Practical Aspects of Pediatrics 5th Edition

FIFTH EDITION PRACTICAL ASPECTS OF

PEDIATRICS

Dr. Mayoor K. Chheda

BHALANfl 'P’uibl Ishers

Practical Aspects of

PEDIATRICS F ifth E dition

Dr. Mayoor K. Chheda

f - -------------------------------------------------------------------------------------------------------------------------------- \

© BHALANI PUBLISHERS — 2009 First Edition Second Edition Third Edition Reprint Reprint Fourth Edition Fifth Edition Reprint Reprint Reprint Reprint

: 1999 2001 2002 2003 : 2004 2006 2009 2009 : 2010 : 2011 2011

Price Rs. 330/ISBN : 978-81-908433-1-7 The author & the publisher have taken special care to ensure that the dosage recommendations specified in the text are precise. However in view of the continuing research & accumulating knowledge, the dose for a few of the drugs as recommended by the manufacturers may vary. Hence the readers are requested to check the manufacturers recommendations for drugs, specially for those drugs which are new in the market or those which are not used frequently in day-to-day practice.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.

TRADEMARKS : All Brand names & product names used in this book are TRADE NAMES; TRADE MARKS or REGISTERED TRADEMARKS of their respective companies or owners. The author & the publisher are not associated with any product or company mentioned in this book. Printed By : Sharp Industries (Mumbai)Tel.: 022-25796604 E-mail: [email protected] Published by : BHALANI PUBLISHERS A-1, Amrita Sadan, Plot No. 13/14, Sector-22, Opp. Terna Hospital, Nerul (W), Navi Mumbai-400706, Tel.: 022-2771 7531, Mobile: 9867214519 Email : [email protected] • www.bhalanipublisher.com Branch: Shop No. 7, Plot No. 265, Sanjoli Co. Op-Hou. Ltd, Sulochana Shetty Marg, Near Sion Hospital, Mumbai - 400022, Tel.: 022-24093098.

r

Foreword With the explosion in the availability of scientific information, it has become necessary for us to run fast to stay where we are. It is virtually impossible for any person to keep pace with all the available literature. Dr. Mayoor K. Chheda’s brief, but informative book Practical Aspects of Pediatrics is being published at the right time when undergraduate and post-graduate students need to stay afloat and swim to their desired destination in the wild sea of exhaustive syllabus.

Dr. (Mrs.) PRAGNYA PAI Ex-Director, Medical Education, Major Hospitals & Ex-Dean Seth G. S. Medical College & KEM Hospital Parel, Mumbai - 400 012.

\

Preface to the First Edition Pediatrics far from being a subset of Medicine has developed into a separate speciality. This book has been written with a view to provide the overburdened Medical Student (Undergraduate as well as Postgraduate) with a concise book on the practical aspects of Pediatrics. Section

I

includes

basic

knowledge

regarding

Pediatric

History

&

Examination & Symptomatology. Section II discusses Systemic Examination & Common Exam Cases. Section III deals with Drugs, X-Rays & Instruments. There is no better way to learn Pediatrics than working sincerely in the wards. There is no shortcut to this approach. The principal object of this book is to help the Medical Student in his ward-work & it is not intended to be a substitute to ward-work. In this book, I have tried to include all those fine practical points which I gathered during daily rounds. Dr. K. N. Shah's weekly case-presentation clinics were also a great help to me in designing this book. I am deeply indebted to all my teachers for the help & support that I have received during my residency. I am especially grateful to Dr. M. P. Colaco; Dr. Surekha Rajyadakhsha, Dr. U. S. Ali; Dr. N. C. Joshi; Dr. R. H. Merchant; Dr. Rashmi Dalvi & all my Seniors at B. J. Wadia Hospital who have contributed somewhere or the other. I also want to thank Dr. J. R. Kamat (KEM Hospital), Dr. R. P Khubchandani (Kasturba Hospital) & Dr. S. Y. Joshi (Cooper Hospital) as I had the privelege to work in their units. I am especially grateful to Dr. (Mrs.) Pradnya Pai (Dean - KEM Hospital) for her willingness to review the text & provide a foreword for the same. I would like to thank my family for their constant encouragement. I would also like to thank Mr. Rajesh Bhalani for Speedy Publication of the book. I hope the book will be received well by the pediatric fraternity. Further suggestions & criticism regarding the book will help in improving its quality & are most welcome. Mumbai

Dr. MAYOOR K. CHHEDA

ft ' ............................................ ' i.

Preface to the Fifth Edition The Fifth Edition of 'Practical Aspects of Pediatrics' follows the Fourth Edition after 3 years. In these 3 years, a number of new vaccines like IPV, Rotavirus vaccine etc have been introduced & well-accepted by the Pediatric fraternity in India. The changes in the immunization Schedule due to the addition of these vaccines have been reflected in the fifth edition. Likewise, the chapter on vaccines has been updated according to the latest information available. A new section on Maintenance of Cold Chain of vaccines has been added. A detailed discussion on Acute Flaccid Paralysis has been added. The discussions following the case-presentations have been updated. The chapters on X-rays & Instruments have been extensively edited. Images of a large number of X-rays have been added. I am grateful to Dr K N Shah, Honorary Pediatrician; Mumbai & Dr. Hemant Shah, Radiologist; Mumbai & Dr. Bharat Boricha Radiologist; Mumbai for allowing me to use their X-rays. A number of instruments have been added to the existing ones in the chapter on Instruments. Inspite of the above changes, there has been a reduction in the number of pages to the book due to the use of new fonts & 2-column format. I would like to thank all & sundry involved in the publication of the book. Mr. Rajesh Bhalani of Bhalani Publishers was extremely supportive inspite of the delay in editing the book & Mr. Chetan Sawant did a good job at DTP. I would like to thank my wife & family for their constant support & encouragement during the edition work of the fifth edition. As always, I remain indebted to the student fraternity & my colleagues for their acceptance of this book. Suggestions & criticisms for improving the book are always welcome. Interested readers may contact me at the following email address.

Email : [email protected] Dr. MAYOOR K. CHHEDA Mumbai ----- ----------------- ---------------. . . . JJ

V

ft------------- ^

Contents Foreword........................................................................................................................................

iii

Preface to the First Edition...........................................................................................................

iv

Preface to the Fifth Edition...........................................................................................................

v

SECTION I Chapter 1 : Pediatric Case Presentation...............................................................

1-4

1.1

History...............................................................................

1

1.2

Examination......................................................................

2

Chapter 2 : The Art of History - Taking & Examination In Pediatrics Pediatrics.....................................................................................

5-35

2.1 2.2

History............................................................................... Examination......................................................................

5 12

Chapter 3 : Differential Diagnosis of Common Symptoms & Signs ........................................................................................... 36-53 3.1

--------- ^

D/D of Common Symptoms..............................................

36

1. Abdominal Distension...............................................

36

2. Abdominal Pain.........................................................

36

3. Altered Taste.............................................................

36

4. Anorexia....................................................................

36

5. Back Pain.................................................................. 6. Bleeding....................................................................

36 37

7. Blue Eyes..................................................................

37

8. Chest Pain.................................................................

37

9. Constipation...............................................................

37

10. Convulsions...............................................................

38

11. Coma.........................................................................

38

12. Cough........................................................................

38

13. Deafness...................................................................

38

14. Delayed Micturition in Newborns..............................

39

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Practical Aspects of Pediatrics

f ■ -- \

15. Delayed Puberty....................................................... ......39 16. Diarrhea.................................................................... ......39 17. Drowsiness............................................................... ......40 18. Dryness of Mouth............................................................40 19. Dyspnea (Breathlessness)....................................... ......40 20. Epistaxis..........................................................................40 21. Excessive Crying...................................................... ......40 22. Excessive Salivation with Drooling.................................40 23. Excessive Sweating........................................................41 24. Fever......................................................................... ......41 25. Gingivitis..........................................................................41 26. Gynaecomastia......................................................... ..... 41 27. Haemetemesis.......................................................... ..... 41 28. Haematuria..................................................................... 41 29. Haemoptysis............................................................. ..... 42 30. Halitosis.......................................................................... 42 31. Headache....................................................................... 42 32. Hicupps..................................................................... ..... 42 33. Hoarse Voice............................................................ ..... 43 34. Jaundice.................................................................... ..... 43 35. Joint Pain / Swelling.................................................. ..... 43 36. Obesity...................................................................... ..... 43 37. Oedema.................................................................... ..... 43 38. Oliguria / Anuria........................................................ .....44 39. Photophobia...................................................................44 40. Precocious Puberty........................................................44 41. Refusal to Feed..............................................................45 42. Short Stature............................................................. .....45 43. Sneezing................................................................... .....45 44. Stomatitis.................................................................. .....45 45. Stridor.............................................................................45 46. Sudden Loss of Vision (Amaurosis)......................... .....45 47. Tall Stature.....................................................................45 48. Torticollis................................................................... .....45

ix

Contents

f-

-------

-------------=----------------- -- ------------------- ---------- ----------------------- -------- _ -------------- V

49. Vertigo....................................................................... ......46 50. Vomiting...........................................................................46 51. Weight loss (Failure to thrive)................................... ..... 46 3.2

D/D of Important Abnormal Signs...........................................47 1. Angular Stomatitis..................................................... ..... 47 2. Appearing & Disappearing Abdominal Masses........ ..... 47 3. Beading of Ribs.............................................................. 47 4. Bossing of Skull........................................................ ..... 47 5. Bow Legs.................................................................. ..... 47 6. Bulging Anterior Fontannel....................................... ..... 47 7. Brittle Hair................................................................. ..... 47 8. Brownish - Yellow Discolouration of Teeth.................... 47 9. Cafe- au-lait spots..................................................... ..... 47 10. Cataract.......................................................................... 48 11. Cat’s Eye Reflex (White Reflex in Eyes).................. ..... 48 12. Clubbing.................................................................... ..... 48 13. Craniotabes.................................................................... 48 14. Cyanosis......................................................................... 49 15. Delayed Closure of Anterior Fontannel.................... ..... 49 16. Depressed Nasal Bridge................................................ 49 17. Down — Slanting (anti-mongoloid) Eyes....................... 49 18. Downward Deviation of eyes.................................... ..... 49 19. Early Closure of Anterior Fontannel......................... ..... 49 20. Epiphyseal Widening....... .............................................. 49 21. Exophthalmos........................................................... ..... 49 22. Hypothermia................................................................... 49 23. Hypotonia of Limbs................................................... ..... 50 24. Hyperplasia of Gums......................................................50 25. Hypertelorism............................................................ .....50 26. Hypertonia................................................................. .....50 27. Hyperventilation........................................................ .....50 28. Hypotelorism............................................................. .....50 29. Lachrymation..................................................................50 30. Large Head (Macrocephaly)..................................... .....51

^^

Practical Aspects of Pediatrics

X

ft— = = = = = ----------------------------------------------------------------------------- -—

,

31. Limitation of Joint Movement....................................

51

32. Lock - jaw (Trismus)..................................................

51

33. Low - Set Ears...........................................................

51

34. Lymphadenopathy....................................................

51

35. Macroglossia............................................................. 36. Macro-Orchidism (Large Testis)...............................

51 51

37. Membrane Formation in Throat (White Membrane in Throat)

51

38. Microcephaly............................................................. 39. Micrognathia (Small Jaw).......................................... 40. Micro-Orchidism (Small Testis).................................

52 52 52

41. 42. 43. 44.

Micropenis................................................................. Neck Stiffness........................................................... Nystagmus................................................................ Pigeon - Shaped Chest.............................................

52 52 52 52

45. Precordial Bulge........................................................

52

46. Proptosis................................................................... 47. Ptosis.........................................................................

52 53

48. 49. 50. 51. 52.

53 53 53 53 53

Puffiness of Eyes...................................................... Purpura...................................................................... Scoliosis.................................................................... Short Neck................................................................. Upward Slanting Eyes (Mongoloid Slant)................. SECTION II

Systemic Examination & List of Important EXAM CASES......................................... 54 Chapter 4 : Cardio Vascular System .................................. .................................. 55-78 4.1 4.2

Congenital Heart Disease................................................. Rheumatic Heart Disease.................................................

55 69

Chapter 5 : Central Nervous System .................................................................. 79-131 5.1 5.2 5.3 5.4 5.5 I

Tuberculous Meningitis (TBM)......................................... 79 Acute Infantile Hemiplegia................................................ 85 Acute Flaccid Paralysis.................................................... 93 Cerebral Palsy.................................................................. 105 Hydrocephalus.................................................................. 114

J

xi

Contents

f- --------------------------------------------------------------------------------------------------------------- ^

5.6 5.7 5.8 5.9

Duchenne Muscular Dystrophy........................................ ....118 Meningomyelocoele [MMC].............................................. ....124 Ataxia................................................................................ ... 126 Microcephaly........................................................................ 127

Chapter 6 : Respiratory System......................................................................... 132-134 6.1

Pleural Effusion................................................................. 132

Chapter 7 : Renal System.................................................................................. 135-142 7.1

Nephrotic Syndrome......................................................... 135

Chapter 8 : Gl System........................................................................................ 143-151 8.1

Hepatosplenomegaly........................................................ 143

Chapter 9 : Miscellanous Cases........................................................................ 152-188 9.1

Protein - Energy Malnutrition [PEM]................................. .... 152

9.2

Down’s Syndrome................................................................. 167

9.3

Hypothyroidism................................................................. .... 172

9.4

Rickets.............................................................................. .... 176

9.5

Short Stature......................................................................... 179

9.6

Normal Neonate.................................................................... 185 SECTION III

Chapter 10 : Drugs............................................................................................. 189-235 10.1

Analgesics & Anti-inflammatory Drugs............................. 189

10.2

Antiamebic Agents............................................................ 191

10.3

Antibiotics & Antimicrobials............................................... 192 1. Sulfonamides................................................................. 192 2. Penicillins....................................................................... 192 3. Semi-synthetic Penicillins...............................................192 4. Cephalosporins.............................................................. 194 5. Aminoglycosides............................................................ 196 6. Broad Spectrum Antibiotics [Tetracyclines &............. 197 Chloramphenicol]

V___________________ __ ________________________________ ____________________________

xii

#

Practical Aspects of Pediatrics

. . .

, 7. Macrolides..................................................................... 198 8. Quinolones................................................................. ... 199 9. Miscellaneous Antimicrobials.................................... ... 200 10.4

Anticonvulsants.................................................................... 202

10.5

Anti-coagulants................................................................. ... 204

10.6

Anti emetics...................................................................... ... 205

10.7

Anti - Fungal Drugs.............................................................. 206

10.8

Anthelmintics.................................................................... ... 208

10.9

Anti Histaminics & Decongestants................................... ... 209

10.10

Antihypertensives............................................................. ... 211 1. ACE Inhibitors............................................................ ... 211 2. Beta-blockers............................................................. ... 211 3. Calcium Channel Blockers............................................ 211 4. Centrally Acting Sympathetic Inhibitors........................ 212 5. Diuretics..................................................................... ...212 6. Vasodilators............................................................... ...213

10.11

Anti-Kala Azar Drugs........................................................ ...213

10.12

Anti-Leprosy Drugs........................................................... ...214

10.13

Anti - Malarial Drugs......................................................... ...214

10.14

Anti-Spasmodics..................................................................215

10.15

Anti-Tubercular Drugs...................................................... ...215

10.16

Anti-Tussive Agents.............................................................216

10.17

Anti-Viral Agents..................................................................217

10.18

Bronchodilators & Drugs used in Bronchial Asthma ...

219

I. Bronchodilators.......................................................... ...219 1.

Sympathomimetics............................................................ ... 219

2.

Methylxanthines.................................................................... 220

3.

Anticholinergics..................................................................... 221

4.

Leukotriene Receptor Antagonists.................................... ... 221

II. Mast Cell Stabilizers.................................................. ...221 III. Corticosteriods.............................................................. 222

^

.

10.19

Cardiotonics.........................................................................222

10.20

Corticosteroids.....................................................................223

-----------------------------------------------------------------------------------------------------------------------

----------------------- ^

xiii

Contents

#

-------------

----------- -----------

— ' ----------

---------------

-------------------------------------------------------------------- %

10.21

Chelating Agents............................... ...................................224

10.22

Haematinics...................................................................... ....224

10.23

Hormones & Drugs Related to Hormonal Glands................ 225 A. Pituitary Gland............................................................. ....225 B. Thyroid hormones........................................................ ....226 C. Pancreatic hormones.......................................................226

10.24

Sedatives.......................................................................... ....227

10.25

Tranquillizers & Antipsychotics................ :....................... ....228

10.26

Tricyclic Antidepressants & Serotonin Inhibitors..................229

10.27

Vitamins............................................................................ ....229

10.28

Others Drugs.........................................................................231

Chapter 11 : Common Drugs Kept in Table Vivas............................................ 236-246 1.

Sodium Bicarbonate......................................................... ....236

2.

Ringer Lactate.................................................................. ....236

3.

Calcium Gluconate........................................................... ....236

4.

Potassium Chloride.......................................................... ....237

5.

25% Glucose.........................................................................237

6.

Aminophylline........................................................................238

7.

Hydrocortisone Hemisuccinate.............................................238

8.

Prednisolone.........................................................................238

9.

Dexamethasone....................................................................238

10.

Adrenaline......................................................................... ....239

11.

Atropine.................................................................................239

12.

ACTH ............................................................................... ....239

13.

Furosemide...........................................................................240

14.

Digoxin.............................................................................. ... 240

15.

Vit. D..................................................................................... 240

16.

Vit. A.................................................................................. ... 241

17.

Vit K...................................................................................... 241

18.

Diazepam......................................................................... ... 241

19.

Phenobarbitone.................................................................... 241

20.

Phenytoin.......................................................................... ... 242

21.

Mannitol : (20% solution).................................................. ... 242

xiv

Practical Aspects of Pediatrics

f

A

-

22.

Penicillin............................................................................

242

23.

Gentamicin........................................................................

243

24.

Streptomycin.....................................................................

244

25.

Chloramphenicol...............................................................

244

26.

Ampicillin...........................................................................

244

27.

Amoxicillin.........................................................................

245

28.

Metronidazole...................................................................

245

29.

Cephalosporins.................................................................

245

Chapter 12 : Vaccination; Newer Vaccines; Combination 247-261 Vaccines & Cold Chain 12.1

Vaccine Administration.....................................................

247

12.2

Newer Vaccines...............................................................

248

1.

Hepatitis B Vaccine .........................................................

248

2.

H. Influenzae B Vaccine...................................................

249

3.

Typhoid Vaccine...............................................................

251

4.

Chickenpox Vaccine.........................................................

253

5.

Hepatitis A Vaccine..........................................................

254

6.

Meningococcal Vaccine...................................................

255

7.

Pneumococcal Vaccine....................................................

255

8.

Inactivated Polio Vaccine (IPV)........................................

257

12.3

Combination Vaccines......................................................

258

12.4

Management of Cold Chain of Vaccines.........................

259

Chapter 13 : X-Rays.......................................................................................... 262-281 13.1

X-Ray Chest.....................................................................

262

13.2

X-Ray Skull.......................................................................

271

13.3

X-Ray Bones....................................................................

273

13.4

X-Ray Abdomen & Barium Contrast Studies...................

279

Chapter 14 : Instruments................................................................................. 282-293 1.

' L

.

- .

Laryngoscope...................................................................

282

2.

Endotracheal Tube...........................................................

283

3.

Ambu Bag.........................................................................

284

4.

Oxygen Reservoir.............................................................

284

---------------------

J

xv

Contents

f----------— -------------

V.

---------------------------------------------------------------------------------------

\

5.

Face Mask........................................................................ ....284

6.

Oxygen hood.........................................................................285

7.

Nasal Oxygen Catheter.................................................... ....285

8.

Metered Dose Inhaler (MDI).................................................285

9.

Dry Powder Inhaler (DPI)................................................. ....286

10.

Spacers.................................................................................286

11.

Nebulizer...............................................................................287

12.

Tongue Depressor............................................................ ....287

13.

Clinical Thermometer....................................................... ....288

14.

Infant Feeding Tube......................................................... ....288

15.

Simple Rubber Catheter................................................... ....289

16.

Foley's Catheter....................................................................290

17.

Urinary Drainage Bag....................................................... ....290

18.

Flatus Tube...........................................................................290

19.

Tuberculin Syringe............................................................ ....290

20.

Scalp Vein Needle............................................................ ....291

21.

IV Canula.......................................................................... ....291

22.

Three-way Connector....................................................... ....291

23.

IV Set................................................................................ ....292

24.

Vilm-Silvermann's Needle.....................................................292

25.

Lumbar-Punctur (L-P Needle).......................................... ....293

26.

Bone-marrow Aspiration Needle...................................... ....293

SECTION - I

Pediatric Case Presentation Though the basic art of history-taking & Examination in Pediatrics remain almost the same as in Adults, there are a few important differ­ ences.

Anthropometric measurements are very important in children whereas they are of hardly any signifi­ cance in adults. The relevant details of History-taking & Examination in children are discussed in-depth in the following chapter (Chapter. 2). The Schematic approach is discussed below in short for easy refe­ rence.

For e.g. the Antenatal, Birth, Perinatal history or the detailed history of the developmental miles­ tones assumes great importance in children, whereas they are irrelevant in adults. Similarly,

Schematic Approach of a Pediatric Case Presentation :

1.1 History Left Hand Side History

Chief History

Birth & Perinatal History : & Pedigree chart

Basic Information :

tP Antenatal History

& Name, age, sex of child.

Immediate postnatal History

& Born of consanguinous/Non consanguinous marriage.

& Relevant details regarding other siblings

& Informant being mother/father/guardian

Religion & Residence (Permanent residence) & Hailing from Native place.

Immunization History : Primary & Booster doses if received.

Chief Complaints : In chronological order : e.g : & Fever 20 days (P Convulsions 8 days cr* Unconsciousness 5 days

Developmental History Relevant History regarding developmental milestones.

Detailed story of the presenting complaints in chronological order with a detailed symptom & system review.

Dietary History : (£> Duration of Breast-feeding

Past History : & History of similar illness in the past.

Type & time of weaning.

ODP of Chief Complaints :

& History of other significant diseases in the past.

& Calorie & protein intake of the food to be calculated.

(P History of common infectious illness like exanthematous illness (Measles), Tuberculosis

Socio-Economic History : & Educational background of parents.

Treatment History : if> Detailed History regarding the treatment received.

& Monthly income of family.

& History of Prior Hospitalization

& Number of persons in family.

Family History : & History of similar illness in family/siblings.

Number of rooms. Housing conditions etc.

tP History of Tuberculosis in family.

1

Section I — Practical Aspects of Pediatrics

2

1.2 Examination

Respiratory System Examination : Examination of the Upper Respiratory Tract : Throat, tonsils, pharynx, frontal & maxillary sinuses etc.

General Examination : Anthropometry

Parameter

Percentiles

Expected (ICMR)

Inspection : Shape of chest, Examination of shoulders & spine, Respiratory movements, Respiratory rate & rhythm, use of accessory muscles of respiration (suprasternal, subcostal, intercostal retractions), Apex impulse, Traile’s sign, Pulsations, dilated veins, scars & sinuses over the chest.

>

Weight-for-age

>

Height-for-age

>

Head Circumference

>

Mid-arm Circumference (between 1-5 years of age)

& Respiratory movements

>

Chest Circumference

& Tactile vocal fremitus

>

Upper segment/Lower segment ratio

Percussion :

(?

Pallor; Cyanosis, Clubbing; Lymphadenopathy; Icterus; Edema; Signs of liver-cell failure. Examination of Head, Face & Neck : Shape of head, Presence or absence of facial dysmorphic features, Anterior Fontannel, Posterior Fontannel, Craniotabes, Macewan’s sign, Transill­ umination of skull, Auscultation of skull, Abn­ ormalities of eyes, ears, nose, mouth & chin; Examination of Mouth & Throat; Examination of the neck (for any swellings, raised JVP etc.), Thyroid gland enlargement etc.

& Evidence of Protein or Vitamin deficiency & Examination of Skin, hair & nails & Examination of Bones, Joints & Spine & Examination of Genitalia & Developmental Assessment

Palpation : Confirm the findings of inspection including : & Palpation of the trachea & the Apex beat

It is difficult to elicit signs in young children. Areas percussed are : Clavicular percussion on either side & Delineate the liver dullness on the right side & the cardiac dullness on the left side (P Percuss anteriorly over both the lung fields, in the axilla & posteriorly over the suprascapular, interscapular & infrascapular areas & deter­ mine if the percussion note over the lung fie­ lds is hyper-resonant, dull, stony dull, imp­ aired or tympanic. Auscultation : The following auscultating the chest :

things

are

noted

while

& Breath sounds : Intensity (normal or decreased) & quality (vesicular, bronchial or bronchovesicular) Vocal resonance

Systemic Examination : Depending on the history, detailed exam­ ination of a particular system should be done while examining the other systems briefly.

Foreign sounds friction rub

like

rales,

rhonchi,

(£> Other signs like Coin test, Succussion splash etc.

pleural

3

Pediatric Case Presentation

Palpation abdomen.

Cardiovascular System Examination : Inspection : Precordium (normal impulse; Pulsations over dilated veins over the chest.

or bulging); the chest (which

Apex area);

of

any

other

lump

over

the

Percussion : Shifting dullness; horse-shoe shaped dullness; fluid thrill

Palpation :

Auscultation :

& Apex beat- position, character (normal, tapping, heaving)

Peristaltic sounds or bruits over the abdomen or the liver

& Parasternal heave & diastolic shock

Central Nervous System :

& Thrills

Higher Functions :

Percussion : Percussion is not very young children. The borders Right, Left & lower) can children. Pericardial Effusion percussion.

useful & reliable in of the heart (Upper, be defined in older may be detected by

Auscultation : Heart sounds : Intensity of the sounds (loud or soft); Splitting of the 2nd sound (normal, wide, fixed or variable, reversed split); Presence of 3rd or 4th heart sounds & Murmurs : Timing of the murmur (e.g. systolic, diastolic etc.); Site of maximum intensity of the murmur; Grade of murmur (1 to 6); Radiation of murmur; Posture in which the murmur is best heard; Change in the murmur with change in respiration or after exercise.

