The Funeral ceremony of Kim Yong Il

<br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />

2 days ago
  at the Kumsusan Memorial Palace in Pyongyang


 a glass coffin a memorial palace in Pyongyang


Kim Jong-il dies aged 69: December 19 as it happened

World leaders call for reform after Kim Jong-il, the leader of North Korea, dies of a heart attack on a train in Pyongyang.

North koreans cry and scream in a display of mourning for their leader Kim Jong II

North Koreans cry and scream in a display of mourning for their leader Kim Jong-
North Korean leader Kim Jong Il has died, Pyongyang announced.

A nation in tears:

SEOUL, South Korea – North Korea announced the death of supreme leader Kim Jong Il and urged its people to rally behind his young son and heir-apparent Monday, while the world watched warily for signs of instability in a nation pursuing nuclear weapons.

South Korea, anxious about the untested, 20-something Kim Jong Un after his father’s 17-year rule, put its military on high alert against the North’s 1.2 million-strong armed forces. President Barack Obama agreed by phone with South Korean President Lee Myung-bak to closely monitor developments.

People on the streets of the North Korean capital, Pyongyang, wailed in grief, some kneeling on the ground or bowing repeatedly as they learned the news that their “dear general” had died of heart failure Saturday at age 69 while carrying out official duties on a train trip.

North Koreans mourn the death of Kim Jong Il… as West fears show of strength from nuclear state’s new leader

  • Kim Jong Il died on a train on Saturday morning of heart attack
  • Came into power in 1994, succeeding his father, Kim Il Sung
  • Third son, Kim Jong Un, unveiled as successor in September 2010
  • His uncle Jang Song Thaek expected to rule behind the scenes as he trains on the job
  • South Korean and Japanese militaries on ‘high alert’
  • North Korea today test-fires short-range missile on eastern coast
  • Fears of behind-the-scenes power struggle which could destabilise region
  • Funeral planned for December 28 in capital of Pyongyang
Kim Jong Il, N. Korea's 'Dear Leader' Dictator, Dead

Kim Jong Il, N. Korea’s ‘Dear Leader’ Dictator, Dead

Dec. 19 (Bloomberg) — Kim Jong Il, the second-generation North Korean dictator who defied global condemnation to build nuclear weapons while his people starved, has died, state media reported. A government statement called on North Koreans to “loyally follow” his son, Kim Jong Un. Rishaad Salamat reports on Bloomberg Television’s “Asia Edge.” (Source: Bloomberg) (/Bloomberg) Correction: Clarification:


North Korean leader Kim Jong Il is dead, according to state television from Pyongyang. There are currently no independent reports confirming his death.

“Our great leader Comrade Kim Jong-il passed away at 8:30 a.m. on Dec. 17,” Korean Central TV reported.

North Korea’s state-run television announced Kim died on Saturday of “physical and mental overwork,” the BBC reported. The AFP said his death was from a heart attack. He reportedly died while traveling.

The world’s only inherited communist ruler, Kim was reported to have been battling health issues that left him further isolated from the outside world.


August ,24th.2011

Kim jong il is dead 2011

North Korea’s leader Kim Jong-Il peers out of a car window after a meeting with Russian officials on August 24, 2011.


North Korean leader Kim Jong Il has been dead for years and replaced by a number of look-alikes, a Japanese academic claims.

One of Kim Jong Il’s doubles in 2008 (left) and the real Kim in 2003

and the information in 2009

Dead body of North Korea’s Kim Jong-Il turns 67


PYONGYANG — Droves of jubilant North Koreans took to the streets nationwide today to celebrate the 67th birthday of North Korean dictator and Great Leader Kim Jong-Il’s dead body.

“We are overjoyed to see the magnificence of our Dear Leader,” emaciated peasant Gwok Shi-Mon said. “He may not be as sprightly as he once was, but his strength and wisdom still show through that glass, coffin-like box in which he sleeps every night.”

Although North Korea denies that Kim, who apparently died last year, is dead, South Korean and U.S. sources said the Kim Jong-Il encased in glass in the rotunda of the reclusive country’s capitol building is indeed the leader’s dead, embalmed body.

“He’s not been seen in public in months,” South Korean Gen. Kai Vi-Tam said from Seoul. “The footage the state-run news agency plays of him is the same every time. It’s of Kim drinking a can of Tab while standing on a balcony waving to an adoring throng of people. At one point Kim picks up a copy of Michael Jackson’s ‘Thriller’ album, and then kills a low-level soldier for accidentally scratching the record while putting the needle on it so the crowd could dance to ‘Beat it’”

Even though Kim lay motionless as hundreds of thousands of North Koreans filed past him, laying crudely wrapped birthday presents in front of the glass box as they passed, His people said they took great comfort in knowing the Dear Leader is close by.

“I could tell the Great Leader was thinking about me as I placed a festively wrapped package of my last pack of cigarettes by his feet,” steel worker Xi Hun-Don said. “I would yank out my own eyeballs with an ax should the Dear Leader deem my cigarettes worthy enough to smoke. That would be a birthday present to me

North Korea expert Professor Toshimitsu Shigemura, a professor of international relations, says Kim died of diabetes in 2003 and has been substituted by up to four body doubles ever since.

Driven by a fear of assassination, Kim allegedly trained his doppelgangers — one of whom underwent plastic surgery — to attend public appearances.

“Scholars don’t trust my reasoning but intelligence people see the possibility that it will turn out to be accurate,” Fox News reported Professor Shigemura as saying.

“I have identified and pinned down every source.”

Kim, 66, has not appeared in public for three weeks amid rumours he is seriously unwell and look Kim in 2004

While Seoul intelligence officials have said they believe he has diabetes and heart problems, they do not think he is near death.

But Professor Shigemura, from Tokyo’s respected Waseda University, believes that Kim actually died sometime during a 42-day absence from public in September 2003.

He claims that whenever anyone is granted a face-to-face meeting with today’s Kim, a senior official is always by his side “like a puppet master”.

Professor Shigemura’s claims, outlined in his book The True Character of Kim Jong-il, have been disputed by North Korean officials.

November 10 2008

Pyongyang, North Korea – With reports of a severe illness having debilitated the North Korean leader, the spin machine in the isolated nation has been working in overdrive. From constant denials to apparently doctored photographs, the government has been doing everything it can to show the world that the ‘Dear Leader’ is alive and well. Now, Kim has appeared on national television to prove he is alive and well, and made a shocking change in the political and social climate of the entire jong-il hip hop master

“We have long been an isolated country, we have long been at odds with our neighbours and the rest of the world but that all changes today,” said Kim in a speech. “I have taken time in isolation and come to the conclusion that the best way for the Korean people to move forward is through music. North Korea will eschew communism and become a hip-hop nation effective immediately. Bling will be issued to every resident starting tomorrow.”

While few details have been released on how the new government will be organized, one immediate change will be the national anthem. Replacing the decades old anthem will be Afrika Bambaataa’s ‘Looking for the Perfect Beat’ (here) and will play in all government offices and schools starting Monday. A redesign of the flag is also on tap, as well as a top down renovation of the schooling system.

“Children will be taught the way of Hip-Hop. Not only the grand history, but also the culture,” continued Kim. “Children must be taught the path, and through the path they will find freedom. It will take a nation of millions to hold us back from our destiny.”

Kim, long an admirer of western culture, has been rumoured to be a lifelong hip-hop fan which in part stemmed from his love of Basketball. In 2000 Former Secretary of State Madeleine Albright presented the leader with a basketball signed by Michael Jordan at the conclusion of a summit between the US and North Korea. He also reportedly uses pure silver chopsticks and has a massive fleet of Mercedes Benz S500’s at his disposal, putting him in line with the upper end of American hip-hop culture.

