After this lecture the students should understand:

The philosophy of clinical examination The place of history taking and physical exam in the perspective of professionalismThe characteristics of clinical examination in infants and childrenThe systematic of clinical examination in infants and children

What is the philosophy?

Doctor as a professional must

be aware that patients are looking

for

attention and help

Patients primarily

want to be examined by a

respected doctor, NOT

to be subjected as

an object of technology

Professionalism should be taught in medical schools and during residencies. Currently, we do suboptimal jobs in medical schools

and a poor job in residencies.

We are, I believe, witnessing an improvement in public esteem and trust in the medical profession. Restoration of full trust will require consistent professional

conduct in medical students, residents, and practitioners of medicine…….

Dr. Haile Debas (2000)Dean, The University of California, San

FranciscoPresident of The American Surgical

Association

The core clinical competencies

1. Patient care

2. Medical knowledge

3. Interpersonal and communication skills

4. Professionalism

5. Practice-based learning & improvement

6. Systems-based practice

What do patients usually want?

Patients usually want to be respected as an individual; they are not numbers or even a member of a group of numbers

So what?

Medicine is the science of uncertaintiesand the art of probabilities

Personal and humane approach!!

Clinical exam in infants and children:

Why special attention?

A child is not a small adult!

Keywords: growth and development

Any information about history, physical, and laboratory / supporting

exams should be judged in relation with the child’s stage of growth and

development.

The diagnostic paradigm:

History

Physical

Routine lab

Special investigations

History(Anamnesis)

Auto-anamnesis: self reporting by the patient Allo-anamnesis: any information other than

by patient (parents, caregiver, referring doctor, previous medical record, previous lab results, etc)

Advances in medical knowledge & technology do not exclude the importance of clinical assessment Appropriate use of medical technology is based on thorough history & physical exam No laboratory or other exams are performed without appropriate clinical information No laboratory or other exams are interpreted without aligning with clinical condition Mastering clinical examination is a must for all doctors caring for patients, from GP to sub-specialist

Listen to them; they are

telling you the diagnosis!!!

History: ≥80%

Supporting exam:5%

Physical exam 10-20%

1. Patient’s identity 2. Chief complaint 3. Clinical course 4. Previous illness 5. History of maternal pregnancy 6. History of delivery 7. Feeding history 8. Immunization status 9. Growth and development 10.Family history11.Environment

Anatomy of history taking

PresentClinical courseBirth

Prenatal

Birth

Nutrition, immunization, growth & development

Past history

123

4

5, 6, etc

11

Who provides the patient’s history? (determines your confidence to the information provided)Be patient, create a conducive atmosphereUse ordinary expression instead of medical termsBe sure that the history-giver understands your pointsUse history taking as a method for health educationALWAYS: make footnotes /remarks at the end of

history taking

Points to remember

1. A 8-year old girl, 30 kg, 130 cm, 3rd grade of elementary school, repeatedly had good ranking in class. She was brought to the clinic due to 3-day high grade fever, stomach ache, and epistaxis

2. A 12-year old boy, basketball player, suspected of suffering from radial fracture.

Should complete history be obtained in all patients

irrespective of their illness?

Remember

It is the patient that should be treated; not

the disease

In general similar to that in adults, i.e. to obtain accurate physical status irrespective of the approach Needs modification due to nature of infants & children: Start with inspection Followed by auscultation: abdomen

& heart End with examination using

equipment

Physical examination

Steps in physical exam

General condition Vital signs Anthropometric

measurements Systematic exam

A. General condition

1. Consciousness : alert, apathetic, somnolent, soporous, comatous2. Appearance : health, mild / moderate / severely ill, distressed3. Color : pale, jaundiced, cyanotic4. Specific facies : syndromes, facies

cholerica, fish-mouth, facies leonina, Cooley’s

facies

B. Vital signs

1. Pulse : rate, regularity, volume, equality

2. Respiration : rate, regularity, pattern3. Blood pressure : of 4 extremities4. Temperature : oral, axillary, rectal Note: always describe complete pulse & respiration!

C. Anthropometric measurements

1. Body length / height: sitting, standing2. Body weight3. Head circumference4. Arm circumference span5. Abdominal circumference6. Nutritional status: W/A, H/A, W/H (plot in standard normal curve NCHS)

D. Systematic examination

Head and neck Chest Abdomen Genitals Extremities Skin, hair, lymph

nodes Neurological

Use of stethoscope

Use binaural stethoscope Bell-shaped side: for low & medium pitched sounds Membrane (diaphragm): for medium to high pitched sounds

For heart exam use bell-shaped side first start without pressure, then with pressure End with diaphragm side

Common mistakes in performing examination

HistoryFail to identify the patient firstMake an incomplete historyProvide a disorganized history

Physical exam: Fail to describe general condition &

vital signs firstIncomplete description of features,

e.g. pulse rate only or respiratory rate only without further characteristics

Developmental Approach

to Physical Exam in Infants

Perform uncomfortable parts of the exam lastComplete the exam with the infant in the parents arm Keep the infants warm and covered Observe general appearance, respiratory rate and effort, overall color

Developmental Approachto Physical Exam in Toddlers

Approach quietly, calmly and slowComplete the assessment wherever the child is comfortableAllow the child to play with your stethoscopeHave a toy or something to distract the childConsider listening to parent or child’s toy to promote comfort

Developmental Approachto Physical Exam in

School Age

Clearly explain the plan and expectations before the examinationAnswers the child’s questions honestlyTalk about topics of interest during the examinationThey may be modest, allow them to keep a gown onInclude them in your history taking

Developmental Approachin Adolescents

Questions should be directed at the adolescent and parentBe honestEnsure privacy during the examination and in sharing informationProvide the adolescent with the opportunity to have the parent step out for history and/or examinationProvide reassurance

Concluding

remarks History taking and physical exam skills require good background knowledge and a sound human relation;

as a part of medical practice, they are science and artThe art of history taking and physical exam are by no means inferior to your scientific knowledge of the disease under investigationRespect the patient and the family if you want to be respected by them; by and large, respecting each other is the key for success in medical practice

How can you be a good examiner?

THINK, PRACTICE,

PRACTICE,

PRACTICE!!!

Thank you