or household, family pedigree if a genetic anomaly is suspected. VIII. Socioeconomic History: y Living Circumstances: place and nature of dwelling, number of persons living in the house, etc y Economic circumstances: members of family who work, sources of funds IX. y Environmental History Environmental circumstances: o Exposure to cigarette smoke and other environmental pollutants (*include what pollutants and the duration of exposure); o Garbage disposal (segregation, recycling); sewage disposal o Water source; drinking, washing. Physical Examination y A good and complete PE largely depends on the approach of the examiner. y The usual order in the examination of adults is not often appropriate for young children y In general, it is best to leave the more unpleasant or uncomfortable parts of the PE y The clinician has to adapt to the various situations and circumstances surrounding the examination and yet 4 y y y y do a thorough examination i.e. auscultate the heart and lungs while patient is asleep and inspect throat when patient is crying The patient is best examined with the minimum of clothing on. Anyone examining a pediatric patient should learn the art of playful interactions and distractions to allay anxiety of the child and to facilitate the examination. Infants and young children can be carried by their caretaker or parent while being examined. In uncooperative patients, the physician should properly immobilize the patient so that certain procedures can be carried out safely. General Survey Mental state or sensorium, level of activity Presence of cardiopulmonary distress or not, color Ambulatory or bedridden Nutritional state (well, under or over nourished) State of hydration Ill looking Vital Signs (T°C), Cardiac Rate (CR)/Pulse Rate (PR), Respiratory rate (RR), Blood Pressure (BP) if >3 y/o CR and RR should be correlated to the condition in which they were taken to be considered clinically significant i.e., was the child quiet, asleep, active, crying and struggling etc. Oral T°C should not be taken in children who are too young and/or are unable to understand instructions. Axillary T°Cs are safer to obtain and are usually 0.5°C lower than oral T°C. Aural or rectal T°C can also be obtained. However, never insert rectal thermometer into an infant who can sit up on his own. Especially if it is made of glass with mercury content The pulse can be described based on: rate (per min), rhythm (regular vs irregular) & volume (full, weak, thready or compressible) Pediatric Blood Pressure (BP) Monitoring: o BP cuff should completely encircle the arm. The inflatable bladder should cover at least 2/3 of the upper arm length and 80-100% of its circumference. o o A more accurate cuff size is one whose inflatable bladder width is 40% of the arm circumference midway between the olecranon and the acromion Using too large or too small a cuff can lead to falsely low or high BP readings respectively I. y y y y y y II. y y y y y III. Anthropometric data 3 major growth parameters include: 1. Weight (wt) in Kg 2. Length (Lt) (for children < 2y/o or Height (Ht) for > 2y/o in cm 3. Head circumference (HC) (for <3 y/o) in cm Other measurements for special circumferences: y Chest circumference (CC) in cm y Abdominal circumference (AC) in cm y Arm span & U/L ratio for children with growth disorders. How should anthropometric measurements be done? y Weight o Is preferably taken with minimal clothing on. An infant weighing scale should be used for children < 2y/o. y Height o Is measured using a vertical board with an attached metric rule and a horizontal headboard that can be brought into a contact with the uppermost point on the head. y Head Circumference (HC) o Should be measured using a nondistensible plastic tape measure placed over the supraorbital ridge in front and extended circumferentially to include the most prominent part of the occiput giving the largest possible measurement y Chest Circumference (CC) o Should be measured in mid inspiration with tape running horizontally around the chest using xiphoid notch as reference point. y Abdominal circumference (AC) o Is measured across the umbilicus in infants. In older children, the subject stands with body 25-30 cm apart. y Arm span o Is measured by asking the patient to stand straight with arms outstretched sidewise parallel to the ground and palms facing front 5 y IV. y y y y y y y y y y Skin Color Tissue turgor (wrinkling or loss of elasticity) Loss of subcutaneous tissue Rash or eruptions Hemorrhages Scars Edema Jaundice Skin turgor can be used to assess dehydration by pinching he skin over the anterior abdominal wall. In the presence of dehydration, the skin does not fall back quickly and remains in folds or tented. This sign cannot be used in malnourished children because of the loss of subcutaneous fat in these children. Head hair, shape or contour, scalp, fontanels, sutures Hair should be observed for the following: o Quantity: increased or decreased, generalized or localized o Color: blonde hair in phenylketonuria, albinism, flag sign in kwashiorkor o Texture: dry coarse hair in hypothyroidism, fine thin hair in malnutrition o Surface characteristics: look for presence of lice and nits o Strength: fragile hair in many congenital syndromes and fungal infections o Abnormal swelling may indicate: hematoma, abscess, tumors, cephalhematoma, caput succedaneum o Sutures: overlapping, gaping o Fontanels: There are 2 major fontanels at birth Anterior fontanel (AF) Posterior fontanel (PF) Auscultation of the skull is important for detecting bruits which may indicate the presence of A-V malformation or may be normal in children <4 