Approach to Pediatric Patients Chaisit Sangtawesin Queen Sirikit National Institute of Child Health

What are the differences between pediatric and adult?

► NeonateThe first 4 weeks of life ► InfantThe first year ► Preschool years ► School age5 – 15 years ► Childhood1 – 15 years ► Adolescent13 – 19 years

First of all ► The child should be placed where he wishes. ► The examiner must remain on patient, friendly, tolerant, good-natured and restrained. ► Use soft, persuative voice.

หลักในการซักประวัติ ► พยายามลดความกังวล ให้ความสนใจอาการ เจ็บป่วย ► กรณีผู้ป่วยมีอาการหนักก็ควรเริ่มถามเฉพาะ จุดที่สำค้ญและตรวจผู้ป่วย ให้การวินิจฉัย และรีบให้การรักษาเบื้องต้นก่อน แล้วจึง ค่อยเก็บรายละเอียดในภายหลัง ► พยายามเข้าใจ เห็นใจ เป็นกันเอง และ ละ เว้นการวิพากษ์วิจารณ์ ► นึกถึงเด็กด้วยเสมอระหว่างการซักประวัติ ► ต้องเข้าใจว่าเด็กแต่ละวัยมีความแตกต่างกัน เด็กแต่ละวัยมีการรับรู้ ปฏิกิริยาตอบสนอง แตกต่างกันตามวุฒิภาวะ การศึกษา พฤติกรรมและการพัฒนาด้านอารมณ์

General inspection ► State of nutrition ► State of activity ► Posture ► Reaction to environment ► Overt deformity ► Relationship to parents ► Conversation ► Injury ► Speech ► Hemorrhage ► Cry ► Facial expression ► Size relative to weight ► Dehydration ► Edema

General inspection ► Respiratory rate ► Respiratory pattern ► Abnormal sounds during breathing:- hoarseness, wheeze, stridor, whoop, cry ► Abnormal smell ► Abnormal posture ► Emotion ► Mouth breathing ► Jaundice ► Cyanosis ► Characteristic facies ► Rash – color, size, distribution, nature ► Fingers ► Nails

Respiratory pattern

► Inspiration composes approximately one-third of the respiratory cycle and expiration the remaining two-thirds. ► It is easiest to hear breath sounds during inspiration and expiratory sounds are less well heard. ► The intensity of breath sounds depends on the location of auscultation and on the bodyshape. auscultation and on the bodyshape. ► They are loudest where the large airways are closest to the body surface, and they are more distant in obese individuals body surface, and they are more distant in obese individuals than thin ones. than thin ones. ► They also tend to be louder in children than in adults. NORMALNORMAL BREATH SOUND

Bronchial breath sounds Bronchial breath sounds Bronchial breath sounds Bronchial breath sounds ► These sounds are louder than normal breath sounds. ► They are heard when there is consolidation of lung tissue with bronchi that open into the consolidation, such as occurs in pneumonia. ► The consolidation leads to better transmission of sound than when the lungs are filled with air.

► Noisy breath sounds produced by the obstruction of the extrathoracic airway. STRIDOR

Grunting Grunting ► Grunting is an abnormal breath sound heard during expiration from the closing of the glottis in respiratory distress of a small infant. ► This grunting was recorded with a microphone in front of the mouth of a premature baby girl with respiratory distress 7 hours after birth

CREPITATION COARSE CREPITATION FINE CREPITATION

Wheezing ► Wheezes are loud sounds that originate in the small airways. ► These sounds have a longer duration than crackles and also have a musical quality. ► They are often detected more easily with forced expiration and are heard in patients with asthma or other obstructive diseases.

Respiratory rate Tachypnea Tachypnea ► Neonate – 2 months < 60/min. ► Infancy< 50/min. ► 1-5 years< 40/min. ► Older children< 30/min.

Heart rate ► HR < 60/min. is considered to be bradycardia ► HR > 220/min. in infancy or > 180/min. in older children is considered to be tachycardia

Blood Pressure

5 th Percentile for Blood Pressure ► Neonate60 ► 1 month – 1 year 70 ► 1+ year70 + (2 X age in years)

Weight ► At birth 3 Kg ► The first 4 monthsBW + (month X 0.8) ► The second 4 monthsBW + (month X 0.7) ► The third 4 monthsBW + (month X 0.6) Infants normally double their birthweight by 5 months and triple their birthweight by 1 year ► Between 1-9 years (4 + years) X 2 ► Between 9-12 yearsYears X 3

Length ► At birth 50 cm ► At 6 months65 cm ► At 1 year75 cm ► At 2 years85 cm ► At 3 years95 cm ► At 4 years 100 cm Infants normally double their height by 4 years old ► Over the next 8 years there is an annual increase of 5.5 cm/year

female males

Upper / Lower segment ► At birth1.7 ► 6 months1.6 ► 15 months1.5 ► 2 years1.4 ► 3 years1.3 ► 5 years1.2 ► Adolescent1

Achondroplasia Marfan syndrome

Anterior fontanelle Posterior fontanelle Frontal bone Parietal bone Sagittal suture Occipital bone

Head circumference ► At birth35 cm ► At 4 months40 cm ► At 1 year45 cm ► At 2 years47 cm ► At 5 years50 cm

Dirty white patches over tonsils and posterior pharyngeal wall Diphtheria

Milky white patches over tonsils Infectious mononucleosis

Enlarge and injected tonsils Acute tonsillitis

Measles Kopliks’ spots

Baby-bottle syndrome

Pectus excavatum Pectus carinatum

Normal Congenital hip dislocation

Barlow Test

Ortolani Test