Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (K), or click on a page image below. Clinical Paediatrics for Postgraduate Examinations, 3e pdf by T. Stephenson DM FRCP FRCPCH. An essential system guide to the postgraduate exam should. Clinical Paediatrics for Postgraduate Examinations by Terence Stephenson, , available at Book Depository with free delivery.
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Clinical Pediatrics for PostGraduate Examination - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free. Clinical Pediatrics for. by Terence Stephenson DM FRCP FRCPCH (Author), Hamish Wallace MD FRCP(Edin) (Author), Angela Edgar (Author) & 0 more. An essential, system-by-system guide to the clinical examination of children, within the postgraduate exam context. includes throughout tips for handling examiners. PDF. Book Review. Clinical Paediatrics for Postgraduate Examinations. Free This is a PDF-only article. The first page of the PDF of this article appears above.
Measure blood pressure e Signs of chronic asthma: Wheezes 0 High-pitched musical noises due to partial obstruction or narrowing of bronchi or bronchioles e Maximal on expiration, which is usually prolonged the positive intrapleural pressure accompanying forced expiration further reduces the lumen of intrathoracic airways e Can occur in inspiration if obstruction is severe; tends to be lower-pitched. Management centres on restoring the energy imbalance in the form of nutritional supplenwntation. Figure 4. Feeding e Passage of a nasogastric tube will reduce the work of breathing e High-calorie feeds should be used with diuretics rather than fluid restriction as these babies often have high metabolic rates. Abdominal ultrasound scan This is good at detecting small- and large-bowel wall thickening, nodal enlargement, abscesses, stones and fistulae.
Ejection click Fig. Normal murmurs previously called innocent or benign Cardiac murmurs are common in paediatrics. Accurate assessment of the child following the guidelines below will help to distinguish normal from pathological murmurs. Diagnosing a normal murmur positively rather than by exclusion will reduce unnecessary referrals and undue anxiety in the parents. The '10 S' test of a normal murmur is as follows: There are basically five types of normal murmur which originate from increased flow velocity.
Still's murmur Early soft systolic murmur heard over the lower left sternal edge. Murmur will decrease or disappear on hyperextension. Try it in an older, cooperative child. Pulmonary flow murmur Soft ejection systolic murmur, usually S: Rarely propagated posteriorly. Can be confused with pulmonary flow murmur associated with ASD but there is no wide fixed splitting of second heart sound.
Often loud, grade 3, the intensity decreases when supine and can be obliterated by gent!!: Still's murnmr is often also present. Supraclavicular or carotid bruit Best heard above the clavicles, although it transmits downwards. Neonatal physiological peripheral artery stenosis murmur Maximal over upper left sternal edge and usually:: Radiates throughout the thorax, to both axillae and to the back. Most disappear by 6 months of age and all have gone by 12 months.
Classification of pathological murmurs e Systolic see Table 3. PSM Left. A summary of murmurs is presented in Figure 3. Continuous l - right BT shunt Venous hum Ejection systolic - subpulmonary stenosis - subaortic stenosis Pulmonary stenosis - ventricuiar septal defect - Fallot's Systolic - coarctation r. Presenting in first week of life - five Ts 0 Transposition of the great arteries - abnormal mixing e Total common mixing: Don't forget other causes of cyanosis ,in the neonatal period: Neonatal period obstructed duct-dependent systemic circulation e Hypoplastic left heart syndrome Coarctation 0 Critical aortic stenosis 0 Tricuspid atresia Interrupted aortic arch.
Signs e Breathltssness e Poor feed ing 0 Sweating e Recurrent chest infections. Causes e Emboli - right-to-left shunt e Th. Recurrent chest infections Increased pulmonary blood flow I congestion. Certain congenital disorders are associated with heart disease. Intrauterine infection e Rubella esp.
Maternal diseases e Diabetes- increased incidence of all CHD, especially septal hypertrophy e Systemic lupus erythematosus - congenital heart block. Some inherited causes of heart disease presenting in older children are listed below: Age of presentation 40 8 Was CHD diagnosed antenatally?
The child will usually have presented with other features of the underlying disorder. How did it present? Current symptoms e Chronic limitation of exercise tolerance- quantify this e How much school is missed? Treatment so far e Cardiac catheterizations or surgery e Admission for drug therapy suggesting previous heart failure e Current medications?