(P Consciousness & Intelligence & Memory iP Orientation in time, place & person & Speech Cranial Nerves : Cranial Nerves 1st

Sense of smell in each nostril

2nd

Visual acuity, Field of vision, Colour Vision, Fundus (Ophthalmoscopic examination)

3rd, 4th & 6th

External ocular movements, Nystagmus, Ptosis / Diplopia / Squint, Pupils

5th

Sensations over the face, Masseter, Temp­ oralis & Pterygoid muscle function, Conju­ nctival & Corneal reflexes, Jaw Jerk

7th

Taste sensation over anterior %rd of tongue, Facial muscle function (ask the . patient to raise his eyebrows, close his eyes tightly, show his teeth, blow his cheeks etc)

& Other sounds : Ejection clicks (aortic or pulmonary); Opening snap or Pericardial rub. 8*

Alimentary System (Per-Abdominal Examination) :

Ringing of bell, Rinne's test & Weber's test.

9th & 10th

Inspection : Shape of the abdomen; movements of the abdomen; Umbilicus; Peristaltic movements; Dilated veins, pulsations, scars or sinuses over the abdomen.

Examination

Sensations over posterior 'A"1 of tongue. (9lh nerve); Palatal movements & movement of uvula on saying 'Ah' with the mouth open; Gag reflex; Nasal regurgitation, Nasal twang in voice (10th nerve)

11th

Sternocleidomastoid function

12th

Movements of tongue at rest & after prot­ rusion

&

Trapezius

Palpation : (P Tenderness, guarding or rigidity. & Palpation of organs >

Liver-Normal or enlarged; edge; borders; consistency; tenderness.

'> Spleen- Not palpable or enlarged. >

Kidneys- Ballotable or not.

Motor System Examination : & Posture of the limbs. & Nutrition of the muscles - Normal, atrophy or hypertrophy. Cp Tone of the muscles - Normal / hypotonia / hypertonia. >

Palpation of muscles

muscle

4

Section I — Practical Aspects ot Pediatrics

>

Posture of limbs

Sensory system examination :

>

Resistance to passive movements

& Superficial sensations - Touch, pain &

>

Range of passive movements

>

Specific tests in infants - Scarf sign, heelto-ear manoeuvre, adductor angle and ankle dorsiflexion.

& Power of the muscles- grade 0 to V. & Co-ordination - In older children (>6-7yrs of age) & only if power > III / V Tests : Gait of patient, tandem walking, Fingernose test, Rebound test, Dysdiadocho-kinesia, Knee-heel test, Rhomberg’s test. (p Involuntary movements : Tremors, athetosis, ballismus, myoclonus, chorea, dystonia.

Reflexes : >

Superficial reflexes - Plantars, abdominal reflexes, Cremasteric reflex, anal reflex.

>

Deep tendon reflexes - Biceps, Triceps, Su­ pinator, Knee jerk, Ankle jerk, (grade 0 to 4+)

temperature.

Deep sensations - Vibration & position & Cortical sensations - Tactile localization, Tactile discrimination & stereognosis.

Signs of Meningeal Irritation : Neck stiffness, Kemig’s sign and Brudzinski’s sign

Cerebellar Signs : Staccato speech, Ataxic Gait, Hypotonia, Nyst­ agmus & Inco-ordination (Rhomberg’s test, fingerto-finger test, dysdiadochokinesia etc.) T ................... ....

......... ~Tv

Diagnosis The closest diagnosis or a Differential Diagnosis (D/D) should be offered after the examination find­ ings; depending on the particular case. This will be discussed individually elsewhere in the text.

The Art of History - Taking & Examination In Pediatrics should also be asked as for e.g. Tuberculosis in the past may lead to Bronchiectasis or Measles may pre­ dispose to Malnutrition or may trigger TBM.

2.1 History Chief History :

Treatment History : The treatment history is relevant in case of chronic diseases like Epilepsy where the patient is on daily anti-convulsant therapy or in Tuberculosis where an inquiry can be made as to how many months the medicines have been taken. History of prior hospitalization is also important to determine the chronicity of the disease.

Basic Information: The basic information as discussed in Chapter 1 is usually provided by the mother, father or a close relative in children. However, an older child can defi­ nitely provide useful bits of information. In fact, in older children the child himself should be able to provide Informtion regarding the chief complaints & the ODR The other information like the Birth his­ tory etc. can be provided by the mother.

Family History The family history assumes significance in case of genetic diseases e.g. X-linked diseases like Ducchene Muscular dystrophy where history of simi­ lar illness in the maternal uncle should be sought for. Family history also assumes significance in case of infectious diseases like Tuberculosis. Thus in ev­ ery child with a suspicion of Tuberculosis, history of contact with an adult patient of Tuberculosis should always be sought for.

Chief Complaints : The complaints with which the patient presented to the doctor should be recorded in chronological order. E.g. Cough since 7 days; Fever since 2 days.

ODP of Chief Complaints : After recording the chief complaints, an attempt must now be made to ascertain the onset of symp­ toms, their duration & the progress of symptoms in­ dividually. Thus, for example in the above case :

The Left-Hand Side History________________

Cough: Onset-Sudden or insidious; duration; fre­ quency; dry or productive; character-barking cough or paroxysmal cough; variation with the time of the day-more during night or immediately after waking up in the morning; variations with posture-more in supine position & less in sitting position etc.

The left-hand side history (i.e. the birth history, Immunization history, developmental history, dietary history & the socio-economic history) should be taken in details as they are especially relevant in children.

Birth History

Fever: Onset-sudden or insidious; Severity-mild, moderate or high; Duration; Character-continuos throughout the day or intermittent; Diurnal variation-e.g. Evening rise of temperature in Hiberculosis; Association with rigors etc.

A detailed Birth History & family pedigree should be enquired & a pedigree chart should be prepared. Fig 2.1 shows a few guidelines as to the construction of the Pedigree chart. | | Male

□-o

Past History :

Q Female Carrier Parents Husband & Wife in a nonconsanguinous marriage

The mother should be asked about the detailed past history of the child-whether he suffered from similar illness in the past. This assumes great sig­ nificance in chronic diseases such as Asthma where the history of repeated attacks of breathlessness in the past would help in immediately clinching the diagnosis. History of other diseases suffered in the past such as Tliberculosis, Measles, Jaundice etc.

□^=o n-po

Consanguinous Marriage

1

Abortion

Index Patient Table continued on next page

5

6

Section I — Practical Aspects of Pediatrics

Table continued from previous page

Immediate Postnatal History : 13 years: 2 doses at an interval of l'A - 2 months

Single dose. Booster every 3 years. 0.5 ml SC, Costly. Optional Vaccine. May be reco­ Deltoid or Anterolateral mmended to following patients : if* Immunocompromised children area of thigh > HIV-affected children >

Children on steroids or immunosuppresive drugs

>

Children with Leukemia

>

Children with Nephrotic synd­ rome

& Adolescents & adults (As the dis­ ease increase in severity with advancing age) & In Close contacts of patients with chickenpox (Contacts without H/o chickenpox affliction) Hepatitis-A Vaccine

Age & Dose :

IM,

Children & Adolescents : 0.5 ml

Deltoid or

Adults : 1ml 2 doses at an interval of 6 months

Anterolateral thigh

area

Costly. Optional Vaccine. May be recommended to following patients : (p Children with chronic liver dise­ of ases (e.g: Hepatitis B/C chronic carriers) (f Adolescents & adults (As the dise­ ase severity increases with incre­ asing age) Close contacts of patients with Hepatitis-A affliction (Contacts who have not suffered from Hepatits-A infection) (p

Food handlers/Sewage Medical Personnel.

workers/

* Due to increase in breakthrough cases of varicella despite vaccination, American Academy of Pediatrics recommends a 2nd dose of Varicella vaccine 4-6 years after the 1st dose (IAP still continues to recommend a single dose only) Table continued on next page

9

The Art of History - Taking & Examination In Pediatrics

Table continued from previous page Vaccine Meningococcal Vaccine

Route, Site & Dose

Age Of Administration

0.5 ml IM/SC, Deltoid or Anterolateral area of thigh

Age : Children > 2 years of age: Single dose Booster (If required): After 3 years

Remarks Recommended to: & In Epidemics of Menin­ gococcal Meningitis iIn children with asplenia (Anatomic or functional) (P In Close contacts of indi­ viduals afflicted with Me­ ningococcal disease.

Pneumococcal Vaccine (23-Valent)

Age & Dose : < 2 years of age: Not recom­ mended

0.5 ml IM/SC, Deltoid or Anterolateral area of thigh

> 2 years of age: 1 dose of vaccine followed by booster dose (as below)

Recommended to: & In children with asplenia (congenital or acquired-as with splenectomy) & Immunocompromised ch­ ildren

Booster dose: 3-5 years after the 1st dose

HIV

> >

Diabetes Mellitus

>

Chronic diseases

>

Chronic cardiac dis­ ease >

> Pneumococcal Vaccine (Protein Conjugate Vaccine - PCV7)

< 6 months of age (2-6 mon­ ths): 3 doses at 6-8 weeks interval + 1 Booster at 12-15 months

0.5 ml IM, Deltoid or Anterolateral thigh

Indications for immunisation are same as that for 23 PS vaccine. In addition, it can also be used as an optional vaccine for primary immu­ nization of infants from affl­ uent families after proper di­ scussion with parents regar­ ding the pros & cons of the vaccine.

SC

It should be used for vacci­ nating children in Endemic areas.

0.5 ml IM, Anterolateral area of thigh

Recommended to: tP Children with adverse reactions to whole-cell vaccine (e.g: persistent crying, high fever, seiz­ ures etc.)

7-11 months of age: 2 doses at 6-8 weeks interval + 1 Booster at 12-15 months. 12-23 months of age: 2 doses at 6-8 weeks interval. >. 2 only Japanese Encephalitis Vaccine

years

of

age:

1

dose

Age & Dose :

Chronic lung disease Nephrotic syndrome & CRF

1-3 Years of age: 0.5 ml > 3 years of age: 1 ml Booster: After 2 years

Acellular Pertusssis Vaccine (Available in combination with Diptheria & Tetanus as DTaP)

Same as Vaccine

that

of

whole-cell

Table continued on next page

Section I — Practical Aspects of Pediatrics

10

Table continued from previous page Vaccine

Age Of Administration

Route, Site & Dose

Inactivated Polio Age & Dose: 3 alternative sch­ 0.5 ml IM / SC, Vaccine (IPV) edules Anterolateral area of 1) 6 weeks, 10 weeks, 14 thigh or Deltoid weeks & l'A years 2)

10 weeks, 18 weeks & l'A years

3)

2 doses at 2 months interval followed by booster at l'A years

Remarks (f>

Presently recommended to children from affluent section of society

1P Use of OPV (scheduled doses &

pulse polio) to be continued in those receiving IPV

(For children between l'A - 5 years: 2 doses at 2 months interval) Rotavirus Vacci­ & Rota Teq™: 3 doses at Per-oral (PO) ages 2 months, 4 months nes: 2 vaccines available & 6 months. & Rotarix™: 2 doses at ages 2 months & 4 months

& Rota Teq™ fs> Rotarix™

&

Human Papilloma

virus

vaccine (HPV) 2 vaccines available & Cervarix™ & Gardasil™

fr Presendy recommended only to children from affluent section of society after proper disc­ ussion with parents regarding the pros & cons of the vaccine

Age of administration & 0.5 ml IM, number of doses : Both Deltoid vaccines are recommended to be given to girls before Pub­ erty (before sexual contact) i.e. at about 10-11 years of age.

Children above 6 months of age should not be vaccinated against Rotavirus due to incr­ eased risk of intussusception in older children.

& Presently recommended only to girls from affluent section of society after proper discussion with the parents regarding the pros & cons of the vaccine

(f> Cervarix™: 3 doses at 0, 1 month & 6 months Gardasil™: 3 doses at 0, 2 months & 6 months

Developmental History A detailed developmental history may not be essential in all cases; but nevertheless the achie­ vement of a few basic milestones like social smile, head-holding, rolling over, sitting (with & without support) pull-to-stand, walking & development of language should always be inquired in all the cases. In children suspected to have delayed development or a CNS disorder, a detailed developmental screening should be undertaken. The developmental history of other siblings should also be inquired as it can be compared to

that of the patient. In older children, scholastic backwardness is an important indication of developmental retardation after ruling out organic causes (like deafness or myopia) & social causes (Poverty, Child Labour). Similarly, social behavior & ability to play games or solve puzzles play an important role in determining the development of the older child. Further details about the developmental milestones & the assessment of development are discussed later in the discussion on General Examination.

The Art of History - Taking & Examination In Pediatrics

11

Table 2.4 : Rice Moongdal Powder

Table 2.3 : Recommendation For Vacc­ ination In HIV Infected Children

Oral Route

WHO

VACCINE

Asymptomatic

Symptomatic

ip BCG

Yes

No

,S> OPV

Yes

Yes

d> DPT

Yes

Yes

& Measles

Yes

Yes

(P Hepatitis-B

Yes

Yes

Hib conjugate

-

-

tP Pneumococcal

-

-

tP Meningococcal

-

-

£> Varicella

-

-

tP Influenza

-

-

500 ml 2 tsp

Sugar

2 tsp

Oil

1 tsp

1 tsp

Salt

1 pinch

1 pinch

Quantity after cooking

275 ml

450 ml

RT ROUTE

In Water

In Milk

In Water

Calories

160

90

120

50

Proteins (gm)

6.0

2.3

5.1

1.4

& Other types of liquid food available in the

hospital are : (described in Table 2.6) Table 2.6 : Liquid Food Other Than RMP

duration

(how

& If top-fed — whether it was Cow’s milk or Formula - Milk & If top-fed — what was the dilution used & Whether he was bottle-fed or fed with a wati spoon & If he was bottle-fed whether the bottle, nipple were washed regularly before each feed. &

300 ml

In Milk

Whether the child has been breast-fed or not. for what

10 tsp

Liquid

ORAL ROUTE

The dietary History should include the foll­ owing details :

Exclusively breast-fed many months)

10 tsp

Table 2.5 : Nutritive Value Of RMP (Per 100 ml)

Dietary History

(P

RT Route

RMP powder

For breast-feeding infants, the frequency, the type of schedule (time or demand), etc should be inquired into.

& Age of weaning, nature & amount of food given to the child should also be asked. fr In older children, food intake during 24 hours prior to the onset of illness should be inquired in detail so as to calculate the approximate calorie & protein intake per day.

Food i R i c e Kanji Egg flip

& Banana flip

Contents

Calories

Proteins

Quantity 100 ml

25-50

0.5-1 gms

1 Egg, Milk (150 ml), Sugar (10 gms)

225

4.5 gms

1 Banana, Milk (150 ml), Sugar (10 gms)

240

1.5 gms

Table 2.7 : Food Exchanges (Approximate values) Food

Proteins

Calories

& Cereals : 1 Cup Rice

2 gms

1 Chappati

2 gms

50 cals

1 Cup Upama

6 gms

250 cals

Ragi (6 tsp)

2 gms

100 cals

1 Chapati = 1 Idli/

2 gms

50 cals

10 gms 43 gms

430 cals

100 cats

1 dosa = 2 Puris = 1 slice of bread. tf" Pulses :

Liquid Diet used in Hospital : & RMP — Rice Moongdal Powder

1 Cup Cooked Dal

Proportion used : Rice : Moongdal 3

:2

1 Cup Cooked Soyabean

300 cals

Table continued on next page

Section I — Practical Aspects of Pediatrics

12

Table continued from previous page Food

Food

Proteins

Calories

ip Milk/ Per 100 ml. :

Amount

Cooked Measure

Leafy

200 gms approx 1.5 katori

Human milk

1.1 gms

65 cals

> Roots

100 gms approx 3A katori

Cow’s milk

3.3 gms

67 cals

> Other

300 gms

approx 2 katori

Buffalo Milk

4.4 gms

104 cals

Curd (100 gms)

3.3 gms

67 cals



4-6 Years

22-26

6-8 Years

20-24

8-10 years

19-22

10-12 Years

18-21

>12 Years

17-20

Blood pressure: The Blood pressure should be measured in all children with an appropriate cuff (The bladder should cover atleast 2A”i of the circum­ ference of the upper arm & should be placed over the inner aspect of the arm so as to cover the brachial artery). The size (width) of the bladder generally used for measuring BP in infants is 4-6 cms & in children 7-9 cms. In children suspected to have a cardiac problem, B.P should be mea­ sured in both the upper arms & also in the lower limbs (for e.g. In preductal co-arctation of aorta, B.P is higher when measured on the right side than on the left side) B.P increases as age increases (Table 2.12)

Table 2.12 : Blood Pressure At Different Ages Age

AVERAGE BP (mms of Hg) Systolic BP

Diastolic BP

Newborn From 1 month to 1 Year

70 70-75

45 45-50

1-2 Years

75-80

45-50

2-4 Years

75-85

50-55

4-6 Years

80-90

50-60

6-8 Years

85-95

55-65

8-10 years 10-12 Years

90-100 95-105

65-75

12-14 Years

100-110

70-80

>12 Years

110-120

80

60-70

The Art of History - Taking & Examination In Pediatrics

unto adolescence. As a general guide to the estimation of average BP from Birth to Ado­ lescence : At Birth-BP is 70/45 - Every year following birth, add 3/year for the systolic BP & 2/year for the diastolic BP.

15

Methods of measurement: □

In neonates & infants below 1 year of age: Beam type (Detecto) weighing machine [accuracy of about 50 grams (+/-)].

□

In older children: Spring machines or bath­ room scales can be used. Electronic scales being more accurate are always preferred; however they are not widely available.

& Anthropometry : The following measurements are very impor­ tant & should always be done. >

Weight (in kgs)

Formulas for weight (Table 2.14) :

>

Height or length (in cms)

>

Head Circumference (in cms)

>

Chest circumference (cms) - upto 3 years of age.

(Percentile charts are ideal methods of calcu­ lating weight-for-age. Classification is based on Harvard’s 50th centile as standard).

>

Mid-arm circumference (cms)- between 1-5 years of age.

>

Upper segment / Lower segment ratio The above measurements should be expre­ ssed in the form of percentiles (derived from percentile charts) & compared to the expected percentiles (ICMR) as shown in Table 2:13.

Table 2.13 : Anthro jometric Measurements Parameter

Percentiles

Expected Perce­ ntiles (ICMR)

Weight-for-age Height-for-age Head circumference Chest circumference

The newborn loses weight in the first few days after birth due to loss of edema fluid & re­ gains birth weight by about the 10"1 day of life. Weight increases by 25-30 grams/day from Day 10 of life to 3 months age. Later on, for­ mulas can be used to determine ideal weights.

Table 2.14 : Formula To Calculate Weight At Different Ages Age

Formula To Calculate Weight In Kgs

3 months to 1 years of age

9 + age (months) 2

1 year to 6 years of age

2 (age in years) + 8

6 years to years of age

7 (age in years) - 5 2

12

Mid-arm circumference Upper segment / lower segment ratio The anthropometric measurements can be broadly divided into Age-dependent Measurements & Age-independent measurements.

> Height-for-age: It is not as sensitive as weight because height cannot be lost, however stunting of height in­ dicates long-term (chronic) malnutrition. Methods of measurement: □

Age-Dependent Measurements >

Weight-for-age : The weight-for-age is a very good index for detecting the nutritional status of the child. The Wellcome Trust classification, IAP clas­ sification, Gomez’ classification, Bengoa’s clas­ sification & Jellife’s classification of PEM are all based on Weight-for-age as the criterion. (These classifications are discussed in detail later on in the chapter on PEM).

Below 2 years of age: Length is measured with the help of Infantometer. The Infantometer is a machine having a mea­ suring scale placed horizontally with two vertical planks on it. One of the planks is fixed whereas the other can be moved over the measuring scale. To measure the length of the infant, he is placed supine on the infantometer with the head touching the fixed vertical plank. Then the legs are extended & the movable vertical plank is brought closer to the child & made to touch

Section I — Practical Aspects of Pediatrics

16

□

the soles of the feet. The length is read on the measuring scale that is provided.

academic & research purposes. Triceps & Subscapular measurement are used.

For children above 2 years of age: The height should preferably be measured us­ ing a Stadiometer. It can also be measured by asking the child to stand against a wall with his bare feet touching each other & the heels, hips, upper back & head touch­ ing the wall. The length is then measured using a measuring tape.

Triceps measurement :

Formulas for height: (Percentile charts pre­ ferred) : At birth

50 cms

1 year

75 cms

2 years

87 cms

3 years

94 cms

4 years

100 cms

Height increases by : 25 cms/year for 1st year of life 12 cms/year year of life

Between 1-6 years age :>10 mm is nor­ mal (< 6 mm is abnormal) Disadvantages : □

Choice of exact site is difficult

□

It is not a very objective method as the pinch of the callipers may be different when done by different people.

□

Edema in case of kwashiorkor can give rise to false rise in the skin-fold thic­ kness.

> Head Circumference : for

2nd

6 cms/year for 3rd year of life & 4-5 cms/year thereafter till puberty. After 2 years age : Height (cms) = age (6) + 77 Based on both weight-for-age & Height-forage, the anthropometric categories of child­ ren (as described by Waterlow in 1972) are :

Table 2.15 : Anthropometric Categories Of Children Anthropome ric Cate­ gories Of Children

Herpeuden’s callipers are used to pinch the skin midway between the tip of acrom­ ion process of scapula & olecranon process of ulna.

Height- Weight- Weight-KirFor-Age For-Age Height

Measurement of head circumference is very important in infants & children. How­ ever, since brain-sparing occurs in acute & milder forms of PEM, brain growth & head circumference remain unaffected except in chronic or severe PEM. Method of measurement : The head circumference is measured with the help of a non-stretchable plastic measuring tape encircling the prominent areas of the forehead & the occiput. Normal cms at birth.

Head

circumference

is

It Increases at the rate of 2 cms/month for Is' 3 months Then at 1 cm/month for next 3 months

□ Normal

N

N

N

Then at 0.5 cms/month for next 6 months

□ Acute malnutrition

1

N

i

Then 2 cms between 1 to 2 years

\

I

I

I

N

□

Acute-on-Chronic Malnutrition

□ Chronic Malnutrition

i

M-Normal, I Decreased.

> Skinfold thickness : This is not a very sensitive or a useful indicator of malnutrition & is generally not used in all cases. It is used primarily for

33-35

1

cm between 2 to 3 years

0.5 cms between 3 to 4 years 0.25 cms between 4 to 6 years after which it remains at adult values. In l$l year of life : Length -Head circumference =--------------------1- 9.5 ( ±. 2.5 cms)

The Art of History - Taking & Examination In Pediatrics

17

> Chest Circumference : The chest circumference is lower than the head circumference at birth. It equals the head circumference by 9 months in western children & by 1-2 years in Indian children & then crosses it. In PEM, because of brain-sparing, the head circumference is not as much affected as the chest cir­ cumference & hence the cross-over may not occur even after 3 years. Method of measurement : The chest circumference is measured with the help of a non-stretchable plastic measuring tape encircling the chest at the level of the nipples.

part giving rise to the gradual reduction in the Upper segment / Lower segment ratio with the progression of age.

Table 2.17 : Upper Segment / Lower Segm­ ent Ratio Age

Upper Segment : Lower Segment Ratio

At Birth

1.7 : 1.0

At 3 Years

1.3 : 1.0

At 7 Years

1.0 : 1.0

Thereafter

1.0 : 1.1

Age - Independent Measurements > Weight for height :

> Mid-arm Circumference :

It is sensitive in acute malnutrition, but not in chronic malnutrition (because both height & weight decrease but weight rem­ ains proportional to height)

The mid-arm Circumference remains constant between 1-4 years of age (16-17 cms) in healthy children (though, it maybe falsely elevated in Kwashiorkar because of edema). The reason for it to remain constant is the replacement of baby fat of infancy with muscles.

% Weight for Weight of child v, -V = -------------------------------------- x 100 ° Weight of normal child of same height

Method of measurement : The mid-arm Circumference can be measured with the help of a non-stretchable plastic measuring tape midway between the olecranon process & the acromian. Grading PEM with the help of Mid-arm cir­ cumference :

Table 2.16 : Mid-arm Circumference Grades Normal Mild PEM Moderate PEM Severe PEM

Circumference In cms

Shakirs Tape (Colour)

16 cms between 13.5 - 16 cms

Green

between 12.5 - 13.5 cms

Yellow

< 12.5 cms

Red

> Upper segment / Lower segment ratio : The upper segment of the body extends from the vertex of the head to the sym­ physis pubis. The lower segment extends from the Symphysis pubis to the heels. The lower part of the body grows rapi­ dly after birth as compared to the upper

>

Rao & Singh’s criteria : Weight (Kg) --------------------------x 100 Ht2 (cms) Normal

=

0.15 - 0.16 This is constant between 1-5 years of age irres­ pective of gender.

In PEM = 0.12 - 0.14

> Mid-aim circumference -------------------------------- ----- Ratio Height (Used in Quae Stick i.e. circumference measuring stick)

Quacker’s

arm

Quae stick is a rod which measures height and it is calibrated in arm circum-ference measurements. For the various height levels, the 3rd percentile values of the expected mid-arm circumference is marked. If the child’s height is greater than his mid-arm circumference value on the Quae stick, he is diagnosed to be malnourished.

Section I — Practical Aspects of Pediatrics

18

> Kanawati & Mclaren’s Index :

months of age. Delayed closure of Post-erior fontannel may be seen in children with Down’s Syndrome.

Mid arm circumference Head circumference Normal Value

= 0.33 [Constant bet­ ween 3 months - 4 years of age irresp­ ective of gender]

>

Craniotabes - It indicates softening of the outer table of the skull. It is elicited by applying pressure on the scalp behind and above the ears (Parietal area). Presence of a snapping sound on application of pressure is indicative of Craniotabes. It may be phy­ siologically present in premature infants or in neonates and para-neonates. It is path­ ologically present in children with Rickets, Hydrocephalus and Vitamin A Poisoning.