“From what I’ve heard he’s an old school guy. Grandmaster Flash, Bambaataa, Fab Five Freddy, those kinds of guys, apparently though he’s always got Wu-Tang Clan playing on his iPod. Supposedly his guilty pleasure is Lil Wayne and he shuts it off every time someone walks into the room,” said Scrape TV North Korean analyst Lee Joo-Chan. “That’s great and all but I don’t see how you can translate your hobby and musical taste into a political system. George Bush made a diligent effort in turning the US into a nation of country bumpkins but failed. It’s an interesting experiment but one that may be doomed to failure.”

Many are looking to Kim to implement the changes much like his father, Kim Il-sung, did when the North was driven into communism. While the younger Kim has been looked at as more of an eccentric rather than formidable leader, some believe that he may still have some of the drive and smarts that his father had.wu tang north korea logo

“He is a little funny in the head, everyone knows that, but he’s got the same blood coursing through his veins and that may serve him well in the transition,” continued Lee. “But we need to see details. In a nation where millions of people are starving do they really need to be putting money into breakdancing lessons? Military service or turntable lessons? I don’t see how hip-hop culture lends itself to Socialism so it’s going to be a hard time getting people to see their country in a new way. More power to him, but it’s going to be tough. Word.”

September 9 2008

Pyongyang, North Korea –Rumours are abound that Kim Jong-il, notorious dictator of South Korea has either died, fallen severely ill, or even passed away years ago and has been replaced by lookalikes ever since. His failure to appear at ceremonies marking the sixtieth anniversary of the founding of North Korea has caused even more of a stir in the intelligence community.

kim jong-il smilingTalk that Kim had died many years ago started to surface in August after an article published in the Japanese newspaper Shukan Gendai. Circumstantial evidence seemed to back up the claim, though no hard evidence was presented. The latest talk of a possible stroke would seem to put a damper on the theory, but would likely result in the same outcome.

“If Kim did in fact die five years ago and was replaced by lookalikes, it would hardly be surprising,” said Scrape TV North Korean analyst Lee Joo-Chan. “If that is untrue and he has just recently become ill or died, it’s likely the regime would implement this procedure in order to cover it up. Whether the original story spawned the idea or vice-versa is an intellectual debate. I have little doubt that they would cover up his death whenever it happens. I wouldn’t be surprised if he’s around in one form or another for many years to come.”

North Korea is of course extremely closed and isolated from the rest of the world, so uncovering reliable information concerning any goings-on in the country is extremely difficult. That process is even more complicated when it comes to information about the “Dear Leader” whose face is plastered across the country and is revered in some ways close to a God.   

“Kim is more than a leader, he has positioned himself as the life blood of the people and it would be incumbent on the government to maintain his existence whether it was fact or not. Kim has thrived on misinformation for many years and this would be no different,” continued Lee. “I think the more interesting talk would be how many people in the country could emulate him. The bouffant hairdo is hard to come by these days and even in North Korea I can’t imagine a whole lot of people lining up to double for a pudgy delusional midget. Of course they may not have a choice.”kim jong-il puppet

The other option of course would be using stock footage of the dictator for public appearances and limit meetings with foreign dignitaries. There is at least one instance of footage being used in place of a live appearance, wherein footage from the movie ‘Team America: World Police’ was accidently broadcast across the country. That film features a literal puppet of Kim. The footage was quickly pulled and seems to have had no ill effects on the leader’s reputation.

“Kim is a very unique person to say the least, and I think it would be very difficult to replace him,” concluded Lee. “Of course with the way North Korea is run, fooling the people wouldn’t be an issue. I hope the South Park guys kept their puppets, they may come in handy again.”   

Neither Matt Stone, Trey Parker, nor the North Korean government had any comment


The Pediatrician And Pediatric science




Dr Iwan Suwandy,MHA

special for my lovng wife Lily W.,MM,

and Grandchild Cessa,celin and antoni


Pediatrician History

Jeffrey Baker

Associate Professor of Pediatrics and Director, History of Medicine Program, Trent Center for Bioethics, Humanities, and History of Medicine

B.S. Duke University
M.D. Duke University School of Medicine
Pediatrics, University of Colorado
Ambulatory Pediatrics, Duke University Medical Center
Ph.D. Duke University

Dr. Baker’s is an academic pediatrician and historian whose scholarship has focused on medical technology, ethics and child health. He has lectured and written extensively on the evolution of premature infant technology. Much of this work is synthesized in his comparative history of neonatal medicine in France and the United States, The Machine in the Nursery: Incubator Technology and the Origins of Newborn Intensive Care (Johns Hopkins University Press, 1996). His more recent work has examined childhood vaccine controversies in the United States and Great Britain. He has also written and edited a history of 20th century American pediatrics commemorating the 75th year anniversary of the American Academy of Pediatrics.

Dr. Baker directs the Medical History Program of the Trent Center for Bioethics, Humanities, and History of Medicine, in which capacity he teaches at all levels of undergraduate and graduate medical education. He has taught undergraduate courses addressing the historical aspects of medical ethics, technology, reproductive medicine, and genetics; currently Dr. Baker directs the Prospective Health Care series within Duke’s Focus program for first-year undergraduate students. Previous responsibilities at Duke have included serving as Interim Director of the Trent Center and Director of the AB Duke Scholarship Program (both between 2005-6), and Medical Director of the Duke Health Center at Southpoint (1999-2003). Dr. Baker practices general pediatrics and serves on the advisory committee for the Pediatric History Center for the American Academy of Pediatrics

1968 – Hattie Elizabeth Alexander died.

Hattie Elizabeth Alexander and Sadie Carlin - 1926
Alexander was a pediatrician and microbiologist who developed the study of antibiotic resistant strains of viruses and pathogens. She developed the first antibiotic treatment for infant meningitis caused by Haemophilus influenzae. Her treatment significantly reduced the mortality rate of the disease. She became one of the first women to head a major medical association when she was the president of the American Pediatric Society in 1964. The photograph is of Miss Alexander (sitting on lab bench) and Sadie Carlin (right) before she received her medical degree

Pediatric University History
Yale Medical University

Department of Pediatrics, 1921-22

The Department of Pediatrics was organized on a full-time basis in 1921 with the appointment of Edwards Park, formerly at Johns Hopkins, as Chairman.Top row: Ernest Caulfield, John C.S. Battey (?), Frank L. Babbot, Joseph Weiner.
Bottom row: Ruth A. Guy, Ethel C. Dunham, Grover F. Powers, Edwards Park, Alfred Theodore Shohl, Martha M. Eliot, Marian C. Putnam.Women were on the faculty of the Medical School from the 1920s on — Martha Eliot and Ethel Dunham had distinguished careers at Yale and at the U.S. Children’s Bureau — but no women were made full professors until 1965.

Pediatric science History

Your Baby’s Eye Exam

The best way to protect your baby’s eyes is through regular professional examinations. Certain infectious, congenital, or hereditary eye diseases may be present at birth or develop shortly thereafter. Yet, when diagnosed early, their impact may be greatly minimized.

So have your baby’s eyes examined – by a licensed eye doctor – before six months of age (or sooner if recommended by your pediatrician) and regularly throughout his or her life.

How Can I Prepare For My Baby’s Eye Exam

Chances are your pediatrician will examine your baby’s eyes in one of your first few visits. The pediatrician will review your baby’s health and family health history. You can prepare for your baby’s appointment using our Eye Exam Checklist. Be sure to tell the pediatrician about any eye health issues in your family, as many of these can be inherited.

How Will the Doctor Test My Baby’s Eyesight?

The pediatrician may use toys and lights to determine your baby’s ability to focus, recognize colors, and perceive depth or dimension. Here are some things you may see during the exam:

  • Alignment Using toys that make noises (or are otherwise intriguing) the pediatrician will cover and quickly uncover each eye to test for a dominant eye
  • Ability to fixate Your pediatrician will move an object in front of your baby’s eyes to see if the eyes can watch and follow the object.
  • Coordination of eye muscles The pediatrician will move a light or some interesting toys in a set pattern to test your baby’s ability to see sharply and clearly at near and far distances.
  • Pupil response to light The pediatrician will shine a small light (a penlight, for example) in your baby’s eye and watch the pupil’s reaction. The pupil normally would get smaller very quickly in response to light.
  • Eyelid health and function The pediatrician will examine each eyelid to be sure it is functioning normally.  This includes a check for drooping eyelid, inflammation, and any other indications that your baby’s eyes need greater attention.