Immunizations up to date? This is as outlined above. Don't forget to: You must be able to discuss the logical sequence of investigations in a child with suspected heart disease. Pao2 same modest rise in Pao 2 e Bony structures- rib notching collaterals in coarctation. Electrocardiogram e Axis e Conduction abnormalities e P-wave abnormalities e Ventricular hypertrophy. Echocardiogram e Detects most cyanotic conditions in the newborn e Very useful for acyanotic conditions septal defects, duct or valvular disease , particularly if accompanied by Doppler measurements of flow velocity.
Cardiac catheterization e To measure pressure gradient across stenosed valve or outflow tract obstruction e To quantify accurately the size of the shunt To determine the exact anatomy of complex lesions when surgery is considered e For intervention by dilatation of valvular stenosis or coarctation.
You would be expected to know how to manage the following. HEART FAILURE Drugs e Only if the child is symptomatic e Diuretics- thiazide or loop diuretics are often used in combination with potassium-sparing to avoid the need for unpalatable potassium supplements e ACE inhibitors- often used in conjunction with diuretics e Digoxin - stillwidely prescribed although there is little evidence to support its use e Dopamine- may be required if the child is hypotensive.
Feeding e Passage of a nasogastric tube will reduce the work of breathing e High-calorie feeds should be used with diuretics rather than fluid restriction as these babies often have high metabolic rates. Monitoring e Daily weights e Assessment of liver size. Ventilation May be required for severe heart failure and for apnoea secondary to prostaglandins.
Surgery Depends on the age of the child, but essentially there are two main reasons for performing surgery in the first year of life: But use with caution, as there may be an accessory pathway in patients with atrial flutter or fibrillation and adenosine may increase conduction down anomalous pathways therapeutic value: A detailed description of antibacterial prophylaxis is given in the British National Formulary. There is a plethora of complex congenital heart conditions but only nine common lesions, which can be categorized into acyanotic and cyanotic groups.
This group represents two-thirds of cases and the conditions are termed simple. The first three cases- left-to-right shunts- can lead to Eisenmenger's syndrome pulmonary hypertension and reversal of the shunt, with consequent cyanosis. Any of the six can occur in combination but they usually occur in isolation, hence the term 'simple. These account for the remaining one-third of the cases and the conditions are often complex lesions.
By definition, there is a significant right-to-left. The algorithm for clinical examination and diagnosis Fig. If you recognise the child as having an obvious syndrome then try to think of the likely underlying cardiac lesions and concentrate on the signs associated with that lesion during your examination.
Yes Yes I Carotid thrill i normal No Apex in i left chest I. AS VSD. Split s 2: PS Fig Algorithm for clinical examination '. Hac j symmetr: S t ASD, prosthetic valve, Lol. Jd Single S2: Exva Hs: The younger the child, the more important is the phase of inspection, the more difficult are palpation and percussion and the less informative is auscultation. Make a point of observing. Listen as well as look.
Do not undress an infant until you know the following: HANDS Clubbing usually cystic fibrosis in exams but may be due to other lung conditions causing chronic infection or hypoxia. FACE Cyanosis respiratory failure ; traumatic petechiae on the eyelids, face and neck may be seen following severe paroxysms of coughing. NECK Tracheal tug, swellings, lymph nodes, cystic hygrom21, thyroid.
Recession e Intercostal - airways obstruction or decreased lung compliance e Subcostal -airways obstruction or decreased lung compliance.
Scars e Sternotomy- usually cardiac surgery e Left thoracotomy repair coarctation - Blalock-Taussig BT shunt - lobectomy e Right thoracotomy oesophageal surgery - BT shunt - lobectomy e Previous chest drains. Rate Table 4.
Watch for any signs of increased work of breathing, such as: Be guided by the age of the child. Chest expansion Place your hands on the chest with your fingers grasping the sides of the chest in such a way that the outstretched thumbs approximate at the tips,. Puited shifted Pleural effusion may be no shift if underlying lung collapse Pneumothorax Collapse Upper lobe pathology Fibrosis Pectus excavatum Scoliosis Dextrocardia think Kartagener's Cardiomegaly think cor pulnionale "0 C1i ttl c..
Pleural thiCkening Pleural effusion without touching the chest, to allow free movement in expansion. To measure maximum chest expansion, ask the child to breathe all the way out, then to take a big breath in.
Make sure your fingers remain tightly but not painfully applied to the chest wall so that the thumbs act as 'calipers'. Anteriorly, the thumbs should be placed at the level of the nipples, while posteriorly, the thumbs should be at T10 level.
