Systems Examination - pediagenosis
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Thursday, October 18, 2018

Systems Examination


Respiratory system
KEY QUESTIONS FROM THE HISTORY
Breathlessness
   Breathless at rest or with activity?
   Poor weight gain in infancy (a sign of respiratory distress)

Cough
   Chronology any link to time of day/activity/environment
   Nature of cough: dry (viral), loose (productive), barking (croup), paradoxical (forced repetitive cough with difficult inspiration, seen in whooping cough)
Feeding in infancy
   Choking (gastro-oesophageal reflux)
   Symptoms with introduction of formula milk (cow’s milk protein allergy)
Fever
N.oisy breathing
   Noise in expiration (wheeze = lower airway obstruction)
   Noise in inspiration (stridor = upper airway obstruction)
Cough, wheeze or stridor in a young child
   If sudden onset, is there a history of inhaled foreign body or choking?
Ear, nose and throat
   Child pulling at their ears (middle ear infection)
   Difficulty in swallowing (tonsillitis or epiglottitis)
   Offensive odour breath (bacterial infection)
   Nasal secretions, bleeding
Family history
   Family history of respiratory problems (asthma, cystic fibrosis)
   Asthma, eczema, hay fever in close relative (atopy)
   Any smokers or pet animals in household?
   Travel to area of high tuberculosis prevalence, or contact with infected relative?



Cardiovascular system
KEY QUESTIONS FROM THE HISTORY
Breathlessness
   Breathing difficulties without signs of acute infection (consider cardiac disease)
Exercise
   Exercise limited by shortness of breath, palpitations or chest pain
   Competitive sports rarely these may need to be limited with some cardiac defects
Colour change
   Cyanosis central (tongue) or peripheral (hands and feet)
   Pale and sweaty, poor perfusion (sign of cardiac failure or an arrhythmia)
Growth
   Feeding problems in babies (breathlessness impairs feeding)
   Poor weight gain on growth chart
Syncope
   Unexplained collapse or fainting
   Collapse linked with exercise
   Palpitations
   Ask the parents to demonstrate rate/rhythm by tapping with their hand
Murmurs
   Previously noted heart murmur (physiological flow murmurs sometimes audible only at times of illness or after exercise)
Family history
   Family history of congenital heart disease
   Sudden death in early adulthood (congenital cardiomyopathy)
Medical condition associated with cardiovascular problems
   Genetic syndromes involving structural heart defects (e.g. Down’s, Turner’s or Marfan’s syndromes)
   Renal problems (hypertension)
   Chemotherapy (some drugs cardiotoxic)



Abdominal system and nutritional status
Nutrition
   Infant feeding pattern duration of breastfeeding
   Note any breastfeeding problems
   Is therea key professional to give support to breastfeeding?
   If formula milk fed, review type and volume (note: 1 fluid ounce = 28 mL)
   Review intake typical infant intake is 100 –150 mL/kg in 24 hours
   Age at weaning on to semi-solids, any choking problems, foods taken
   Detail what the child eats in a typical day
   Review calorie intake and nutritional balance
   Level of appetite, any difficult feeding behaviours
   Pattern of weight gain
   Review the parent-held health record (UK Red Book) growth pattern
Vomiting
   Vomiting frequency, colour
   Green vomit in infancy suggests bile (gastrointestinal obstruction)
   Posseting (small vomits of milk in mouth) in infancy suggests gastro-oesophageal reflux
   Blood in vomit in infancy suggests maternal blood swallowed with breastfeeding
   Blood in vomit in older children suggests oesophageal bleeding due to vomiting
Bowel habit
   Faeces—frequency, consistency, colour, any mucus, blood, greasy faeces
   Diarrhoea—frequency, consistency, urgency, blood, link with diet
   In newborn, meconium should be passed in first 24 hours after birth
   Age of potty training (child develops awareness and can con- trol bowel movement to use potty)
   Constipation straining, pain, reduced frequency, hard faeces
   Soiling of faeces in underwear (seen with overflow in constipation)
   Encopresis (behavioural problem of passing faeces in inappropriate place)
Pain
   Abdominal pain site, radiation, chronology, nature, exacerbating and relieving factors
Family history
   Family history of liver, kidney, bowel disease
Genito-urinary symptoms
   Urinary frequency, dysuria, haematuria
   Enuresis (childhood urinary incontinence) by day and night
   Age at menarche, cycle frequency, regularity
   Menstrual bleeding flow, duration, pain symptoms



Neurological assessment
   Problems during pregnancy or neonatal period
   Review development:
  loss of developmental milestone skills (regression, a sign of serious problems)
  pattern of delay—global or limited (e.g. isolated speech and language delay)
   Headache symptoms
   Early morning vomiting (raised intracranial pressure)
   Involuntary movement, convulsion, unexplained collapse, altered consciousness level
   Sensory symptoms
   Urinary and faecal continence
   Hearing or vision problems, squint
   School performance
   Behaviour, mood, empathy, concentration
   Coordination, clumsiness, gait problems
   Function how is the child limited by any neurological impairment?
   Home environment any adaptations to assist care?
   Extra support received:
  who assists with care of the child?
  respite to parents
  financial support to assist with care and mobility
   Family history of neurological problems:
  epilepsy, blindness, deafness, learning difficulty, genetic disorder


The visual system

Musculoskeletal system
Newborn
   Risk factors for congenital hip dysplasia female gender, breech, family history
Older children
   Inflammation—joint pain, swelling, heat, restricted move- ment
   Limitation to activities (sports, walking distance)
   Gait problems:
  limp with pain, hemiplegia
  waddling gait with diplegia, muscle weakness, congenital dislocation of the hip
  tip-toe walking—often behavioural but may also be a sign of diplegic cerebral palsy
   Fever or skin rash (autoimmune disorders, septic arthritis)


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