If your pediatrician sees anything out of the ordinary, you’ll be advised to make an appointment with a licensed eye doctor who will perform a more comprehensive evaluation of your baby’s eyes.

What Does a Comprehensive Eye Exam Involve

Babies should have their first comprehensive eye exam by a licensed eye doctor at six months. A licensed eye doctor will perform additional tests that the pediatrician does not.  This is essential if there are any major vision issues that run in your family, as they may have been inherited.   

Your eye doctor will conduct some of the same tests you saw in your pediatrician’s office, but with some important additions:

  • Vision correction The eye doctor will use eye drops to help your baby’s pupils dilate, creating a better window to the back of your baby’s eyes.  This dilation allows your doctor to check for Nearsightedness (myopia), Farsightedness (hyperopia) and Astigmatism.  The drops take about 45 minutes to work, and will blur your baby’s vision and cause a little light sensitivity for a few hours. Using a retinoscope, the doctor will move the light to see it reflected in the pupil.  The shape of the reflection helps the doctor determine if your baby has vision issues that require correction.
  • The interior and back of the eye After dilating your baby’s eyes and dimming the lights, the doctor will use a special instrument called an ophthalmoscope to see through to the retina and optic nerve at the back of the eye. This is where clues to many eye diseases first show up.
  • Tests for a specific issue Be sure to discuss any other concerns you have about your baby’s eyes such as crossed eyes and nystagmus, so your doctor can do the appropriate tests and advise you on the action required.

What If I Can’t Afford to Have My Baby’s Eyes Examined?

Not everyone can afford the preventive health care their babies need – so the American Optometric Association (AOA) has a special program designed to help parents.

Parents can get a FREE comprehensive eye examination for their baby during the first year of the baby’s life. It’s called InfantSee, and the AOA provides the information you need to find a participating eye care professional in your area

Vivian Riggs and Andrew Stella-Vega, both in the USF Health Information Systems department, designed an online preadmission testing history and physical form that not only provides pertinent information ahead of scheduled surgeries, but the information perfectly interfaces with existing patient record and scheduling software (GE’s Perioperative).

2.The pre-admission testing online health history has improved workflow, reduced waste, and improved continuity

Andrew Stella-Vega (left) and Vivian Riggs earned GE’s top award.

This integration has several benefits, chief among them saving time for both patients and nurse schedulers. In addition, the new program – with the checks-and-balances aspect of its targeted medical questions – means fewer same-day cancellations, which cause holes in the surgery schedule that could otherwise be filled with another patient and, many times, waste supplies that are opened in the prepared operating room but need to be discarded because they are exposed and no longer usable.

“The pre-admission testing online health history has improved workflow, reduced waste, and improved continuity,” said Adele Emery, RN, director of the USF Health Ambulatory Surgery Center (ASC).

“The development of the USF online patient health history questionnaire is a major improvement in the preoperative evaluation process,” said Ward Longbottom, MD, who has been the co-medical director and director of anesthesiology at the USF Morsani surgery center since its opening and has been instrumental in the development of the online questionnaire. “It is highly efficient and cost effective along with being a huge patient satisfier. No more lengthy  telephone assessments or inconvenient unnecessary preoperative visits. With the online health history, we’ve seen decreases and hope to eliminate the number of phone calls to patients just to get their health histories. And the ease of integrating this information into our electronic patient records means it can be easily reviewed by the entire health team instantaneously.”

With the new program, patients fill out the easy-to-use, secure online form (created by application developer Stella-Vega) at their convenience prior to surgery. Through an interface program (created by Perioperative System Manager Riggs) the information carries over into the patients’ EMR and the ASC’s scheduling.

GE’s first-place award went to the USF Health IS team.

Previous to the new program, lengthy phone calls between nurse coordinators and patients, excess paperwork in the world of electronic medical records, and miscues in communication between patient and medical personnel were the norm, Riggs said.

“This program definitely streamlined the process for the ASC,” Riggs said. “Preadmission testing nursing labor hours have been cut by 66 percent for patients opting to use the online form. Anesthesiologists reported only positive outcomes and improvement in their patient workflow. And patients seem to really like the process, too. The feedback has been great.”

Stella-Vega said that the next step is to build the tracking programs.

“We’re building the business and number-crunching side of the program now,” he said. “But it’s pretty much unlimited what we can do with this.”

“Vivian and Andrew created a very innovative solution to a basic need at the ASC,” said Sidney Fernandes, interim chief information officer and director of the Application Development for USF Health Information Systems. “This is an ideal project on several levels: it showed good teamwork, it is patient-centered, and it offers great system and workflow improvements.”

The integrated form is one of several projects the USF Health IS department has spearheaded that has benefitted clinical and academic departments throughout USF Health, Fernandes said.

How unique is this new program? Two things hint that the program is significant.

First, Riggs and Stella-Vega earned GE’s 2011 Customer Innovation Award for their work. GE Healthcare provides the awards to recognize organizations that have implemented its GE Centricity Perioperative software in ways that result in marked improvements in clinical efficiency and financial performance. They accepted the first-place award at the GE Healthcare Perioperative conference in early September.

And second, Riggs has received calls from several hospitals and medical facilities asking about the program.

“We built this program from the ground up with input from our anesthesiologist expert, Dr. Ward Longbottom, the Preadmission Testing Nurses, and GE” Riggs said. “Paperwork has begun for the patent.”

Story by Sarah A. Worth, photos by Eric Younghas, USF Health Office of Communications

3.Pediatric Anamnesa (History)

Pediatric History chaudhary photo

The pediatric history, though essentially similar to that for adults, should contain certain information usually not recorded for the older patient.  In addition, some areas of the history require greater or lesser emphasis.  These notes are not intended to define the entire pediatric history, but rather to emphasize the main differences from the history for adults.




  • Identifying
  • The
  • Chief
  • Patient
  • Medical
  • Review of

Identifying Information

The age and sex of every patient, at the beginning, are essential for orderly consideration.  These facts must be included at the beginning of every write-up.

The Informant

One of the most important aspects of the pediatric history is that it is usually obtained from a person other than the patient.  Thus, identification of the source of the information and an estimate of the reliability of that individual are extremely important.  Information may be exaggerated, minimized or withheld by the parent or other individual providing the history.  Since the history is usually taken while the child is present, it is appropriate to turn to him/ her occasionally (provided that he/she is old enough to respond) and seek confirmation of the complaint by asking direct questions, such as “Can you show me where it hurts?”  For the older child, differences between the parent’s assessment of the situation and the child’s version may become apparent.  This type of information can be very useful to the examiner in his/her evaluation of the family, as can other observations of the interaction of patient and child (excessive dependency, unusual degrees of permissiveness or discipline).

Chief Complaint

This is the primary reason why the patient or parent(s) is seeking medical aid and should be in his/her own words.  Remember that the reason stated by the parent for bringing the child to medical care may not be the real one.  The mother who just wants her child to “have a thorough check-up” actually may be seeking help with behavioral problems, school difficulties or other complaints that are uncomfortable for her to discuss.

Patient Profile

The “work” of the young child is play, and that of the older child is school.  Questions about these activities should therefore replace those relating to work and life style for the adult.

Past Medical History

The past medical history of the child should begin with the pregnancy which results in his birth, with particular attention to its length, any significant illnesses or bleeding, the adequacy of prenatal care, and exposure to any drugs or irradiation.  The length of labor, the type of delivery, and the birth weight should be recorded if known.  Problems during the neonatal course, such as the need for being in an incubator, of receiving oxygen, or the presence of “mucus”, jaundice, or cyanosis should be identified.  If the mother’s recollection is hazy (which is frequent for this kind of information), two useful clues may be obtained by determining whether the infant was brought to the mother early and regularly, and whether he went home on schedule with her.  If a Cesarean section was done, indicate why.