Chest expansion can be measured in an older child and should be at least 4 em. Diminution of movement on one side indicates pathology on that side. Both hyperinflation and restrictive lung disease can reduce expansion symmetrically, and formal pulmonary function testing provides more reliable information. Tactile vocal fremitus Table 4. We recommend doing vocal resonance as pathology is more easily detected.
To test tactile vocal fremitus, place the palm of the hand on either side of the upper chest and ask the child to say '99'. Most children will happily engage in the game. Compare right and left, anteriorly and posteriorly. To avoid scaring him with a resounding blow to the chest, say: The commonest mistake is not pressing hard enough with the left hand, so that a muffled percussion note results.
Horizontal fissure Oblique fissure Left lung Fig. Do not ask. You must use a paediatric stethoscope, not an adult or a neonatal one. The bell or diaphragm of the stethoscope can be used for auscultation. Are the breath sounds normal?
Are there added sounds? Are these in inspi ration, expiration or both? Abnormal breath sounds Table 4.
Bronchial Fig. Prolonged expiration e In asthma or emphysema e To prevent closure of alveoli. Added sounds Conducted upper airway sounds These sounds make examination of young children very difficult and are the cause of most false-positive findings. Most infants 'gurgle' and many toddlers are 'snotty'. Remember that serious bacterial infections tend to localize one ear, one joint, one lung lobe , whereas viral upper respiratory tract infections have wider effects red eyes, runny nose, red throat, skin rash, myalgia, etc.
These sounds are heard without a stethoscope and will remain as background noise when auscultating. A useful ploy is to place the stethoscope on the side of the neck after listening to the chest. If coarse, variable crackles heard in the chest are obviously louder over the neck, they arc certainly conducted upper airways sounds. Wheezes 0 High-pitched musical noises due to partial obstruction or narrowing of bronchi or bronchioles e Maximal on expiration, which is usually prolonged the positive intrapleural pressure accompanying forced expiration further reduces the lumen of intrathoracic airways e Can occur in inspiration if obstruction is severe; tends to be lower-pitched.
Common causes e Asthma only one likely in the exam Bronchiolitis accompanied by crepitations. Less common unilateral causes e Foreign body or other cause of fixed localized large airway narrowing, e. Crackles These are non-musical sounds, generally heard during inspiration: Fine, high-pitched at the bases, alveolar level - pulmonary oedema - fibrosing alveoli tis especially at the end of inspiration e Coarse, variable pitch, bubbly secretions in bronchioles - pncumonw - bronchiectasis.
The second condition in each of the above cnses is rarer but n1ore likely in the exam. Check whether the cmcklcs clear after coughing. Pneumothorax click e Rhythmical sound, synchronous with cardiac systole e Heard with or without a stethoscope e Caused by shallow left pneumothorax between the two layers overlying the heart. Alterations of breath sounds and vocal resonance depend on the same criteria and alter together.
The findings are the same as for tactile vocal fremitus, but the sounds are louder over areas of consolidation. In some cases the sounds can be transmitted clearly when whis- pering, without voice distortion, known as whispering pectoriloquy.
Don't forget to examine for lymphadenopathy if you have not already done so. Table 4. You must be well rehearsed in history- taking and examination appropriate to each of the conditions. Furthermore, you will need to know the appropriate investigations and management and be able to discuss current topical issues.
Asthma can be defined as 'recurrent reversible small airways obstruction'. Ck JGIM. Percussion note Stony dull Dull Dull Dull. Resonant Vocal resonance Absent lncreased. Age of onset Is there any relevant prior respiratory illness, e. Precipitants e Upper respiratory tract infections e Exercise and emotion e House dust mite e Grass pollen e Seasonal variation spring and autumn peaks e Animal dander ask about pets e Parental cigarette smoking, especially maternal smoking both ante- and postnatal Damp housing mouldy Particular environmental settings, e.
These are clearly expensive and inconvenient changes for most families to make and the rewards may be limited. Compliance with these measures, therefore, suggests asthma which has been difficult to control. Severity and chronicity of symptoms e How frequent are the symptoms? Courses of oral steroids? Family history of asthma or atopy Is there such a family history, especially in the mother and other first-degree relatives?
