KB Viva Guide

Clinical Examination In Pediatrics FAQs

Respiratory system

4 components of examination of respiratory system

 Inspection
 Palpation
 Percussion
 Auscultation

Normal Resp. Rate

Normal Respiratory rate

Age Range Rapid
Newborn 30-50 >60
Infant 20-30 >50
Toddler 20-30 >40
Child 15-20 >30

Terms for Chest Shapes

 Pectus carinatum-prominent sternum, pigeon chest

 Pectus excavatum- Marked sternal depression
 Harrison’s sulcus- in drawing of lower chest with rib flaring

Findings in Asthmatic child

 Jerky respiration- up down chest movement instead of in-out

 Tendency to raise shoulders near ears during deep inspiration
 Overblown upper chest and lower may have Harrison’s sulcus-

Wheeze=rhonchus=rhonchi=continuous sound=dry sound

  Mucosal edema
 Excessive mucus
 Bronchospasm

Due to

 Acute laryngo trachea bronchitis

 Acute bronchitis
 Acute bronchiolitis
 Acute bronchopeumonia

Crackle=crepitition= discontinuos sound=wet sound

Cardiovascular system
Cyanotic CHD

 Transposition of great vessels

 Pulmonary stenosis
 Fallots Tetralogy
o Large VSD
o Right ventricular hypertrophy
o Overriding aorta
o Pulmonary atresia

Normal heart rate at rest

Age Average rate Upper limit of normal
0-6 months 140 160
6-12 months 130 150
1-2 years 110 130
2-6 years 100 120
6-10years 95 110
11-14years 85 100
 Symptoms of severe cyanosis-clubbing, squatting after exercise
 BP in children recorded on right hand
The Abdomen
Liver 1-2 cm below right costal margin- normal upto 2-3 years

Signs

Large ears- fragile X syndrome

Flat nose- Down’s syndrome

Diphtheria

 Sever lymphadenitis
 Bull neck
 Grayish membrane
 Notable toxicity

Kissing tonsils- large tonsils that meet in the midline

Protruding tongue- congential hypothyroidism

Buccal mucosa-

Kopliks sopts- small salt grain like with red margins- measles

Oral cavity terms

 Raniula- cyst on anterior floor of mouth

 Quinsy- peritonsillar absecess
 Glossoptosis- backward displacement of tongue
 Microganthia- small chin

Nervous system

Primitive reflexes appearance and disappearance

Reflex Appearance Disappearance
stepping Birth 2 month
 Moro Birth 3-5 months
Palmar Grasp Birth 2 months
Plantar grasp birth 8-10 months
Asymmetric tonic reflex Newborn 1-6 months

Large head Macrocephaly

 Familial trait
 Hydrocephalus

Small head- microcephaly

 Perinatal hypoxia
 Intrauterine infection
 Chromosomal disorder

Neck Stiffness

Kernig’s sign

Unreliable under 3 yrs

Flex knee and hip at right angle and extend the leg

+ ve- pain and limitation of movement

Brudzinski’s sign

While doing Kernig’s manouever- the child flexes the contralaterla knee to reduce
the tension off the lower spine

Cracked pot note

On skull percussion- raised intracranial pressure

Setting sun sign

Hydrocephalus

Cerebral palsy
Disorder of movement and posture presenting in infancy and characterized by
one or a combination of hypotonia, spasticity, ataxia, involuntary movements

Rickets

 Frontal bossing
Box shaped head, large head found in rickets- vitamin D deficiency

Other findings

 Rachitic rosary- thickening of costochondral junctions

 Widening of epiphysis of long bones especially wrist (x ray shows cupping of
articulating surface)
 Bow legs
 Knock knee
 Craniotabes- soft skull bones
Ping pong ball-When the parieto-occipital part of skull is pressed- the
feeling is of depression and then rebounding as seen in a ping pong (table
tennis) ball.
Examination of newborn

Apgar score- Checked at 1 and 5 minutes after birth

Score of 0, 1 or 2 is given

 Appearance
 Pulse
 Grimace
 Activity
 Respiration

Normal- 7-10

Moderate CNS depression- 3-6

Severe CNS depression-0-2

Milia-whitish, pin head spots around nose- harmless

Lanugo hair- cover newborns till 2-3 weeks after birth.