>

Macewan’s sign - it should be elicited only if the anterior fontannel is closed as it is positive in infancy due to open anterior fon­ tannel. The skull is percussed with the fin­ ger & cracked-pot sound is heard. It is pre­ sent (positive Macewarfs sign) in case of rai­ sed ICT due to separation of sutures.

Healthy children = > 0.31 Mild PEM

= 0.31 - 0.28

Moderate PEM = 0.28 - 0.25 Severe PEM

= Transillumination of skull : Should be done in a dark room with a torch placed over the frontal region & occipital region.

& Examination of Head, Face & Neck >

Shape of head : It is important in cases of craniosynostosis (premature fusion of sutures of skull.) eg : Brachycephaly-Decreased ante­ roposterior diameter of skull due to bilateral fusion of coronal sutures. Dolichocephaly Increased A-P diameter of skull due to fusion of sagittal suture. Plagiocephaly-Asy­ mmetrical skull due to fusion of unilateral coronal suture. The head may be flattened on one side in infants who sleep in only one position or in children with Torticollis.

>

Presence or absence of facial dysmorphic features suggestive of certain syndromes : e.g. Down’s syndrome. Look for facial par­ alysis (It may be seen unilaterally in chil­ dren with Acute Infantile Hemiplegia. Bell’s palsy, Cerebral Palsy etc. Bilateral Facial pa­ lsy may be seen in Guaillain-Barre Syn­ drome.)

>

Anterior Fontannel - open or closed; nor­ mal, bulging (raised ICT)

>

Posterior Fontannel - It usually closes by 2-3

□

In Frontal region - If translucency exce­ eds 1 inch, it is abnormal.

□

In Occipital region - If translucency exceeds half-an-inch, it is abnormal.

Abnormal translucency of skull may occur in hydrocephalus, subdural effusion, Hematoma etc. >

Auscultation of skull for bruits in patients with raised ICT.

> Abnormalities of eyes, ears, nose, mouth &

chin : e.g. Bitot’s spots in eyes in vitamin A deficiency; Low-set ears in Down’s syn­ drome; Look for Otorrhea, Wax & examine the tympanic membrane of each ear to det­ ect perforations, glue ear etc.

> Examination of Mouth & Throat : □

Look for evidence of cleft lip or cleft palate.

□

Examine the buccal mucosa : Koplik’s spots (Bluish-white spots seen in the buccal mucosa near the ope-

The Art of History - Taking & Examination In Pediatrics

19

ning of the parotid duct) may be seen in Measles. Thrush (White patches which bleed on scraping) may be seen in neonates, in immunosuppressed children or in pati­ ents on prolonged antibiotic therapy.

& Evidence of Protein or Vitamin deficiency : >

Look for signs of PEM (These are covered in detail in chapter on PEM).

>

Look for signs of Vitamin deficiency

Mouth ulcers may be seen in Vit­ amin B deficiency, in children on Anti­ biotics, in immunosuppressed children or in children with Leukemia. □

Presence of Angular stomatitis & cheilo­ sis are suggestive of vitamin B defic­ iency.

□

Dentition - Delayed primary dentition may either be due to hereditary causes or Vitamin D & Calcium deficiency. Hyg­ iene of teeth & gums should also be det­ ermined. Bleeding from gums is indi­ cative of Scurvy (Vitamin C deficiency).

□

□

>

for

evidence

>

□

□

Vitamin B deficiency - Angular stomatitis & cheilosis

□

Vitamin C deficiency - Bleeding gums

□

Vitamin D deficiency - Delayed closure of anterior fontannel, bossing of skull, rachi­ tic rosary, bow legs, knock knees, protru­ ded abdomen etc.

Examination of Skin : The skin should be examined for its : □

Colour - Depigmented lesions may be due to Vitiligo, Tinea Versicolour or Pityriasis alba whereas generalised depigmentation occurs in Albinism, Chediak-Higashi syn­ drome. Hyperpigmented lesions may be nevi, hemangiomas, petechiae, ecchymoses, Cafe-au-lait spots etc.

□

Turgor - to detect dehydration,

□

Infections - Pyoderma, scabies, fungal infe­ ctions etc.

of

□

Examination of the neck : □

Vitamin A deficiency - Xerophthalmia or Bitot’s spots

& Examination of Skin, hair & nails :

Tongue: Examine the colour of the ton­ gue. Beefy red tongue is seen in Niacin deficiency whereas Magenta tongue is seen in Riboflavine deficiency. Absence of papillae over the tongue (Bald tongue) is suggestive of Vitamin B12 deficiency. Coated tongue is seen in chronic illn­ esses or in Enteric fever. Examine the throat pharyngitis or tonsillitis.

□

Look for Swelling of the neck - It may be seen in Diptheria, Mumps or Cellulitis. Webbing of the neck may be seen in girls with Turner’s Syndrome. Look for enlargement of the neck veins. Measure the JVP (In patients with heart failure, the neck veins are distended and JVP is raised). Look for abnormal venous pulsations. Palpate the Carotid artery.

□

Palpate the lymph nodes in both the ante­ rior and posterior cervical triangles of the neck. Enlarged and matted lymph nodes in the anterior cervical triangle of the neck frequently indicates Tuberculosis.

□

Look for enlargement of the Thyroid gland or any other abnormal swellings in the neck.

>

Rash - Measles, Chickenpox, etc.

□

Signs of Vitamin A deficiency - Toad-skin

□

Signs of PEM - covered in detail in chap­ ter on PEM

□

Miscellaneous - eg : Subcutaneous nod­ ules (seen on extensor surfaces of the body in Rheumatic fever), Xanthomas and Xant­ helasmas (seen in Hypercholesterolemia), Striae (seen in Cushing’s syndrome) etc.

Examination of Nails : The nails should be examined to determine the presence of Pallor, Cyanosis, Clubbing, Chronic Iron deficiency (Platynychia or Koilonychia). Brittleness of nails is seen in PEM. The nails may be absent in patients with Ectoder­ mal dysplasia, Paronychia (Infections around the nails) is common in children with PEM.

>

Examination of Hair : The hair should be examined for their

Section I — Practical Aspects of Pediatrics

20

colour, thickness, sparseness, brittleness (Hair are light-coloured, thin, sparse, brittle with areas of alopecia in PEM) & presence of lice (Pediculosis). Seborrheic dermatitis of scalp should also be noted, as extensive & resistant seborrheic dermatitis is frequently seen in HIV-positive children. Excessive hair over the body may be seen in children with Cushing’s syndrome, hypot­ hyroidism and in certain chronic diseases.

(P Examination of Bones, Joints & Spine : >

Examination of Bones : The bones should be examined for any swelling, deformities, fractures, tenderness at any site. [Tenderness in extremities may be seen in patients with injury or infection or in patients with Vitamin C deficiency (Scurvy)]. Limbs should be examined for deformities like bow-legs, knock-knees, club-feet (Talipes equino-varus) & difference in the size of both the lower limbs (Limb-length inequality). Limh-length inequality is common in Con­ genital dislocation of hips (CDH) which goes unnoticed at birth & in early life. Swelling at the wrists (Widening of the epiphysis of the radius) is a sure sign of Rickets. Bow-legs are physiological till 2 years of life. They are con­ sidered to be pathological only when the dis­ tance between the medial aspect of both the knees exceed 10 cms when the medial mal­ leoli of both the ankles are in close proximity to each other. Similarly, Knock-knees are physi­ ological between 2 to 4 years of age. They are considered to be pathological only when the distance between the medial aspect of the medial malleoli of both the feet exceed 10 cms when the two knees are in close proxim­ ity to each other.

>

Examination of Joints : Joints should be examined for colour (red­ ness indicates infection or inflammation), temperature (hot joints indicate infection or inflammation), Swelling, tenderness on pal­ pation and limitation of movement. Joint ex­ amination is important in patients with Rheu­ matic Fever & in Septic Arthritis which may occur in malnourished children. Tuberculous arthritis, though rare, should also be kept in

mind. In Septic and Rheumatoid arthritis, the joints are red, hot, Swollen, tender and have limited movement due to pain. In Rheumatic arthritis (Rheumatic fever) there may be Ar­ thralgia (Painful joints without any other signs of inflammation like heat or swelling) or Ar­ thritis (however, swelling is not as great as in Septic or Rheumatoid arthritis) >

Examination of spine : The spine should be examined to detect any swelling (Pott’s spine), Tenderness (fractures of vertebrae) or deformities such as kyphosis, scoliosis, lordosis etc. Spine should also be examined to detect the presense of a sinus (spina bifida) or sac (Meningomyelocoele). Movement of the spine should also be ex­ amined. The patient should be asked to bend forward and to sit up from a lying-down posi­ tion. Limitation of motion of the spine may be seen in cases of Meningitis, Osteomyeli­ tis, fractures or Para-vertebral muscle spasms. Excessive motion of the spine is seen in pa­ tients with Hypotonia.

& Examination of Genitalia : The genitalia of the child should be examined to detect any abnormalities or diseases & to as­ sess the sexual maturity in adolescents (table 2.18 & 2.19). In boys, the penis should be examined for presence of phimosis. The scrotum should be palpated for the testes. Sometimes testis may be retractile or undescended. It is important to dis­ tinguish between them as undescended testis re­ quire to be surgically placed in the scrotum (un­ descended testis have a high risk of developing carcinoma). Hernia & hydrocoele should also be ruled out in boys.

& Assessment of Development: A detailed assessment of development is not required in all the cases. Only in patients suspec­ ted to have cerebral palsy or mental retardation, a thorough examination of the developmental milestones should be undertaken. A short his­ tory regarding achievement of developmental milestones like social smile, holding the head, sitting, standing etc from the mother can help determine whether the milestones are delayed or not.

The Art of History - Taking & Examination In Pediatrics

21

Table 2.18 : Stages Of Sexual Maturity In Boys (Tanner’s) Penis

Testes & Scrotum

SMR Stage

Pubic Hair

Small (Pre-adolescent)

None

1

Small (Pre-adolescent)

2

Scrotum enlarges with alteration in Slight enlargement the pink texture which darkens

3

Becomes larger

4

Scrotum becomes large & dark in Becomes long; Gians increases in Almost adult-like but less in amount size & breadth colour Adult size Adult pattern (spread to me­ Adult size dial surface of thighs)

5

Few, straight, mildly pig­ mented Darkens & start curling

Becomes longer

Table 2.19 : Stages Of Sexual Maturity In Girls (Tanner’s)

1

Pre-adolescent

2

Breast & nipple grow as a small mound; diam­ Few, lightly-coloured hair appear on medial border of labia eter of areola increases. Enlargement of breast & areola without sepa­ Hairs become dark & start curling. ration of contour

3

Pre-adolescent

4

Nipple & areola grow to form a secondary Hairs become coarse, curly & grow in amount mound

5

Mature breasts with areola forming part of gen­Adult pattern (feminine inverted triangle) with spread eral breast contour & nipple projecting beyond to the medial surface of the thighs. it.

The following important milestones should be achieved at the age-limits indicated below : Social smile

2'A months.

Head holding

3'A-4 months.

Sitting with support

7-8 months.

Sitting without support

9 months.

Standing

1 year.

Walking

l‘/2 years.

Basic Principles about Development: >

>

Pubic Hair

Breasts

SMR Stage

Development proceeds in a cephalo-caudal di­ rection. Thus, infants first develop head con­ trol followed by ability to grasp, sit, crawl, stand, walk. Certain primitive reflexes like grasp reflex must be lost before coresponding voluntary movements like active grasp can be achie­ ved. eg. Reflexes like assymetric tonic neck reflex should be lost before voluntary movements like rolling over can be achieved.

>

The generalized mass activity of infants is replaced by specific responses, eg. On showing a toy, an infant shows excitement by moving arms, legs & trunk while an older child merely smiles & reaches for the object.

>

Delay in achieving a single milestone need not necessarily imply mental retardation, however gross developmental delay is hig­ hly indicative of mental retardation.

>

In preterm babies corrected age (concept ional age) should be used as the chronc logical age in the 1st year of life. The developmental examination include: assesment of the following : □

Assesment of Milestones

□

Primitive reflexes

□

Assessment of muscle tone

These are discussed below in detail.

Section I — Practical Aspects of Pediatrics

22

Milestones Gross Motor Milestones : Table 2.20 : Gross Motor Milestones Age Birth

Ventral Suspension* Complete lack of head control

IV2 month Momentarily holds head in the same (6 weeks) plane as the rest of the body 3 months Lifts head well beyond the plane of the body. Good head control achieved. *

Prone Position**

Sitting (Pull To Sit)***

Head turned to one side, pelvis high Complete head lag. Back is up & knees drawn up under the abdo­ rounded men Lifts the chin above the ground. Legs Head lag decreases straighten. Lifts chin & shoulder above the Head lag is very slight. ground. Legs are fully extened.

Ventral suspension: Infant is held away from the table in a prone position by supporting the abdomen with the examiner’s hand. (palm). Look for the flexion of the extremities & extension of the neck.

** Prone position: Place the child in a prone position on the table & look for the position of the head, upper limbs, pelvis & the lower limbs. * * *Pull-to-sit: After making the child lie down on the table in a supine position, pull the child to a sitting position by holding both his hands & lifting him at the forearms.

After the age of 3 months, ventral suspension posture is not used for developmental testing. Walking reflex disappears by 6-8 weeks

Table 2.20 : Gross Motor Milestones (Continued) Age

Prone Position

Sitting Position

Upright Position (Standing / Walking)

4 months

Supports own weight on forearms & No Head Lag lifts upper part of body above the ground

6 months

Supports own weight on hands with Lifts head above couch spon­ Can bear almost all his Weight on extended elbows. Rolls over from taneously. Can sit momen­ both legs if supported Prone-to-supine position tarily with support.

7 months

Rolls over from Supine-to-Prone po­ sition

Can sit without support for a few minutes.

9 months

Crawls

Steady while sitting

11 months

Creeps like a bear

—

—

— Pulls to stand Can Cruise holding on to the fur­ niture.

12 months — Walks with a broad-based gait & steps of unequal length.

3 years — Goes up stairs one foot per step. Can stand on one leg

15 months — Walks well without support

4 years — Goes down stairs one foot per step

18 months — Creeps steps upwards & downwards

6 years — Can skip on both feet.

2 years — Runs, Walks backwards, Can go up & down stairs 2 feet per step

The Art of History - Taking & Examination In Pediatrics

23

Fine Motor Milestones :

9 months

1 month — Hands remain closed

— Enjoys Peek-a-boo games. Resists pulling away of toys.

3 months — Grasp reflex disappears. Opens hands spontaneously

1 year

4 months — Grasps objects placed in his hand. Initially object is held on the ulnar side of the hand (ulnar grasp) Hands come together as he plays (in centre)

l‘/2 years

— Mimics action of others; Toilet training started.

2 years

— Wears simple garments/socks/ shoes.

5 months — Can grasp object voluntarily. Plays with his own toes

4 years 5 years

— Releases an object on command.

15 months — Can drink from a cup. months

—

Can feed himself with Scribbles spontaneously

spoon.

2 years — Can build a tower of 6 blocks. Copies a horizontal line. 3 years

o

_|_

5 years — Copies a Triangle

A

6 years — Copies a Hexagon

^

7 years — Copies a Kite

^

8 years — Copies a Double-lined cross =jj= g

11 years — Copies a Cube

gj

Social / Cognitive Milestones : 1 month — Looks at the face intently when spoken to IV2-2 months — Social smile 3 months — Recognizes mother — Shows interest in surroundings. —

— Responds to sound

3 months

— Coos, Laughs aloud

6 months

— Babbles (Gaga, da, dada, Mama)

9 months

— Imitates sounds; Responds to name.

Shows likes & dislikes. Smiles at mirror image. Stretches arms out when mother is going to lift him up.

— Speaks 1 word with meaning; Understands spoken speech — Speaks 1-2 Meaningful words (Monosyllables)

15-18 months— Child Jargon l'A years 2 years

— Speaks atleast 6 words — Begins combining words ( 2 - 3 word sentences) — Points to atleast 1 body part.

3 years

9 years — Copies a Cylinder

months

1 month

1 year

4 years — Copies a Cross

6

— Dresses without supervision. Domestic role play.

10 months

— Can dress/undress himself, Builds a tower of 9 cubes. — Copies a Circle

— Plays with other children

Language Milestones :

9 months — Pincer grasp achieved

18

— Unbuttons dresses — Can dress & undress with help

6-8 months — Transfers object from one hand to other. Grasp now becomes radial [i.e. the object in hand is held against the thenar eminence)

1 year

3 years

— Comes when called; Pulls mother’s clothes to attract attention.

4 years 5 years

— Good Vocabulary; 6 word sentences; knows age & sex. — Can tell a story — Speaks atleast 10 word sentences; Names atleast 4 Colours.

Sphincter Control : Bowel Control is achieved before bladder control at about 1.5-2 years.

Bladder Control : 1.5 years

— Dry by day.

2 years

— 50% are Dry by night.

3 years

— 75% are Dry by night.

5 years

— 90% are Dry by night.

24

Section I — Practical Aspects of Pediatrics

The Primitive Reflexes There are more than 70 primitive reflexes described - however not all are useful. For routine examination of development & in the management of Cerebral Palsy(CP) the following reflexes are considered to be important. They are : Moro’s reflex & Rooting & Sucking reflexes & Asymmetrical tonic neck reflex & Grasp reflex Parachute reflex & Landau’s reflex Deep tendon jerks (Biceps & knee jerks) & Ankle clonus.

& Rooting & Sucking reflexes : On stimulation of the baby’s cheeks or the lips or the angle of the mouth, the Rooting reflex is initiated. On touching the lower lips, the lip low­ ers on the side of the stimulation & the tongue moves towards the site of stimulation. On touch­ ing the centre of the upper lip, the upper lip is elevated & the tongue moves towards the site of stimulation. The Rooting reflex is present at birth & disappears after 3-4 months of age. The Sucking reflex is elicited by putting a clean finger into the baby's mouth resulting in vigorous sucking.

& Asymmetric tonic neck reflex :

Description Of The Primitive Reflexes : & Moro’s reflex: The baby is held supine over the hand & arm with the palm supporting the head of the baby at an angle of approximately 45° from the couch & then the head is allowed to fall back a short distance (by about 30°). The other method is to lay the baby supine on the couch supporting the head with the palm of the hand a few cms above the table & then rapidly releasing the head causing sudden exten­ sion of the neck & eliciting the reflex. The reflex consists of abduction & extension of the arms along with the opening of the hands followed by a slow adduction & flexion of the arms resembling an embrace. The reflex is associated with crying & extension of the neck & movement of the legs. The Moro’s reflex appears after 28 weeks of

Table 2.21 : Moro’s Reflex Abnormal Moro's Reflex

gestation & disappears after 4 months of age. It is a vestibular reflex.

Asymmetric Moro’s Reflex

> Preterm babies - reflex is > Fracture of humerus or clavicle. incomplete with absence of adduction phase > Hypertonic CP - reflex is >• Infantile hemiplegia. less extensive with little movement of arms > Brain damage (HIE) or > Erb’s palsy. maternal sedation-reflex is slow & reduced.

In the supine posture, on rotating the head of the child on one side, there is hypertonia seen in the upper limb on the same side & extension of the lower limb. The reflex appears at birth & dis­ appears after 4-5 months. The reflex is vigorous & persists for a longer time in patients with CP(Spastic CP).

& Grasp reflex : On stimulation of the palm of the hand (Pal­ mar grasp reflex), the infant flexes the fingers & grips the stimulating object. (On stimulating the sole, the toes flex - called as Plantar grasp reflex). Care should be taken not to touch the dorsum of the hand or the foot while eliciting the reflex as then the fingers or the toes will extend & the reflex will not be elicited properly. The palmar grasp re­ flex disappears by about 4 months. Vigorous & per­ sistent grasp reflex is seen in CP & Kernicterus.

& Parachute reflex: On holding the child in ventral suspension & lowering him towards the bed the arms of the baby extend (as if to prevent injury). This reflex appears at 7-9 months of age & persists through­ out life. It is incomplete or absent in children with CP (asymmetrical reflex is seen in infantile hemiplegia).

& Landau’s reflex: On holding the child in prone position by sup­ porting with the palm of the hand; the head, trunk, hand & legs extend. If the head is lowered, the

The Art of History - Taking & Examination In Pediatrics

elbows, hips & knees begin to flex. This reflex appears after 6 months of age & disappears after 15-18 months of age. It is absent in cases of CP & mental retardation & also in disorders of muscle tone. & The Deep tendon jerks & Ankle clonus are elicited as in adults. These are described later on in Examination of CNS. The tendon jerks are ex­ aggerated & Ankle clonus may be present in spas­ tic CP or Pyramidal tract lesions. The jerks may be absent in patients with Brain damage.

25

>

Barrel-shaped chest as in emphysema.

>

Funnel-shaped chest as in Marfan’s syndrome (pectus excavatum).

& Costochondral beading (Rachitic rosary) - seen in Rickets. (P Localized areas of retraction (In collapse of lung) or bulging (In empyema) may be seen intercos­ tal ly. Look at the shoulders. In fibrosis of lung on one side (seen in tuberculosis) drooping of shoulder may occur on the affected side.

(P Examine the spine for kyphosis or scoliosis.

Assessment Of Muscle Tone This is covered in detail later on in the examina­ tion of central nervous system. It is essential to test muscle tone in cases of CP as majority of children with CP are spastic (i.e. they have hypertonia). In addition to the usual methods of estimating muscle tone there are a number of other tests to assess muscle tone in infancy. They are described later in the chap­ ter on examination of C.N.S.

Systemic Examination : Depending on the History, detailed examination of the particular system should be done.

Respiratory System________________________ In the General Examination, special attention should be paid to Respiratory rate, rhythm, c h a r ­ acter of respiration, anemia, cyanosis & lymphadenopathy. The Upper respiratory tract should also be ex­ amined thoroughly. This includes : & Examination of Throat, tonsils & posterior pha­ ryngeal wall & Tenderness over the frontal &/or maxillary sinuses & Movement of alae nasii

Examination of Chest: Inspection: In infants, inspection may be carried out with the child lying supine on the bed, but the best position for inspection in older children is the sitting position. The following should be noted in inspection :

& Shape of chest: Normal shape of chest in infants is circular. Look for: >

Pigeon-shaped chest - as in Rickets (Pectus carinatum).

& Observe the respiratory movements-Whether equal on both the sides or not. Make a note of the respiratory rate & rhythm. Look for the use of ac­ cessory muscles of respiration. Also look for su­ prasternal, intercostal & subcostal retractions. They indicate obstruction of the airways either due to a foreign body or due to asthma. & Detect the position of the apex impulse. In chil­ dren it is usually located in the 4th Left Intercostal space just outside the midclavicular line. Its posi­ tion can be altered in case of shift of mediastinum due to pulmonary pathology. & Look for Traille’s sign : The Traille’s sign is the prominence of the tendon of the sternocleidomas­ toid muscle near the clavicle on one side. It oc­ curs due to the deviation of trachea on the same side (Tracheal deviation is because of shift of mediastinum, probably due to any pulmonary pathology). & Look for any Pulsations, Dilated veins, Scars & Sinuses over the chest.

Palpation : Confirm the findings of inspection. & The respiratory movements are assessed by plac­ ing the hands over both the sides of the chest with the thumbs apposed to each other in the midline. Then, the child is asked to take a deep inspiration & the movement of the two thumbs on both the sides is observed. (Look for equality of movements on the two sides). fr Palpate the trachea by placing the middle finger in the suprasternal notch with the index & the ring finger over the site of attachment of the sternomastoid tendons to the medial ends of the clavicle on either side. Normally, the middle fin­ ger will touch the trachea in the center. If the

Section I — Practical Aspects of Pediatrics

26

□

trachea is deviated, the middle finger will slide into the space between the deviated trachea & the sternomastoid tendon. (P The position of the apex beat should be confirmed by palpation. & Tactile Vocal Fremitus : The vocal fremitus is compared over both the sides by asking the child to speak one-one-one & palpating the chest over identical areas on the two sides. The equality (or inequality) of vocal fremitus is compared on the two sides. Vocal Resonance is more reliable & easier to perform than Tactile Vocal Fremitus.

Broncho-vesicular sounds (Expiration is louder & longer than inspiration & there is no pause between the two) are heard in Bronchial asthma & Emphysema.

(£> Vocal Resonance : The child is asked to repeat one-one-one (cry of a smaller child suffices) & the chest & back on both the sides are auscultated for the quality of the sounds.

Table 2.22 : Changes In Vocal Resonance Increases In

Decreases In

Percussion :

>

Consolidation

>

Pleural effusion

It is very difficult to elicit signs in young chil­ dren with percussion due to the small size of the chest & inability of the younger child to co-operate in the examination.

>

Superficial cavity

>

Pneumothorax

The areas percussed are: & Clavicular percussion on either side. & Determining the liver dullness on the right side & the cardiac dullness on the left side. & Percussing anteriorly over both the lung fields, in the axilla & posteriorly over the suprascapular, interscapular & infrascapular areas. Determine if the percussion note over the lung fields is hyper-resonant, dull, stony dull, impaired or tympanic.

Auscultation: The chest & the back (suprascapular, inter­ scapular & infrascapular regions) are then aus­ cultated to determine :

> Emphysema > Collapse / fibrosis >

Other alterations in the vocal resonance are : >

Whispering pectoriloquoy - Whispered sound is heard clearly on auscultation. Occurs in Cavitatory tuberculosis.

>

Bronchophony - Increased vocal resonance, but the sounds are not very clear. Occurs in Pneu­ monia.

>

Aegophony - Nasal quality of sound like the bleating of a goat. Occurs above the level of Pneumothorax & Pleural Effusion.

C? Foreign Sounds : The foreign sounds to be looked for are : >

Rales - These are crackling sounds which are heard in Pneumonia, Bronchiectasis, Lung abscess, Cavity, Pulmonary edema & Left-sided heart failure.

>

Rhonchi / Wheeze - Rhonchi are continuos musical sounds due to air passing through narrowed airways & are heard in Bronchial asthma, Foreign body obstructing the bron­ chus & in bronchitis.