years old with febrile illness. Face Inspect face for symmetry, expression, unusual facies, deformities, lumps and bumps Adenoid facies: Term used to describe child with long face, short upper lip, pinched nose & open mouth, often associated with pharyngeal tonsillar & adenoid hyperthrophy and chronic upper airway obstruction Eyes Lids, conjunctivae, sclerae, pupils, extraocular movements, vision, strabismus, opacities, discharge, red orange reflex (ROR) up to 24mo, corneal light reflex, cross-cover test. Ears and mastoids The size, shape, location & disposition of the ear in relation to the rest of the head should be noted. Discharge from ear canal: watery, purulent or bloody Inspect also the postauricular & mastoid areas To ensure success, otoscopy should be done with proper positioning & immobilization of the child Nose and paranasal sinuses Check the patency of nares, alar flaring, presence and character of discharge, position of septum, sinus tenderness For better visualization of nasal cavity, have patient seated, tilt patient s head up facing the examiner, then press & lift the tip of the nose upward to enlarge the opening of the nares. To detect sinus tenderness, press below both eyebrows and on both maxillary areas . Mouth and throat: Lips, gums, tongue, mucous membrane, dentition, palate, posterior pharyngeal wall, tonsils Lips: Check for color (pale, cyanotic, cherry red), moisture or dryness, excoriations, cleft Gums: Color (reddish and bleed easily in gingivitis, reddish with hyperthrophy in children who were given phenytoin), continuity (ulcers, vesicles in herpetic gingivostomatitis), bleeding (in purpura, trauma, leukemia). Tongue: o size (large in Beckwith syndrome) o moisture (dry with dehydration) o color (pale, blue in central cyanosis, strawberry tongue in scarlet fever & Kawasaki s disease) o milky white coatings that bleed when scratched (thrush) VII. y VIII. y y y y V. y y IX. y y y X. y y y y y VI. y 6 For throat exam, use bright light. Ask the patient to open mouth and say Aaaahh . Inspect the anterior structures, then the tongue and under, then the posterior structures which can be visualized using tongue depressor. Caution: If epiglottis is strongly suspected, do not do throat exam Physical Examination y Oropharyngeal mucosa: note for presence of thrush, vesicles, ulcers, Koplik spots. y Palate & uvula area: o Note symmetry. Bulging on one side with uvula shift to contralateral side may signify the presence of peritonsillar abscess or parapharyngeal tumor. o Note for presence of cleft, rash like petechiae, vesicles, ulcers thrush o High arched palate in congenital malformation syndromes y The posterior pharyngeal area contains collection of lymphoid tissues spread out over the surface. During upper respiratory tract infections, the lymph nodes hyperthrophy and give the surface a cobblestone appearance. Note for the presence of post-nasal drippings. y Dentition: There are 20 milk teeth that should be present by 24 months of age. Note color, mottling or pitting of enamel (flourosis), dental caries. y Note for excessive drooling. Children normally drool in the first year of life but usually not after 18 mo of age. y Tonsils: presence or absence, size, surface color, exudates, adherent membrane. Tonsillar size should be correlated to the age of the patient. They are usually hyperthrophied during early childhood from toddler to school age period. y The color of healthy oral mucosa in general is usually pinkish-reddish. Congestion or erythema of the oral mucosa should be redder than the usual. When assessing tonsils & posterior pharyngeal wall congestion, they should be compared with the rest of the oral mucosa y XI. y y Neck Venous, engorgement, flexibility, rigidity, masses, lymph nodes Swelling: in severe diphtheria (bull neck), subcutaneous emphysema, y y y y webbing of neck in Turner syndrome, obesity Position: torticollis, opisthotonus Masses: lymph nodes, dermoid cyst, thyroglossal duct cyst, branchial cyst, enlarged thyroid, cystic hygroma. All should be described as to location, size, rate of growth, shape, margin, surface, consistency, color, warmth, pulsation, adhesion to surrounding structures). Draining lymph nodes as in scrofula Among overweight or obese children, look for acanthosis nigricans , which consists of velvety hyperpigmented grayish coarsened skin at the neck, axialla, groin and is strongly associated with insulin resistance . Chest and lungs The chest circumference (CC) is smaller than that of the head in the first 9-12 months of life. After 1 y/o, the CC should be larger than the HC. A small thoracic cage is seen in Ellis Van Crevald sydrome. Inspection: o Size and shape: in infancy, AP diameter is equal to transverse diameter; after 2 yrs, transverse diameter>AP diameter o Movement with respirations: In newborns & young infants, movement is mostly abdominal. After 4-5 yr of age, most of the respiration is due to intercostals muscles. Chest expansion: o Assessed by placing the palms of the hand symmetric ally on the posterior surface of the chest with the thumbs touching each other in the midline. Vocal Fremitus: o The child is asked to repeat the word tres tres or ninety nine repeatedly while the examiner palpates all areas of the chest & back. Percussion: o Direct percussions with 1 finger over the chest wall is easily done on small infants and gives valuable information but requires experience. The direct, 2 finger technique is the most common method for percussing the chest. Auscultation: o Stethoscope should be placed on the bare skin of the chest wall. Warm the chest piece first if it is cold. Use the bell in