Transcript Welcome to: Course 473 Peds

Welcome to:
Course
473 Peds
Dr Mohamad-Hani Ali Temsah
Asst. Professor of Pediatrics
Pediatric Intensivist
KKUH – King Saud University
Riyadh – Saudi Arabia
Goals
• By completing this course, each student is
expected to
 Have general knowledge about pediatrics
 Master the basic principles and skills of
pediatrics that will allow him to work as an
efficient and safe intern
Keys to Success in this course
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Punctuality
Motivation
Lots of clinical exposure
Critical thinking
Make good use of your teachers
Reading …. Practicing ….. Feedback!
Recommended Readings
http://www.geocities.com/kkuh_pedia
Student s Guide Student’
Distribution
􀁺4 Major groups A,B,C, and D; each
subdivided into 3 subgroups (e.g. A1, A2,
A3) total of 12 subgroups:
􀁺 subgroups in KKUH
􀁺 subgroups in KFMC / RMC
􀁺Swab in week 7
Activities
􀁺Tutorials: always come prepared
􀁺Clinical sessions: 9-12 am, 2/wk
􀁺Ward rotation: as a sub intern
􀁺OPD: AM or PM
􀁺ER: 8-12, 12-4, 4-8
􀁺Nursery: AM or PM
􀁺Morning report: important to attend & participate
Activities
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Clerking:
Should be genuine
Hand written, readable and clear
Stick to the given format
Strictly adhere to time limits
Different cases, from different systems
Exams
• MCQs:
 Mid-Cycle: usually in week 9
 Final: week 12
 Case scenario format
• OSCE:
 week 12
 5 stations including history taking, physical
examination and oral
Extra Notes
• Extra sessions arranged for the whole group
should only be on Thursdays
• Remember to fill the course evaluation sheet
and submit it during the mid-cycle exam
• Remember: We are here for you
• WE WISH YOU THE BEST OF LUCK
History Taking in Pediatrics
Similar to adults, Plus!
History
• Patient ID
• Family History (FHX)
• Present Complaint(s) ( C/O)
• Social History
• History of Present
Complaint(s) (HPI)
• Vaccination History
• Past Medical History (PMHX)
• Pregnancy and delivery
• Neonatal History
• Systemic Review
• Nutritional History
• Developmental History
• Drugs
• Allergy
Identifying Data:
• Patient's name, age, sex;
 Informant (parent): Reliability!
Chief Compliant (CC):
• Reason that the child is seeking medical care and
duration of the symptom.
History of Present Illness (HPI):
• Describe the course of the patient's illness,
 when and how it began,
 character of the symptoms;
 aggravating or alleviating factors;
 pertinent positives and negatives,
 past diagnostic testing.
Past Medical History (PMH):
• Medical problems,
• hospitalizations,
• operations;
Perinatal History:
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Gestational age at birth,
obstetrical complications, type of delivery,
birth weight,
Apgar scores,
complications (eg, infection, jaundice),
length of hospital stay.
Nutrition:
 Breast feeding vs. bottle
 Amount and frequency
 Quality of food
Medications:
• Names and dosages
• Allergies to Rx or Food
Developmental History
1. Gross Motor: e.g. sitting and walking
2. Fine Motor:e.g. Pincer grasp and scribble
3. Language:e.g. say “mama”“baba”and two words
sentence
4. Social: e.g. smiling, playing with others
• Relationships with siblings, peers, adults.
• School grade and performance, behavioral
problems.
Immunizations:
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Know the local schedule
Type of vaccine: killed or live-attenuated
How they are given?
Adverse reactions
Avoid “up to date”
Family History
• More detailed
• Learn to draw family pedigree
Family History:
• Medical problems in family, including
 the patient's disorder;
 diabetes, seizures, asthma, allergies, cancer, cardiac,
renal or GI disease,
 tuberculosis,
 smoking.
Social History:
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School level and grades
Relationship with parents and siblings
Friends
Family situation, smoking, drugs.
Parental level of education.
Safety: Child car seats, smoke detectors, bicycle
helmets.
Review of Systems (ROS)
• General: Overall health, weight loss, behavioral
changes, fever, fatigue.
• Skin: Rashes, moles, bruising, lumps/bumps,
nail/hair changes.
• Eyes: Visual problems, eye pain.
• Ear, nose, throat: Frequency of colds,
pharyngitis, otitis media.
Cont. ROS
• Lungs: Cough, shortness of breath, wheezing.
• Cardiovascular: Chest pain, murmurs, syncope.
• Gastrointestinal: Nausea/vomiting, spitting up,
diarrhea, recurrent abdominal pain, constipation,
blood in stools.
Cont. ROS
• Genitourinary: Dysuria, hematuria, polyuria,
discharge.
• Musculoskeletal: Weakness, joint pain, gait
abnormalities, scoliosis.
• Neurological: Headache, seizures.
• Endocrine: Growth delay, polyphagia, excessive
thirst/fluid intake, menses duration, amount of
flow.
TIPS
• Some parents may exaggerate or mislead you so
ask specific questions
• Avoid leading questions!
• Show appreciation and empathy with parents
anxiety and worry
• Be aware of the sensitivity of some issues in the
family life
• Take note of the parents behavior
Questions?