>

Pleural friction rub - Harsh, creaking sound heard all over the chest (audible during in­ spiration & expiration but disappears on breath holding) associated with pain & ten­ derness heard in early stages of Pleural effu­ sion.

tr* Breath sounds : >

Intensity of breath sounds: Whether normal, increased or decreased on either side.

> Type of breath sounds: □

Vesicular sounds (A long inspiration is fol­ lowed by a short expiration without a pause) Eire normal.

□

Bronchial breath sounds (A low intensity inspiration & a loud expiration occupy the same duration of time & are separated by a definite pause) are heard in Consolidation or a large Cavity.

Bronchial obstruction

The Art of History - Taking & Examination In Pediatrics

Cardio-Vascular System____________________________ In the General examination special attention should be paid to Pulse, BP, JVP, Cyanosis & Edema feet.

Inspection : &

Observe the precordium - In Cardiomegaly (chronic), there is bulging of the precordium.

Look for the apex impulse. (P Look for pulsations & dilated veins over the chest. Note down the area in which the pulsations are present & the direction in which the blood flows in case of dilated veins.

27

per border extends beyond the 2nd I-C space, it is in­ dicative of Pericardial Effusion, Aortic aneurysm etc. If the left border extends beyond the apex beat or the right border extends to the right parasternal region, it is indicative of Pericardial Effusion.

Auscultation: Auscultation should not only cover the mitral, tri­ cuspid, aortic or pulmonary areas; but should also include the 3rd & the 4lh parasternal areas on both the sides, the neck, the thyroid gland, axillary region & the back (for e.g. the pansystolic murmur of Mitral regurgitation is heard best in the mitral area but ra­ diates to the axilla & in some cases to the back also).

Palpation :

Heart sounds :

(r> Apex beat :

Clinically two heart sounds (lsl & 2nd) are usu­ ally audible, altough in certain cases a 3rd or even a 4th heart sound maybe heard. The Is'heart sound (due to the closure of the mitral & the tricuspid valves) is single & is best heard in the mitral area. The 2nd heart sound (due to the closure of the aor­ tic & the pulmonary valves) is split (because there is a time lag between the closure of the aortic valve & the pulmonary valve) & is best heard in the aortic & pulmonary areas. In children below 6 months of age, the pulmonary component of the 2nd heart sound (P2) appears louder than the aortic component (A2).

>

Position of the apex beat : In children it is normally located in the 4th Left Intercostal space just outside the mid-clavicular line.

>

Character of the apex beat: Whether it is Nor­ mal, Heaving or Tapping. A Heaving apex beat is seen in Left ventricular hypertrophy whereas a tapping apex beat is usually due to a pal­ pable 1st heart sound which occurs in Mitral stenosis.

(P Parasternal Heave & Diastolic Shock : Parasternal heave is a heaving impulse in the left parasternal region synchronized with systole & occurs in Right Ventricular enlargement. Diastolic shock is a palpable 2nd Heart sound in the Pulmonary area. If the pulmonary compo­ nent of the 2nd heart sound is loud it is usually due to Pulmonary hypertension whereas a loud aortic component is usually due to Systemic hyperten­ sion. & Thrills: A loud murmur which becomes palpable through the chest wall is known as a Thrill. It has a typical vibratory sensation like the purring of a cat. Note the site of the thrill (Mitral area, Pulmo­ nary area etc.) & the timing of the thrill in relation to the cardiac cycle (Pansystolic, Systolic, Dias­ tolic etc.)

The 3rd heart sound (S3) is normally inaudible. It may be audible in a few normal children as well as in Mitral or Tricuspid regurgitation & in CCE It is heard when there is increased flow of blood into the ventricles during diastole due to any reason. The 4th heart sound (S4) is rarely heard & may be detected in Pulmonary hypertension or severe Pulmonary stenosis. It represents the atrial con­ traction. The following things should be noted while auscultating the heart sounds : >

Intensity of the heart sounds (Loud or soft)

>

Splitting of the sounds (especially the 2nd heart sound). Whether the split is normal or wide; whether the split is fixed (equal during inspi­ ration & expiration) or variable (varies with respiration); whether the split is reversed (P2 occurs earlier than A2).

>

Presence or absence of 3rd & 4th heart sounds.

Percussion: Percussion is not very useful & reliable in young children. The borders of the heart (Upper, Right, Left & lower) can be defined in older children. If the up­

28

Section I — Practical Aspects of Pediatrics

& Murmurs: Murmurs occur due to turbulent blood flow. The turbulence may either be due to a diseased or abnormal valve or a defect (hole) in the heart

□

>

muscle. Timing of the murmur in relation to the car­ diac cycle- e.g. systolic, diastolic, continuos etc.

>

Site of maximum intensity of the murmure.g. Mitral area in Mitral stenosis.

>

Grading the intensity of the murmur (from grade 1 to 6,1 being barely audible to grade 6 which is heard with the stethoscope not touching the chest wall) All murmurs above grade 4 are associated with a thrill.

>

Radiation of the murmur to a particular sitee.g. the murmur in mitral regurgitation is radiated to the axilla & also to the back.

>

Posture in which the murmur is best hearde.g. the mid-diastolic murmur of mitral steno­ sis is best heard with the patient turned on the left side.

>

>

Change in the murmur with changes in respi­ ration : All murmurs originating from the right side of the heart become louder during inspi­ ration (due to increased stroke output of the right heart during inspiration). Similarly, all murmurs from the left side of the heart be­ come louder during expiration (e.g. the early diastolic murmur of aortic regurgitation is best heard along the left sternal edge with the patient bending forward & breathing out. Change in murmur with exercise- e.g the mid­ diastolic murmur of mitral stenosis becomes louder following exercise.

Miscellaneous sounds : >

Ejection clicks : Ejection clicks are clicking sounds heard best in the aortic or the pulmonary area just after the 1st heart sound. They are due to open­ ing of the diseased aortic or pulmonary valves. □

Aotic ejection click: Heard best in the aor­ tic area & transmitted to the apex. Occurs in Co-arctation of aorta, aortic stenosis or aortic regurgitation.

Opening Snap : It is a snapping sound which occurs due to the forceful opening of the diseased valve (mi­ tral or tricuspid) as in mitral or tricuspid steno­ sis. It is heard best just medial to the apex after the 2nd heart sound.

The following things should be noted : >

Pulmonary ejection click: Heard best in the pulmonary area. Occurs in pulmonary stenosis or pulmonary hypertension.

>

Pericardial Rub : It is a coarse, leathery, superficial, to-andfro sound heard throughout the cardiac cycle & all over the chest which is unaffected by respiration but becomes louder in the sitting position & varies in intensity on application of pressure over the chest by the stethoscope. It is heard in early stages of Pericardial Effu­ sion.

Alimentary

System

(Per-Abdominal

Examination) Special attention should be paid to pallor, icterus, lymphadenopathy, edema feet & signs of liver-cell failure (such as spider naevi, palmar erythema, pa­ rotid swelling, flapping tremors etc) in general ex­ amination.

Inspection: The abdomen should be inspected for the follow­ ing :

(P Shape of the abdomen : Whether it is normal, scaphoid(sunken) or distended. Scaphoid abdomen is seen in PEM. Distension of the abdo­ men is seen in obese persons; in ascites; with organomegaly (hepatomegaly or splenomegaly); in rickets etc.

& Movements of the abdomen : The abdominal movements occur with respiration. They are ab­ sent in peritonitis.

& Umbilicus- normal or everted (in ascites). Pres­ ence of umbilical granuloma or discharge of se­ rous fluid or blood from the umbilicus should be noted. Persistent urachus leads to discharge of urine from the umbilicus.

Peristaltic movements : Exaggerated peristaltic movements are seen in pyloric stenosis,

The Art of History - Taking & Examination In Pediatrics

Hirschsprung’s disease or obstruction of the in­ testines due to any cause. (p Dilated veins : In case of portal hypertension, di­ lated veins are seen periumbilically with flow of blood away from the umbilicus (caput medusae) whereas in superior or inferior vena cava obstruc­ tion, dilated veins are seen in the flanks. In SVC obstruction, flow of blood is above downwards, whereas in IVC obstruction, it is below upwards. & Abnormal pulsation’s; scars or sinuses over the abdomen if any should be noted.

29

also be percussed to determine whether it is cystic or not. In ascites, depending on the amount of fluid present, various types of dullness are seen. Thus in case of minimal fluid accumulation, puddle sign should be elicited with the child on his elbows & knees. Shifting dullness & horse-shoe shaped dull­ ness are seen with moderate ascites. In massive as­ cites (with a tense abdomen) fluid thrill will be present.

Auscultation : Peristaltic sounds should be auscultated. They are best heard just to the right of the umbilicus. They may be normal(2-3/minute) / decreased / absent (Paralytic ileus) or exaggerated. (In gas­ troenteritis or obstruction of distal bowel).

Palpation : The child should relax & be co-operative during palpation as crying would lead to the abdomen being tense & the findings unreliable. & Look whether on gentle palpation, the abdomen is normal or there is Tenderness (child may wince or cry), Guarding or Rigidity. Palpation of various organs : The following organs are palpated. In massive ascites, dipping method (palpation with both the hands) is used to displace the fluid. >

Liver : Whether it is normal (Liver is nor­ mally palpable upto 1 inch below the costal margin in the right mid-clavicular line upto first 2-3 years of age); enlarged (determine the span of the liver); rounded or sharp edge; bor­ ders; consistency (soft, hard, nodular) & ten­ derness over the liver.

>

Spleen : Normally just palpable in neonates & paraneonates. Later on, a palpable spleen denotes splenomegaly. [Should be palpated in supine & right lateral position (hooking method) to detect mild splenomegaly.]

>

Kidneys : Palpated bimanually.

Palpation of any lump (if present) over the abdo­ men (site-quadrant of abdomen; size, shape, con­ sistency, tenderness, movements of the lump with respiration, its mobility in relation to skin, un­ derlying & adjoining structures etc).

Percussion : While percussing the abdomen; the presence of Shifting dullness, horse-shoe shaped dullness or fluid thrill should be noted. Any abnormal mass should

& Bruits : Bruits over the abdomen may be present due to aortic aneurysms. Bruits over liver suggest tumour or telengiectasia. Venous hum in the epi­ gastric region may be heard in portal hyperten­ sion due to blood flowing through the porto-systemic circulation.

Central Nervous System___________________ The Examination of CNS is different from that of the other systems as the routine sequence of inspection, palpation, percussion, auscultation is not followed. In the General examination, special attention should be paid to examination of Head, face & neck (discussed earlier in general examination). Exami­ nation of spine is equally important. Vital param­ eters, anemia, cyanosis etc should also be looked into. Developmental assessment & Elicitation of primitive reflexes is very important in all CNS cases.

Higher Functions : &

Consciousness - The level of consciousness should be determined (normal, drowsy, stupor­ ous etc.). This is discussed earlier in General ex­ amination.

& Intelligence & Memory - In a younger child, the alertness of the child is an indirect indication of the intelligence of the child. In older children, intelligence can be determined by asking them to add 2 + 3 or subtract 3 from 5 mentally. The memory can be determined by asking them the

Section I — Practical Aspects of Pediatrics

30

names of their parents or asking them to repeat a small sequence of digits forwards & backwards.

& Orientation of time, place & person - The older child should be able to tell the time (day or night, day of week), the location of the residence or his school & recognize a person (for e.g. the exam­ iner is a doctor) & Speech - Inability to speak is known as aphasia. Damage to the cortical speech center (Broca’s area) of the brain causes aphasia. Inability to speak properly (dysarthria) may occur due to Cerebral Palsy, Bulbar palsy, Cleft palate etc. Look out for stuttering, stammering, slurring & stac­ cato speech. Nasal twang in speech occurs in cleft palate or in vagus nerve paralysis.

Cranial Nerves Examination : Examination of the cranial nerves requires co­ operation from the child. Hence, it may not be pos­ sible to examine all the cranial nerves in younger children.

1st Cranial Nerve (Olfactory Nerve): Each nostril should be tested individually for the sense of smell using non-irritant substances like cof­ fee, chocolates etc. (Irritating substances stimulate the trigeminal nerve & hence should be avoided).

2nd Cranial Nerve (Optic nerve): & Visual acuity - It is not possible to test visual acu­ ity in children below 3-4 years of age using the standard Snellen’s charts. In older children, Snellen’s charts are used to test distant-vision whereas Jaeggar’s charts are used to test near-vision.

Field of vision - The field of vision is tested by the confrontation method in children above 3-4 years of age. Perimetry test is possible only in children above 9-10 years of age. (P Colour vision - Is tested by Ishihara’s pseudoisochromatic plates in children above 3 years of age.

(p Fundus examination - Fundus should be exam­ ined with the ophthalmoscope after pupillary dilatation to determine whether the disc is nor­ mal or the presence of papilledema, retinal hem­ orrhages, chorioretinitis, choroidal tubercles or cherry-red spot (Tay-Sach’s disease)

3rd (Oculomotor), 4th (Trochlear) & 6th (Abdu­ cent) Cranial nerves: (r> Examine the external ocular movements by ask­ ing the child to look at the examiner’s finger with­ out moving the head. The finger is then moved horizontally sideways & vertically ups & down. & Look for Nystagmus while checking the external ocular movements. The Nystagmus is usually horizontal in Cerebellar lesions, vertical in brainstem lesions & rotatory in labyrinthine le­ sions. & Look for Ptosis or Diplopia (These occur in 3rd nerve paralysis) or squint. & Examine the pupils of each eye for the shape, size, response to light & accommodation & equal­ ity.

5th cranial Nerve(Trigeminal nerve): The 5th cranial nerve (3 branches - Ophthalmic, Maxillary & Mandibular) is tested by examining: & Sensations over the face on either side - the sen­ sory function of the 3 branches are tested sepa­ rately & bilaterally (over the forehead, over the cheeks & over the chin). Pain, touch & tempera­ ture are all tested with the help of a pin, cotton & hot & cold test tubes respectively. & The motor function is tested by examining the Masseter, Temporalis & Pterygoid muscles. To test the Masseter & Temporalis ask the child to clench his teeth. The masseters & temporalis do not be­ come prominent on the affected side. To test the pterygoids, the child is asked to open his mouth. In paralysis of pteygoid muscle, the jaw is devi­ ated towards the paralyzed side (Pushed by the opposite pterygoid muscle). & Conjunctival & corneal reflexes - Lost on the af­ fected side. & Jaw jerk - Lost in peripheral trigeminal nerve le­ sion & brisk in pyramidal tract lesion above the trigeminal nerve nucleus.

7th Cranial nerve (Facial nerve): & The sensory function is tested by examining the taste sensation (sweet, salty, sour & bitter) on the anterior %rd of the tongue. & The motor function is tested by examining the facial muscles. (Table 2.23)

The Art of History - Taking & Examination In Pediatrics

31

Table 2.23 : Testing The Motor Function Of 7th Cranial Nerve Elicitation Raise the (look up)

Result Of Loss Of Function (On The Affected Side)

The accessory nerve is examined by testing the sternocleidomastoid & trapezius muscles. The ster­ nocleidomastoid is tested by asking the child to ro­ tate his chin against pressure. The trapezius is tested by asking the child to shrug his shoulders against resistance.

Drooping of the angle of the mouth on the affected side with asymmetry of the face

12th (Hypoglossal) Cranial Nerve :

Blow the cheeks. The ex­ Air leaks out on the paralyzed aminer then taps on the side cheeks with his finger

In UMN paralysis, forehead, eyes & facial expres­ sions are spared due to bilateral representation of the upper part of the face in the cortex. In LMN paralysis there is total facial palsy. Bilateral facial palsy (Mask­ like face with bilateral Bell’s phenomenon & dysar­ thria) is common in Guaillain-Barre syndrome.

The hypoglossal nerve is tested by examining the tongue at rest & the movements of the tongue after protrusion from the mouth. In paralysis on one side, the tongue deviates to the paralyzed side on protru­ sion due to the unopposed action of the opposite genioglossus muscle. At rest, there is atrophy with fi­ brillations & fasciculations on the affected side of the tongue.

Motor system examination :

8th Cranial Nerve (Auditory Nerve): In infants, the auditory function is assessed by making some sound (like that of a bell) on either side & noting the response of the child like turning of the head toward the sound, startling, cessation of activity etc. In older children, hearing is tested with Rinne’s & Weber’s test. (Table 2.24)

9th (Glossopharyngeal) & 10th (Vagus) Cranial Nerves: ft Sensory function : Sensations (superficial & taste) over the posterior ‘/3rd of the tongue. ft Motor function : Look for the palatal movements on both the sides after asking the pa­ tient to open his mouth & say­ ing ‘ah’. Normally the uvula is in the center, but gets pulled to the normal side in case of paralysis of the palatal muscles.

ft Gag reflex : Tested by stimulating the pharynx with a tongue depressor. The normal response is gagging. It is lost in 9 & 10lh nerve lesions.

11th (Accessory) Cranial Nerve :

eyebrows Loss of wrinkles on the fore­ head

Close the eyes tightly Bell’s phenomenon (eyeball with the examiner atte­ turns upwards & outwards on closing the eyes tightly) mpting to open them Show the teeth

of feeds through the nose etc.

& Posture of the limbs : The child may adopt a particular posture due to changes in the muscle tone. For e.g. in decer­ ebrate rigidity, there is extension of all the 4 limbs with internal rotation of the arms & plantar flex­ ion of the feet.

& Nutrition of the muscles : Assess whether the muscles are normal, atro­ phied (wasted) or hypertrophied. The nutrition of the muscles can be gauged by measuring the cir­

Table 2.24 : Rinne’s Test & Weber’s Test Result Normal Sensorineural deafness

Rinne's Test*

Weber's Test**

Air conduction better than bone Vibrations heard equally on conduction both sides Both air & bone conduction are Vibrations are heard better decreased, but air conduction is on the healthy side better than bone conduction

Conduction deaf­ Bone conduction is better than air Vibrations are heard better on the affected side. ft Affection of the vagus nerve ness (Middle ear conduction disease) causes dysphagia, loss of swal­ lowing reflex, drooling, nasal * Rinne’s test: A vibrating tuning fork (256Hz) is placed in front of the ear (Air conduction) & then over the mastoid bone on the same side (Bone conduction). twang in voice, regurgitation * * Weber’s test: The vibrating tuning fork is placed over the center of the patient’s forehead.

Section I — Practical Aspects of Pediatrics

32

cumference of the limbs at the same site on both the limbs. Atrophy of the muscles is generally seen in LMN lesions, PEM & Systemic diseases like Tuberculosis. Common causes of LMN lesions are Poliomyelitis, muscular dystrophy etc. Hyper­ trophied muscles are seen in Ducchene muscular dystrophy (DMD).

months. The adductor angle is narrow in case of hypertonia & broad in case of hypotonia. >

& Tone of the muscles : Tone of the muscles in older children can be tested by 4 different ways. This is discussed be­ low in Table 2.25.

Table 2.25 : Tests To Assess Tone Of Muscles Hypotonia Hypertonia

Tests

Normal

Palpation of muscles

Normal

Flabby

Posture of limb

Normal

Limp

Stiff

Resistance to passive Normal movements

Decreased

Increased

Normal

Increased

Decreased

Range of passive movements

Rigid

In Infants, the tone is assessed by the follow­ ing tests (Also helpful in early diagnosis of spas­ tic CP). >

>

>

Scarf Sign : It is used to assess the tone of the muscles of the upper limbs. With the infant lying supine, the upper limb (with the elbow flexed) is pulled across the chest holding at the hand. Normally, in infants less then 3 months old, the elbow does not cross the mid­ line, between 4-6 months it crosses the mid­ line & beyond 6 month it crosses the anterior axillary line. In hypotonia, the elbow crosses the above limits whereas in hypertonia, it will be far less than the above limits. Heel-to-ear manoeuvre : In the supine position, lift both the legs upwards & towards the ears without lifting the pelvis above the table. In hy­ potonia, there will be no resistance while per­ forming the test whereas in spasticity, it will be very difficult to perform the above manoeuvre. Adductor angle : In the supine position & with the legs extended, both the hips are abducted fully by holding at the knees with the index fingers (so that the knees are extended). The adductor angle is the angle between the two thighs. It is 40 - 75 below 3 months of age, 75 -110° between 4-6 months, 110°-150° be­ tween 7-9 months & 140°- 160° above 10

Anlcle dorsiflexion: The foot is dorsiflexed on the anterior aspect of the leg by pressing the thumb over the sole. The angle between the dorsum of the foot & the anterior aspect of the leg is measured. (Generally, it is 60 - 75 dur­ ing infancy). The angle is more in case of hy­ pertonia & less in hypotonia.

& Power of the muscles : In infants & young children, it may not be pos­ sible to test the power of individual muscles (Table 2.26) or muscle groups due to inability of the child to comprehend what the examiner wants to do. An indirect assessment of the power in all the limbs can be done by observing the spontaneous movements of the child while in bed, when he gets up from the supine to the sitting position (whether he supports himself with the arms or not); how he holds an object, whether he refuses to use a particular hand (hemiplegia or monople­ gia); how he walks (e.g. Circumduction gait in case of hemiplegia).

Table 2.26 : Tests To Assess The Power Of Individual Muscles (Muscle groups) Muscle To Be Tested

Mode Of Testing The Muscle

Deltoids

Abduction of arms from rest to hori­ zontal position

Biceps

Flexion of elbow joint with the fore­ arm in supinated position

Triceps

With the elbow fully flexed, ask the child to extend the arm.

Gluteus maximus In Prone position, the patient attempts to lift his knee off the bed against re­ sistance Quadriceps

In the supine position & with the knee partially flexed, the patient attempts to extend his knee against resistance

Hamstrings

In the prone position, the patient tries to flex his knee against resistance

Gastrocnemius & Soleus

In the supine position & with the knees extended, the patient attempts to push down the sole of the foot against re­ sistance In the supine position & with the knees extended, the patient attempts to dorsiflex his foot against resistance

Tibialis anterior

33

The Art of History - Taking & Examination In Pediatrics

In older children, active movements at all joints should be tested with & without resistance. (Table 2.26)

push it along the shin upto the dorsum of the foot. Look for tremors & dysmetria. >

Power is graded as described in Table 2.27

Table 2.27 : Grading Of Power Movement

Grade

0 1 2

None

3

Movement possible against gravity but not against resistance

Flickering movement Movement possible after elimination of gravity

4

Movement possible against gravity & against some resistance

5

Normal Power

& Involuntary movements : Look for Abnormal movements. They are : >

Tremors : Regular, rhythmic, repetative os­ cillations of a part of a body around a fixed point, usually in one plane.

>

Athetosis : Slow, involuntary, writhing movements more marked in distal extremity, consisting of alternate pronation & supination & flexion & extension of limbs (under cover of hypotonia)

>

Ballismus : Violent flinging or rotational excursion of limbs, usually proximal (usu­ ally Upper limbs)

>

Myoclonus : Involuntary, repetative, inst­ antaneous, shock-like contractions of muscles or group of muscles.

>

Chorea : Rapid, jerky, involuntary, quassi purposive, non-repetative movements which are increased by stress & disappear during sleep (under cover of hypotonia)

>

Dystonia : Simultaneous contraction of agonist & antagonist group of muscles which results in abnormal postures that are transiently sustained.

>

Tics : Spasmodic, involuntary, repetative, stereotyped non-rhythmic movements which are exacerbated by stress & which may affect any muscle group.

& Co-ordination : Co-ordination can be tested only in children above 6-7 years of age & only when the Power of the muscles is equal to or above Grade 3. Co-or­ dination is examined by doing the following tests. >

Gait of the patient - Observe the gait-whether the patient is ataxic & has a broad-based gait.

>

Tandem Walking - Patient is asked to walk in a straight line placing one foot directly in front of the other with both the eyes open & closed. If the patient walks well with eyes open, but sways on closure of the eyes, it is sensory ataxia. If the patient sways even with the eyes open, it is cerebellar ataxia.

>

>

>

>

Finger-nose test - The child is asked to abduct his arm fully & then to alternately touch his nose & the examiner’s finger (the examiner moves his finger in different directions). Look for tremors & dysmetria (finger missing the target). Rebound test - The patient’s shoulder & el­ bow are flexed & the examiner pulls at the wrist against resistance & then suddenly re­ leases it. Normally the triceps checks further flexion. In cerebellar lesions, this is abolished & the patient may hit himself. Dysdiadochokinesia - Patient is asked to al­ ternately supinate & pronate his hands briskly. In cerebellar lesions, he is unable to do so & does the test very slowly. Rnee-heel test - Patient is asked to put the heel of one foot on the knee of the other leg & then

Rhomberg’s test - Ask the patient to stand with the feet close together with the eyes open & closed. If he stands properly with the eyes open but sways when they are closed, it is known as Positive Rhomberg’s sign (seen in sensory ataxia). If he sways even with his eyes open, it is due to cerebellar lesion.

& Reflexes: > Superficial Reflexes : Table 2.28 describes Tests to assess the Superficial reflexes The absence of superficial reflexes usu­ ally indicates : □

Pyramidal lesions above the level of the reflex arc

□

Lesions of the local reflex arc

34

Section I — Practical Aspects of Pediatrics

Table 2.28 : Tests To Assess Superficial Reflexes Superficial Reflexes

Method Of Elicitation

Response

Plantar reflex* (S,)

Stroke the lateral border of the sole of Normal response is Plantar flexion of all the toes. the foot from the heel to the toes. In pyramidal lesions, there is dorsiflexion of the big toe with fanning of the other toes.

Abdominal reflexes (DM2)

Stroke the skin of the abdomen from Contraction of the abdominal muscles of the same the lateral end towards the midline side towards the site of stimulation.

Cremasteric reflex (L, 2)

Stroke the skin of the medial side of Contraction of cremasteric muscle & elevation of the thigh from above downwards the testicle on the stimulated side Stroke the skin in the perianal region Contraction of the anal sphincter.

Anal Reflex (S^j)

* In infants less than 2 years of age, the plantars may be extensors bilaterally. This is a normal response in infants. However, unilateral extensor plantar response is definitely pathological.

Thus for e.g. absence of Cremasteric reflex (L., 2) indicates pyramidal lesions above the level of L, 2 or Lesion of the local reflex arc of L, 2.