Mongolian blue spots- seen in newborns, dark blue normal pigmentation over
sacrum, buttocks and back of legs

Capput Succedeneum (upasheershaka)-soft, diffused edema, pitting on

presenting part of skull

Cephalhematoma- subperiosteal hematoma, limited by suture lines, well defined

margins

Tears- appear in newborns after3-4 weeks

Oral cavity

Epithelial pearls- small, white areas on heard palate

Macroglossia- large tongue

  Down syndrome
 Congenital hypothyroidism

Torticolis- crooked neck may be due to sternocleidomastoid tumor

Count umbilical vessels- 2 arteries and 1 vein

Normal position of newborn is of flexion

Primitive reflexes or Neonatal reflexes

 Rooting reflex
o In response to touch on cheeks- baby will turn his or her head
towards the touch
o Stimulation of upper lip- opens the mouth
o Absence- indicates severe neurological deficit
 Stepping Reflex
o Baby held upright, feet placed on firm surface
o As one foot pressed down on the surface the other is raised as if to
take a step ahead
 Moro reflex- always done last as it makes baby cry
o Baby’s body supported with one arm and hand and the head with
other hand
o The hand holding head is then lowered a few centimeters
o Positive response- baby abducts and extends arms and then flexes
them
o Unilateral response indicates local abnormality like fracture or
brachial plexus injury

Assessment of gestation: Prematurity- born before 37 weeks

 Shape and form of pinna-pinna flat against skull and unfolded

 Absence of breast nodule
 Absence of palmar and plantar creases
  Undescended testis and absence of scrotal rugosities
 Underdeveloped labia majora and exposed labia minora
 Excess of lanugo hair

Postmaturity- born after 42 weeks

 Dry loose peeling skin

 Overgrown nails
 Abundant scalp hair
 Visible creases on palms and soles of feet
 Minimal fat deposits
 Green, brown, or yellow coloring of skin from meconium staining (the first
stool passed while in the womb)
 More alert and "wide-eyed"

Low birth weight- < 2.5 kg/2500gms

Complications-

More prone to

 Hypothermia
 Hypoglycemia
 Perinatal asphyxia
 Fluid and electrolyte imbalance
 Hyperbilirubinemia
 Anemia
 Infections
 Neurological complications

VLBW- very low birth weight-<1,500gm

Extremely LBW- <1000gm

Neonatal jaundice-
Imbalance in bilirubin production and elimination

Types -2

 Physiological (includes breast milk jaundice)

 Pathological- hemolytic jaundice

Causes

Physiological-

Elevation of unconjugated bilirubin

Neonatal physiologic jaundice results from simultaneous occurrence of the

following

 Bilirubin production is elevated because of increased breakdown of fetal

erythrocytes. This is the result of the shortened lifespan of fetal
erythrocytes and the higher erythrocyte mass in neonates.
 Shorter life span of fetal red blood cells,[4] being approximately 80 to 90
days in a full term infant,[6] compared to 100 to 120 days in adults
 Hepatic excretory capacity is low both because of low concentrations of the
binding protein ligandin in the hepatocytes and because of low activity of
glucuronyl transferase, the enzyme responsible for binding bilirubin to
glucuronic acid, thus making bilirubin water soluble (conjugation).

Develops on- 2-3rd day

Disappears by- 10 days

Bilirubin levels-

Phase one

 Term infants - jaundice lasts for about 10 days with a rapid rise of serum
bilirubin up to (12 mg/dL).
  Preterm infants - jaundice lasts for about two weeks, with a rapid rise of
serum bilirubin up to (15 mg/dL).

Phase two - bilirubin levels decline to about (2 mg/dL) for two weeks, eventually
mimicking adult values.

 Preterm infants - phase two can last more than one month.
 Exclusively breastfed infants - phase two can last more than one month.

Pathological Jaundice of Neonates (Unconjugated Pathological

Hyperbilirubinemia)
Any of the following features characterizes pathological jaundice:

 Clinical jaundice appearing in the first 24 hours or greater than 14 days of

life.
 Increases in the level of total bilirubin by more than (0.5 mg/dL) per hour
or) 5 mg/dL per 24 hours.
 Total bilirubin more than (19.5 mg/dL) (hyperbilirubinemia).
 Direct bilirubin more than (2.0 mg/dL).
 Neonatal jaundice

Neonatal Jaundice

Unconjugated bilirubin Conjugated Bilirubin

Pathological Physiological Hepatic Post hepatic

Hemolytic Non-hemolytic

Intrinsic causes Extrinsic causes

Unconjugated

Hemolytic (HDFN- hemolytic disease of fetus and newborn)erythroblastosis

fetalis

Intrinsic causes of hemolysis[edit]