Passive smoking Do any family members smoke cigarettes? Treatment What i:: What previous treatinents have been tried and have failed? A Morgan-Dennie fold is a double fold under the eye in eczematous or allergic children e Examine the nose with an auriscope and large speculum.
Atopic mucosa is pale and oedematous with watery mucus present e Cushinoid appearance? Measure blood pressure e Signs of chronic asthma: Harrison's sulcus - hyperinflation - persistent recession and wheeze despite bronchodilators e Record pulse, pulsus paradoxus, respiratory rate and temperature, as the child may have come into hospital with an acute exacerbation e Check the child's inhaler technique e Measure the peak expiratory flow rate PEFR: Skin tests e Most specific allergens e.
To do well you must be familiar with commonly discussed topics and be aware of the controversial issues in the management of asthma. Acute exacerbation Know the 'danger signs' Table 4. Figure 4. You must know the detailed management of acute severe asthma, including interpretation of blood gases and indications for referral to intensive care, for discussion in the long case and oral examination.
Aminophylline i. Hydrocortisone i. Oxygen high flow , 2. Bronchodilator- hrs: Adequat e hydration 7. RR, respiratory rate; b. Turbohaler Acuhaler Nebulizer e School teachers to be made aware of the diagnosis and to know that the inhaler should be available to the child when necessary. You must be familiar with the current British Thoracic Guidelines for the stepwise approach to ensuring good control and also have an understanding of the method of action of these drugs Fig.
It is essential that you are familiar with the various delivery systems and are able to demonstrate their use if requested Table 4. Despite increased awareness and improved treatment, mortality from asthma has changed little in the last two decades. Morbidity is more difficult to quantify. Incidence seems to be increasing. You should be able to discuss the possible reasons for this.
You should be able to discuss the side-effects associated with oral steroids and the debates about the potential side-effects associated with inhaled steroids.
Leukotrienes are the most potent and important mediators of inflammation in acute and chronic asthma. Leukotriene-receptor antagonists, such as Montelukast, have both. They have been shown to be effective in adults over a wide spectrum of asthma severity, either as monotherapy or in combination with inhaled steroids.
You should consider whether the child's current treatment is appropriate for the apparent asthma severity. This 1s an autosomally inherited, fatal, multisystem disorder. The carrier frequency is l: There are now as many adults ;15 children with CF in the UK.
Step down treatment when good control achieved til a. There is often an associated micro-colon. Ask the parent if he or she can remember at what age meconium was first passed - 48 hours or more would be noteworthy. Recently, delay in passing meco- nium has been shown to be related to the effect of the CF modifier gene on chromosome Complications Respiratory e Sinusitis, often associated with recurrent nasal polyps e Known bacterial infection - Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa or Burkholderia cepacia, atypical mycobacteria e Bronchial hyperreactivity with wheeze and evidence of reversible airway obstruction e Allergic bronchopulmonary aspergillosis e Minor haernoptysis is common - usually related to respiratory infection e Major haemoptysis, in older children and adults, is rare and may require angiography and bronchial artery embolization e Progressive decline in lung function leading to respiratory failure and the development of cor pulmonale.
Gllendocrine There is an increased incidence of coeliac disease and Crohn's disease e Growth failure and delayed puberty have traditionally been thought to correlate better with the severity of respiratory disease.
Family history e Other siblings may be affected e Has the family had counselling about the risk associated with subsequent pregnancies? Treatment regimens e Postural drainage and physiotherapy regimens e Prophylactic antibiotics- inhaled or oral e Current antibiotics for intercurrent infection e Inhaled bronchodilators or steroids e Mucolytics - DNAse e Pancreatic supplements e Antacids or proton pump inhibitors e Vitamin supplements fat-soluble e Overnight nutritional support past and present - gastric tube feeding overnight, parenteral nutrition, nutritional supplements orally.
Immunizations e Obtain a detailed history of past immunizations -ask specifically if the child has been immunized against pertussis and measles, both of which can be particularly nasty in CF patients. General e Well or unwell? Nutritional status: Exlras- oxygen, pulse oximeter, sputum pots, inhzders Tunnelled centre:!
Abdomen e Gastrostomy tube in situ e Scars suggesting surgery for neonatal or later bowel obstruction e Palpable liver due to hyperinflated chest - may be enlarged although the liver is frequently involved, there is rarely hepatomegaly e Splenomegaly may result from portal hypertension; if so, look for other signs of advanced cirrhosis Ch.
