Pediatric examination

1. Pemeriksaan Fisik
Pediatrik

2. Outline
History taking
General survey
Vital signs
The skin
Head
Neck
Thorax and lungs
Cardiovascular
Abdomen
Extremities

3. History Taking
● Family history of CVD
● Gestastional and perinatal history
maternal infection, maternal medication, maternal condition
● Growth and development
poor weight gain, cyanosis, frequent LRTI

4. General Survey
Weight
Height
Head circumference
Skin: central cyanosis

6. Vital Signs: Blood Pressure
● The width of the BP cuff should be 40% to 50% of the circumfer-
ence of the arm (or leg) with the cuff long enough to completely or
nearly completely encircle the extremity.
● The NHBPEP recommends Korotkoff phase 5 (K5) as the diastolic
pressure but this is debatable. Earlier studies indicate that K4 agrees
better with true diastolic pressure for children ≤12 years.
● The child should be in sitting position with the arm at the heart level.

8. Auscultatory vs oscillometric method
The oscillometric method also provides some advantages over the auscultation method.
(1) It eliminates observer-related variations.
(2) It can be successfully used in infants and small children. Auscultatory BP measurement in
small infants is not only difficult to obtain but also not accurate.

9. Comparison of arm and leg BP values.
Four-extremity BP measurements are often obtained in neonates and children to rule out COA.
● Even with a considerably wider cuff used for the thigh, the Dinamap systolic pressure in the thigh
or calf is about 5 to 10 mm Hg higher than that in the arm. This reflects in part the phenomenon
of peripheral amplification of systolic pressure (see below). If the systolic pressure is lower in the
leg, COA may be present.
● In the newborn, the systolic pressures in the arm and the calf are the same. Absence of a higher
systolic pressure in the leg in the newborn may be related to the presence of normally narrow
aortic isthmus.

10. Vital Signs: Heart Rate

11. Vital Signs: Respiratory Rate

12. The Head
● Fontanelle
● Skull symmetry and head circumference
● Facial symmetry
● Ophthalmoscopic examination
● Low set ears

13. Neck
● Palpate the lymph nodes of the neck and assess
for any additional masses such as congenital cysts.
● Infants necks are short, it is best to palpate the
neck while infants are lying supine
● Older children are best examined while sitting
● Check the position of the thyroid cartilage and
trachea

14. Thorax and Lungs - Inspection
● General appearance
● Respiratory rate
● Audible breath sound and
work of breathing
● Malformations of other
systems may be associated
with varying frequen- cy of
CHD

16. Palpation
Precordium Peripheral pulses
-A hyperactive precordium is characteristic of high volume
overload, such as L-R shunt lesions or severe valvular
regurgitation.
-A thrill is real diagnostic value. The location of the thrill
suggests certain cardiac anomalies: ULSB → PS; URSB →,
AS; LLSB → VSD; suprasternal notch → AS, occasionally
PS, PDA, or COA; over the carotid arteries, AS or COA.
- Check for the rate, irregularities (arrhythmias) and volume
(bounding, full, or thready).
-Strong arm pulses and weak leg pulses suggest COA.
-The right brachial artery pulse stronger than the left brachial
artery
pulse may suggest COA or supravalvular AS.
-Bounding pulses are found in aortic runoff lesions (e.g.,
PDA, AR,
large systemic AV fistula).

17. Auscultation

18. Auscultation
.
Innocent murmurs Pathologic murmurs
Over 80% of children have innocent murmurs of
one type or other sometime during childhood,
most commonly beginning at about 3 or 4 years
of age. All innocent heart murmurs are
accentuated or brought out in high-output states,
most importantly with fever
When one or more of the following are present,
the murmur is likely to be pathologic and require
cardiac consultation: (1) symptoms, (2) cyanosis,
(3) abnormal chest radiography (heart size
and/or silhouette and pulmonary vascularity), (4)
abnormal ECG, (5)
a systolic murmur that is loud (grade 3/6 or with
a thrill) and long in duration, (6) a diastolic
murmur, (7) abnormal heart sounds, and (8)
abnormally strong or weak pulses.

25. Abdomen
Inspect the abdomen with the infant lying supine (and, optimally, asleep).
Inspect the newborn’s umbilical cord to detect abnormalities. Normally, there are
two thick-walled umbilical arteries and one larger but thin-walled umbilical vein
which is usually located at the 12 o’clock position.
Auscultation: An increase in pitch or frequency of bowel sounds is heard with
gastroenteritis or, rarely, with intestinal obstruction.
Percussion: may note greater tympanitic sound because of the infant’s propensity
to swallow air

26. Palpation: start gently in the lower abdomen to palpate liver, moving upward. the
liver edge in most infants, 1 to 3 cm below the right costal margin
The spleen, like the liver, is felt easily in most infants. It is soft with a sharp edge
and it projects downward like a tongue from under the left costal margin. The
spleen is moveable and rarely extends more than 1 to 2 cm below the left costal
margin.

27. Extremities
Peripheral cyanosis
Musculosceletal
Gait
Coordination