#ir #peds
Preschooler
Case 4: A 3-year-old female presents
with abdominal pain and fever over the
past day. Patient has some vomiting
and diarrhea. Emesis is nonbilious
and nonbloody. Diarrhea is watery
and yellow. The patient has also had
decreased oral intake and urine output. On
exam, the patient is febrile and appears
uncomfortable.
Performing a good abdominal exam is
critical for the assessment of this patient,
but can often be challenging. Children
cannot developmentally pinpoint the
location of abdominal pain until they are at
least four years old, and perhaps not even
then. With symptoms and an exam that are
nonspecifi c, abdominal pathology can be
very diffi cult to diagnose in this age group.
Attempt to calm and distract the patient as
much as possible.
For infants, make sure to have a pacifi er
available during the abdominal exam.
Another option for the crying infant is to use
sucrose to calm them during auscultation
and palpation. Flexing the hips will also
facilitate relaxation and a better exam. For
patients that are ticklish, you can have the
child place their hand on yours and push
down as if they are doing the exam.
For children with abdominal pain, make sure
to always undress the patient and evaluate for
rashes to assure that diseases like HenochSchönlein
Purpura (HSP) are not missed.
Also, referred pain is very common, and
pneumonia or strep throat may present with
abdominal pain of any location with focal or
diffuse pain on exam.
Using the above techniques, the patient
in the case was found to have signifi cant
tenderness without rebound. Upon further
evaluation, the patient was found to have
acute appendicitis.
The above tips and tricks should allow
for a smoother encounter with the pediatric
patient. If the tactics are not working,
do your physical exam in stages. Start
quickly with the most essential, then return
frequently to perform each additional
layer. Always remember that a graceful
approach will go a long way with assessing
children.
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Tricking Kids into the Perfect Exam: Tips for Evaluating the Pediatric Patientelp attract the child’s
attention.
Upon examination of this patient, he had
right-sided weakness which resolved
within an hour. The patient was diagnosed
with Todd’s paralysis and new-onset
seizure disorder.
<span>Preschooler
Case 4: A 3-year-old female presents
with abdominal pain and fever over the
past day. Patient has some vomiting
and diarrhea. Emesis is nonbilious
and nonbloody. Diarrhea is watery
and yellow. The patient has also had
decreased oral intake and urine output. On
exam, the patient is febrile and appears
uncomfortable.
Performing a good abdominal exam is
critical for the assessment of this patient,
but can often be challenging. Children
Figure 1: Additional Tips & Tricks
General
Always undress.
Eyes
If trying to get a newborn to open their eyes, holding the infant’s head and dipping it down will cause
them to open their eyes.
Never try to pry a baby’s eyes open when they are crying as you will not be able to over power them and
will just anger them more.
Infants should fi x and follow a moving object with both eyes by 3 months of age. Use bright objects or
noises to help assess extraocular movements.
Ears
If having a hard time looking in the ears, hold arms above head.
If unable to turn their head, wiggle the otoscope light in front of their eyes and then move it to the
opposite side of the ear you want to look in. The child will often track with the light and turn their head
so their ear is then right in front of you.
Have parent stabilize the head. Use one hand to grab the pinna while holding the otoscope with the
thumb and index fi nger and using the little fi nger and heel of the hand to stabilize the otoscope against
the side of the face (See Figure 2).2
Mouth/Throat
Wetting the tongue depressor makes it taste better.
Have the child pant like a dog when doing a throat swab as it helps prevent gagging.
Heart
If worried about murmurs, gently and briefl y blow in the face of a neonate which slows down their heart
rate momentarily so that you can better ausculate for murmurs.
Lungs
If you want them to take a deep breath, can have them blow out the light on the otoscope or can ask
them to pretend to blow out the birthday candles.
cannot developmentally pinpoint the
location of abdominal pain until they are at
least four years old, and perhaps not even
then. With symptoms and an exam that are
nonspecifi c, abdominal pathology can be
very diffi cult to diagnose in this age group.
Attempt to calm and distract the patient as
much as possible.
For infants, make sure to have a pacifi er
available during the abdominal exam.
Another option for the crying infant is to use
sucrose to calm them during auscultation
and palpation. Flexing the hips will also
facilitate relaxation and a better exam. For
patients that are ticklish, you can have the
child place their hand on yours and push
down as if they are doing the exam.
For children with abdominal pain, make sure
to always undress the patient and evaluate for
rashes to assure that diseases like HenochSchönlein
Purpura (HSP) are not missed.
Also, referred pain is very common, and
pneumonia or strep throat may present with
abdominal pain of any location with focal or
diffuse pain on exam.
Using the above techniques, the patient
in the case was found to have signifi cant
tenderness without rebound. Upon further
evaluation, the patient was found to have
acute appendicitis.
The above tips and tricks should allow
for a smoother encounter with the pediatric
patient. If the tactics are not working,
do your physical exam in stages. Start
quickly with the most essential, then return
frequently to perform each additional
layer. Always remember that a graceful
approach will go a long way with assessing
children. <span><body><html> Summary
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