For children in the first two or three years of life, information about early feeding patterns can be important, and should therefore be obtained regularly.  Was the infant breast or bottle fed; when were solid foods such as cereal begun; were vitamins or iron given; when was the child weaned from the breast or bottle?

The history regarding communicable diseases is particularly important in children, since the lifelong immunity conferred by most of these diseases is an important consideration in the differential diagnosis in a child with an acute infection.  For similar reasons, the immunization status in regard to diphtheria, tetanus, pertussis, varicella, poliomyelitis, hemophilus influenza Type B, hepatitis B, rubeola, rubella mumps, and stretococcal pneumoniae should be obtained for each patient.  Some patients may have been immunized against influenza, typhoid or other conditions, particularly if they have underlying heart problems or have been abroad.

Family Medical History

A question about congenital anomalies is warranted, particularly if the patient is being evaluated for an anomaly.  ANY DISEASE WHICH IS SUSPECTED IN THE PATIENT MAY NEED TO BE SOUGHT IN THE FAMILY.  Remember – This should be reported from the standpoint of the patient.  (eg. mom may state that her dad has hypertension but you would write: paternal grandfather with hypertension.)

Review of Systems

The systemic review must be tailored to the age and primary complaints of the patient.  A question about urinary or fecal incontinence has little meaning for the small infant!  On the other hand, the occurrence of bedwetting after age five years would be of significance and should be recorded.  Similarly, subtle complaints such as palpitations or parethesias may not be readily recognized or interpreted by a child.

An extremely important aspect of the review of systems in childhood relates to growth and development.  When possible, it is desirable to obtain previously recorded growth data, as are often available from physician’s instruction booklets or from baby books kept by the parents;  these data may be compared with those obtained at the time of the present evaluation.  It is sometimes useful to compare the growth of an individual child with that of his siblings.

Development data may be more difficult to obtain, particularly as children become older; again, baby books may be helpful.  Though information about all of the aspects of development (motor, adaptive, language and personal/social) is desirable, it is often difficult to ascertain the precise ages at which the child achieved a specific milestone.  Recollections about the following tend to be reasonably accurate:

     1.  Motor – age when walked alone, rode a tricycle

     2.  Adaptive – age when learned to button up

     3.  Language – first words and use of words as short sentences

     4.  Personal/Social – age when toilet trained

It is also important to develop some understanding regarding the personality and behavior of the child.  Inquiry should be made regarding the child’s relationship with adults, siblings, and peers.  Patients should be asked about overall behavioral patterns, such as “nervousness,” hyperactivity, or a tendency to become upset with light provocation.  Habits such as thumbsucking, nail biting, and pica should be asked about, as should the common behavioral problems like temper tantrums, sleep disturbances and unusual fears.  It is desirable to get information about whether the child is easy or difficult to discipline, and who in the family is responsible for most punishment.  Detailed discussions about behavior problems should not, of course, be conducted in the child’s presence.


Burnout, Injuries & the Over Trained School Athlete

November 8, 2011 By 3 Comments

The American Academy of Pediatrics recognizes the importance of physical exercise and the potential for school athletics to provide a structured regular form of physical activity for kids.  In an attempt to keep children safe, the AAP makes recommendations regarding the prevention and management of concussions, little league elbow, and various other medical conditions, from bleeding disorders to playing with a single functioning eye or kidney.  The guidelines while helpful do not address each clinical scenario.

In the last 6 weeks, the following children were seen in my office**:

  • 16 yo volleyball player with a history of a fractured spine who trains 5 days a week year round in only one sport
  • 15 yo healthy appearing wrestler with a BMI at the 50% who wants to lose 10 pounds
  • A seventh grader with two days of persistent headache after head trauma during a basketball game
  • Soccer player with one kidney 
  • An obviously anxious 12 yo straight A student with chest pain at every football practice despite a completely negative medical work up for lung and heart problems
  • 17 yo who plays 3 different sports not because he enjoys them but because “he needs to keep his options open for college.”  His practices leave no time for family meals.                                 (**Stories changed slightly to protect identities)

Parents and athletes who present for sport physicals are not interested in modifying their training, changing sports, or slowing down.  Parents expect my signature and clearance, and if I don’t provide it, they can go to the local retail clinic, seek care at another office practice or from a specialty physician.

30-45 million children 6-18yo participate in some type of athletics.  Although exercise is essential to good health, participation in school athletics often results in injury.  For instance, according to the Center for Disease Control, high school athletes account for an estimated 2 million injuries, 500,000 doctor visits, and 30,000 hospitalizations annually.

The CDC funded a study in 2005-06 that included a representative sample of high school athletes from across the nation.  Athletic trainers at the schools tracked injuries (occurred while practicing or playing a game, required medical attention from the trainer or a physician and kept the athlete out of activity for at least one day beyond the injury) and entered them into a internet surveillance system.  They tracked 4.2 million athletes playing football, wrestling, basketball, soccer, baseball, softball and volleyball (see the table below).  Injury rates were highest for football, wrestling and soccer with competition more likely to cause injury than practice.   80% of the 1.4 million injuries were new not recurrent problems.

TABLE. Sport-specific injury rates* in practice, competition,

and overall — High School Sports-Related Injury Surveillance

Study, United States, 2005–06 school year


Sport                       Practice               Competition         Overall

Boys’ football         2.54                           12.09                          4.36

Boys’ wrestling      2.04                           3.93                            2.50

Boys’ soccer           1.58                            4.22                            2.43

Girls’ soccer           1.10                            5.21                             2.36

Girls’ basketball    1.37                           3.60                            2.01

Boys’ basketball     1.46                          2.98                             1.89

Girls’ volleyball     1.48                           1.92                             1.64

Boys’ baseball        0.87                          1.77                             1.19

Girls’ softball         0.79                          1.78                              1.13

Total                       1.69                         4.63                            2.44

* Per 1,000 athlete exposures (i.e., practices or competitions).

Although this study included common sports, there are roughly 30 different options for high school athletics.  If parents and athletes knew the injury rates of various sports upfront would that influence their choice of sport?  The injury rates of junior high, middle school and even elementary school children were not addressed in this study.  However, we do know that the age at which kids play competitively is decreasing and thus injuries are increasing in this younger group.  Maybe our youngest kids should only practice and not compete as that nearly doubles the risk of injury.

The AAP recommends that children be at least 6 years old before playing team sports.  Furthermore the clinical report that addresses injuries and overtraining in athletes encourages pediatricians to:

  1. Encourage athletes to strive to have at least 1 to 2 days off per week from competitive athletics, sport-specific training and competitive practice (scrimmage) to allow them to recover both physically and psychologically. 
  2. Advise athletes that the weekly training time, number of repetitions, or total distanceshould not increase by more than 10% eachweek (eg, increase total running mileage by 2 miles if currently running a total of 20 miles per week). 
  3. Encourage the athlete to take at least 2 to 3 months away froma specific sport during the year. 
  4. Emphasize that the focus of sports participation should be on fun, skill acquisition, safety, and sportsmanship. 
  5. Encourage the athlete to participate on only 1 team during aseason. If the athleteis also a member of a traveling or select team, then that participation time should be incorporated into the aforementioned guidelines. 
  6. If the athlete complains of nonspecific muscle or joint problems, fatigue, or poor academic performance, be alert for possible burnout. Questions pertaining to sport motivation may be appropriate. 
  7. Advocate for the development of a medical advisory board for weekend athletic tournaments to educate athletes about heat or cold illness, overparticipation, associated overuse injuries, and/or burnout. 
  8. Encourage the development of educational opportunities for athletes, parents, and coaches to provide information about appropriate nutrition and fluids, sport safety, and the avoidance of overtraining to achieve optimal performance and good health. 
  9. Convey a special caution to parents with younger athletes who participate in multigame tournaments in short periods oftime. 