• Contact e-mail:
[email protected]
Pediatric Physical
Examination
Video Demos
(45 minutes)
Observation:
• Child's facial expression (pain), response to
social overtures.
• Interaction with caretakers and examiner.
• Body position (leaning forward in sitting
position; epiglottitis, pericarditis).
• Weak cry (serious illness), high-pitched cry
(increased intracranial pressure, metabolic
disorder); moaning (serious illness, meningitis),
grunting (respiratory distress).
Does the child appear to be:
(1) Well, acutely ill/toxic, chronically ill, wasted, or
malnourished?
(2) Alert and active or lethargic/fatigued?
(3) Well hydrated or dehydrated?
(4) Unusual body odors?
Vital Signs:
• Respiratory rate, blood pressure, pulse,
temperature.
• Measurements: Height, weight; head
circumference in children up-to 2 years; plot on
growth charts and determine growth percentiles.
• Skin: Cyanosis, jaundice, pallor, rashes, skin turgor, edema,
hemangiomas, café au lait spots, nevi, Mongolian spots, hair
distribution, capillary refill (in seconds).
• Lymph Nodes: Location, size, tenderness, mobility and
consistency of cervical, axillary, supraclavicular, and inguinal
nodes.
• Head: Size, shape, asymmetry, cephalohematoma, bossing,
molding, bruits, fontanelles (size, tension), dilated veins, facial
asymmetry.
• Eyes: Pupils equal round and reactive to light and
accommodation ( PERRLA); extraocular movements intact (
EOMI); Brushfield's spots; epicanthic folds, discharge,
conjunctiva; red reflex, corneal opacities, cataracts, fundi;
strabismus (eye deviation), visual acuity.
• Ears: Pinnas (position, size), tympanic membranes
(landmarks, mobility, erythema, dull, shiny, bulging),
hearing.
• Nose: Shape, discharge, bleeding, mucosa, patency.
• Mouth: Lips (thinness, downturning, fissures, cleft lip),
teeth, mucus membrane color and moisture (enanthem,
Epstein's pearls), tongue, cleft palate.
• Throat: Tonsils (erythema, exudate), postnasal drip,
hoarseness, stridor.
• Neck: Torticollis, lymphadenopathy, thyroid nodules,
position of trachea.
• Thorax: Shape, symmetry, intercostal or substemal retractions.
• Breasts: Turner stage, size, shape, symmetry, masses, nipple
discharge, gynecomastia.
• Lungs: Breathing rate, depth, expansion, prolongation of
expiration, fremitus, dullness to percussion, breath sounds,
crackles, wheezing, rhonchi.
• Heart: Location of apical impulse. Regular rate and rhythm (
RRR), first and second heart sounds (S1, S2); gallops (S3, S4),
murmurs (location, position in cycle, intensity grade 1-6, pitch,
effect of change of position, transmission). Comparison of
brachial and femoral pulses.
• Abdomen: Contour, visible peristalsis, respiratory
movements, dilated veins, umbilicus, bowel sounds,
bruits, hernia. Rebound tenderness, tympany;
hepatomegaly, splenomegaly, masses.
• Genitalia: Circumcision, hypospadias, phimosis, size
of testes, cryptorchidism, hydrocele, hernia, inguinal
masses, discharge, labial adhesions, clitoral hypertrophy,
pubertal changes.
• Rectum and Anus: Erythema, excoriation, fissures,
prolapse, imperforate anus. Anal tone, masses,
tenderness, anal reflex.
• Extremities: Bow legs (infancy), knock knees (age 2 to
3 years). Edema (grade 1-4+), cyanosis, clubbing. Joint
range of motion, swelling, redness, tenderness. A
"click" felt on rotation of hips indicates developmental
hip dislocation (Barlow maneuver). Extra digits, simian
lines, pitting of nails, flat feet.
• Spine and Back: Scoliosis, rigidity, pilonidal dimple,
pilonidal cyst, sacral hair tufts; tenderness over spine or
costovertebral tenderness.
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Neurological Examination:
Behavior: Level of consciousness, intelligence, emotional status.
Motor system: Gait, muscle tone, strength (graded 0 to 5).
Reflexes
Deep Tendon Reflexes: Biceps, brachioradialis, triceps, patellar,
and Achilles reflexes (graded 1-4).
• Superficial Reflexes: Abdominal, cremasteric, plantar reflexes
• Neonatal Reflexes: Babinski, Landau, Moro, rooting, suck,
grasp, tonic neck reflexes.
• Developmental Assessment: Delayed abilities for age on
developmental screening test.
• Laboratory Evaluation: Electrolytes (sodium,
potassium, bicarbonate, chloride, BUN, creatinine),
CBC (hemoglobin, hematocrit, WBC count, platelets,
differential); X-rays, urinalysis ( UA).
• Assessment: Assign a number to each problem, and
discuss each problem separately. Discuss the differential
diagnosis, and give reasons that support the working
diagnosis. Give reasons for excluding other diagnoses.
• Plan: Describe therapeutic plan for each numbered
problem, including testing, laboratory studies,
medications, antibiotics, and consultations.
Work Hard,
Become Excellent!
Best Wishes!