Pediatric Clinical

Diagnosis

Sudigdo Sastroasmoro
Department of Child Health, Medical School
University of Indonesia, Jakarta
After this lecture the students should
understand:
The philosophy of clinical examination
The place of history taking and physical exam in
the perspective of professionalism
The characteristics of clinical examination in
infants and children
The 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 Francisco
President of The American Surgical Association


University of Arkansas Medical School
CODE OF PROFESSIONAL CONDUCT
FOR MEDICAL STUDENTS
A. Professional obligations
Respect for learning
Respect for persons
Respect for patients
confidentiality
Honesty, integrity
Responsibility for patient care
Awareness of limitations
Deportment as professional
etc
B. Professional Ideals
Clinical virtues-
Conscientiousness
Collegiality
Personal health
Objectivity
Responsibility to society
If the above rules are followed, you, as a medical
student, and in the future a physician, should find your
professional life extremely rewarding.
When you were born,
you cried and the world rejoiced.
Live your life in such a manner
so that when you die the world cries
and you rejoice.
Old Indian Saying
Profession is a complex concept, the definition of
which has been attempted for centuries. It has
been studied and defined by many from a variety
of disciplines with some agreements, much
conflict, and some useful additions.
Profession: a declaration, promise,
commitment publicly announced

Profession and professionalism are words with
elastic meanings.
A Profession is
a recognizable occupation in which
practitioners have a degree of autonomy over
their work, are involved in working with
significant applied theory, and work within a
framework of values and ethics which are
broadly agreed across the occupation.
Components of professionalism
Competence
Accountability
Altruism Collegiality
Ethics
What is professional competence?

The habitual and judicious use of
communication, knowledge, technical skills,
clinical reasoning, emotions, values, and
reflection in daily practice for the benefit of
the individual and community being served.
Competence builds on a foundation of basic
clinical skills, scientific knowledge, and moral
development
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 uncertainties
and 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 childs stage of
growth and development.



The diagnostic
paradigm:


History
(Anamnesis)

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

History: 80%
Supporting exam: 5%
Physical exam 10-20%
1. Patients ID
2. Chief complaint boleh bukan berupa keluhan, misalnya mau vaksinasi, dirujuk dsb
3. Clinical course sdah diobati sendiri/dokter, ada diagnosis
4. Previous illness
5. History of maternal pregnancy
6. History of delivery
7. Feeding history
8. Immunization status
9. Growth & development
10. Family history
11. Environment
Anatomy of history taking
Present Clinical course Birth
Prenatal
Birth
Nutrition, immunization, growth & development
Past history
1
2 3
4
5, 6, etc
Who provides the patients history?
(determines your confidence to the information provided)
Be patient, make a conducive atmosphere
Use daily words instead of medical terms
Be sure that the history-giver understands your points
Use history taking as a method for health education
ALWAYS: make footnotes /remarks at the end of
history taking
Points to remember

1. An 8-year old girl, 30 kg, 130 cm, 3
rd
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, & nosebleed

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:
Inspection
Auscultation abdomen & thorax
Examination using equipments (misal : dengan
nasal speculum)
Physical examination
Steps in
physical exam
General condition
Vital signs
Anthropometric measurements
Systematic exam
A. General condition
1. Consciousness : alert, apathetic, somnolent,
sophorous, comatose
2. Appearance : healthy, mildly/moderately/
severely ill, distressed
3. Color : pale, jaundice, cyanotic
4. Specific facies : syndromes, facies cholerica,
fish-mouth, facies leonina,
Cooleys facies
B. Vital signs
1. Pulse : rate, regularity, volume,
equality
2. Respiration : rate, regularity, pattern
3. Blood pressure : of 4 extremities
(setidaknya sekali
selama hidup)
4. Temperature : oral, axillary, rectal
Note: always describe complete pulse & respiration!
C. Anthropometric measurements
1. Body length/height : sitting, standing
2. Body weight
3. Head circumference
4. Arm circumference
5. Abdominal circumference
6. Nutritional status: W/A, H/A, W/H plot in
standard normal curves
(NCHS)
D. Systematic examination
Head & neck
Chest
Abdomen
Genitals
Extremities
Skin, hair, lymph nodes
Neurological
Use of stethoscope
Use binaural stethoscope
Bell-shaped side : low-medium pitched
sounds
Membrane (diaphragm): medium-high pitched
For heart examination:
Bell-shaped first
Without pressure, then with pressure
Membrane
Common mistakes in
performing examination
History
Fail to identify the patient first
Make an incomplete history
Provide a disorganized history
Physical exam:
Fail to describe general condition & vital signs first
Incomplete description of features, e.g. pulse rate
only or respiratory rate only without further
characteristics

Put your notes in every element of physical exam
where appropriate

Example: The child was cooperative, fighting,
etc.

Components of professionalism
Competence
Accountability
Altruism Collegiality
Ethics
Patients preference
Evidence from
valid research
Physicians competence
EBM



What is Evidence-based Medicine?



The conscientious, explicit, and judicious use of
current best evidence in making decisions about
the care of individual patients
Pemanfaatan bukti mutakhir yang sahih dalam
tatalaksana pasien
Integration of (1) physicians competence,
(2) valid evidence from studies,
and (3) patients preference
WHY EBM?
1. New evidence are continuously generated
2. We usually fail to get the new evidence
3. Our clinical performance deteriorates with
time (the slippery slope)
4. Traditional CME does not improve clinical
performance
5. EBM encourages self directed learning
process which should overcome the above
shortages
Years after graduation
Relative
% of
remaining
knowledge

2 4 6 8 10 12
$
100%
THE SLIPPERY SLOPE
Patient with
problem
Search the
evidence
Critically
appraise
the evidence
Formulate
in answerable
question
Apply
the evidence
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 art
The art of history taking and physical exam are by no
means inferior to your scientific knowledge of the
disease under investigation
Respect 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
A great doctor.
Three young moms are chatting about their
3-year-old sons
Mrs. A.: John must be a great lawyer then. He argues
everything all the time with definitely terrific
arguments for his age!
Mrs. B: Im sure Mike will become a cute engineer.
He destroys every toys we gave, and reconstructs
them successfully. Yes, always! Fantastic!!
Mrs. C: No doubt, Greg is a typical great doctor. How
do you know? Asked Mrs. A and B. He never
comes when called, Mrs. C explained calmly.

How can you be a good
examiner?


THINK,
PRACTICE,
PRACTICE,
PRACTICE
!!!