Genetic Dysfunction found in Non-neuronal cells for Neurological Disorders

La Jolla, November 9, 2011 – Al La Spada, MD, PhD, et al, used a variety of transgenic mouse models to show that SCA7 results from genetic dysfunction in associated non-neuronal support cells to affected neurons. In collaboration with researchers at UC San Diego School of Medicine and University of Washington, the findings were published in the November 9 issue of the Journal of Neuroscience.
Kawasaki Disease Triggers May Be Wind-Borne

La Jolla, November 10, 2011 – In an issue of Scientific Reports published on November 10, 2011, Prof. Jane Burns et al suggest large-scale wind currents from Asia to Japan and across the North Pacific may be linked to Kawasaki Disease (KD).
Third Annual Pediatrics Translational Research Symposium at Rady Children’s Hospital-San Diego, 2011

October 25th, 2011 – UC San Diego’s Department of Pediatrics and Rady Children’s Hospital proudly hosted the third annual Pediatric Translational Research Symposium on Advanced Genomics and Personalized Medicine. Held at the Acute Care Pavilion at Rady Children’s Hospital, the Symposium was well-attended, with over 100 attendees.

Faculty, Fellows, Residents, and Clinicians invited to our Annual 2011 Pediatric Translational Research Symposium that will be held: Tuesday, October 25, 2011, Acute Care Pavilion Conference Room, Rady Children’s Hospital Campus (Kearny Mesa) from 8:30 am – 4:15 pm; *Breakfast, Lunch, & Refreshments will be provided; * Parking Validation Available
Gahagan named Chief of New Pediatrics Division at UC San Diego

September 26th, La Jolla – Sheila Gahagan, M.D., M.P.H., Professor of Clinical Pediatrics and Division Chief of Child Development and Community Health, has been recently appointed as Division Chief of Academic General Pediatrics, joining this group with the Division of Child Development and Community Health.
Dr. Mark Sawyer Interviewed by Infectious Diseases in Children

In an interview with Infectious Diseases in Children, Dr. Mark Sawyer says vaccination rates are not as strong as they should be, and young babies are at the highest risk for pertussis, a whooping cough that is nearly as contagious as chickenpox.
Obese kids may face social, emotional woes

Dr. Jeffrey Schwimmer, a pediatric gastroenterologist and an associate professor of pediatrics at UCSD and RCHSD, said the physical health risks of obesity in childhood can have lifelong consequences. Those include sleep apnea and fatty liver disease, which can, over time, cause irreversible damage to the liver, diabetes and high blood pressure.
Sivagnanam Receives 2011 NASPGHAN Young Faculty Investigator Award

September 19, 2011, La Jolla, CA – Dr. Mamata Sivagnanam, Asst. Professor and physician-scientist in the Division of Pediatric Gastroenterology, Hepatology and Nutrition at UC San Diego and Rady Children’s Hospital-San Diego, was awarded this year’s NASPGHAN Young Faculty Investigator Award.
What’s in a kids meal? Not Happy News, Researchers Find

The study of data compiled by Dr. Kerri Boutelle et al. in the Department of Pediatrics at the University of California, San Diego, appearing this week in the new journal Childhood Obesity, showed that convenience resulted in lunchtime meals that accounted for between 36 and 51 percent of a child’s daily caloric needs.
Sander Receives 3 Transformative Collaborative Project Awards from Beta Cell Biology Consortium (BCBC)

August 24, 2011, La Jolla, CA – Dr. Maike Sander, Associate Professor in Pediatrics and Cellular & Molecular Medicine, was awarded over $2M collectively in 3 Transformative Collaborative Project Awards from the Beta Cell Biology Consortium (BCBC).
Meet UC San Diego’s New Pediatric Chief Residents, 2011-2012

August 21st, 2011, La Jolla, CA – UC San Diego’s Department of Pediatrics at the School of Medicine, welcomes 3 new Chief Residents for the 2011-2012 academic year – Drs. Megan Browning, Monique Mayo, and Tina Udaka.
UC San Diego’s Alysson Muotri named 2011 Poptech Science Fellow

Dr. Alysson Muotri, Assistant Professor in the Department of Pediatrics/Cellular & Molecular Medicine, University of California, San Diego has been named a 2011 PopTech Science and Public Leadership Fellow. Muotri’s work is currently using stem cells to study possible causes – and cures – for autism and other mental disorders.
UC San Diego School of Medicine Names Feldstein as New Division Chief for Pediatric Gastroenterology and Nutrition

July 1st, La Jolla, CA – The Department of Pediatrics, UC San Diego, Rady Children’s Hospital-San Diego, names Ariel Feldstein, MD, as the Division Chief for Pediatric Gastroenterology and Nutrition. Feldstein joins the Department of Pediatrics from the Cleveland Clinic in Cleveland, Ohio, where he was the Director of Research for the Pediatric Institute.
Low VAPB Protein Levels May Be Cause for Inherited ALS

Published in the June, 2011 issue of Human Molecular Genetics, Alysson R. Muotri, Ph.D. Assistant Professor at UC San Diego’s Department of Pediatrics and Cellular and Molecular Medicine, reported evidence of reduced levels of the VAPB protein which may play a central role in causing inherited amyotrophic lateral sclerosis (ALS).
NEURON: La Spada et al. Discovers Regulators and Noncoding RNA Role in Neurodegenerative Disorders

NEURON, June 22, 2011: Dr. Albert La Spada – Division Chief of Genetics in UC San Diego’s Department of Pediatrics and Cellular and Molecular Medicine, and Rady Children’s Hospital-San Diego, recently identified the mechanism contributing to the transcriptional dysregulation in Spinocerebellar ataxia 7, an inherited neurological disorder.
Sander elected to American Society for Clinical Investigation, 2011

Dr. Maike Sander, associate professor in pediatrics and cellular & molecular medicine, was elected to the America Society for Clinical Investigation. Dr. Sander joins 62 other UC San Diego faculty members who have been elected to the Society since the inception of the UC San Diego School of Medicine.
Immunity: Nizet et al Discovers How Immune System Fights Anthrax Infections

June 22, 2011 – Scientists in collaboration with Dr. Nizet at the School of Medicine and Skaggs School of Pharmacy and Pharmaceutical Sciences have uncovered how the body’s immune system launches its survival response to the notorious and deadly bacterium anthrax. Published in the June 22 issue of the journal Immunity, the research describes key emergency signals the body sends out when challenged by a life-threatening infection.
TIME: Parent-Only Education Helps Children Lose Weight

Current treatment programs generally require participation by both parents and children in a plan that combines nutrition education and exercise with behavior therapy techniques.Kerri N. Boutelle, PhD, associate professor of pediatrics and psychiatry at UC San Diego and Rady Children’s Hospital, San Diego, demonstrated that parent-only groups are an equally viable method for weight loss.
Anders Receives 2011 Leonard Tow Humanism in Medicine Faculty Award

May 31, 2011, La Jolla – Dr. Bronwen Anders, professor of pediatrics at UC San Diego, was awarded the prestigious peer-nominated Leonard Tow Humanism in Medicine Award presented by the Arnold P. Gold Foundation. In addition to peer-nominations, Dr. Anders was selected by a subcommittee of the School’s Faculty Council as the faculty recipient of the award.
Tremoulet et al finds Filipino Children at Higher Risk in KD

May 6, 2011, Pediatric Infectious Disease Journal: Tremoulet et al. at UC San Diego, Rady Children’s Hospital-San Diego, finds that Filipino children with KD are at a higher risk for inflammation of the blood vessels of the heart than those of other Asian and non-Asian backgrounds.
King Receives $1.3 Million CIRM Award for Type 1 Diabetes Stem Cell Research