> Deep Tendon reflexes : The Deep Tendon reflexes are elicited in older children by tapping at specific sites as discussed in Table 2.29 with the help of a ham­ mer. In infants & younger children, the re­ flexes are elicited with the finger or the edge of diaphragm of the stethoscope instead of the hammer.

can be determined. The following sensations should be tested & com­ pared at identical sites on both the sides of the body.

& Superficial sensation: > Touch sensation- Tested with cotton wool > Pain sensation- Tested with pin prick > Temperature sensation- Tested with two testtubes (hot & cold)

ft Deep sensations:

Reflexes can be graded as described in Table 2.30. Table 2.31 describes various causes of absent & brisk deep Tendon reflexes

>

Vibration : A vibrating tuning fork (128hz) is placed on some bony prominence of the body.

>

Position : Close the patient’s eyes & flex his great toe passively & ask him to put the other toe in the same position.

Sensory System Examination: It is difficult to examine the sensations in infants & young children. In infants only the pain sensation

ft Cortical sensations: >

Tactile localization : Ask the patient to accu-

Table 2.29 : The Deep Tendon Reflexes & Their Mode Of Elicitation Reflex

Nerve & Spinal Level

Elicitation

Response

Biceps

Musculocutaneous (CM)

Tap the biceps tendon after partial flex­ Farther flexion of the elbow & visible ion & pronation of the elbow contraction of the biceps muscle

Triceps

Radial (C7 J

Tap the triceps tendon just above the el­ Extension of the elbow & visible contrac­ bow after flexing the elbow above the chest tion of the triceps muscle

Supinator Radial (CM)

Tap the brachioradialis tendon at the Further flexion & pronation of the elbow lower end of the radius after partial flex­ & visible contraction of the brach­ ion & pronation of the elbow ioradialis muscle

Knee jerk

Femoral (LM)

Tap the quadriceps tendon just below Extension of the knees & visible contrac­ the knee after partially flexing the knees tion of the quadriceps muscle & supporting them with the hands in the supine position

Ankle

Sciatic nerve (S, 2)

Tap the tendo-achilles after partially Plantar flexion of the ankle & visible flexing the knee & externally rotating thecontraction of the gastrocnemius muscle leg

The Art of History - Taking & Examination In Pediatrics

Table 2.30 : Grading Of Reflexes Absent reflexes 0 Sluggish reflexes (seen with reinforcement*) 1+ (+) 2+ (++) Normal Brisk 3+ ( + ++) 4+ (+ + ++) Brisk with clonus * Reinforcement of Jerks is achieved by askingthe patient to clench the teeth or fists or by Jendrassik’s manoeuvre (flexing the fingers of the two hands against each other & pulling in the opposite direction.)

Table 2.31 : Causes Of Absent & Brisk Deep Tendon reflexes Absent DTR*

Brisk DTR*

35

tion of their shape, weight & form. Loss of this ability is called as astereognosis.

Signs of meningeal Irritation: & Neck Stiffness: It is tested by passively flexing the neck of the child in the supine position. The older child can be asked to touch his chin to his chest. In a crying infant, the head is brought beyond the edge of the table & then the neck is flexed to test for neck stiffness. Neck stiffness is present if there is resistance to passive flexion of the neck & pain occurs on forcible attempt to flex the neck.

Lower motor neuron le­Upper motor neuron lesions Causes of neck stiffness are discussed later in (Pyramidal lesions) sions chapter 3 on D/D of abnormal symptoms & signs. Severely Spastic childrenTetanus or Strychnine poison­ & Kernig’s Sign : ing In the supine position, with the hips & knees Contracture of the musclesHysteria in flexed position, extend the knees. Normally Stage of neuronal shockIn insmall children, the reflexes this is possible upto 140 . It is restricted in men­ may frequently be exagger­ upper motor neuron lesi­ ated without any reason ons ingitis. * DTR - Deep Tendon Reflexes

rately locate the site of stimulation of skin with finger tip.

>

>

Tactile discrimination- Tested by simulta­ neously touching 2 areas of the skin with 2 pins (pin-ends). Normally tactile discrimina­ tion is appreciated best over the tips of the fingers (4-6mms) & least over the back. Stereognosis : Ability to recognize familiar objects such as coins, keys, etc. by recogni­

$ Brudzinski’s Sign : On flexion of the neck in supine position, there is flexion of the hips & knees in case of men­ ingitis. Also, on flexion of one leg the other leg also flexes in meningitis.

Cerebellar Signs: Cerebellar lesions are usually characterized by Staccato speech, Ataxic gait, Hypotonia, Nystagmus & Inco-ordination (The various tests for examining co-ordination are already discussed previously).

Differential Diagnosis of Common Symptoms & Signs The following is an account of the common causes of symptoms as encountered in day-to-day practice. This is by no means an exhaustive list as it tries to enlist only the common causes seen in day-to-day practice.

Altered Taste : The Commonest Cause for Alteration of Taste is Drugs. The term for Unpleasant taste is ‘Cacogeusia’. The following are some of the common causes of Altered Taste. & Drugs : > Acetazolamide

3.1 D/D of Common Symptoms ] Abdominal Distension :

>

Griseofulvin

>

Antihistamines

>

Metronidazole

>

Ethambutol

>

Phenytoin

rf5, Gaseous distention (due to aerophagy, intestinal infections).

(£> Facial Palsy

£ Hypotonia (e.g. Malnutrition, Rickets etc.)

& Liver Failure

Chronic constipation (Faecoliths)

& Renal Failure

Obesity.

& Cushing’s Syndrome

In the above conditions the abdominal distension is usually non-progressive.

& Hyperthyroidism. & "Rimer's syndrome.

Ascites.

& Familial Dysautonomia.

& Lump in the abdomen.

& Zinc Deficiency.

if Acute abdomen (Surgical abdomen) (e.g. Para­ lytic ileus, Intestinal obstruction, Peritonitis).

Anorexia :

In the above 3 conditions the distension is progressive & requires urgent intervention.

iPhysiological

Abdominal Pain : tP Infant colic Infections :

& Chronic constipation.

The decreased appetite of toddlers (due to decreased growth) as compared to infants may be regarded by some parents to be of concern. Acute febrile illness. Pulmonary Tuberculosis.

& Parasite infestation. Liver diseases:

e.g. Ascariasis, Amebiasis.

(r> Renal diseases:

& Gastritis / Peptic ulcer. t? Hepatitis

Hepatitis Uraemia due to chronic renal failure.

& Endocrinopathies :Hypothyroidism.

Gastro - enteritis Functional tP Surgical Causes e.g. : Ureteric / Renal colic (Calculi)

& Drugs :

Digitalis.

(r> Malignancy :

Leukemias, Lymphomas.

& Psychiatric : disorders

Depression; Behavioral disorders.

Biliary colic (cholelithiasis)

Back Pain :

Intestinal obstruction (Intussuception) Appendicitis

Bad Posture : Causes Ligamentous Strain & Muscle Spasm.

Hernias

(P Severe Atheletic : May cause Intervertebral Exercises disc lesions or ligam­ entous strain.

Pancreatitis tfi Miscellaneous : Sickle-cell crisis Lead poisoning. 36

37

Differential Diagnosis of Common Symptoms & Signs

if Ankylosing Spondylitis.

Chest Pain :

if Spondylolisthesis: One vertebra Slips forward over the other.

if Thoracic Causes : > Trauma > Costochondritis if Intrathoracic Causes : > Diseases of respiratory system : □ Pleurisy □ Pneumothorax □ Pneumonia □ Collapse of lung □ Pulmonary embolism. > Diseases of heart: □ Pericarditis □ Valvular lesions □ Aortic aneurysm & blood vessels □ Aortitis. > Diseases of Mediastinum : □ Mediastinal emphysema

if Discitis. if Scheurmann’s disease. if Pain due to Abdominal Conditions Radiating to the back, if Psychological

Bleeding : Can be classified into Generalized,bleeding (i.e. bleeding at more than one site) or localized (at one site only).

if Generalized bleeding : > Mucous membrane bleeds : i.e petechiae — usually signify Platelet disorder, e.g. : Leukaemia, ITP, Aplastic Other rare platelet disorders. >

anaemia,

Deep-seated bleeds : i.e. Hematomas, hemarthroses etc. —

usually signify Coagulation disorders.

e.g. : Coagulation Factor deficiency (Hemop­ hilia A, B), DIC, Septic Shock

& Localized bleeding (at one site only) : > From Nose (Epistaxis) : □

Picking the nose (trauma)

□

Foreign body in nosf

□

Hypertension

From Gums : □ Scurvy > From lungs (Hemoptysis) : >

□

Tuberculosis □ Bronchiectasis

> From Upper GI tract (Hematemesis) : □

Liver cell failure

□

Drugs causing severe gastritis.

> From Rectum: □

Fissures

□

Piles (uncommon)

□

Polyps.

Blue Eyes (Sclera) : if Infants below 1 year of age if Marfan’s syndrome if Ehler - Danlos syndrome if Osteogenesis imperfecta

> Diseases of Oesophagus : □ Oesophagitis □ Achalasia if Referred Pain : From abdomen — e.g. : Peptic ulcer, Liver absc­ ess, Pancreatitis if Psychogenic or Functional. Constipation : if Functional : Habitual Constipation or Psy chogenic Constipation, if Organic : > Imbalanced diet. > Recent acute illness & poor intake > Intestinal Causes : □ Hirschprung’s disease (Surgical Causes) □ Rectal/anal stenosis □ Stricture/Volvulus > Metabolic Causes : □ Dehydration □ Hypokalemia □ Hypercalcemia. > Endocrinal Causes: Hypothyroidism. > Drugs : Narcotics, antidepressants, Calc­ ium preparations etc. > Due to severe painful defaecation — e.g. Anal fissures.

38

Section I — Practical Aspects of Pediatrics

Convulsions : & Febrile Convulsion : >

Commonest Cause (between 6 months - 5 years of age).

& Intracranial Infection : >

Bacterial (Pyogenic) Meningitis.

>

Viral Encephalitis

>

Tuberculous Meningitis.

>

Brain abscess (Localized seizures)

(P Metabolic Causes : >

Hypoglycemia

>

Hypocalcemia.

>

Hypomagnesemia.

>

Hyponatremia / Hypernatremia.

>

Pyridoxine dependency

>

Inborn errors of Metabolism - e.g. Maple Syrup Urine Disease, Phenylketonuria

>

Organic acidemias > >

Mitochondrial disorders, e.g - Leigh’s disease. Storage disorders e.g. - Gangliosidosis.

& Structural abnormalities :

Normal CSF

Abnormal CSF*

□ Hypoxia / Hyperoxia □ Hyponatremia/ Hyp­ ernatremia. □ Renal failure □ Hepatic Coma. > Shock > Poisoning with narcotics > Drugs - Salicylates, Bar­ biturates. * Abnormal CSF - CSF picture showing abnormal pressure / cells / proteins

cP Causes associated with Focal Neurological

Deficits : Normal CSF

Abnormal CSF*

> Vascular - Cerebral> Infections - Brain abscess / arterial occlusion > Todds paralysis > > Demyelinating dis­> orders > Cerebral contusion>

Subdural empyema Vascular - AV Malformation Brain tumours Trauma with Intracranial hemorrhage.

* Abnormal CSF - CSF picture showing abnormal pressure / cells / proteins

Cough : > Neurofibromatosis of the brain fr Respiratory Tract Infection : > Acute URTI or LRTI > Tuberous Sclerosis > Chronic Infection - Sinusitis, adenoiditis, > Lissencephaly / Schizencephaly. > Tuberculosis & Birth asphyxia (HIE) > Bronchiectasis Trauma &■ CNS hemorrhage. > Lung abscess & Hypertensive encephalopathy & Hyper-reactive airways : Asthma. tP Drug - associated seizures — e.g. Overdose of Theophylline / aminophylline. Sudden Withdr­ Irritation of respiratory tract : awal of benzodiazepines / barbiturates > Aspiration syndromes > Foreign body (P Unknown : Idiopathic Epilepsy. & Extrapulmonary Causes : Cause Cough by exte­ rnal pressure on Trachea & bronchi Coma : > Pulmonary congestion in L —> R shunts 6* Causes not usually associated with Focal Neur­ > Aortic aneursyms ological Deficit : > Dilated Left atrium Abnormal CSF* Normal CSF > Enlargement of heart > Head injury/concussion > CNS infections - Meningi­ > Enlargement of Mediastinal Lymph Nodes tis, Encephalitis > Septicemia > Left Ventricular Failure > Subarachnoid hemorrhage. > Post-ictal Reflex Causes : Foreign body or wax in exter­ > Midline brain tumours. > Hypertensive enceph­ nal ear (by irritation of Vagus nerve) alopathy > Hydrocephalus & Psychogenic Causes. > Metabolic encephalopa­ > Lead poisoning. thy : Deafness : □ Hypoglycemia / Hy­ perglycemia Deafness may be partial or complete. The causes of Deafness can be divided into two categories. >

Sturge-Weber Syndrome

Differential Diagnosis of Common Symptoms & Signs

39

> > > >

& Acquired & Congenital

Causes of Acquired Deafness are : >

Extreme Prematurity.

>

Hypoxic-ischemic disease of Newborn.

>

Neonatal Jaundice.

>

Prolonged Nasotracheal Intubation.

>

Recurrent Otitis Media.

>

Glue Ear

>

Severe Adenoids

>

Infections such as Measles, Mumps, Meni­ ngitis etc.

>

Trauma.

>

Drugs : Aminoglycosides.

>

Repeated exposure to very loud noise.

Furosemide.



Familial (Genetic)

>

Mental Retardation.

>

Cerebral Palsy.

>

Prenatal : Diseases or Drugs in the Mother during pregnancy can adversely affect the fetus. >

Rubella

>

Syphilis.

>

Quinine.

>

Chicken-pox.

>

Vancomycin.

>

Down’s Syndrome. Hypothyroidism.

& Girls :

> > > > >

Familial (Normal Variants) Malnutrition. Severe Chronic Diseases. Hirner’s Syndrome. Pituitary diseases - e.g. Craniopharyngioma, Gonadotrophin deficiency. > Testicular Feminization Syndrome.

Aminoglycosides

>

>

Delayed Puberty : & Boys : > Familial (Normal Variants) > Malnutrition. > Asthma > Severe Chronic disease. > Cystic Fibrosis. > Mumps. > Pituitary Disease - e.g. Craniopharyngioma. > Hermaphrodism. > Klinefelter’s Syndrome. > Kallman’s Syndrome > Noonan’s Syndrome. > Prader-Willi Syndrome. > Drugs such as Cyclophosphamide. > Complications following Torsion of Testis or Undescended Testis. (Delayed Surgery).

Maternal Drugs

Maternal Diseases

Tubular / Cortical Necrosis. Nephritis. Congenital Nephrotic Syndrome. Urethral Diverticulum.

>

Cleft Palate.

>

Albinism.

Diarrhea :

>

Osteogenesis imperfecta.

>

Various syndromes like : Pierre Robin Syn­ drome, Alport’s Syndrome, Kallman’s Syn­ drome, Refsums disease, Lowe’s Syndrome.

Acute Diarrhea ; £f>Gastroenteritis - Viral / Bacterial & Systemic infection Antibiotic associated e.g. Following ampicillin use. Food poisoning. Chronic Diarrhea :

Delayed Micturition In Newborns : V3"1 of all children pass urine within 12 hours after birth; 'Alh in the next 12 hours & only 7% after 24 hours.

Infants

Causes of delayed micturition in Newborns are ; tfi Post infectious >

Bilateral renal Agenesis. (Associated empty bladder & absence of ascites).

>

Dehydration (Due to fluid Restriction).

>

Bilateral Renal Vein Thrombosis.

with

Cow’s milk intolerance & Enzyme deficiency 1?

Older Children fr Post infectious Enzyme deficiency & Irritable bowel syndrome

& Irritable bowel syndrome & Inflammatory bowel disease, Celiac disease

i& Giardiasis

Section I — Practical Aspects of Pediatrics

40

>

Drowsiness :

□

tP Lack of sleep

& Excessive Fatigue. tP High fever

Diseases such as Meningitis. Anticonvulsants. > Tranquillizers. 6? Hypoglycemia. Anticonvulsants > Tranquillizers. > Anticholinergics > Atropine > Codeine Mouth-breathing (During Common cold or in Enlarged Adenoids). Sjogren’s Syndrome. tP Psychological.

Hematological causes : Anemia.

Epistaxis : Trauma. tP Nose-picking. tP Acute Rhinitis. (P Foreign body in the nose.

Diphtheria.

(P Tuberculosis. tP Syphilis. tP Pertussis. (p Bleeding Diathesis. C? Tumours or Polyps. (P Severe Hepatic Failure.

Excessive Crying : Intussuception >

Obstructed hernia

>

Torsion of Testis

>

Intestinal obstruction

>

Acute appendicitis

DYSPNEA (Breathlessness) :

(p Fractures / Trauma

Respiratory causes : □ Pneumonia □ Pleural Effusion □ Pneumothorax > Metabolic causes - Acidosis of any cause > Bronchial asthma > Psychogenic hyperventilation. tP Breathlessness due to exertion : > Cardiac causes : □ Congenital heart disease □ Rheumatic heart disease > Respiratory diseases : □ Asthma □ Pulmonary fibrosis

& Following Vaccination - e.g. : DPT vaccination due to Pertussis component may cause persi­ stant crying in few infants.

Excessive Salivation With Drooling : & Stomatitis. Analgesics >

Antihistaminics

>

Tricyclic Antidepressants

>

Anticholinergics

>

Phenothiazines.

Fever : (P Infections anywhere in the body : — Bacterial / Viral / Fungal / Protozoal e.g. URTI / LRTI / UTI / CNS infection Meningitis etc. & Vaccines. (r> Tissue Injury - e.g. Trauma, burns, IM injection, Infarction, & Malignancy - e.g. Leukemias, Lymphomas. & Autoimmune disorders - e.g. SLE, JRA Inflammatory disorders - e.g. Inflammatory bowel disease (r> Drugs - e.g. Amphotericin - B; Drug fever Endocrine Causes - Thyrotoxicosis. (r> Metabolic causes - Gout, Uremia. Factitious Fever.

Gingivitis : & Dental Caries.

& Hepatic cirrhosis. Renal Failure. (P Drugs : > Cytotoxic Drugs >

Digitalis

>

INH

>

Gonadotrophins

>

Oestrogens & Progesterones.

>

Spironolactone

>

Tranquillizers.

& Adrenal or Testicular Tumour. & Klinefelter’s Syndrome.

Haemetemesis : & Oesophageal - Oesophagitis, Oesophageal Varices. (P Gastric ulcer & Duodenal ulcer & Gastritis due to drugs like NSAID’s & Tumours & Bleeding Dyscrasias & Liver cell failure & Septicemia.

Haematuria : Haematuria can occur due to Systemic Disorders or Due to Diseases related to the Urinary Tract :

Systemic Disorders : & Bleeding Dyscrasias & Infective Endocarditis & Drugs - Anticoagulants / Antiplatelet agents (j> Exercise (excessive)

42

Section I — Practical Aspects of Pediatrics

Diseases related to the Urinary Tract :

> Bleeding Dyscrasias : □

(P Kidney (Renal Disorders) :

Leukemia

> > > > > > >

Acute Glomerulonephritis □ Idiopathic Thrombocytopenic Purpura (ITP) Acute Pyelonephritis □ Anticoagulant Drugs Stones (calculus) > Trauma : □ Contusion Trauma □ Fractured Trachea / Bronchus Tumour > Iatrogenic : Following Intubation, Bronchos­ Henoch-Schonlein Purpura (HSP) copy, Lung Biopsy Hemolytic-Uremic Syndrome (HUS) > SLE Halitosis : (P Collecting System Disorders (involving Ureter, & Foreign body in the Nose. Bladder & Urethra) : (9 Atrophic Rhinitis. > Calculus > Infection & Septic conditions in the Nose, Mouth, Sinuses. > Trauma > Foreign body Consumption of Garlic or Onions > Tumour & Diseases such as Tonsillitis or Diphtheria.

Haemoptysis : Haemoptysis means presence of blood in cough. The blood in cough can originate either from the Upper Respiratory Tract or the Lower Respiratory

Tract. & Upper Respiratory Tract (Mouth, Pharynx & Larynx) Disorders : > Trauma > Infection > Malignancy

& Lower Respiratory Tract Disorders (True Haemoptysis) : > Respiratory causes : □ Respiratory Tract Infections: Cardiac Causes : □ Left ventricular failure - causing Pulmo­ nary edema □ Primary Pulmonary Hypertension > Congenital Causes : □ Pulmonary Sequestration > Immunological causes : □ SLE □ Henoch-Schonlein Purpura. □ Goodpasture’s syndrome

Drugs : > >

Heavy Metals like Lead, mercury, Bismuth etc.

Alcohol.

Headache : & Intracranial Causes : >

Meningitis

>

Intracranial SOL (tumour)

>

Head injury

>

t ICT - Benign raised ICT

>

I ICT - Post-LP Headache

& Extracranial Causes (Referred pain) : >

Eyes - Refraction errors

>

Teeth - Dental root abscesses

>

Paranasal sinuses - Frontal / Maxillary sinusitis

>

Bones & Joints - T-M joint inflammation as in Juvenile Rheumatoid Arthritis (JRA)

& Migraine. i9 Psychogenic headache. & Tension headache c? Headache in cases of acute febrile illnesses.

Hicupps : tf> Normal in infants especially after feeding Following an acute respiratory infection. Diaphagmatic Pleural Effusion. (r> Subphrenic abscess. & Peritonitis.

Differential Diagnosis of Common Symptoms & Signs

43

cP Uraemia.

>

Alpha-1 antitrypsin deficiency.

& Encephalitis.

>

Drugs.

& Brain Tumours

>

Dubin Johnson Syndrome

& Drugs.

>

Rotor Syndrome.

Hoarse Voice :

Joint Pain / Swelling :

& Prolonged Crying or Shouting.

& Trauma.

& Acute Infectious Laryngitis.

(P Post-infectious arthritis / Septic arthritis.

if

Laryngitis due to Diphtheria, Tuberculosis etc.

(p Tuberculous arthritis

& Wernig - Hoffman’s Syndrome.

& Reactive arthritis

& Trauma due to Intubation.

& Hemophilia

Enlarged Mediastinal Lymph Nodes.

&

& Steroid Inhalers. & Cretinism.

arthritis

(JRA)

or

Rheu­

Obesity :

& Rickets.

& Simple Obesity - Caused due to imbalance between food intake & energy output (Increased intake along which decreased exercise).

i$ Foreign body. & Myaesthenia Gravis. Congenital defects cysts or tumours.

Juvenile Rheumatoid matic fever.

such

as

Laryngeal

webs

Jaundice : Can be classified into : & Hemolytic (Pre-hepatic) :

& Familial.

Metabolic Diseases / Endocrine Diseases : >

Hypothyroidism.

>

Hypopituitarism.

>

Cushing’s syndrome.

Drugs - e.g. Sodium Valproate. > RBC Membrane defects - Spherocytosis, Ell(P Rare Syndromes: iptocytosis.

> RBC Enzyme defects - G6PD Deficiency > Globin chain synthesis defect - Thalas­ semias > Acquired hemolysis - due to drugs like Sulfa, Penicillin, antimalarials. Liver cell disease (Hepatic) : > Neonatal Jaundice > Viral Hepatitis > Criggler - Najjar Syndrome > Gilberts disease > Galactosemia > Hypothyroidism. > Drugs - like Novobiocin, Pregnanediol, AKT. > Sepsis. > IU infection - like TORCH Infections. Obstructive (Post-hepatic) : > Biliary atresia. > Choledochal Cyst. > Inspissated bile > Strictures & Calculus in biliary tree

>

Prader-Willi Syndrome.

>

Laurence-Moon-Biedel Syndrome

>

Turner’s Syndrome

>

Carpenter’s Syndrome

& Obesity due to physical disability causing decr­

eased exercise : >

Cerebral Palsy.

>

Duchenne Muscular Dystrophy.

Oedema : Generalized Oedema :

> Cardiac causes :

CCF, Left ventricular failure

>

Renal causes

Nephrotic syndrome, acute nephritis

>

Hepatic causes :

Cirrhosis of liver, Portal hypertension

> Endocrine causes: > Allergic causes : > Nutritional causes:

Myxedema Angioneurotic edema Anemia, Hypoproteinemia, Beri-Beri

Section I — Practical Aspects of Pediatrics

44

& Localized Oedema >

Traumatic >

Inflammatory: >

> >

Lymphatic i

& Phlyctenular Conjunctivitis. Fracture,

sprains

Cellulitis,

Boils,

& Iridocyclitis. Abscess

Filariasis / Post-operation / Metastatis causing pre­ ssure on Lymph Nodes

Venous Metabolic

Venous Thrombosis, Varic­ ose Veins. Gout

Oliguria / anuria can be because of poor forma­ tion of urine (Pre-renal & renal) or Retention of urine (Post-renal)

Poor formation of Urine : Pre Renal

Renal

& Hypovolemia : Diarrhea & Dehydration

& Acute Tubular Necrosis

cr* Glomerulonephritis & HUS (Hemolytic-Uremic Syndrome)

Burns Hypoproteinemia

& Vitamin A deficiency. Albinism.

Constitutional or Familial.

>

Intracranial Causes : □ Tumour in the Hypothalamus.

& Tumours

tP Hypotension : Septicemia

iNephrotic Syndrome

□

Hydrocephalus.

□

Sequelae of Encephalitis.

DIC

>

Congenital Adrenal Hyperplasia.

Heart failure

>

Testicular Tumour.

Hypoxia : Pneumonia

>

Hypothyroidism.

>

Drugs : Androgens (Will cause Isosexual Precocious Puberty)

RDS (Respiratory Dis­ tress Syndrome)

Oestrogens (Will cause Heterosexual Precocious Puberty).

Retention of Urine (Post-renal) : Urinary outlet obstruction : >

PU valves

>

Phimosis (In males)

>

Meatal Stenosis (In males)

Neurological Problems : e.g. Poliomyelitis Guiallain-Barre Syndrome (GBS) Transverse myelitis tP VUR (Vesico-ureteral reflux)

& Girls : Precocious Puberty in Girls is Constitu­ tional in the majority of cases. It can be Isosexual (Secondary Sexual characters are that of a female) or Heterosexual (secondary sexual characters resembling those of males).