 Membrane conditions
 Spherocytosis
 Hereditary elliptocytosis
 Systemic conditions
 Sepsis
 Arteriovenous malformation
 Enzyme conditions
 Glucose-6-phosphate dehydrogenase deficiency (also called G6PD
deficiency)
 Pyruvate kinase deficiency
 Globin synthesis defect
 sickle cell disease
 Alpha-thalassemia, e.g. HbH disease

Extrinsic causes of hemolysis

 Alloimmunity (The neonatal or cord blood gives a positive direct Coombs

test and the maternal blood gives a positive indirect Coombs test)
 Hemolytic disease of the newborn (ABO)[1]
 Rh disease[1]
 Hemolytic disease of the newborn (anti-Kell)
 Hemolytic disease of the newborn (anti-Rhc)
 Other blood type mismatches causing hemolytic disease of the newborn

Non-hemolytic causes

 Breast milk jaundice

  Cephalohematoma
 Polycythemia
 Urinary tract infection
 Sepsis
 Hypothyroidism
 Gilbert's syndrome
 Crigler-Najjar syndrome
 High GI obstruction

Conjugated (Direct)

Liver causes

 Infections
 Sepsis
 Hepatitis A
 Hepatitis B
 TORCH infections
 Metabolic
 Galactosemia
 Alpha-1-antitrypsin deficiency, which is commonly missed, and must be
considered in DDx
 Cystic fibrosis
 Dubin-Johnson Syndrome
 Rotor syndrome
 Drugs
 Total parenteral nutrition
 Idiopathic

Post-liver

 Biliary atresia or bile duct obstruction

 Alagille syndrome
 Choledochal cyst
Phototherapy

Phototherapy is the use of visible light for the treatment of hyperbilirubinemia in

the newborn. This relatively common therapy lowers the serum bilirubin level by
transforming bilirubin into water-soluble isomers that can be eliminated without
conjugation in the liver.

During this type of phototherapy:

 The baby is undressed so that as much of the skin as possible is exposed to

the light.
 The baby's eyes are covered to protect the nerve layer at the back of the
eye (retina) from the bright light.
 Feeding should continue on a regular schedule. There is no need to stop
breast-feeding.
 The bilirubin level is measured at least once a day.

Kernicterus- Staining of brain and nervous tissue due to high levels of bilirubin

Can cause seizures, deafness, brain damage and death

Pathological jaundice management

 Blood transfusions (for severe anemia)

 Intravenous fluids (for low blood pressure)
 Help for respiratory distress using oxygen, surfactant, or a mechanical
breathing machine
 Exchange transfusion to replace the baby's damaged blood with fresh
blood. The exchange transfusion helps increase the red blood cell count
and lower the levels of bilirubin. An exchange transfusion is done by
alternating giving and withdrawing blood in small amounts through a vein
or artery. Exchange transfusions may need to be repeated if the bilirubin
levels remain high.
  Intravenous immunoglobin(IVIG). IVIG is a solution made from blood
plasma that contains antibodies to help the baby's immune system. IVIG
may help reduce the breakdown of red blood cells and lower bilirubin
levels.

Hydrops fetalis: This occurs as the baby's organs are unable to handle the
anemia. The heart begins to fail and large amounts of fluid build up in the baby's
tissues and organs. A fetus with hydrops is at great risk of being stillborn.

Diagnosis- Coombs test (refer notes)

Clinical assessment of Bilirubin level

Kramer’s rule

Jaundice always progresses form head to trunk and then extremities

 Head and neck -5-7mg/dL

 Chest -8-0 mg/dL
 Lower abdomen and thigh- 12-15mg/dL
 Soles and palms -> 15mg/dL
National Immunization Schedule

l
Age Disease Vaccination Remarks
No.