Dr. C.C. King, Associate Research Scientist, in the Pediatric Diabetes Research Center, UC San Diego, has been awarded $1,313,649 to understand the role of microRNAs in the stem cell differentiation process pertaining to insulin-producing cells and possible treatments for type 1 diabetes. The proposed research may provide critical insight to the regulatory mechanisms of cell differentiation and create opportunities to better control differentiation of hESCs into insulin-producing cells.
UC San Diego Pediatrics Group Works To Get San Diego Kids Fully Immunized

Dr. Mark Sawyer is a pediatrician in infectious diseases at UCSD, Rady Children’s Hospital. “We need to help protect others who can’t be immunized, either because their immune system is compromised, or they’re too young. The only way to protect everybody is to get everyone immunized.”
Itkin-Ansari and Tremoulet Receive Prestigious Hartwell Biomedical Research Awards

April 6, 2011 – Pamela Itkin-Ansari, PhD and Adriana Tremoulet, MD, assistant professors in the Department of Pediatrics, UC San Diego, Rady Children’s Hospital-San Diego, are two among twelve recipients of the Hartwell Individual Biomedical Research Awards, honoring researchers whose work contributes to the advancement of children’s health.
NATURE: Structure Formed by Strep Protein can Trigger Toxic Shock

Dr. Partho Ghosh, professor of chemistry and biochemistry, and Dr. Victor Nizet, professor of pediatrics, have collaborated to show how a bacterial protein called M1 combines with human fibrinogen, forming a complex that activates white blood cells to provoke uncontrolled inflammation and shock during severe strep infections.
Stucky Fisher Receives Highest Honor from Society of Hospital Medicine

March 31st, 2011 – Dr. Erin Stucky Fisher, Vice Chair of Clinical Affairs, Professor of Clinical Pediatrics and Hospitalist at UC San Diego, Rady Children’s Hospital-San Diego, was one of four hospitalists to receive the highest honor as a Master of Hospital Medicine (MHM) by the Society of Hospital Medicine this year.

The Department of Pediatrics at UC San Diego, Rady Children’s Hospital-San Diego, congratulates incoming interns for Fall 2011. During the three years of consecutive training, the resident will evolve progressively with increasing knowledge and responsibility to all aspects of general pediatric medicine.
UC San Diego Pediatricians talk about Fetal Alcohol Syndrome on KPBS Radio Show

“Drinking alcohol during pregnancy is one of the leading causes of birth defects.”Drs. Kenneth Lyons Jones, Doris Trauner, and Christina Chambers talk about the characteristics and prevalence of fetal alcohol syndrome on KPBS radio.



 23rd Annual Graduate French and Italian Symposium

Forming and De-forming the human body

April 16-17, 2010

Keynote Presentation by
Walton O. Schalick, III, MD, PhD
Assistant Professor of Medical History, Rehabilitation Medicine,
History of Science and Pediatrics, University of Wisconsin-Madison

23rd Annual Graduate French and Italian Symposium

Forming and De-forming the human body

April 16-17, 2010

Keynote Presentation by
Walton O. Schalick, III, MD, PhD
Assistant Professor of Medical History, Rehabilitation Medicine,
History of Science and Pediatrics, University of Wisconsin-Madison

2010 Symposium website

Keynote Speaker: Walton O. Schalick, III, MD, PhD

We are delighted to have Walton O. Schalick, III, MD, PhD give this year’s keynote address,“‘Caveat corpus:’ Disabled Bodies and the Medical Marketplace in Medieval and Nineteenth-century France.

Walt is Assistant Professor of Medical History, Rehabilitation Medicine, History of Science and Pediatrics at the University of Wisconsin-Madison. Walt’s research embraces a triptych of: the history of medieval medicine and pharmacology, the history of children with physical disabilities in 19th- and 20th-century Europe and the US, and the practical ethics of pediatric emergency research, some of which has appeared in articles and chapters and the balance of which is pending in two monographs. He is Associate Editor for the five-volume, Encyclopedia of Disability (2005), which won Best Reference Award from the Library Journal and an Outstanding Award from the American Library Association’s Booklist Journal.

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Mission statement of the GAFIS symposium

The Graduate Student Symposium of GAFIS, now in its 23rd year, provides a forum for intellectual and scholarly exchange in a positive collegial atmosphere. Interdisciplinary in nature, this national event gives future colleagues the chance to meet each other and to hear about current issues in upcoming research. Excellence and pertinence are assured through an anonymous and peer juried selection process.

Basic criteria for the selection process:

  • Presentations must address the topic of the symposium, respecting all constraints given in the call.
  • Presentations should be innovative, problematizing the chosen issue within a theoretical framework.
  • Presentations should be organized into focused panels that clearly complement each other.

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Call for papers
Abstract deadline February 1, 2010

The body is a big sagacity,
a plurality with one sense,
a war and a peace,
a flock and a shepherd.
– Friedrich Nietzsche

The human body has continued to captivate intellectuals of the arts and sciences throughout history, whether through an aesthetic or physiological study of its structural form and internal mechanisms or in an attempt to comprehend the complexities of the mind that reside within the biological machine. Literature, art, music, film, and storytelling often turn our attention to these ideas of the body, and their inquiries into the physical body and the mind have framed our universal conceptions of health and disease while also giving rise to myriad variations on the notions of bodily normality and abnormality. The body becomes a receptacle for our non-corporeal collective and individual identities, divisions, and prejudices. Sick or well, beautiful or ugly, powerless or powerful, the body is the site of competing visions that structure our perceptions of its physical form and its philosophical and social signification. While we frequently favor the “normal” and thereby reject the “abnormal”, it is the bodily abnormalities that best explore and question our definitions and interpretations of the body. Reflection on these bodily deviations not only elucidates what we consider to be normal and why, but it also destabilizes conventional distinctions between the typical and the atypical, between conformity and deviancy.

The 23rd Annual Symposium of the Graduate Association of French and Italian Students seeks to investigate various representations of the deformed or deviant body in order to explore what constitutes our formulation of health (normality) and disease (abnormality).

We welcome submissions from all applicable disciplines that shed light on the ways in which we can “reform” our general conceptions of the body through the lens of the deviant or otherwise “deformed” body.

Suggested topics include, but are not limited to:

The Sick Body:

  • Physical illnesses, epidemics, disabilities, doctors and medicine
  • Mental illnesses, neuroses, psychoses, the mentally ill as Other, treatment, therapy, the fragmentation of the self
  • Medical or societal definitions of the healthy and unhealthy human body

The Ugly Body:

  • Aesthetic conceptions of the body in artistic, visual, literary and cinematographic forms
  • Physical deformities, monstrosities, the grotesque
  • Fragmentation, bodily manipulation or transformation

The Sexual Body:

  • Queer studies and the queering of the body, sexuality, transsexuality
  • Gender studies, Woman as Other, masculinities and feminities, social or physical gendered roles
  • Eroticism, fetishism, masochism

The Powerless Body:

  • Crimes against the individual, crimes against humanity, genocide, persecution, destruction of the body
  • Politics, authority, regulation of the body
  • Effects of colonialism, occupation, wars on the body

We invite abstracts in English ranging from 200 – 250 words that relate to or expand upon the topics suggested above. Papers will be limited to 20 minutes and must be presented in English. In your abstract, please include name, email address, academic affiliation, and AV requests. Along with your abstract submission, please suggest the category or categories to which you feel your submission is best suited.

Please address inquiries and abstract submissions to Theresa Pesavento and Tina Petraglia at“>. Abstracts must be received no later than February 1, 2010. For further information, please visit our official GAFIS symposium website listed below.






















Physical Examination of the Infant and Child

  • Introduction
  • Approach to
    the Child
  • Vital Signs
    and Measurements
  • Head to
  • H&P Tips


Many students, and experienced physicians, approach the examination of the infant and child with trepidation and lack of confidence.  In actuality, the thorough examination of a pediatric patient can be accomplished in only a few minutes if the examiner takes the time to establish rapport with his patient, approaches the task in an organized and logical way, and is familiar with the normal variations in pediatric patients.  You are encouraged to use every opportunity for examining the infant or child, for only with experience will you be able to accomplish the task easily and interpret the findings accurately.