Pubertal staging Puberty is often delayed in these children. Carrier screening This is offered at some centres to mothers booking in early pregnancy. Partners of carrier mothers are then also offered screening and prenatal diagnosis can be performed for those couples who are both found to be carriers. Termination of pregnancy would be offered if the fetus was found to be affected by CF. Neonatal screening This is carried out in some regions using measurements of immunoreactive trypsin IRT on a Guthrie card sample.
IRT is high in a neonate with CF. This test is sensitive but not very specific. High lRT levels combined with 6F50R mutation analysis, which can also be ci1rricd out on a Guthrie card sarnp1e, improves the specificity of the neonatal screening. CF screening results in earlier diagnosis of index cases, and studies have shown that the initiation of early treatment in groups of patients diagnosed i ,.
No sign. Screening also provides the possibility of genetic counselling for further pregnancies. False positives and negatives are also possible if the test is incorrectly performed by inexperienced technicians.
A minimum of rng of sweat must be collected. Sweat chloride in affected patients usually exceeds sweat sodium concentration. Sweat tests in the first 6 weeks of life are unreliable.
A falsely elevated sweat test can result from: This technique is only used as i1 research tool at present. Gene testing The CF gene lies on the long arm of chromosome 7. This is a large gene of kb and over mutations within the CF gene have been described. This mutation, indicates that three base-pairs have been deleted from the CF gene resulting in the omission of one phenylalanine amino acid from the protein the CF transmembrane conductance regulator protein encoded by the gene.
The cystic fibrosis transmembrane regulator CFTR is a membrane protein. This mem. Respiratory Physiotherapy All CF patients require regular physiotherapy at least twice daily. Postural drainage and percussion are routine for infants and young children; older children may be allowed more independence with postural drainage and special breathing techniques.
Compliance may be a problem in teenagers. Physical exercise Regular vigorous physical exercise should be encouraged as tolerated to strengthen the muscles and prevent reaccumulation of secretions.
Prompt treatment of infections Antibiotic therapy in CF is controversial. Most centres start oral flucloxacillin following diagnosis, e. Acute infections require treatment with an antibiotic appropriate for the organism's sensitivities. Intravenous antibiotics, including tobramycin, are likely to be required for acute infections. Nebulized antibiotics, Colomycin and tobramycin, reduce the frequency of respiratory exacerbations in patients colonized with Pseudomonas cepacia.
Nebulized acetylcysteine This has not been proven to be of significant benefit. Mucolytics such as dornase, a DNAse agent, are new drugs which significantly reduce sputum viscosity and increase mucociliary clearance.
Inhaled steroids are also frequently used for these patients after physiotherapy. Long-term oral steroids These remain controversial.
Their use is intended as anti-inflammatory therapy. There is no established safe dosage for long-term treatment, which has been shown to be associated with unacceptable side-effects such as diabetes, cataracts and growth suppression.
Prophylactic antibiotics Although this is a controversial area, most celltres practise this puiicy to prevent persistent bacterial infection with Sl11phylococcus in infancy. Long-term nebulized antibiotics are given tu patients chronically colonized with Pseudonwnas aeruginosa. Management centres on restoring the energy imbalance in the form of nutritional supplenwntation.
Pancreatic enzyme supplements Pancreatic enzyme preparations consist of enteric-coated microspheres within a gelatin capsule and are given with all meals and snacks.
The use of high-dose pancreatic enzyme supplements has been associated with reports of strictures of the terminal ileum requiring partial colectomy when used in excessive dosage.
Absent pancreatic bicarbonate secretion and poor neutralization of stomach acid result in reduced efficacy of pancreatic enzyme supplements. H 2 blockers have not been shown significantly to improve pancreatic enzyme activity. Omeprazole, a protein pump blocker, is probably more effective. Improved weight gain can usually be achieved, and is often accompanied by increased well-be ng.
Distal intestinal obstruction syndrome DIOS is characterized by palpable faecal lumps in the caecum and ascending colon. These may cause colicky abdominal pain sometimes associated with meals, leading to subacute or complete intestinal obstruction.
W year-olds and 4. Common problems are: Long-term 'cure' Lung transplantation This is the ultimate rescue therapy for CF patients in respiratory failure. Quality of life is significantly enhanced but lifelong immunosuppression with ciclosporin, azathioprine and prednisolone will be required.
Early clinical trials are underway to address the safety and efficacy questions. It seems likely that, if successful, the patients who will benefit most from gene therapy are those who have preserved lung function and minimal established lung damage.