Causes : >

Constitutional

>

Intracranial Causes : □ Tumours

>

Adrenal Causes : □ Adrenocortical tumour.

(9 Stones & blood clots (P Antispasmodic drugs

Photophobia : & Foreign body in the Eye. & Corneal Infection or Corneal Ulcer.

□

□

Hydrocephalus.

Congenital adrenal hyperplasia (Heter­ osexual).

Hypothyroidism.

Differential Diagnosis of Common Symptoms & Signs

45

>

Hepatic Carcinoma.

>

Herpes

>

Ovarian Tumour (Heterosexual).

>

Vincent’s infection

>

Albright’s Syndrome.

>

Drugs : □ Anabolic steroids

& Vitamin deficiency : Vitamin B complex defic­ iency (esp. Riboflavin deficiency) &

□ Hormones.

Allergic Reactions Syndrome.

including

Stevens

Johnson’s

& Aphthous Ulcers.

Refusal To Feed : (9 Acute Infections : especially Meningitis, Pneu­ monias etc. & Local causes : Oral thrush, Oral ulcers, Glossitis, Stomatitis

& Kawasaki’s Syndrome.

Stridor : cr”

(P Chronic infections / Worm infestation & Tuberculosis

& Forced feeding [Well-grown child] >

Causes of short stature will be discussed elsew­ here in the text along with the case presentation.

Sneezing : Sneezing occurs very frequently in normal newborn babies & in the first 2 months of life. It should not be confused with Rhinitis. The Causes of Sneezing are : & Common cold (Commonest Cause - Especially at the onset).

Epiglottitis

>

Short Stature :

Croup (acute laryngotracheo-bronchitis)

Diphtheria >

Pharyngeal / retropharyngeal abscess.

ifi Congenital lesions like Vascular rings, stenosis Infective process & Demyelination

& Allergic Rhinitis

& Vasculitis

& Foreign body in the nose.

i

Toxin

Rare Causes include : > Post-Encephalitis.

c? Trauma

>

& Leukemia

Epilepsy (especially during the Aura phase of Temporal lobe Epilepsy).

& Migraine Raised ICT.

Stomatitis :

Tall Stature :

P Drugs :

& Constitutional or familial

>

Antibiotics (Sulfa group; Tetracycline; Lincomycin)

>

Steroids (esp. Inhaled steroids).

>

Antimetabolites (e.g. Vincristine, Actinomycin D)

>

Griseofulvin.

Infections : > Candidiasis. >

HIV

$

Gigantism

& Klinefelter’s Syndrome & Marfan’s Syndrome & Pituitary Adenoma. iP XYY Syndrome.

Torticollis : ifi Due to Bone & Joint Involvement : Torticollis can occur due to involvement of the

Section I — Practical Aspects of Pediatrics

46

cervical vertebra & joints in Injury or disease.

& Drugs :

>

Trauma.

>

Scoliosis.

>

Tumour

>

Osteites.

>

Juvenile Rheumatoid arthritis (When chro­ nic - causes neck stiffness & Torticollis)

>

Rare Syndromes like the Klippel-Feil Syn­ drome.

> Metronidazole. > Antihistaminics. > NSAID’s > Anticonvulsants. > Piperazine. > Aminophylline. > Quinine. > Alcohol. > Salicylates. > Betablockers. > INH. & Due to Auditory Pathology : > Chronic Otitis Media. > Labyrinthitis. i D u e to CNS Pathology : > Brain Tumour > Post-Encephalitis or Post-Meningitis Sequelae. > Cerebellar Lesions. > Multiple Sclerosis. > Following Head Injury

(P Due to Muscular Involvement : >

Congenital Torticollis : It occurs due to a sternomastoid tumour. The sternomastoid tumour occurs due to pressure exerted against the sternomastoid muscle in utero.

>

Poliomyelitis.

>

“Rheumatic” neck (Stiff viral Myositis in nature.

neck)

-

Probably

& Due to Soft tissue involvement : Abscesses like Tonsillar or Retropharyngeal abscesses may cause Torticollis either due to their mass or due to muscle guarding.

Intracranial causes : >

Tumour in the Posterior Fossa.

>

AV malformation in the brain.

i& Drugs. & Psychological causes : >

Hysterical.

>

Tics.

>

Rarely it may be due to Habit.

(P Other rare causes like : >

Spasmodic Torticollis.

>

Paroxysmal Torticollis.

>

Ocular Torticollis.

Vertigo :

Benign Paroxysmal Vertigo : >

Sodden attack of vertigo lasting for a few minutes associated with vomiting & nysta­ gmus, occuring in children between 1-3 years of age.

>

The cause is unknown & Investigation such as EEG are normal.

(P Epilepsy - esp. Temporal lobe epilepsy.

& Prodromal Symptom in : >

Migraine

>

Hypoglycemia.

Vomiting : & Infections :

UTI > Gastroenteritis > > Appendicitis > Hepatitis > Pancreatitis > Meningitis Surgical Abdomen (Acute abdomen) : > Intestinal Obstruction > Peritonitis & Feeding problems : > Force Feeding & CNS Disorders : > Head Injury / SOL (due to Raised ICT) & Post-tussive : > Following Persistent Cough Drugs : > NSAID’s > Metronidazole > Steroids > Aminophylline Miscellaneous : > Psychogenic > CCF Weight Loss [Failure to Thrive] : (P Deficient intake of food, if Poor absorption : > Vomiting

Differential Diagnosis of Common Symptoms & Signs

47

>

Diarrhea

if Cleido - cranial dysostosis

>

Malaborption syndromes

if Hurlers syndrome

if Intestinal causes :

(f Achondroplasia

>

Amebiasis

>

Worm infestation

>

Tuberculous enteritis

Bow Legs :

tf Hepatic & Pancreatic causes : >

Cirrhosis

>

Pancreatitis

Bowing of legs is said to Abnormal if the gap between the medial femoral condyles is >10 cms when the legs are extended & the internal malleoli are in contact with each other with the child lying in supine position.

Causes of Bowing of legs are :

if Cardiac Causes : CCF if Endocrine Causes : Diabetes Mellitus, Thyrotox­ icosis

if Normal - In late infancy if Rickets.

if Metabolic Causes : Chronic Renal Failure

if Renal Osteodystrophy,

if Infectious Causes : Pulmonary Tuberculosis

if Caffey’s disease,

tf Hematological Causes : Anemia

if Blount’s disease.

if Malignancies : Leukemia

Bulging Anterior Fontannel : '---------------------------------------------- !---- T

3.2 D/D of Important Abnormal Signs]

tP Physiological : In a crying infant, if Raised ICT : Intra-cranial SOL.

Angular Stomatitis :

if Hydrocephalus,

if Riboflavin deficiency,

if Hypervitaminosis A.

if Drooling of Saliva

if Following steroid therapy,

if Fungal infection

if Hyperparathyroidism.

if Syphilitic Rhagades

Brittle Hair : Appearing & Disappearing Abdominal

if Kwashiorkar.

Masses :

if Chronic debilitating disease.

if Urinary bladder,

if Hernia

if Cretinism.

if Hydronephrosis

if Mobile Spleen,

if Hypervitaminosis A.

if Fecal masses.

if Round worms,

if Congenital Syphilis

5 mm in size & 5 in number, if Post pubertal : >15 mm in size & 6 in number.

Section I — Practical Aspects of Pediatrics

48

& Isolated Cafe-au-lait spot >15 cms in size. & Any Cafe-au-lait spot in the centre of the body. Persistent hyperplastic primary vitreous. > Organized vitreous hemorrhage. Retina : > Retinoblastoma. > Retinal detachment. > Retinal dysplasia > Atrophic chorioretinal scars > Retinopathy of prematurity. > Endophthalmitis.

Chediak-Higashi Syndrome. & Fanconi’s Anemia.

Clubbing : Causes of Clubbing :

Cataract :

& Cardiac Causes :

Prematurity. Cr* Hereditary (Familial, Idiopathic) (P Chromosomal anomalies :

> Cyanotic Congenital Heart Diseases e.g. Fallot’s Tetralogy. > Infective endocarditis. & Pulmonary Causes : > Bronchiectasis. > Empyema (Chronic) > Lung Abscess. > Pulmonary Tuberculosis. & Intestinal Causes : > Ulcerative Colitis. > Crohn’s Disease. Hepatic Causes : Cirrhosis (esp. in Biliary Cirr­ hosis). Endocrinal Causes : Myxedema. & Miscellaneous Causes : > Familial > Idiopathic. > Malabsorption Syndrome.

>

13, 18 & 21 Trisomy.

>

Turners Syndrome.

Developmental anomalies : Persistent strand of pupillary membrane.

tfi Congenital infections : >

Toxoplasmosis.

>

CMV inclusion disease.

>

Syphilis.

>

Rubella.

>

Herpes Simplex

(r> Metabolic Causes : >

Galactosemia.

>

Hypocalcemia.

>

Hypoparathyroidism.

>

Juvenile onset Diabetes Mellitus.

>

Wilson’s disease.

>

Mucopolysaccharidosis.

& Drugs : >

Steroids.

& Trauma : >

Contusion.

>

Penetrating injury.

& Toxic agents : >

Radiation.

Cat’s Eye Reflex (White Reflex In Eyes) : Lens : >

Cataract.

Grades of Clubbing : I : Softening of nail bed. II : Obliteration of angle of nail bed. III : Parrot-beak / Drum stick appearance. IV : Hypertrophic osteo-arthropathy. Craniotabes : Physiological & Rickets. (P Hydrocephalus. & Hypervitaminosis A. Osteogenesis Imperfecta. & Congenital Syphilis.

Differential Diagnosis of Common Symptoms & Signs

49

ft Congenital syphilis. Cyanosis : ft Skeletal dysplasias Central Cyanosis : ft Mucopolysaccharidosis. ft Cardiac Causes : > Cyanotic congenital heart diseases e.g. Fall- ft Familial. ots tetralogy. Down-Slanting (Anti-Mongoloid) Eyes : > CCF > ASD / VSD / PDA with reversal of shunt (Ei- ft Trisomy 18 (Edward’s Syndrome) ft Cri-du-chat syndrome senmenger’s physiology) ft Turner’s syndrome. ft Pulmonary Causes : > Any lung pathology with severe involvement ft Apert’s syndrome. of the lung parenchyma, e.g. Severe pneu­ monia, bronchopneumonia. Downward deviation of Eyes : > Collapse of Lung due to any cause. ft Hydrocephalus

Peripheral Cyanosis : ft Shock. ft Local vasoconstriction due to any cause. ft Polycythemia. Abnormal Pigments Causing Cyanosis : ft Methaemoglobinemia. Delayed Closure Of Anterior Font­ annel : ft Preterm infants. ft IUGR infants. ft Malnutrition. ft Rickets ft Cretinism. ft Hydrocephalus. ft Down’s Syndrome ft Thalassemia Major. ft Congenital Syphilis. ft Skeletal Dysplasias : > Osteogenesis imperfecta > Cleidocranial dysostosis. > Achondroplasia. > Pyknodysostosis. ft Mucopolysaccharidosis ft Trisomy 13 & 18. ft Hypophosphatasia.

ft Kernicterus ft Premature infants

Early Closure Of Anterior Fonta­ nnel : ft Craniosynostosis. ft Primary microcephaly.

Epiphyseal Widening : ft Rickets. ft Metaphyseal dysostosis. ft Congenital epiphysial dysplasia. ft Rubella, CMV Infection. ft Copper deficiency.

Exophthalmos : ft Thyrotoxicosis. ft Retro-orbital hemorrhage. ft Orbital cellulitis & abscess. ft Cavernous sinus thrombosis. ft Crouzon’s disease. ft Neuroblastoma Metastasis. ft AV aneurysm.

Hypothermia : ft Exposure to Extreme Cold. ft Septicemia. ft PEM.

Depressed Nasal Bridge : ft Down’s Syndrome ft Thalassemia major ft Cretinism.

ft Hypothyroidism. ft Hypoglycemia. ft Drugs.

Section I — Practical Aspects of Pediatrics

50

Hypotonia Of Limbs : LMN Lesions :

ft Ant horn cell : > Poliomyelitis > Spino-muscular atrophy

ft Peripheral nerve : > Guaillain - Barre Syndrome. > Polyneuropathy. > Familial dysautonomia.

ft Neuro-muscular Junction : > Myaesthenia gravis > Botulism.

ft Muscle : > Congenital Myopathy > Polymyositis > Glycogen storage disorders. > Hypothyroidism. UMN Lesions :

ft Stage of Spinal Shock ft Cerebral palsy (Hypotonic CP) ft Intra-ventricular hemorrhage. ft Storage disorders. ft Metabolic Causes : > Hyperammonemia. > Hyperglycemia. > Hypercalcemia. > Organic Acidemia > Hypocalcemia. > Renal Tubular Acidosis. ft Cerebellar disease ft Trisomies (13, 18 & 21) e.g. Down’s Syndrome. ft Flaccid Coma. Mixed :

ft Krabbe’s disease ft Zellwegar’s Syndrome. Hyperplasia Of Gums : ft Poor oral hygiene. ft Scurvy. ft Phenytoin therapy. ft Hurler’s Syndrome. ft Histiocytosis.

Hypertelorism : ft Down’s Syndrome. ft Cretinism. ft Thalassemia Major ft Turner’s Syndrome ft Cri-du-chat syndrome ft Noonan Syndrome. ft Racial ft Rubinstein - Taybi Syndrome. Hypertonia : ft All UMN lesions after the stage of spinal shock including Cerebral Palsy (Spastic form) ft Extrapyramidal Causes : Cogwheel rigidity. Lead - Pipe rigidity. ft Tetanus. ft Strychnine poisoning. ft Hysteria. ft Local causes : e.g. Arthritis. Infections. Trauma etc. Hyperventilation : ft Hypernatremic Dehydration. ft Metabolic Acidosis. ft Diabetic Acidosis. ft Uraemia. ft Drugs - Salicylates Aminophylline ft Reye’s Syndrome ft Hysteria. Hypotelorism : ft Genetic variant ft Cyclops ft Scaphocephaly ft Ethmocephaly ft Holoprosencephaly Lachrymation : ft Trauma. ft Foreign body in the eye. ft Infections of the Eye : > Conjunctivitis

Differential Diagnosis of Common Symptoms & Signs

>

Conjunctival or Corneal Ulcers

>

Phlyctenular Conjunctivitis.

ft Associated with Rhinitis (Common cold) ft In Measles. ft Strong Odours. ft Facial Palsy. ft Due to chronic Blepharitis. ft Due to Eye strain ft Drugs.

Large Head (Macrocephaly) : ft Conditions associated with increase in weight of brain : >

51

ft ft ft ft

T-M joint arthritis. Brain Tumour. Phenothiazine overdose. Encephalitis.

Low-Set Ears : ft Down’s Syndrome ft Trisomy 13 & 18. ft Turner’s Syndrome. ft Cri-du-chat Syndrome. ft Carpenter Syndrome. ft Apert Syndrome ft Renal agenesis.

Megalencephaly : Hydrocephalus.

Lymphadenopathy :

□

Storage disorders.

ft Any infection in the drainage area of the lymph

□

Achondroplasia.

□

Gigantism.

□

Tay-Sachs disease.

□

Neurofibromatosis.

□

>

Subdural haematoma.

>

Intracranial SOL.

>

Arachnoid Cysts.

ft Skeletal Disorders Causing Macrocephaly : >

Achondroplasia.

>

Pyknodysostosis.

>

Cleidocranial Dysostosis.

>

Hurler’s Syndrome.

>

Cerebral Gigantism.

nodes (bacterial, viral, fungal or protozoal in nature). ft Acute systemic bacterial infection. ft Acute systemic viral infection - Infectious mon­ onucleosis, Rubella, HIV. etc. ft Chronic infection - e.g. Tuberculosis. ft Lymphoreticular malignancy - e.g. Lymphoma, Leukemia, etc. Macroglossia : ft Down’s Syndrome. ft Hypothyroidism. ft Mucopolysaccharidosis. ft GSD (Glycogen - Storage disorders) ft DMD (Duchenne Muscular dystrophy).

Limitation Of Joint Movement : ft Diseases of the Joint. >

Arthritis (JRA)

>

Congenital dislocation of the hip.

ft Contracture of Muscles. ft Hypertonia. ft Cerebral Palsy ft Diabetes Mellitus ft Myotonic Dystrophy. ft Nail Patella Syndrome, Hurler’s syndrome etc.

Lock-Jaw (Trismus) : ft Tetanus. ft Strychnine poisoning.

Macro-Orchidism (Large Testis) : Hypothyroidism Testicular tumours Precocious puberty Congenital syndromes like Fragile ‘X’ syndrome Occasionally in Henoch-Schonlein purpura

ft ft ft ft ft

Membrane

Formation

In

Throat

(White Membrane in Throat) :

ft Bacterial infection : Streptococcal infection; Diphtheria

ft Viral infection ; Ebstein-Barr Virus. ft Fungal infection : Candida.

52

Section I — Practical Aspects of Pediatrics

ft Others :

Microcephaly : Causes of Microcephaly will along with the case- presentation.

be

discussed

Micrognathia (Small Jaw) : ft Pierre-Robin Syndrome

later

> Post-LP (Lumbar Puncture). > Voluntary neck rigidity. > Hysterical > Drugs - Phenothiazines > Strychnine poisoning.

ft Rubinstein - Taybi Syndrome ft Cri-du-chat Syndrome ft Di-George Syndrome ft Fetal alcohol Syndrome ft Trisomy 13 ft Trisomy 18

Micro-Orchidism (Small Testis) : ft Hypothalamic diseases ft Hypopituitarism ft Klinefelter’s syndrome (XXY)

Nystagmus : ft On looking outside from a Moving Vehicle. ft Visual Defects. ft Astigmatism. ft Albinism. ft Hypothyroidism. ft Congenital Nystagmus. ft Drugs - Anticonvulsants, Salicylates. ft Cerebellar Ataxia. ft Cerebellar Tumour or abscess.

ft Rudimentary testes syndrome ft Radiation ft Chemotherapy

Micropenis : ft Klinefelter’s Syndrome. ft Down’s Syndrome. ft Prader - Willi Syndrome. ft Carpenter’s Syndrome. ft Cornelia-de-lange syndrome. ft X-linked hypogammaglobulinemia.

Pigeon-Shaped Chest : ft Rickets ft Congenital ft Skeletal dysplasia. Emphysema ft Chronic Respiratory Distress. ft Mucopolysaccharidosis - Type IV ft Massive Cardiomegaly. ft Marfans Syndrome. ft Noonan Syndrome.

ft Hypopituitarism.

Neck Stiffness : ft ' CNS Causes : >

Meningitis.

> > > >

Encephalitis Posterior fossa lesion Trauma Herniation of brain stem

ft Spinal Causes : >

Koch’s spine

>

Retropharyngeal abscess

>

Lymphadenitis adjacent to vertebral column.

ft Systemic Infection : >

Meningismus [e.g. associated with Typhoid, Apical Pneumonia)

>

Poliomyelitis.

>

Tetanus.

Precordial Bulge : ft Cardiomegaly ft Pericardial Effusion. ft Retrocardiac tumours ft Mediastinal tumour. ft Skeletal Dysplasias.

ft ft ft ft ft

Scoliosis. Rickets Cellulitis Lipoma Rib Tumours

Proptosis : ft Thyrotoxicosis. ft Trauma - Fracture of Base of Skull. ft Orbital Cellulitis. ft Ethmoidal Sinus Inflammation (Ethmoiditis). ft Dermoid Cysts. ft Orbital encephalocele. ft Tiimours such as Neuroblastoma, Retinoblas­ toma, Teratomas, Gliomas etc.

Differential Diagnosis of Common Symptoms & Signs

53

ft Cavernous Sinus Thrombosis. ft AV aneurysms. ft Craniostenosis.

> > > >

Uremia. Hemolytic Uremic Syndrome. Hemophilia. Aplastic Anemia. > Scurvy.

Ptosis :

ft Myaesthenia gravis. ft Horner’s Syndrome. ft Oculomotor Palsy.

ft ft ft

Puffiness Of Eyes : ft Hypoproteinemia. ft CCF. ft Angioneurotic edema. ft Constrictive Pericarditis. ft Myxedema. ft Spasmodic Cough ft Cavernous sinus Thrombosis. ft Conjunctivitis. ft Familial

Purpura : ft In Neonates : >

Septicemia.

> DIC

Myotonic Dystrophy. Congenital Ptosis. Scoliosis : Noonan Syndrome. ft Postural Scoliosis : > Commonest. > Scoliosis usually disappears when the pati­ ent bends down. ft Compensatory Scoliosis : > This occurs due to any cause which leads to shortening of one of the legs (Unequal length of legs) ft Scoliosis which persists when the child bends down is known as Structural Scoliosis : Its causes are : > Poliomyelitis. > Muscular Dystrophy. > Marfan’s syndrome. > Osteogenesis Imperfecta. > Hemi-vertebra. > Idiopathic.

>

Maternal infections - CMV, Rubella, Toxop­ lasmosis, AIDS.

>

Maternal autoimmune diseases - like throm­ bocytopenia.

>

ABO Incompatibility.

>

Congenital Leukemia.

ft After the Neonatal Period : >

Trauma.

>

Leukemia. >

Idiopathic Thrombocytopenic Purpura.

>

Henoch - Schonlein Purpura.

>

Due to Drugs.

>

Meningococcemia.

>

Septicemia.

Short Neck : ft Obesity (False appearance due to folds of • adipose tissue) ft Down’s syndrome ft Turner’s syndrome ft Hurler’s syndrome ft Noonan syndrome Upward

Slanting

Slant) : Down’s Syndrome Prader-Willi Syndrome. Ectodermal Dysplasia. Racial.

ft ft ft ft

Eyes

(Mongoloid

(?------------------------------------------------------------------------------------------------------

Systemic Examination & Exam Related Cases The basic History taking and Examination are history in the following cases. However it should be the same as in General Medicine, exceptions being noted that each patient is a different case & his the Findings specific to children. History may not fit the general pattern.Thus each A thorough knowledge of the symptamatology & patient merits his own different History. However basic skills in communication are a must for proper the proformas are meant to cover the negative History in detail as well as the complications & the History-taking & examination in pediatrics. History related to the differential diagnosis can be The following section deals with a general presented or ruled out as is the case. proforma which should be followed while taking the

List Of Important Exam Cases Long Cases

Short Cases

ft CVS : > Congenital Heart Disease >

ft CVS : > Congenital Heart Disease

Rheumatic Heart Disease

ft CNS : > Hydrocephalus

ft CNS : > TBM (Tuberculous Meningitis)

>

Ducchene muscular dystrophy

>

AIH (Acute Infantile Hemiplegia)

>

Meningomyelocoele

>

Acute Flaccid paralysis

>

Microcephaly

>

Cerebral Palsy

>

Meningomyelocoele

>

Ataxia

ft Respiratory System : > Pleural Effusion ft Renal System : > Nephrotic Syndrome

ft GI System : > Hepatosplenomegaly with / without Jaundice / Ascites / Pallor

ft GI System : > Hepatosplenomegaly with / without Jaundice / Ascites / Pallor

ft Miscellaneous : > PEM (Protein-Energy Malnutrition)

ft Miscellaneous : > PEM (Protein-Energy Malnutrition)

54

>

Down’s syndrome

>

Hypothyroidism

>

Rickets

>

Short Stature

>

Normal Newborn

SECTION

Cardio Vascular System 4.1. Congenital Heart Disease

□

H/o Hemoptysis

□

H/o Convulsions/Unconsciousness/altered sensorium

□

H/o tender pads of fingers (Osier's nodes)

□

H/o dental procedures/surgery

Proforma History : & Chief Complaints : >

Cough/cold/breathlessness/fever - off & on since birth

>

H/o increased precordial activity

>

H/o breathlessness since birth

>

H/o failure to thrive

>

H/o Cyanosis/Cyanotic spells —> in c/o Cyanotic Heart disease

>

H/s/o Cerebral abscess —» in c/o Cyanotic Heart Disease i.e. : H/o fever/vomiting/focal seizures/hemiparesis/focal neurological deficits

>

H/s/o Cerebral infarct —> in c/o Cyanotic Heart Disease i.e. : H/o vomiting/focal seizures/hemiparesis/focal neurological deficts

>

H/o repeated respiratory tract infections (suggestive of pulmonary Plethora due to L —» R shunt)

>

H/o Cyanosis/Cyanotic spells : If present —> ask for : □

Time of day when occurs

□

Aggravating factors

□

Duration

□

Relieving factors

>

H/o Squatting Episodes.

>

H/o Prior Hospitalization & Drug History [If pt. is on (Digitalis/lasix) daily medication etc.]

Etiological History : > Birth History : □

H/o Prematurity increased incidence of VSD/PDA; Increased incidence of IU infection such as Rubella which causes both Prematurity & Congenital heart disease

H/s/o CCF in infancy :

□

H/o Cyanosis in newborn Period

□

H/o Breathlessness, cyanosis, Excessive Perspiration over forehead on feeding

□

H/o affected siblings

□

□

H/o suck - rest - suck cycle.

H/o prolonged jaundice [petechiac etc in newborn period (S/o IU infection)]

& ODP —> Depending on the Chief complaints elicit the symptoms in details

& H/o Associated factors/Negative History/

Complications : >

□ □

□ □ □ > >

> Antenatal History :

H/o decreased intake during feeds. H/o Edema over legs/body

□

H/o fever with rash in mother during pregnancy [IU infection]

□

H/o Irradiation [X-rays] during pregnancy

H/o repeated respiratory tract infections

H/o failure to thrive. H/o abdominal distension/abdominal pain

H/o increased Precordial activity noted since birth

□

H/o Drug intake/alcohol intake

□

H/o Diabetes mellitus [increased inci­ dence of TGA]

□

H/o Toxemia

(P Developmental History

H/s/o infective endocarditis : □ H/o high fever with chills

& Dietary History

□

& Immunization History

H/o Petechial hemorrhages

• □ H/o Hematuria

& Socioeconomic History ____ 55

Taken as — routine in detail

Section II — Practical Aspects of Pediatrics

56

□

Examination :

□

(P General Examination :

□

>

General condition of the patient

>

Vitals : □ Temperature / Pulse / Respiration / B.R □

Pulse in all 4 Limbs

□

BP in both UL & LL in older child

>

Anthropometry —» Head & Chest circumference, Total length & weight with percentiles.