Approach to the Child

The normal apprehension of the young patient can often be alleviated by a gentle and friendly approach.  Most physicians develop a few “tricks” that fit their style and personality, and help them to achieve a satisfactory examination.  It may be useful to allow an infant to have his bottle or a pacifier.  An older infant or a young child is often best examined on his mother’s lap.  Allowing the child to touch or play with the examination instruments may relieve his fear of them.  It is often helpful to establish physical contact with the child prior to the examination, such as handing him a toy or even playing with him gently.  Above all, carry out first those parts of the examination that would be most interfered with by crying, such as auscultation of the heart or palpation of the abdomen; examination of the ears, eyes, and throat or a rectal examination should be deferred until last!  If all else fails, and using a kind and understanding attitude, restrain the child firmly but gently, and get the examination done as expeditiously as possible despite his apprehension and resistance. 












Vital Signs and Measurements

The temperature of infants and pre-school children child is best taken rectally since most younger children cannot be trusted to hold the thermometer under the tongue without biting or dropping it.  The heart rate of young infants is often easiest to measure by auscultation at the cardiac apex.  The respiratory rate should always be counted, especially in infants, since tachypnea may not be appreciated otherwise. Length is recorded for infants and toddlers less than 3 years while supine; height is recorded for the older child who is measured while standing.  Measurement of head circumference is done at the time of each visit during the first two years of life, but usually only on the first visit thereafter, unless apparently abnormal.

Head to Toe Exam

  • Lymph
  • Eyes
  • Ears
  • Mouth and
  • Chest
  • Abdomen
  • Extremities

Lymph Tissues

The findings of nodes up to one centimeter in diameter in the anterior cervical and inguinal regions is common in children, and of itself should not be considered to be significant.  We reiterate strongly the notation in your text regarding the frequency with which normal children have normally large tonsils.


Lack of cooperation of the patient discourages routine funduscopic examination in infants and young children, but at least the presence of a red reflex should be determined.  The early diagnosis of strabismus, if present, is essential, and should be determined by identifying an asymmetric reflection of a bright light in the eyes, or by the use of the “cover test.”  (Cover one eye at a time, and observe for shifts of the uncovered eye, or of the covered one after the cover is quickly removed.)


Otoscopic examination is an essential part of every pediatric evaluation.  In the infant, the canal is directed upward, so the auricle should be pulled downward to view the drum, rather than upward and back as in the older child and adult.

Mouth and Throat

This phase of the examination is usually best left until last; even some very “good” children become upset when approached by a physician with a light in one hand and a tongue blade in the other.  Every child should be given the opportunity of opening his mouth and extruding his tongue without “assistance”; it is often possible to visualize all structures down to and including the epiglottis in this way.  If the child is uncooperative and resistant, assistance of the mother or nurse should be obtained so that the examination can be conducted as expeditiously as possible; the hands and head can be immobilized at the same time for example by “pinning” the raised arms of the supine child against the side of his head.

The most common health problem of children is dental caries; inspection of the teeth and gums should be a routine part of each examination.


During early infancy, and especially in premature infants, respiratory movement may be irregular, intermittent and variable in rate and depth.  Pauses between breaths up to 10 seconds, in the absence of cyanosis or other indicators of respiratory distress, are common in normal infants during sleep.  Breathing during infancy and early childhood is characteristically abdominal or diaphragmatic in appearance.  Thoracic movements with breathing become more predominant around age 7-8 years and older.  The normal range of respiratory rates, sleeping and awake is found in your references.

Slight retractions with inspiration are commonly observed, especially during infancy.  More pronounced retractions, especially when associated with tachypnea, are seen with important pulmonary disease.

Percussion is performed in infants and children in much the same manner as for adult patients.  Auscultation requires a stethoscope with small enough bell or diaphragm to fit closely over the interspaces.  In infancy and through age 5-6 years, breath sounds are relatively louder and harsher compared with those in adults.  Classify breath sounds as:

Vesicular (loud during inspiration, medium-to-high pitched, and long duration; heard best over the upper lung fields and into the axillae).

Tracheal (heard over the trachea / upper sternal region;  more tubular and higher pitched than vesicular breath sounds).

Bonchovesicular (longest during expiration, with high pitch and increased amplitude compared to inspiratory phase sounds; heard best between scapulae and parasternal anteriorly).

Rhonchi (musical continuous sounds; includes categories of wheezing and vibrations).

Rales (crackling or bubbling; fine versus coarse).

Rubs (grating, jerky, leathery, creaking, rubbing sounds which can be intensified with increased pressure on the chest wall with the stethoscope).

Heart and Blood Pressure

Examination of the heart begins with inspection for the normal apical impulse as well as any unusual precordial impulses.  These may be difficult to palpate in infants, but by age 4-7 years most children will have a palpable apical impulse in the 5th to 6th interspace within the mammary line.  It is best palpated with the child sitting and leaning forward.  During this portion of the cardiac exam, it is important to palpate for pathological thrills associated with the louder (grade 4 and louder) murmurs.  The determination of heart size by percussion is of limited accuracy for most examiners (malposition of the apical impulse is usually a better indicator of possible cardiac enlargement).

The resting pulse rate should be recorded for comparison with reference values.  The normal range of resting heart rates for infants and children is found in your references.

In sinus arrhythmia the pulse rate increases during inspiration and slows during expiration.  This is a normal finding in most children above age three.  A slow heart rate (relative to the ranges described above) is frequently noted in healthy trained athletes. 

Palpation of the femoral pulses should be routinely performed to detect possible coarctation of the aorta, however presence of a normal femoral pulse does not exclude coarctation.

The preferred stethoscope for cardiac auscultation in children is one with a combined bell (for low frequency sounds) and small diameter diaphragm (for mid-to-high frequency sounds).  Examine heart sounds with the patient in the following positions:  supine, left lateral decubitus, sitting, leaning forward, and standing.  In most normal children, S1 is louder than S2 near the apex, and the converse is true near the base.  Splitting of S2 is best appreciated using the diaphragm near the base of the heart.  The sounds split during inspiration and are almost synchronous during expiration.  In the newborn, S2 is either a single sound or minimally split due to the normally high neonatal pulmonary arterial resistance and afterload, plus the relatively fast heart rates in this age group.  An apical S3 is often heard during diastole in normal children.  When an S3 is present in a tachycardic patient or with other findings suggesting heart disease, it is more appropriate to label it as a gallop rhythm.  S4 diastolic sounds are never normal.

Heart murmurs are present in around 50% of children, while the incidence of congenital heart disease is slightly less than 1% in the general population.  Clearly therefore, most murmurs will turn out to be innocent.  Determining whether a murmur is normal (innocent) or pathological requires more than simply listening to heart sounds.  This assessment includes relevant past and family history, other aspects of the physical examination, occasionally laboratory testing (e.g., chest x-ray, electrocardiography, and/or echocardiography), and is frequently made clear simply on the basis of follow-up.

Describe murmurs on the basis of:

Position in the cardiac cycle (e.g., systolic, diastolic, continuous).

Either ejection or regurgitant in character.  Ejection murmurs are generally heard over the base and are frequently normal or innocent.  Regurgitant systolic murmurs are always pathological, and are heard closer to the apex.  Regurgitant diastolic murmurs are also always pathological in origin.

Transmission (i.e., where does the murmur radiate).

Duration (e.g., early systolic, holosystolic, early diastolic).

Quality (e.g., blowing, rasping, rumbling, etc.)

Pitch (e.g., high pitch or frequency heard best with the diaphragm versus low-pitch heard best with the bell).

Intensity (i.e., grade 1-6)

Response to exercise and/or change of position (e.g., loudest while supine).