1 AT BIRTH HEPATITIS B HEP B VACCINE -I

2 AT BIRTH POLIO ORAL PV 0 DOSE

BIRTH TO 6
3 TUBERCULOSIS BCG
WK

4 4 -6 WEEKS HEPATITIS B HEP B VACCINE -II

DIPHTHERIA
5 6 WEEKS PERTUSIS TETANUS DPT-I OPV -I
POLIO

DIPHTHERIA
DPT-II OPV-II HEP B
6 10 WK PERTUSIS TETANUS *DELHI GOVT RECOMMENDATION
VACCINE III*
POLIO HEPATITIS B

DIPHTHERIA
DPT-III OPV- III HEP B
7 14 WEEKS PERTUSIS TETANUS *DELHI GOVT RECOMMENDATION
VACCINE IV*
POLIO

8 24 WEEKS HEPATITIS B HEP B VACCINE III* *IAP RECOMMENDATION

9 9 -12MTHS POLIO MEASLES OPV-IV MEASLES

MUMPS MEASELES
10 15-18 MTHS MMR*
RUBELLA

DIPHTHERIA
*RECOMMENDED BY DELHI GOVT
11 18 MTHS PERTUSIS TETANUS DPT –BOOSTER I OPV –V
& IAP ONLY
POLIO

12 24 MTHS TYPHOID TYPHOID* *IAP RECOMMENDATION

DIPHTHERIA
DPT BOOSTER – II OPV -
13 4-5 YR PERTUSIS TETANUS
VI
POLIO
Pulse Polio Immunization
With the global initiative of eradication of polio in 1988 following World Health
Assembly resolution in 1988, Pulse Polio Immunization programme was launched
in India in 1995.

Children in the age group of 0-5 years administered polio drops during National
and Sub-national immunization rounds (in high risk areas) every year. About 172
million children are immunized during each National Immunization Day (NID).

The last polio case in the country was reported from Howrah district of West
Bengal with date of onset 13th January 2011. Thereafter no polio case has been
reported in the country (25th May 2012).

WHO on 24th February 2012 removed India from the list of countries with active
endemic wild polio virus transmission.

The Pulse Polio Initiative (PPI) aims at covering every individual in the country. It
aspires to reach even children in remote communities through an improved social
mobilisation plan.[2]

Objectives:

 Not a single child should miss the immunization, leaving no chance of polio
occurrence.
 Cases of Acute Flaccid Paralysis (AFP) to be reported in time and stool
specimens of them to be collected within 14 days. Outbreak Response
Immunization (ORI) to be conducted as early as possible.
 Maintaining high level of surveillance.
 Performance of good mop-up operations where polio has disappeared.
Terms related to Ortho in newborns and children:

 Talipes equino varus- club foot (inward turning of ankle and foot)
 Genu Varum- Bow legged
 Genu Valgum- Knock knee
 Genu recurvation- legs bent backwards
 Gibbus- sharply angled kyphosis

Neural tube defects

 Spina bifida- failure of fusion of vertebral arches

 Meningocele- open vertebral arches with overlying meningeal sac
containing CSF
 Myelomenigocele- Unfused vertebral arches with exposed neural tissue
 Anencephaly- almost complete absence of cerebral hemispheres
 Encephalcele- herniation of brain through congenital skull defect

Height ref points

 Birth- 50cm
 1 year-75 cm
 4 years- 100 cm
 12-3 years- 150 cm

Head Circumference

 Birth- 35cm
 1year- 47 cm
 2 yr- 49 cm
 4 yr- 50cm
 8 yrs- 52cm
 15yrs- 55 cm
Signs of Dehydration and degree of dehydration (refer notes)

ORS composition

Reduced osmolarity ORS grams/litre Reduced osmolarity ORS mmol/litre

Sodium chloride 2.6 Sodium 75

Glucose, anhydrous 13.5 Chloride 65

Potassium chloride 1.5 Glucose, anhydrous 75

Trisodium citrate, dihydrate 2.9 Potassium 20

Citrate 10

Total Osmolarity 245

Home made ORS recipe –

The "simple solution" Preparing One (1) Litre Oral Rehydration Solution [ORS] using Salt, Sugar and
Water at Home Mix an oral rehydration solution using one of the following recipes; depending on
ingredients and container availability:

Ingredients:

 Half (1/2) level teaspoon of Salt

 Six (6) level teaspoons of Sugar
 One (1) Litre of clean drinking or boiled water and then cooled 5 cupfuls (each cup about 200
ml.)

Preparation Method: Stir the mixture till the salt and sugar dissolve.
Sandifer’s syndrome- arching, posturing, apparent dystonic movements which
occur in children with reflux esophagitis after eating and may be confuse for
convulsions.

Lightwood’s Law- Viral infections tend to spread while bacterial are usually
localized

TORCH- Toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex

NTD- Neural Tube defect

CDH- Congenital Dislocated Hips

CHD- Congenital heart disease

SGA- Small for gestational age

IVH –Intra ventricular hemorrhage

CPAP-Continuous positive airway pressure

PEEP- Positive end expiratory pressure

IPPV- Intermittent positive pressure ventilation

NEC- Necrotizing entero colitis

PFC- persistent fetal circulation

Fanconi’s anemia- congenital aplastic anemia

Ortolani’s test/maneuver- done to check congenital dislocation of hips