>

Pallor/Cyanosis/Clubbing/Raised JVP/Hepatojugular reflex/Icterus/Lymphadenopathy/ Pedal edema/Periorbital edema

>

>

>

Signs of failure to thrive/vitamin deficiency : Bossing of skull/beading of ribs

□

Eye changes [Vit A Deficiency]

□

Skin & hair changes of Kwashiorkar

Dysmorphic Features : □ Microcephaly □

>

&

Oral

Axis

□

Chamber Hypertrophy

□

Size of defect

□

Pressure in chamber of heart Associated defects □

>

Vegetations (Infective Endocarditis)

Catheterization (Only if surgery is

(f> Investigations to rule out Complications : > CBC - WBC count is raised in Infective Endocarditis & Respiratory tract Infections >

ESR & CRP - ESR decreases in CCF/ESR & CRP increase in Infective Endocarditis

>

Blood Culture - To R/o Infective Endocarditis CT Scan* - If Abscess/Infarct in CNS

> [Infective

fr Systemic Examination : Examination of the CVS (Inspection, Palpation Percussion, & the other systems in brief.

Sinus rhythm

□

□

>

Hygiene

□

> 2D Echo & Colour doppler :

Cataract [Rubella]

Dentition Endocarditis]

Respiratory Pathology

considered & undertaken)

Splinter hemorrhages/Osler’s nodes/ Janeway’s lesions/Roth Spots

□

Pulmonary fields (Oligemia or plethora)

> ECG :

Peripheral signs of infective endocarditis : □

Cardiac shape

ABG* - Hypoxia & acidosis (If patient is in Cyanosis / Cyanotic spell)

* (These Investigations should be done only if the History is suggestive).

cr> Investigations to determine the Etiology : in detail Auscultation)

>

Torch Titres (If the history & examination findings are suggestive of IU infection).

General Principles Of Treatment : Diagnosis :

(Refer to the discussion for details)

Congenital, Cyanotic/Acyanotic Heart Disease with L —» R or R —> L shunt [occuring in systole/ diastole]

Treatment of acute respiratory infection (If patient presents with fever/cough/cold) Infective Endocarditis prophylaxis.

with/without sinus rhythm

Nutritional Management :

with/without CCF

>

High Calorie, High Protein Diet

with/without Pulmonary Hypertension

>

Salt-restricted Diet (if CCF)

with/without Infective Endocarditis

>

Fluid restriction (if CCF)

with/without Failure to thrive

>

Treatment of anemia

Most probable diagnosis being.....................

Treatment of CCF : > Salt restricted Diet > Digitalis

Investigations : (Refer to the discussion for details)

& To prove the diagnosis : >

> >

Fluid Restriction > ACE inhibitors

Diuretics

X-ray chest —> Look for :

tf" Definitive Surgical Management : > Depending on the case

□

& Treatment of Cyanotic spells (If present)

Cardiomegaly

57

Cardio Vascular System

cP In c/o congenital Cyanotic Heart Disease : >

Prevent Polycythemia [Exchange Transfusion] >

Prevent Dehydration [Adequate Fluids],

Discussion On Congenital ______ Heart Diseases_______ Congenital Heart Diseases can be broadly divided into Acyanotic Heart Diseases & Cyanotic Heart Dis­ eases. (Table 4.11)

Table 4.11 : Broad Classification Of Cong­ enital Heart Disease Acyanotic

Cyanotic

& Atrial septal defect (ASD) & Tetralogy of Fallot (TOF) Ventricular septal defect & Tricuspid atresia (VSD) & Transposition of the Great arteries (TGA) Patent Ductus Arteriosus (PDA) (9 Double-outlet Right Ve­ ntricle (DORV) with pul­ Co-arctation of Aorta monic stenosis & Aortic stenosis (AS) Pulmonic stenosis (PS) 19

Mitral valve prolapse

& Congenital Mitral Steno­ sis

Ventricular Septal Defect (VSD): Definition : VSD refers to an abnormal communica­ tion between the two ventricles due to failure of clo­ sure of the inter-ventricular septum.

Incidence: (P Commonest amongst all the congenital lesions affecting the heart (more than 20%) [Approxi­ mately 1 to 4 per 1000 live births] & Prevalence ranges from 3 to 3.5 per 1000 live births & More common in premature infants than full-term babies & More common in females than in males (Ratio is 1.3:1) &

More common in infants with anomalies like Trisomy 13, 18, 21 etc.

chromosomal

& Outlet VSD's are more common in South-East Asian race.

20% in S-E 5-25% Asians)

Peri-membranous VSD's 75-80%

In the muscular portion of the septum-May be api­ cal, central, marginal or multiple (Swiss-cheese)

In the Peri-membranous area of septum (left-ventricular outflow area just below the aortic valve)

—

Atrio-ventricular conduction defects are common.

close spo­ Rates of spontaneous closure Rarely closes spo­ Does not close sponta­ 50-70% ntaneously (Majority in are same as muscular VSD's. ntaneously neously infancy & >90% before 78 years of age)

58

Section II — Practical Aspects of Pediatrics

Pathophysiology : The presence of a L —> R shunt results in certain physiological changes & corresponding clinical signs. These are depicted below in the form of a table (Table 4.13)

Table. 4.13 : Physiological Changes due to VSD & The Characteristic Clinical Signs Physiological Changes

Clinical Signs

Blood flows through the VSD during systole from Left Pansystolic murmur which drowns the 1st heart sound ventricle to the right ventricle ■*(S,) 1 At the end of systole, LVP < Pressure in the aorta, but ^ Early closure of aortic valve (A2) Continuation of mur­ LVP > RVP mur beyond \ (thus drowning A2) | Right ventricle derives a large quantity of blood due to Ejection systolic murmur at the Pulmonary area (drowned the shunt, which passes on to the pulmonary trunk by the pansystolic murmur; however this results in conthrough the normal-sized pulmonary valve duction of the Pansystolic murmur to the Left paraster­ nal region)

____ I ......................

Large quantity of blood flowing through the right ven­ Loud & Late P2 (Early A2 combined with a Late P2 results tricle delays the closure of Pulmonary valve in a widely split S2) l Large quantity of blood passing through the pulmonary Plethora of lung fields (appreciated on X-ray) artery to lungs i1 From lungs to the Left Atrium _> Left atrial enlargement '*• 1 ........................................................................................................................................................ Large quantity of blood passes from the enlarged Left Mid-diastolic murmur at the apical area atrium through a normal-sized mitral valve into the Left ventricle

The hemodynamic changes in VSD depend on 2 factors : & Size of the VSD (small VSD’s are < ’/3rd the size of the aortic orifice; medium-sized VSD’s are between '/3rd to 2/3rd the size of the aortic orifice whereas large VSD's are equal to or greater in size to that of the aortic orifice.) tP Resistance offered by the pulmonary vascular bed. Based on these 2 factors, VSD’s can be classified into different categories (depicted in Table 4.14)

Table 4.14 : Classification Of VSD’ Category

Right Ventricular Pressure (RVP)

(f> Small VSD

Normal

s Based On Hemodynamic Factors Pulmonary Vascular Resistance (PVR) Normal

Consequence Very little functional disturbance.

May close spontaneously. & Medium-sized RVP Elevated but less than PVR Elevated but less than sys­ Rarely develop pulmonary vascular VSD that of Left Ventricular Pres­ temic vascular resistance (SVR) disease (Occasionally closes spon­ sure (LVP) taneously) Large VSD RVP = LVP PVR Elevated Associated with pulmonary vascu­ lar disease. & Large VSD with RVP = LVP PVR > SVR Reversal of shunt with cyanosis Eisenmengerization

Cardio Vascular System

59

Clinical Features : Symptoms Table 4.15 : Symptoms Of Different Types Of VSD Category & Small VSD &

Symptoms Generally asymptomatic. Detected incidentally on a routine examination due to the presence of a murmur. However, there is increased risk of infective endocarditis

Medium-sized Symptoms are mild initially, but with the development of CCF*, there is increased precordial activity, excessive coughing during feeds, excessive perspiration & inability to feed properly due VSD to fatigue

Large VSD

In addition to symptoms due to CCF* as discussed above, there is failure to thrive, repeated respiratory tract infections, excessive breathlessness & suck-rest-suck cycle (child sucks —» stops to take rest due to breathlessness & fatigue —» falls asleep —»wakes up early due to hunger —> sucks again)

if Large VSD with Due to reversal of shunt, there is a reduction in the pulmonary plethora & cardiomegaly. Thus symptoms of CCF & repeated respiratory tract infections abate. Instead, the following symp­ Eisenmengeriztoms may occur : ation > Cyanosis > Hemoptysis >

Dizziness > Arrhythmias

>

Syncope > Sudden death

* CCF may develop earlier than usual in case of : > Associated ASD or PDA > Prematurity, anemia, infection etc.

Signs Table 4.16 : Clinical Signs Of Different Types Of VSD Category

Small

Medium-Sized

VSD

VSD

VSD With

Large VSD

Eisenmengerization

General Examination Appearance

Cachexia + (Failure to thrive)

Cachexia +

Tachycardia +

Small

Normal / small

Tachypnea +

Tachypnea

Normal / Tachypnea

Normal

Usually Normal

May be high

Normal Absent

Normal Absent

Normal / High Elevated Normal Present during fits Present of crying or during feeding

Absent

Absent

May be present

Normal

May show mild growth retardation

& Pulse

Normal

& Respiration

Normal

Blood Pressure JVP & Cyanosis

Pedal Edema

Usually absent

Systemic Examination | CVS Examination Inspection (? Precordium

Normal

& Apex impulse Precordial Pulsations

Normal Absent

Mild bulging ’ Normal Present

Bulging

Bulging

Shifted (LVH) Present

Normal / shifted Present Table continued on next page

60

Section II — Practical Aspects of Pediatrics

Table continued from previous page

Table 4.16 : Clinical Signs Of Different Types Of VSD Category

Small

Medium-Sized

VSD

VSD

VSD With

Large VSD

Eisenmengerization

Palpation & Apex beat

Normal

Hyperdynamic

tP Diastolic shock [Pal­ Absent Absent pable 2nd heart sound (PJ1 & Thrill Systolic thrill Systolic thrill + in left paras­ ternal region Percussion Normal Normal Auscultation & Heart sounds > SI > S2 & Murmurs > Systolic

> Diastolic

Heaving

Right ventricular impulse (heaving apex, but retraction is lateral to the apex)

Present

Present

Systolic thrill +

Thrill is Absent

Cardiomegaly

Normal

Normal

Drowned by murmur

Drowned by murmur.

Drowned by murmur

Split

Widely Split

Loud & widely split Loud & Single

Soft, high fre­ quency, early systolic mur­ mur localized to Left Para­ sternal region

Loud, high frequency, Pansystolic mur­ Pansystolic murmur is abolisPansystolic murmur, mur becomes short shed. Grade > 4/6 heard & faints & may be maximum in Left silent at the end of parasternal region (3r X-ray chest

Normal

Plethora of the lung fields

> ECG

Normal

Right axis deviation. Prolonged Biventricular hypertro­ PR interval. 'P'mitrale (Left atrial phy. 'P' Pulmonale (Right enlargement may be present) atrial enlargement) may be present.

Large VSD With Eisenmengerization

Pulmonary plethora, Plethora & Cardiomegaly decrease. Cardiomegaly, Enlarged Right atrial & ventricular enlargement Pulmonary trunk may be present . Pulmonary trunk enlarged. P waves are normal. Right axis de­ viation. Tall 'R' wave may be seen in V,. Ventricular arrhythmias may be seen

Cardio Vascular System

□

61

Location of the VSD (Perimembranous, muscular, inlet or outlet)

Fluid restriction

□

Limitation of activity (is generally selfimposed by the child due to breathless­ ness & fatigue)

□

Diuretics :

□

Size of the VSD

□

Dimensions of the heart chambers

□

Pressure in the heart chambers

□

Direction of the flow blood through the shunt (Colour doppler)

A Furosemide: 1 mg/kg/day in 2-3 divided doses

□

Vegetations (Infective Endocarditis)

□

Other associated defects

-v* Spironolactone : 2-3 mg/kg/day in 2-3 divided doses

> Catherization (To be done only if surgery is considered) Catheterization is helpful in determining : □ Anatomy of the defect □

Associated defects

□

Estimation of the workload of the 2 ven­ tricles & the pulmonary vascular resis­ tance.

>

CBC : To rule out Infective Endocarditis & Res­

>

ESR : ESR decreases in CCF & increases in Infective Endocarditis Blood culture: To rule out Infective Endocarditis

piratory tract infections

Treatment :

Digoxin : 0.04 mg/kg Digitalizing dose fol­ lowed by 0.01 mg/kg/day maintenance dose

□

ACE Inhibitors : Captopril (0.1-0.3 mg/kg. TDS) or Enalapril (0.1 mg/kg/day q 12 hourly)

□

Treatment of anemia

□

Vitamin & Calcium supplementation.

& Specific Treatment (Treatment of the defect):

& Treatment of Complications :

>

>

Treatment of repeated respiratory tract infec­ tions (prompt Antibiotic therapy).

>

Treatment of CCF : □

□

> Treatment of Infective Endocarditis (with ap­ propriate antibiotics) > Treatment of arrhythmias (if present) - with appropriate anti-arrhythmics > Nutritional management for cachexia : □ High calorie & protein diet (with fluid & salt restriction)

& To rule out Complications :

>

□

Small VSD: □

Reassurance & repeated evaluations to de­ termine whether the VSD closes spontanously or the clinical condition worsens.

□

Infective Endocarditis Prophylaxis : Refer to flowchart (Fig 4.11).

Salt-restricted diet

Fig. 4.11 : Infective Endocarditis Prophylaxis Infective Endocarditis Prophylaxis Minor Surgery (Dental Procedures, Tattoing etc.)

Major Surgery (Gastro-intestinal or Genito-urinary)

Non-allergic to ^-lactams Non-allergic to p-lactams

A

Oral Medication Parenteral Medication*

A

Amoxicillin 50 mg/kg PO 1 hour before the procedure

A

Ampicillin 50 mg/kg IM/IV lA hour before the procedure

Oral Medication

4 Clindamycin 20 mg/kg PO or Azithromycin 15 mg/kg POl hour before the procedure

* Parenteral Medication - In Patients unable to take oral medication.

Parenteral Medication*

A

Clindamycin 20 mg/kg IV Zi hour before the procedure

Ampicillin 50 mg /kg + Gentamicin 1.5-2 mg/kg/ IM / IV '/2 hour before the procedure + Ampicilin IM / IV or Amoxicillin PO 25 mg / kg 6-8 hours after the procedure

Allergic to p-lactams

A

Vancomycin 20 mg / kg slow IV infusion (over 1 hour) + Gentamicin 1.5-2 mg / kg IM / IV Zi hour before the procedure

Section II — Practical Aspects of Pediatrics

62

>

Moderate VSD : Moderate-sized VSD's (especially Perimembranous & muscular VSD's) may close spontaneously. Hence, the medical man­ agement should try to (a) Control CCF (b) Prevent pulmonary hypertension (c) Prevent respiratory tract infections & (d) Infective endocarditis prophylaxis. If, the shunt closes spontaneously (in infancy) medical mana­ gement proves successful in avoiding surgery. However, if there is no appreciable decrease in shunt size beyond infancy, surgical closure should be carried out to prevent development of Pulmonary hyper­ tension.

>

Large - sized VSD's : Large VSD's rarely close spontaneously. Since, CCF & cachexia develops in about 3-6 months, surgery should be carried out by 3-6 months of age (even earlier in case of uncon­ trolled CCF with large VSD's). In the meanwhile, medical management as in moderate VSD's should be given.

Modes of Surgical Closure: □

Open Surgical repair: Patch closure of VSD through Right ventriculotomy or a transatrial approach.

□

Catheter occlusion : May be considered as alternative method in case of Muscular & Peri-membranous VSD's. The catheter de­ vices have 2 opposing discs which are in­ serted via catheterization to occlude the defect.

□

Pulmonary artery banding : It is a pallia­ tive procedure used in patients where sur­ gical closure is not possible (Swiss-cheese VSD's, complicated cases etc.) By decreas­ ing the L —> R shunt, development of CCF is delayed.

Indications of Surgical Closure: □

Uncontrolled CCF

□

Cachexia

□

Repeated respiratory tract infections

□

Large VSD's

Contra-indication of Surgical Closure: □

Swiss-Cheese VSD's

□

Severe pulmonary hypertension

□

Prematurity & other complication like sep­ ticemia etc.

Tetralogy of Fallot (VSD with Pulmonic stenosis) Incidence: It is the commonest cyanotic congenital heart dis­ ease. Incidence of TOF is about 0.4-0.5 per 1000 live births.

Pathophysiology: Tetralogy of Fallot comprises of the following 4 anatomical components (P Ventricular septal defect (VSD) & Pulmonic stenosis (PS) & Right ventricular hypertrophy (RVH) (P Overriding (or dextroposition) of the aorta. The basic defect which gives rise to the above 4 components is the improper alignment of the Infundibular septum. The infundibular part of the septum deviates anteriorly & upwards resulting in its malalignment with the trabecular part of the septum. The point of non-union results in a VSD. The infundibular septum which has devi­ ated upwards & anteriorly creates obstruction to the outflow of blood from the right ventricle (Pul­ monary stenosis). The obstruction to the right ven­ tricular outflow results in its hypertrophy (RVH). It also causes dextroposition (over-riding) of the aorta. The Hemodynamic changes depend upon : & Degree of Pulmonary stenosis & hence the Pulmo­ nary vascular resistance (PVR) & Systemic vascular resistance (SVR) When, PVR < SVR : L —» R shunt PVR = SVR : Balanced situation PVR > SVR : R —> L Shunt (Cyanosis) Variants of TOF : cr> Pulmonary atresia with VSD (10% Cases of TOF) : The Pulmonary trunk is atretic & there is no com­ munication between the right ventricle & the pulmo­ nary artery. The right ventricle empties into the Aorta through the VSD. The lungs are perfused by collateral vessels. The collaterals are : > A Patent Ductus arterious >

Collaterals from major systemic arteries □ Collaterals between bronchial artery & Pulmo­ nary artery (bronchial collaterals) □ Collaterals from the descending aorta.

Cardio Vascular System

& Pentalogy of Fallot’s (10-15% Cases of TOF) : It is Fallot’s tetralogy with atrial septal defect (ASD) (P Right-sided aortic arch (20% Cases) (P Pink Fallot’s - The Pulmonic stenosis is mild & the shunt across the VSD is balanced so that the Cyano­ sis is not readily visible Double-outlet right ventricle (DORV) : When the over-riding of the aorta exceeds 50% & the aortic valve & the mitral valve are separated by a muscular septum­ like projection, the defect assumes a form of DORV.

Clinical Features : Symptoms: &

Cyanosis

is the predominant symptom. However, it is often absent in neonates. It generally appears within the 1st year of life & by 5 years almost all patients are cyanosed.

& Exertional breathlessness. & Wheezing Cyanotic spells Cyanotic spells usually occur before 2 years of life (Peak in infancy). The spells occur early in the morning after sleep or after a bout of crying. There is increase in the respiratory rate & depth —> Hyperpnea -> Cyanosis —> Syncope (Occasional convulsions or death) Causes of cyanotic spells : Sudden rise of cardiac output (after getting up in the morning or crying) —y Increased venous return to the heart -» However due to pulmonic stenosis, this extra quantity of blood is shunted through the VSD (R —» L, shunt) -> Deoxygenated blood stimulates the respiratory centre -» Hyperpnea —> Further rise of car­ diac output & tachycardia -> Propagates the vicious cycle again.

63

Retardation of growth : Occurs due to chronic cy­ anosis in untreated cases of Fallot's. It may also lead to delayed Puberty.

Signs : General Examination : & Appearance of the patient: The patient is gener­ ally cachectic with failure to thrive Fallot's may be associated with dysmorphic syndromes like Down's Syndrome, Poland's syn­ drome etc.

tP Vital Parameters : >

Pulse - usually normal or low

>

BP - usually normal

& JVP - usually normal (Raised in c/o CCF) & Pedal Edema - usually absent (Present in c/o CCF) & Cyanosis is the chief distinguishing feature. It is deep on the lips, mouth, fingernails & toenails.

tP Clubbing may be seen in majority of patents of TOF after a few years

(P Anthropometry - Weight & height are below aver­ age. Puberty is often delayed. i$ Scoliosis is common in adolescents Systemic Examination : & CVS Examination :

> Inspection: □ Precordium

- Usually normal or mildly bulging. Harrison’s sulcus (a groove at the lower aspect of the chest overlying the at­ tachment of the diaphragm to the rib cage) may develop because of long-standing breathlessness.

□

if> Squatting Episodes :

□

Squatting posture is adopted by the patient to abort the cyanotic attack or decrease its severity. Mechanism : > Squatting decreases the venous return from the legs —»less of unsaturated blood reaches the heart —> Decreased cyanosis. > Squatting increases the systemic vascular resis­ tance —> Decreases the shunting of blood through the VSD —> More blood available to the lungs for oxygenation —» Decreased cyanosis.

aortic arch may be visible at the right up­ per sternal border

> Palpation : □ Apex beat - Hyperdynamic apex beat may be present

Other postures adopted are : >

Sitting with the legs drawn underneath

>

Crossing the legs while standing

>

Mother holds the infant with his legs flexed on the abdomen.

Apex impulse - Right ventricular impulse Pulsations - Pulsations due to right-sided

>

□

Diastolic shock (Palpable 2nd heart sound) due to the loud aortic component (A2) is usually felt at the Pulmonary area

□

Thrill - A systolic thrill may be felt in the left parasternal region

Percussion Cardiomegaly occurs only in patients with CCF.

Section II — Practical Aspects of Pediatrics

64

> Auscultation : □ Heart sounds:

>

Aortic regurgitation with TOF

>

Post-shunt surgery

S, - Normal

tP Erythrocytosis

S2 - Usually single. (P2 is soft & inau­ dible due to low pulmonary blood flow & low pulmonary pressure)

ifi Infective Endocarditis : Infective endocarditis is slightly more common in patients with TOF than in normal children. However, its incidence in­ creases after surgery (palliative or corrective)

□ Murmurs: In early Fallot’s, an Ejection systolic may be heard at the left parasternal region (murmur is heard due to the pulmonic stenosis, not due to the VSD). This murmur becomes soft with increasing pulmonary stenosis & may be absent during cyanotic spells (due to greatly reduced pulmonary blood flow)

murmur

Diastolic murmur

in Fallot’s may oc­ cur in adolescents or young adults due to Aortic regurgitation

& Severe wheezing &/or Stridor: This occurs when the aorta becomes severely enlarged & puts exter­ nal pressure on the trachea resulting in its ob­ struction.

Nasal Speech - after repeated Cyanotic spells. If> Retarded growth & delayed puberty

Investigations : & To prove the diagnosis :

> X-ray chest: The typical appearance of the heart in TOF is ‘Boot-shaped’ or ‘Couer-en-Sabot’. The fea­ tures on X-ray chest are : □ Oligemic lung fields (outer '/3rd of lung fields do not show any vascularity)

Continous murmurs may be heard widely all over the chest due to exten­ sive nonbrachial collateral circulation in cases of Pulmonary atresia □ Other sounds: An Ejection click may precede the systolic murmur

Complications :

□

Dilated root of aorta

□

Concave left heart border (pulmonary ar­ tery segment)

□

Right ventricular hypertrophy causing upturning of the apex of the heart

& Cerebral thrombotic episodes : It generally oc­ curs in children less than 2 years of age. Throm­ bosis usually develops in either the cerebral veins or the sinuses within the dura. It is common in children with polycythemia or it may be triggered by dehydration.

> ECG:

& Cerebral abscess: It generally occurs in children more than 2 years of age. It is characterized by an insidious onset followed by fever, nausea, vomit­ ing, headache, convulsions or focal neurological deficits. 19

□

S/o Right ventricular hypertrophy - Tall ‘R’ wave in lead V,

□

S/o chronic underfilling of the left ventricle : rS waves in leads V2-V6.

□

Peaked ‘P’ waves

□

Right-bundle branch block (prolonged QRS) may be seen in adults

> 2D Echo & Colour Doppler : 2D Echo is helpful in determining :

CCF : CCF is uncommon in TOF. :

□

Causes of CCF in TOF are : > Pink Fallot’s >

Anemia

>

Excessive systemic —> pulmonary collateral circu­ lation

>

Secondary bacterial infection or Subacute bacte­ rial endocarditis

>

Systemic hypertension

□ >

The presence of TOF □

The location of the pulmonic stenosis

□

The degree of pulmonic stenosis

□

The degree of overriding of the aorta Direction of the flow through the shunt (colour doppler)

Catheterization of the heart: Catheterization of the heart detects high pressure in the right ventricle (equivalent to the systemic pressure).

Cardio Vascular System

65

It also shows a low pressure in the pulmonary circulation. >

Ventriculography - shows the exact extent of the defect in the patient

To rule out Complications : > CBC - Infective endocarditis; Secondary bac­ terial infections; Brain abscess >

ESR - Decreases in CCF & Increases in Infec­ tive Endocarditis

Blood culture - Infective Endocarditis ABG - In case of cyanotic spells > CT Scan/MRI - To rule out Cerebral thrombo­ >

>

sis or brain abscess.

Treatment: Medical Management: > In case of neonates with severe pulmonary atresia - emergency medical treatment is needed to maintain the pulmonary blood flow till surgery can be done.

>

□

IV Glucose & Soda-bicarb - to prevent hy­ poglycemia & acidosis

□

100% Oxygen - to prevent hypoxia

□

IV infusion of prostaglandin E, (0.1-0.2 mcg/kg/min) to keep the ductus arteriosus patent (which provides sufficient pulmo­ nary blood flow) till surgery can be per­ formed.