Blood pressure determination in the arms and legs should be included in routine well-baby and well-child examinations.  Except for infants, the BP should be taken while the child is sitting.  Blood pressures recorded with an inappropriately small cuff will be too high, and those with too large a cuff may be falsely low.  The proper cuff has a width which is approximately 40% the circumference of the extremity where it is placed.  The two measurement methods in most widespread clinical use are sphygmomanometric and oscillometric (e.g., the Dynamap automated BP device).  The normal range for blood pressure varies depending upon age, size (e.g., height), and sex of the patient.  Tables of normal blood pressures are found in your references.


The liver edge in the infant is often palpable one to three centimeters below the right costal margin; apparent hepatomegaly may be the result of depression of the diaphragm (e.g. due to a lower respiratory infection or asthma) –appreciation of the normal consistency and edge of the liver will help in identifying this problem.  The spleen tip may also be palpable in normal young children.  Palpation of the femoral pulse should be a routine part of the examination of the young infant, since it may lead to the diagnosis of coarctation of the aorta.

The presence of an inguinal hernia may be detected in the infant and young child by palpating over the inguinal canal for the presence of the sac which is manifested by thickening of the cord structures and sometimes by the sensation of a “silk-glove” beneath the examining finger.  A hernia in a female may contain the ovary which can be identified as a small mass within the protruding sac.

Genitalia: Male

The urinary meatus should always be inspected; a tiny round opening instead of the normal slit may indicate the presence of stenosis.  Because of the very active cremasteric reflex, small children may appear to have cryptorchidism; if the hands are warm and gentle, the apparently undescended testis can often be milked down the canal and into the scrotum to confirm its normal location.

Tanner staging is important.

Genitalia: Female

Adhesions of the labial mucosa are fairly common in young girls, and probably require no treatment if not extensive.  A white discharge is often seen in normal girls during the year or so preceding the onset of menstruation.  Inspection of the vaginal orifice for foreign bodies, or the obtaining of vaginal material for laboratory examination, is sometimes facilitated by placing the child in the knee-chest position.  Digital or instrumental examinations of the vagina are not done routinely in children, but only on specific indication.  Tanner staging is important.

Anus and Rectum

Rectal examinations are not done routinely in children, but should certainly be performed on the slightest indication, including some of those complaints for which a pelvic examination would be done in the adult female.  Rectal exam may be helpful in identifying the presence of a vaginal foreign body.  INSPECTION IS MANDATORY IN ANY EVENT.


The shape of the legs and feet of infants and young children is determined to some extent by the intrauterine position.  Some degree of bowing and inward rotation is common, but external rotation may occur.  The foot of the infant tends to appear flat, and the pre-school child’s foot is often pronated.  In the latter circumstance, having the child stand on his toes may reassure the examiner of the normalcy of the longitudinal arch.  Mild degrees of knock-knee and bow-legs are not significant in young children.

The ability of the thigh to be abducted at the hip should be tested throughout infancy, since inability to abduct is the commonest presenting finding in infants with congenital hip dysplasia.













Robert E. Merrill, M.D.
Former Assistant Editor ofThe Journal of Pediatrics


Perhaps the second most difficult area in the entire process is spelling.  We hold to the notion that those who have at least one college degree and will soon have another, should be able to use English with reasonable facility.  Some common errors, along with notes of explanation follow.  Please understand that this list barely scratches the surface.

Mucous This is the adjective and is not to be confused with:
Mucus  This is the noun.  They are not interchangeable.  Nouns are things which adjectives modify.
Funduscopic The only correct way, believe it or not.
Inflammation There are 2 “m’s” in this word.
Inflamed There is only 1 “m” here, so save them.
Vomiting Save your “t’s”, they also may become valuable some day.
Enfamil A proprietary milk product.
Organomegaly One “l” is enough.
Microcephalic With 2 “l’s” it becomes an outrageous pun.

Words to be Avoided and Words to be Used Correctly

There are many lay terms that have no place in a medical document.  Others are not words at all and should never be used anywhere.  Some of these are:

Mucousy The word you are looking for us mucoid.
Pussy Here the word is purulent.  No further comment seems advisable.
Temperature We all have a temperature; some of us have a fever.
Phlegm The word is mucus, not to be confused with mucous.
To seize Meaning to have a seizure.  To seize is to grab.
Matter A lay term if it means pus in the eye.
Stomach Meaning abdomen.
  There is no such thing as an acute abdomen.  There may be an acutely inflamed abdomen.

Strictly avoid the apothecary system at all costs.  The most confusing term is grains which may be abbreviated gr. and which in turn may be confused with grams.  To protect yourself and to protect your patients, never use this term.  Absolutely.  It is not difficult to remember that 65 mg = one of those things.  Other units in the apothecary system are even more archaic.


Don’t use them!


The organization of your write up should be constructed with the following thoughts in mind.

Please remember that the chief complaint is exactly that–not a complete history.

The present illness should contain all of the information which is germane to the problem which brought the patient into the hospital.  This must include both positive findings and pertinent negatives.  The review of systems must contain all of the remaining points which may be germane to the case.  For example, if the patient is thought to have asthma, then you will wish to include some comments in the present illness or review of systems in regard to symptoms of cystic fibrosis, which always is part of the differential of asthma.  But not both.  Relative importance is the determining factor; there are no absolute rules.  Repeat nothing.  Once you have mentioned it once in the history, please feel free to reference it throughout.  Always time everything in relation to admission in chronological order.  Absolute times and dates are worthless.

Omit nothing in the physical examination.  Those parts of the body which you do not invade must still be viewed and described.  Specifically, this refers to ear drums, fundi, breasts, genitalia, and the remainder of the perineum.  Always fully describe every abnormality.  Size, shape, tenderness, color, and so on.

If you admit a patient who has been in several times for the same problem (for example, a patient with a malignancy, hemophilia, myelomeningocele, or some other chronic condition), you may limit your write up to a review of all available information succinctly presented, a description of the present illness or present episode which brought the patient to the hospital, and the usual complete physical examination.

In the family history, be sure that the facts are related to the suspected diagnosis.  This will demand a  knowledge of genetic patterns which are to be found in textbooks.  For example, the questions to be asked, if you suspect hemophilia or cystic fibrosis must be quite specific and different.


The conclusions which you reach are the most important part of the entire write up and of course the conclusions must be based on what has gone before.  In other words, the findings should logically lead to the conclusions.  You are entitled to at least  one diagnosis.  Avoid even a very short list of “rule-outs.”  We wish to know what you think the patient has, not what he does not have and we wish to know why you reached a certain conclusion.  The diagnosis is meant to explain the chief complaint, which was the primary reason for admission to the hospital.  In every instance where an etiology can be suspected, it must be indicated.  Using the term virus or some other generality is not acceptable.  When you write out the  plan for the patient, do not include any order with which you do not agree.   Anything which you think should be done and is not ordered should be listed with the reason given.  Do not lump chemistries; do not indicate a  “CMP.”.  Rather, designate those portions of that study which are indicated in this instance.  Always explain any order which is in any way debatable, indicating why you think that order should be written or that study requested.

Please review this paper carefully.  If you will adhere to these suggestions, you will find that there will be much more time for advanced learning.



H&P Grading Form

grading form


The Rare Imperial Qing Landscape Decorations Ceramic Found In Indonesia












The Driwan’s  Cybermuseum


The Rare Qing Imperial Landscape Decoration Ceramic

Found In Indonesia


During Qing Dinasty, not many landscape decoration ceramic gift by the emperor to Indonesian Sultanate.

I have only found two ceramic from the imperial Qing de Zhen one bigger plate 35 cm and one cup, many repro items with lower quality exist.

If the Indonesian collectors have the  imperial landscape decoration ceramic which found in Indonesia , please be kind to  report.

I need the informations to complete my research,for that thanks very much.

For all collectors Merry Christmas 2011 and happy new year 2012

Jakarta,December 2011

Dr Iwan suwandy,MHA


Dr Iwan Collections

original artifact(digital restoration)

International Collections

The end @ copyright Dr Iwan Suwandy 2011