THE PEDIATRICIAN AND PEDRIATRIC SCIENCE
Dr Iwan Suwandy,MHA
special for my lovng wife Lily W.,MM,
and Grandchild Cessa,celin and antoni
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.
Pediatric University History
Yale Medical University
Department of Pediatrics, 1921-22
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)
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.
- Review of
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.
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).
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.
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
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.
- 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.
- 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).
- Encourage the athlete to take at least 2 to 3 months away froma specific sport during the year.
- Emphasize that the focus of sports participation should be on fun, skill acquisition, safety, and sportsmanship.
- 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.
- 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.
- 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.
- 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.
- Convey a special caution to parents with younger athletes who participate in multigame tournaments in short periods oftime.
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
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.
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.
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 firstname.lastname@example.org#0000ff“>. 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
- Approach to
- Vital Signs
- 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.
NO MATTER WHAT, ALWAYS TELL THE CHILD THE TRUTH ABOUT WHAT IS TO HAPPEN.
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
- Mouth and
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.
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.
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.
SOME TIPS ON RECORDING A HISTORY AND PHYSICAL EXAMINATION
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.|
|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