XII. y y y y y y 7 young infants as the diaphragm can pick up sounds from larger areas. XIII. y y Heart & Vascular system Precordium, visible pulsations, apex beat, thrills, heart sounds, pulses Inspection: o Precordium: adynamic or dynamic o Look for visible pulsations over various parts of the chest and in the epigastrium o Apex beat corresponds to the lowest and outermost point of the cardiac impulse normally located at the 4th LICS MCL until 7 y/o when it shifts to the 5th LICS MCL Palpation: o Thrills: purring vibratory sensations felt by the palm placed over the precordium. They are the palpable equivalent of murmurs & correlate with the area of maximal auscultatory intensity of the murmur Abdomen Note the size and shape of abdomen, presence of prominent vessels, striae, pulsations, peristaltic movements, movement in relation to respiration, umbilical hernia. If there is abdominal distention, measure the abdominal circumference (AC) Auscultation of abdomen to detect bowel sounds should be done prior to palpation and percussion as both procedures can alter findings. Percussion: o normally the abdomen sounds tympanitic on percussion except when percussed over solid organs like the liver or a full bladder o When dullness is noted in areas normally tympanitic on percussion, suspect presence of fluid or tumor o Percussion is used to: detect presence of fluid in the peritoneal cavity through 2 methods, i.e. fluid wave and shifting dullness Kidneys Palpation of Kidneys o Have patient lie supine and the abdomen relaxed o o o Place the patient of one hand posteriorly at the flank, pushing the kidneys forward With the other hand placed anteriorly below the costal margin, push the abdominal wall backwards and upwards. The kidney is best felt at deep inspiration. The kidney is fixed and does not move with respiration Occasionally, the left kidney can be palpable in thin or malnourished children. XVI. y y Inguinal regions Hydrocoele, undescended testes, and lymph nodes are common causes of swelling in the inguinal region. If masses are present, take note of fluctuations in size in relation to coughing or crying and whether they spontaneously resolve or not. Genitalia Male genitalia o Prepuce should be easily retractable so that when the preputial folds are held up both hands with the patient in supine position, a tunnel is formed and the meatal opening can be seen at the end of the tunnel. o Phimosis is present if the preputial sac is very narrow and cannot be retracted o The urethra opens at the tip of the penis. Hypospadia is present if meatus is located on the under surface of urethra. Epispadia is present if urethral orifice is on the dorsal surface of the penis. Female genitalia o Gynecologic exam of the pediatric or adolescent patient if necessary, should be treated with extra gentle care to prevent psychological trauma. o The procedure should be well explained first to the patient o In older children, examination of the genitalia can be facilitated by allowing the mother to help you in the examination For both adolescent male and females, do sexual maturity testing if indicated. XVII. y XIV. y y y y y y XV. y 8 XVIII. y y y Anus and Rectum Prepare the child for the exam. Place on left lateral decubitus with legs flexed against the abdomen to expose anus Look for location, patency, fissures, tags, hemorrhoids, presence of pinworms, prolapse, etc. Rectal exam is necessary, it is best carried out with child in left lateral decubitus with right leg drawn up into his/her abdomen and the head curled down as in fetal position. Extremities Check for clubbing, cyanosis, swelling and mobility of joints deformities, and in newborns, test for congenital hip dislocation Spine Inspect the spine for deformities, sacrococcygeal dimple, pilonidal sinus, and local tenderness Palpate the spine for local tenderness especially if oteomyelitis or vertebral tumor is suspected. Tenderness between the vertebrae may be elicited in disc inflammation. Screen for scoliosis by inspecting the back. Suspect scoliosis if shoulder is elevated on one side, with prominent scapula on side of involvement, and with leg-length discrepancy. Lymph Nodes Check size, number, location, consistency, tenderness, mobility, discrete or matted. Most lymph nodes are not usually palpable in the newborn. As the child grows older and get exposed to antigenic stimulation, lymphoid tissues increase in volume so that the cervical, axillary and inguinal lymph nodes become palpable in childhood especially during infections Regional adenopathy is usually the result of infection in the involved node and/or its drainage area. Generalized lymphadenopathy characterized by enlargement of >2 noncontiguous node regions, is usually caused by systemic diseases like infections lymphproliferative diseases, metabolic storage diseases, histiocytic disorders, hypersensitivity reactions, connective tissue diseases. Differentiating lymphadenopathy due to acute bacterial infections, TB and malignant causes: o Acute bacterial infections: usually tender, sometimes with erythema and warmth of the overlying skin. o TB: maybe matted, sometimes with draining sinus o Malignancy: usually firm and nontender, may be matted or fixed to the skin or underlying structures --------------------------------------------------------------------END OF TRANSCRIPTION ~~ copy-paste lng poi to sa ppt n bngay ni doc espos..pro ung sa mga parts n ndiscuss nya, may mga additional notes nman kht papano ..sorry, kung mahaba, ano nga nman mggwa ko, ganun ppt ni doc .hihihi!!! HAPPY STUDYING!!! >> first official tranx in Cor Christi XIX. y ~^_^ XX. y y y XXI. y y y y y 9 10