In infants where the pulmonary stenosis is not so severe: □ □

Prophylaxis for Infective Endocarditis Prevention & treatment of cyanotic spells :

Prevention of cyanotic spells: Oral propranalol - 0.5 mg/kg qds ❖ Prevent anemia Iron supplementation - 3-6 mg/kg/day

Treatment of Cyanotic spells : Place the child in the Knee-chest posi­ tion -y- Administer humidified oxygen Administer IV sodium bicarbonate to correct the acidosis -v- Administer SC morphine in a dose of 0.1-0.2 mg/kg to calm the infant Administer IV propranalol - 0.1 mg/kg

In refractory cases - IV methoxamine can also be used to increase the periph­ eral resistance

fr Treatment of Complications : > Treatment of cerebral thrombosis : Treatment is generally supportive. Ad­ equate hydration should be maintained to pre­ vent sludging of blood. Cerebral edema should be adequately tackled to prevent permanent neurological deficits. Physiotherapy can re­ duce the long-term morbidity & should be started after the acute attack. > Treatment of Cerebral abscess : □ Antibiotic therapy in high doses for a mini­ mum of 21 days (The spectrum of antibi­ otic therapy generally includes a 3rd gen­ eration cephalosporin - e.g. cefotaxime or ceftriaxone along with an aminoglycoside antibiotic - e.g. Amikacin) □ Surgical drainage of the abscess if possible □ Anti-epileptic drugs in case of convulsions □ To decrease the raised ICT - IV Lasix / Mannitol / Acetazolamide may be useful. > Treatment of CCF > Treatment of Infective Endocarditis

& Surgical Management of TOF : Indications for surgery: > Decreased exercise tolerance > Having attained the right age for surgery > Repeated cyanotic spells > Severe growth retardation > Polycythemia Types of Surgical procedures ; > Palliative surgery > Corrective surgery > Palliative surgery : Indications : Cyanosed patients who do not qualify for corrective surgery (e.g. neonates with pulmonary atresia causing severe cyano­ sis)

Types : □

Systemic-to-pulmonary artery shunt sur­ gery :

This is done to increase the pulmonary blood flow.

Section II — Practical Aspects of Pediatrics

66

Complications of corrective surgery :

Types of Shunts:

□

Table 4.18 : Different Types Of Shunt Surgery In Tetralogy Of Fallot Shunt Type •

Subclavian artery Pulmonaiy arteiy

• Pott's shunt

Descending aorta —> Left pulmonary artery

• Waterson’s shunt

Ascending aorta —> Right pulmonary artery

B-T shunt is generally preferred over the other two because of the high risk of CCF & progressive pulmonary vascular disease with the other two shunts.

Age of Surgery: BT shunt can be done even in prema­ ture infants & neonates.

Complications of shunt surgery: ■v’- Horner’s syndrome - may be temporary -Y- Diaphragmatic paresis CCF - due to large shunt

Types of BT shunt: Original B-T shunt : Anastamosis of subclavian artery directly to the pul­ monary artery ■4* Modified B-T shunt (preferred nowa­ days) : The subclavian artery & the pul­ monary artery are anastamosed sideto-side with the help of a conduit □

□

Pulmonary regurgitation due to valvotomy for pulmonary stenosis

□

Incomplete closure of VSD

Arteries Anastomosed

Blalock-Taussig shunt (BT shunt)

Percutaneous Balloon dilatation of the pul­ monic stenosis : This has been given up nowadays due to the damage caused to the pulmonary valve by forceful dilatation.

Cr* ASD very rarely presents in pediatic age group hence ASD’s are rarely symptomatic before adulthood & as such are never kept as exam cases unless clearcut symptoms & signs are present. &

VSD/PDA/TOF Diseases group.

are

are common Congenital present in Pediatric age

1000 (0.8%)

If 1 sib is affected — 4% chance (every conception has 4% chance of having CHD) If >2 sibs affected or 1 parent is affected— 25 - 30% chances of CHD. If a 2nd child is also affected by C.H.D following the presence of C.H.D in 1st child, environmental factors leadings to C.H.D should be ruled out.

cf" Few general rules regarding etiological causes in C.H.D can be considered as : >

SGA/Preterm child —> Increased incidence of PDA & VSD

>

LGA child (Infant of diabetic mother) —» Increased incidence of TGA

>

Full term child with Heart Disease —> Increased likelihood of Cyanotic Heart Disease

The best age for corrective surgery is be­ tween 3 months - l'A years (because the infant can tolerate the surgery better & the pulmo­ nary arteries have grown slightly larger)

Low Birth weight & Congenital Heart Disease may suggest Intra-uterine infections or Down’s syndrome (If other features are also present).

In patients with B-T shunt, corrective sur­ gery is done when cyanosis worsens.

Procedure :

which

cf* Incidence of C.H.D in general population = 8/

> Corrective surgery :

Age of surgery:

Arrhythmias (including heart blocks)

□ CCF

& Causes of Cough & cold since birth :

□

Patch closure of the VSD

>

□

If the outlet of the right ventricle is obstructed by muscle fibres - they are removed.

Any Cardiac Disease)

>

□

If the pulmonary valve is stenosed - Valvotomy is done

Any Lung malities)

>

Cleft Palate

□

In patients with shunt surgery - closure of shunt

>

Tracheo-esophageal fistula (H - variety may go unrecognised for months)

Pathology Pathology

(Congenital (anatomic

Heart abnor­

67

Cardio Vascular System

>

GER (Gastroesophageal reflux)

>

Immunodeficiency (HIV infection)

& Clubbing in a case of Cyanotic Congenital Heart Disease >

Rare Causes include : >

Volvulus of stomach

>

Hyaline Membrane Disease with damaged lung.

May appear as early as 8 - 10 weeks. Clubbing may appear within 24 hours in case of infective Endocarditis.

& Few Pulmonary stenotic situations (Cyanotic

Causes of Cyanosis from birth :

condition) include :

>

Cyanotic Congenital Heart Disease

>

TOF (Tetralogy of fallot)

>

Respiratory causes (intermittent cyanosis in c/o respiratory tract infection)

>

DORV with Pulmonary stenosis (PS)

>

Tricuspid atresia with PS

Gastro-esophageal reflux (Intermittent, recurrent Cyanosis)

>

TAPVR with PS

>

VSD with PS (without overriding of aorta)

>

TGA with VSD with PS

> >

Methaemoglobinemia.

Table 4.19 : Differentation Between Resp­ iratory Cyanosis & Cardiac Cyanosis

& Causes of delayed developmental miles­ tones in c/o Congenital Heart Disease : >

Hypoxia (Hence development is more delayed in Cyanotic as compared to acyanotic Heart Disease)

>

Increased basal metabolic rate

>

CCF

> Tachypnea present. > Dsypnea present. > On Crying - Cyanosis > On Crying - Cyanosis in­

>

Infective endocarditis

>

Acidosis

creases. > On administration of > P02 does not rise substan­ tially on giving 100% 02 100% 02 (Hyperoxia test) -P02 > 150 > PC02may be increased > PC02 usually normal or low

>

Repeated respiratory tract infections

>

Anorexia & feeding difficulties

>

Genetic/Endocrine problems

Cardiac Cyanosis

Respiratory Cyanosis

> Associated respiratory > No associated respiratory condition condition present

> Appears later on in life. > May appear at/immedi­ ately after birth

decreases.

& Causes of Failure to thrive in c/o Cong­ enital Heart Disease : >

Hypoxia

Table 4.20 : Differentiation Between Meth­ emoglobinemia & Cyanotic Congenital

>

CCF

>

Increased basal metabolic rate

Heart Disease

>

IUGR (IU infection)

>

Repeated respiratory infections

>

Anemia

>

Infective Endocarditis

>

Chronic medication & Hospitalization

Cyanotic Congenital Heart Disease

Methaemoglobinaemia > No associated symptoms > Clubbing is not present

>

Associated symptoms present. > Clubbing may be present.

> Therapeutic trial of Ascor­ > bic acid + Methylene blue —> may be successful > Blood when withdrawn > Blood exposed to air turns bright red. from body & exposed to air does not turn red > Familial incidence is more > Familial incidence is less > H/o drug intake - like Dap-> H/o drug intake in mother may be present during sone may be present pregnancy.

& Incidence of Infective Endocarditis in Cyanotic Heart Disease is less as compared to that in Acyanotic Heart Disease, because bacteria need oxygen for their growth, hence they do not thrive well in Cyanotic situations.

& Maternal condition known to cause CHD in infant : Rubella

—> PDA/Peripheral Pulmo­ nic Stenosis

Alcoholism

—> VSD

Section II — Practical Aspects of Pediatrics

68

Diabetes Mellitus —» TGA Phenyl Ketonuria —» Mitral regurgitation & Drugs producing Congenital Heart Diseases include : >

Antiepileptics like Phenytoin & Valproate

>

Alcohol

>

Anticoagulants like Warfarin

>

Thalidomide

>

Antimetabolites like Methotrexate

>

Progesterone

>

Lithium

& Sudden Improvement in Symptoms of VSD :

Causes : >

Closure of VSD

>

Fallotization of VSD i.e. Development of Pulmonary stenosis

& With the help of Fetal Echo, VSD can be picked up antenatally at about 7 months. & Predisposing factors for Infective Endocarditis are :

> > > > >

Poor oral hygiene. Diarrhea Dental procedures Cardiac surgery Operations (Surgery) > Artificial devices (e.g, Valves, Stents etc. placed in the body) > Focus of infection anywhere in the body & Fundus findings in Infective Endocarditis : > Earliest change — Petechial hemorrhages > Roth spots > Flame-shaped hemorrhages > Papilledema & X - Ray findings in Infective Endocarditis associated with Cong. Heart disease : > Pulmonary infarct because of Embolus (wedge-shaped infarct) > Cardiomegaly > Pulmonary edema > CCF with Kerley's lines > Pneumonitis

& The 2 major criteria for diagnosis of Infective Endocarditis are : >

Vegetations (seen on 2D Echo)

>

Positive Blood Culture.

(P Reason why a pt with CCF does not improve despite Treatment : > Anemia > Associated cardiac anamolies > Infection > Poor compliance > Infective endocarditis In a preterm child, the following causes can lead to non-closure of PDA : > Anemia > Hypoxia > Infection > Fluid overload > Acidosis > CCF These conditions should be treated first before administration of Prostaglandin inhibitors (like Indomethacin)

Before administration of inhibitors (Indomethacin) :

Prostaglandin

BT/CT/PT/PTTK/Platelet count/BUN/S. Electrolytes / S. Creatinine should be done & confirmed as normal.

& A rough estimate as to the time of development of Eisenmengerization in a c/o Congential Heart disease : >

PDA —> 11 years (2nd decade)

>

VSD —» 22 years (3rd decade)

>

ASD —» 33 years (4th decade)

& Importance of Iron supplementation in CHD : >

Treatment of anemia

>

Decreases the incidence of LRTI

>

Improvement of exercise tolerance

>

Prevents Cyanotic spells [in c/o Cyanotic diseases]

>

Decreased Incidence of CCF

69

Cardio Vascular System

& History to rule out Differential Diagnosis : >

To r/o Congenital heart disease — H/o Cyanotic spells / Cyanosis / Squatting / Suckrest-Suck cycle / symptoms from birth / repeated LRTI/breathlessness on feeding/ failure to thrive.

>

To rule out Juvenile rheumatoid arthritis (JRA) — H/o Morning stiffness/spine pain/

Proforma History : (P Chief Complaints : >

H/o Breathlessness on exertion

>

H/o ftlpitations

>

H/o Chest pain

>

H/o Syncopal attacks

>

H/o Cough/Cold/Fever/Hemoptysis

>

H/o Arthritis (Joint Pains)

>

Rarely - H/o involuntary movements like choreic movements

& History of Major & Minor Criteria : >

>

H/o Carditis : □ ask about lsl five points as discussed above in Chief Complaints H/o arthritis : □ H/o joint pains which involve large joints

To r/o Leukaemia — H/o weight loss/pallor/ bone pain/bleeding.

>

To r/o SLE — H/o facial rash with fever with joint pain

& Birth History & Immunization History

Dietary History & Developmental History & Socioeconomic History

Examination :

□

H/o Swelling ---------- 1 To differentiate

& General Examination :

□

H/o restriction of — arthritis from movement -------------- ' arthralgia

>

H/o subcutaneous nodules

>

H/o rash over body (abdomen) which is evanescent in nature (Erythema marginatum)

>

H/o fever with joint pains in past — Minor criterion

>

H/o sore throat/scarlet fever (i.e. rash with fever)/Abdominal pain, Epistaxis - Supp­ ortive criterion H/o Patient taking Penicillin injection every 21 days in past.

History of Complications :

>

>

H/s/o CCF : □ H/o Edema feet/Puffiness of face □

H/o Abdominal pain

□

H/o anorexia/nausea/vomiting

H/s/o Infective Endocarditis : □ H/o fever with chills/Petechial hemorrhages/Osler’s nodes/Janeway lesion/ Hemoptysis/Hematuria

joint

To r/o Reactive arthritis — H/o fever with loose motions/blood in stools with joint pain.

Migratory nature of pain

H/o involuntary movements like chorea

>

>

□

>

>

Temporo-mandibular joint pain/small Pain/stiffness of joint after prolonged use.

The proforma is the same as in Congenital Heart disease. >

Look for Subcutaneous Nodules & Erythema Marginatum

>

Peripheral signs of Aortic regurgitation — if present should be mentioned in General Examination.

>

Look for ination)

arthritis/arthralgia

(joint

exam­

& Systemic Examination : As usual, examining : > CVS in detail (Inspection, Palpaltion, Percussion, Auscultation) & other systems in brief >

RS - Basal rales

>

PA - Hepatosplenomegaly

>

CNS - Look for Involuntary movements (Choreic movements)

Diagnosis : A c/o Rheumatic fever with Pansystolic murmur or Mid-diastolic murmur grade............. /VI in sinus rhythm with/without Pulmonary Hypertension

Section II — Practical Aspects of Pediatrics

70

with/without CCF

>

Aspirin - duration & dose as per severity

with/without Infective Endocarditis

>

Steroid - duration & dose as per severity

with/without active signs of Rheumatic fever

>

Treatment of CCF

Most probable diagnosis being................................

>

Treatment of Chorea : □ Bed rest

Investigations (See discussion on rf & rhd for details)

To prove streptococcal infection : >

ASLO Titre

>

Throat Swab

& To prove inflammation : >

WBC Count

>

ESR

>

CRP

& To determine Severity & type of Cardiac lesion : >

X-Ray Chest

>

ECG

>

2D Echo

>

Cardiac Catheterization & Angiography —» If Surgery is considered.

& To rule out Complications : Blood Culture — Infective Endocarditis General Principles Of Treatment Of

□

Anti-inflammatory agents

□

Sedatives

□

Phenobarbitone

□

Haloperidol

□

Chlorpromazine

(7.................

Discussion on Rheumatic fever (RF) & Rheumatic Heart Disease (RHD) Definition : Rheumatic fever (RF) is an acute inflammatory disease which usually follows throat infections caused by Beta-hemolytic Group A Streptococci & tends to be recurring in nature.

Incidence : Incidence of Rheumatic fever is about 1/1000 in Developing countries. Rheumatic heart disease is re­ sponsible for 15-20% of all cardiac admissions in developing countries.

Rheumatic Fever/Rheumatic Heart

Etiology :

DISEASE : (See discussion on RF & RHD for

There is a complex interplay between the caus­ ative agent (streptococci), host & the enviornment which results in development of Rheumatic fever. Thus, group A stroptococcal throat infection preceedes the initiation of either the 1st attack or recurrence of RF. RF is commonest between 5-15 years of age due to decreased immunity in children & increased con­ tact with school children and occurs with greater fre­ quency in siblings & twins (the pattern of attack is also similar in siblings affected with RF). Poverty, overcrowding, malnutrition & non-availability of an­ tibiotics are the factors responsible for increased in­ cidence of RF in urban areas & slums.

details) & Treatment of CCF (P Treatment of Infective Endocarditis Infective Endocarditis Prophylaxis iNutritional Treatment : >

High Calorie diet

>

Treatment of anemia

>

Salt restricted diet —i if CCF is

>

Fluid restriction _______ 1 present

Treatment of Rheumatic fever : > Bed rest — Strict bed rest as per the severity >

>

Monitor : □ Basal pulse Rate (daily) □

ESR (weekly)

□

CRP (as & when required)

Benzathine Penicillin (dose as per weight) Stat & every 21 days after that

Pathogenesis : Rheumatic fever is a Post-streptococcal disease (i.e. a non-infective complication of streptococcal infections). However only throat infections & not skin infections cause RF (Skin infections usually lead to Acute glomerulonephritis). The theories for develop­ ment of Rheumatic fever are : & Cytotoxic theory : Toxins produced by strepto­ cocci diffuse out & lead to rheumatic fever (how­

Cardio Vascular System

71

ever the latent period between the throat infec­ tion & rheumatic fever does not support this theory). &

Autoimmune theory : Streptococcal antigens cross-react with the human antigens (Myocardial proteins & glycoproteins of the heart valves). Thus, antibodies produced against the streptococci act on the host tissues (myocardium) & damage them. This is the accepted theory for the develop­ ment of Rheumatic fever.

Clinical Features : Streptococcal Latent Period Pharyngitis

(3 weeks)

Symptoms: >

Malaise & tiredness (early symptoms if cardi­ tis is the only features of RF.)

>

Symptoms due to CCF : □ □

Pedal Edema

□

Abdominal Pain (right hypochondriac pain)

□

Precordial pain

Signs : Rheumatic Fever

> General Examination : □

[Latent Period is of same duration in 1st attack & in recur­ rences)

Bounding pulse in mitral regurgitation or collapsing (water-hammer) pulse in aortic regurgitation.

Onset: Onset is acute in arthritis, sub-acute if carditis is the sole manifestation & chronic if chorea is the only feature.

& Joint Involvement in RF :

>

>

It may be arthralgia (Pain but no swelling) or arthritis (Pain with all signs of inflammation like swelling, redness etc.) Arthritis is the com­ monest manifestation of RF (In 3/4th number of patients) & occurs very early in the course of the disease. Generally, it affects several joints & is migra­ tory in nature (Joints are affected one after the other, each joint being inflammed for a few days to a week) Joints (especially larger joints) of the lower limbs are affected first followed by that of the upper limbs (Knees & ankles are most com­ monly affected).

>

Pain appears early & is usually more as com­ pared to the swelling

>

There is no residual deformity & X-ray is nor­ mal except for Effusion.

Pulse: ■4- Tachycardia out of proportion to the degree of fever. Tachycardia is even present during sleep (Sleeping tachy­ cardia)

An acute attack of Rheumatic fever lasts from 4 weeks to 3 months. (Duration of the attack is shortest in isolated arthritis, longer in chorea & longest in carditis.

>

Exertional breathlessness

□

Pedal Edema

□

Raised JVP

> CVS Examination : □

Inspection Bulging precordium (In case of cardiomegaly) with pulsations seen over the chest

□

Palpation : Shifting of the apex beat with thrills (if murmurs are loud enough)

□

Percussion : Cardiomegaly may be present

□

Auscultation : Heart sounds : O Indistinct S, due to 1st degree AV block. O Gallop rhythm due to loud S3 Murmurs

O Murmur of mitral regurgitation Pansystolic murmur heard best at the apex, generally above grade 3/6 & radiating to the axilla & back with no changes following change in pos­ ture or respiration.

& Carditis : It is the most severe of all the manifestations of RF because it can cause death or significant morbidity by causing permanent change in the structure of valves & thereby the function of the heart.

O

Carey-Coomb’s murmur

- Apical, mid-diastolic murmur which oc­ curs due to ‘relative stenosis’ of

72

Section II — Practical Aspects of Pediatrics

mitral valve when compared to the huge ventricular chamber (due to dilatation of the ventricle)

O Murmur of aortic regurgitation

(Less common)

: It is a early dias­ tolic murmur heard best in the left parasternal region with the patient in sitting posture, leaning forward & breathing out.

mon in females than males (Ratio being 2:1) & usually occurs in children & adolescents, being rare in adults. It is primarily a neurological disorder consist­ ing of: > Involuntary movements (Chorea): Choreic movements usually involve the proximal joints & are abrupt, fast, involuntary, Quasi-purposive, jerky, non-repetitive move­ ments which decrease on rest & disappear during sleep but increase on excitement. The face & the upper limbs are most commonly involved in chorea.

O Murmurs of mitral stenosis & Aor­

tic stenosis (denotes previous attack of RF): ❖

Murmur of Mitral stenosis - It is a mid-diastolic murmur heard best at the apex. It is usually preeceded by an opening snap which occurs shortly after S2 (Absence of opening snap indi­ cates a fused, calcified & thick­ ened mitral valve which gener­ ally occurs in later years) & con­ cludes with presystolic accen­ tuation (due to atrial systole leading to increased blood flow). It is best heard with the bell of the stethoscope with the pa­ tient turned towards the left side & after a brief period of exercise.

❖

Murmur of Aortic stenosis - It is a crescendo-decrescendo mur­ mur which is preeceded by an aortic ejection click (due to opening of the diseased aortic valve). The murmur is soft to begin with, reaches a peak in mid-systole & then again soft­ ens down before S2 (Ejection systolic murmur). It is heard best in the aortic region & radi­ ates to the neck.

Other sounds :

Pericardial Friction rub : It is a crackling leathery sound heard all over the chest, in systole as well as diastole & varies with changes in pressure ap­ plied by the stethoscope on the chest. It occurs due to Pericadial Effusion. & Chorea (Sydenham’s chorea) Chorea generally occurs several weeks or months after the throat infection. It is more com­

>

Incoherent speech

>

Weakness of the muscles

>

Hypotonia

>

Hung-up reflexes

>

Inco-ordination (become them to button a shirt)

>

Emotional disturbances with Inappropriate smiles, facial grimaces, weird facial expres­ sions & often transient psychosis.

fidgety on asking

Signs used to Elicit Chorea are : >

Milkmaid’s grip: On asking the patient to shake the examiner’s hand, the patient’s grip increases & decreases alternatively thus re­ sembling the milking action of the milkmaid.

>

Pronator sign : On raising the arms above the head, there is pronation of one or both the hands.

>

Spooning of hands : On projecting the hands forward there is flexion of the wrist, exten­ sion at the finger joints & abduction of the thumb.

>

Jack-in-the box tongue

: On asking the patient to protrude his tongue, the tongue flits in & out.

(P Subcutaneous nodules (3-30%) >

Subcutaneous nodules are late manifestation of RF, appearing after weeks to months fol­ lowing throat infection & lasting for 1-2 weeks.

>

They are firm, painless, spherical nodules about Vi to 1 inch in diameter, free from the overlying skin & underlying structures & typi­ cally appear on extensor surfaces of the body. (The sites of occurence of subcutaneous nod­ ules in RF are : Occipital region, behind the ears, along the spine, along the olecranon process-elbow).

73

Cardio Vascular System

>

95% of patients with subcutaneous nodules have Carditis

>

To differentiate a subcutaneous nodule of RF from an enlarged lymph node -» biopsy should be done as the subcutaneous nodule contains Aschoff bodies.

ft Erythema Marginatum (2-12%): >

It is an early manifestation occuring generally in patients with carditis.

>

It is a slightly raised, erythematous, evanes­ cent, non-pruritic, serpiginous rash, about an inch in diameter, which appears on the trunk

>

It is rarely visible in adults & in dark people.

ft Other features of RF (All are not included in

Jones Criteria):

are much more important indication of recent infection. Since the antibody levels decrease after l'/2-2 months, ALSO test is not helpful in cases of chorea. ft Tests to prove Inflammation : >

WBC Count - Generally elevated

>

ESR - Elevated

>

CRP - Elevated

ESR & CRP are very sensitive tests. If ESR & CRP are normal, the patient is unlike to have RF. Conversely, persistence of raised ESR (&/or CRP) in a patient with RF indicates continuing activity of RF. ft Tests to determine the severity & type of Car­ diac lesion :

>

Fever - Fever is usually present in arthritis & carditis but not in chorea.

>

X-ray chest - May show cardiomegaly or Peri­ cardial Effusion

>

Anorexia

> Epistaxis (rare)

>

>

Weight loss

> Pallor

>

Abdominal pain > Pneumonia (rare)

ECG - Prolonged P-R interval is seen in 30-35% of patients with RF. The Criteria for calling the P-R interval as prolonged depends on the age. Upto 12 years of age, P-R interval >0.16 is pro­ longed, whereas above 12 years of age, it is called prolonged if it exceeds 0.18-0.2 seconds.

>

2DEcho - Useful for identifying valvular le­ sions & their severity. It may also pickup veget­ ations on the valves if Infective Endocarditis is suspected.

>

Cardiac Catheterization & Angiography: These tests are done only if surgery is considered for valvular lesions eg: Mitral valvotomy or valve replacement surgery for mitral stenosis.

Signs of activity of Rheumatic fever : ft Signs suggestive of active carditis : > Tachycardia (Sleeping pulse rate > 100) >

Muffled Heart sounds

>

Changing murmur

>

Enlarging heart size

>

Pericardial rub/Effusion

>

CCF

ft Fever without any other cause. ft Arthritis ft Chorea ft Subcutaneous nodules ft Erythema Marginatum ft Increase in ESR/CRP

Investigations : ft Tests to prove Streptococcal Infection in the recent past: >

Throat culture - usually negative because of the time lag between the throat infection & development of RF

>

ASLO test: It is a streptococcal antibody test. About 75% of patients with RF have eleva­ ted ASLO titres (Remaining 25% have el­ evated titres of other streptococcal antibody tests). In children, ASLO titres above 300U are considered as abnormal. Changes in titres

ft Tests to rule out Complications : >

Blood Culture - to rule out Infective En­ docarditis

Table 4.21 : Revised Diagnosis Of RF Major Criteria tf> Arthritis Carditis & Chorea & Subcutane­ ous Nodules & Erythema Marginatum

Jones

Minor Criteria & Arthralgia