To date, gene therapy trials have not proved sufficiently effective at adequately correcting the cellular defect to be introduced more widely. Repeated administration of CFTR using an adenovirus vector results in progressively less effective gene transfer, probably due to the development of blocking antibodies. This is the commonest serious chronic lung disease affecting infants under 1 year of age in the UK.
Such children are now relatively commonly used as long cases in the Membership examination. A major determinant of survival in very premature neonates is difficulty with ventilation associated with lung immaturity. Definition Chronic lung disease of prematurity, formerly known as BPD, is a consequence of barotrauma and volume trauma resulting from artificial ventilation, oxygen toxicity and infection in the immature lungs and is defined as lung damage associated with oxygen dependency at 36 weeks post-conceptual age i.
There is a move away from the old term of bronchopulmonary dysplasia, which was used to Jescribe radiological appearances in the damaged lung, as a consequence of artificial ventilation, and an oxygen dependency at 28 days of life.
Delivery e Requirement for active resuscitation e Evidence of aspiration syndrome? Neonatal intensive care e Duration- including length of time 0 2 by day, 0 2 by night e Ventilation conventional versus high-frequency oscillation - steroids - chest drains for pneumothoraces Other problems patent ductus arteriosus: Support Community nurses. Medication e ipratropium bromide, ,8 2 -agonists, inhaler devices e Vitamin, calcium and phosphate supplements e Nutritional supplements.
If there is a loud second heart sound, pulmonary hypertension may have developed. Extrapulmonary pathology This is common and should be looked for specifically. Developmental assessment e Milestones must be viewed in light of the corrected gestational age e Delayed motor development may be exacerbated by: Neurological assessment Ten per f born at less than g birlhweight will hi1VE' a major e.
Ventilation Postnatal dexamethasone Postnatal dexamethasone is known to reduce the duration of ventilator dependency and recent meta-analysis indicates that early treatment with steroids significantly reduces the morbidity and mortality associated with chronic lung disease. I Iowever, steroid treatment is associated with a number of side-effects which must be considered, including increased risk of infection, hypertension, hyperglycaemia, spontaneous gastrointestinal haemorrhage or perforation and impaired antibody response to Haemophilus influenzae B immunization.
Recent meta-analysis suggests that some systemic steroid regimens are associated with significantiy increased neurodevelopmental risk of cerebral palsy.
Inhaled corticosteroids Inhaled steroids are usually tried as a 'systemic steroid-sparing treatment' when an infant with chronic lung disease cannot be weaned off dexamethasone without rebound increased oxygen requirement. Diuretics The use of diuretics may result in short-term improvements in lung function but it is difficult to be sure that there are any long-term gilins.
Chronic furosemide frusemide administration is associated with hypercal- caemia which may lead to renal calcification. Nutrition Perhaps the most important, but neglected, aspect of long-term treatment is to optimize nutrition, thereby improving somatic growth and lung growth. It may be necessary for feeds partly or wholly to be given by nasogastric tube at home, and carbohydrate, fat, folic acid, vitamin 0 and iron supplements n1ay be indicated.
Emotional support This is very important for the parents. Infants who have survived a long period of intensive care will generate anxieties in parents and GPs when they develop even trivial symptoms.
There should be easy and ready access to a known paediatrician and the help of counsell ors, therapists, specialist health visi tors or family support nurses. Intercurrent infections These infants have a limited respiratory reserve and are more susceptibl e Lo infections, particularly respiratory syncytial virus RSV in the winter months.
Kartagener's syndrome e pneumoma e pleural effusion e chronic asthma chronic stridor e fibrosing alveolitis. However, young children may find this frightening and be uncooperative, so you must try to make friends with the child whilst making your inspection and positioning him or her appropriately. Young children may be better examined on their mother's knee. Expose from the nipples to the knees unless the patient is a pubertal girl, and do not expose genitalia of older children.
Anaemia Look at nailbcds and palmar creases suggesting malabsorption or chronic gastrointestinal blood loss recent acute haemorrhage is unlikely in the exam. Koilonychia 8 Iron deficiency - also look for smooth tongue and angular stomatitis e Very rare in the UK. Leuconychia e Cirrhosis.
The patient may need oxygen and this is an indication for transplantation. Spider naevi e A cutaneous vascular malformation with a central arteriole supplying a number of radiating capillaries Fig.
They are distributed over the area that is drained by the superior vena cava. More than three is a significant number in prepubertal children occasionally, more may be seen in girls without any underlying abnormality e Chronic liver disease excess oestrogens e Telangiectasia, as in: Osler-Weber-Rendu syndrome - ataxic telangiectasia. There are five important causes of macroglossia: Remember the five Fs also organomegaly: Obvious masses or visible organomegaly Scars Don't forget: Caput medusae Veins drain away from the umbilicus due to portal vein obstruction.
If present, then look for other signs of liver disease liver failure is a specific end-stage problem , e. Superior vena cava SVC obstruction Fig.
Inferior vena cava IVC obstruction Fig. Stomas e Ileostomy versus colostomy position e Mucous fistula e Caecostomy tube for antegrade enemas in some children with chronic constipation the so-called MACE procedure, or Malone antegrade colonic enema. You should inspect the genitalia of an infant without being specifically invited to do so by the examiner: Press on veins with two fingers 2. Pull fingers apart 3. Lift one finger - - does vein fill?
Bruising Liver dysfunction H: Pigmentation e Depigmentation vitiligo e Hyperpigmentation - cafe-au-lait patches - incontinentia pigmentosa not so rare in exams!
Nappy In infants, examine the urine and stool at this stage. NECK Don't forget to check for lymphadenopathy, especially if there is splenomegaly, but this can be left until the end. Ask the child to help you by placing your hand over their hand and feeling the tummy together.
Gentle palpation e Tell the child what you are going to do and ask if the tummy is sore anywhere. Be gentle: Deep palpation Now repeat the sequence and palpate more deeply. Tenderness is unlikely in the exarn but, if found, you rnust detect: Organ palpation Table 5. Begin in the right iliac fossa and work up towards the costal margin.
Children frequently have a palpable liver edge up to 2 em. If hepatomegaly is present, describe: Specify the upper border by counting the rib spaces. Spleen e Palpate from the right iliac fossa with the left hand splinting the lower edge of the rib cage posteriorly. Kidneys Bimanual palpation - push up with the left hand in the renal angle the costovertebral angle and feel the kidney anteriorly with the right hand.
Ballot kidneys between hands. A common mistake made by candidates is to push too laterally with their left hand. Masses If a mass is found, remember to describe: I lac fo.
Percuss for the following unless the child is uncooperative: To demonstrate ascites, test for shifting dullness and a fluid thrill, involving the examiner in the latter. The test for shifting dullness is shown in Figure 5.
In the supine position, free fluid, which is dull to percussion, gravitates to the lowest part of the abdomen, and the gut, which contains resonant gas, floats upwards. Percussion from the umbilicus towards the flanks reveals a line of demarcation where the resonance of the bowel gas becomes the dullness of the free fluid. The position at which this occurs should be marked. If the patient is then rolled over onto the side, the fluid moves to the lower flank and the line of demarcation between dullness and resonance shifts see below.
In gross ascites, the abdomen is generally distended, the umbilicus is everted, the flanks are especially full, and the scrotum is full. The skin may also be oedematous. Ansameera marked it as to-read May 07, Felona Hassan marked it as to-read Oct 31, Rabia Khan marked it as to-read Mar 03, Jwan Fuad marked it as to-read May 06, Zizo Goqwana marked it as to-read Oct 18, Gabriela added it Jan 18, Ram Manohar marked it as to-read Feb 24, Olga Cirstea marked it as to-read Jun 11, MdJalal Uddin added it Jan 14, Ankur Srivastava added it Feb 20, Hannah marked it as to-read Mar 20, Isaac Oti-Boateng marked it as to-read Apr 04, Shehab Ellawindy marked it as to-read Jul 13, Abdulla marked it as to-read Aug 06, Sajjad Shad marked it as to-read Oct 31, Deathskullx marked it as to-read Nov 21, Ali marked it as to-read Dec 08, Su Myat marked it as to-read Jan 06, Ann marked it as to-read Jan 13, Shadman marked it as to-read Jan 17, Samir Gawesh added it Jan 26, Dakalo Mudzielwana marked it as to-read Feb 27, Syed Kazmi marked it as to-read May 15, Product details Format Paperback pages Dimensions x x 16mm Long case.
The cardiovascular system. The respiratory system. The abdomen. Growth and endocrinology. The nervous system.
The developmental examination. The musculoskeletal system. Common exam syndromes.