IAP Clinical Examination in Pediatrics Baldev Prajapati
INDEX
Page numbers followed by b refer to box, f refer to figure, and t to table.
A
Abdomen 157, 351
distention of 158, 165, 165b, 189f
examination of 170, 172f
inspection of 173b
movements of 173
palpation of 177t
percussion of 188
shape of 172, 173
Abdominal viscus, perforation of 498
Abducens nerve palsy 288
Abductor digiti minimi 310f
Abductor pollicis 310f
brevis 310f
card test 310f
Aberrant left coronary artery originating from pulmonary artery 224
Abscess 435
Acanthosis nigricans 68f
Acarus mite
high power view of 392f
low power of 392f
Achilles jerk 322
Acid-fast bacillus 25
Acidosis, severe 491
Acne 381
Acrocephaly 51
Acrocyanosis 348
Acrodermatitis enteropathica 381
Acromelia 72
Acute febrile encephalitic syndrome 19
Acute left ventricular failure 491
Acute respiratory failure 200b
signs of 199
Addictive drugs 339
Adductor angle 146, 302, 303f
Adelaide coma scale 278
Adenoid
enlarged 426f
facies 426f
hypertrophy 425
Adenoviruses 195
Adventitious sounds 44, 214, 217
Advisory Committee on Immunization Practices Technique 454
Age appropriate vision screening charts 408t
Age-specific normal respiratory rates 42t
Air embolism 462, 467, 498
Alae nasi, flaring of 199
Alimentary system 157
Alkali, ingestion of 478
Allen and tumbling E chart 410f
Allen cards 408
Allen test 468, 468f, 470
Allergic disorders 373
Allergy 454
Alopecia 386
areata 381
Alport syndrome 419
Amaurotic cat's eye reflex 397
American Academy of Ophthalmology 395
American Academy of Pediatrics 395
American Association for Pediatric Ophthalmology and Strabismus 395
American Association of Certified Orthoptists 395
Amiel-Tison method 147t
Amino acids 98
Aminoglycosides 339
Amnionitis, history of 340
Anacrotic pulse 232
Anal fissure 167
Anal reflex 319
Ancillary testing 449
Anemia 259, 340
hemolytic 182, 185
Anesthesia 313, 451
Angiofibroma, juvenile nasopharyngeal 428, 429
Angiotensin-converting enzyme 196
Aniridia 58
Ankle
clonus, elicitation of 322f
jerk 322
Anosmia 281
Anotia 419, 422
Antecubital fossa 456
Anterior horn cells 335
Anthropometric indices, interpretation of 122
Anthropometry 49, 111, 124, 344
Antinuclear antibody 366
Antithyroid drugs 339
Anxiety 15
Aorta 40
Aortic regurgitation 41, 229, 263
Aortic stenosis 222224, 231, 264
Apert syndrome 55
Apex beat 243, 244, 259
method of palpation of 243, 244f
types of 245
Apgar scoring system 341, 344, 345t
Aplasia cutis congenital 381
Apnea 489
test 446, 448
Apneic oxygenation method 448
Appetite 158, 169
Appropriate growth charts 344
Aqueous humor 396
Arachidonic acid 98
Arm span 121
Arm, midpoint of 117
Arnold Chiari malformation 329
Arrhythmias 224, 498
cardiac 467
Arteriovenous fistula 229, 496
Arthralgia 369
Arthritis 259, 362, 366, 366t, 369, 370, 372
acute 362, 370
chronic 362, 370, 371
Articular cartilage 370
Articular diseases 363
Articulation, disorder of 280
Artificial CO2 augmentation procedure 448
Ascites 165, 452
signs of 189
Asthma
acute severe bronchial 233
bronchial 14, 163, 195
Asymmetric tonic neck reflex 151, 354
Ataxia 273, 326, 327
telangiectasia 387
Atelectasis 218
Athetosis 312
Atopic dermatitis 368f, 381, 389
Atrial septal defect 222, 226, 253, 254, 261
Atrophy 379
Atropine 483
Auditory brainstem response 424
Auditory steady state response 424
Auricle, hematoma of 420f
Auscultation 212, 250, 350
areas of 251
cardiac 250, 251t
method of 212
Autism 155
Autoinflammatory disorders 362
Autonomic nervous system 330
manifestation of 331
Autonomic neuropathies 331
Autonomic system 331
AVPU pediatric response scale 278b
Axillary lymph nodes 80
right anterior 81
right apical 81
right lateral 81
right posterior 81
Axillary suspension 351, 352f
Axillary temperature 37
B
Baby friendly hospital initiative 91
Bacillus Calmette-Guérin 23
vaccination 454
Back pain 273
Bacteremia 274
Bacterial endocarditis 286
subacute 407
Bacterial infections 388, 391
Bacterial meningitis 266, 268, 269, 271, 295, 419
Ballismus 312
Barbiturates 491
Barlow tests 357
Barognosis 316
Basal ganglia diseases 301
Basal metabolic rate 229
Basilic vein 456
Beau's line 71, 387
Beckwith-Wiedemann syndrome 64
Behavioral audiometry 424
Bell's palsy 292
Bell's phenomenon 291
Benzodiazepine 329
Biceps jerk, elicitation of 320f
Bifid uvula 67f
Bilious vomiting 161
Birth
asphyxia 337, 342
weight 222, 336, 425
Bisferiens pulse 231
Bladder 273
Bleeding 493
causes of 167b
diathesis 494
manifestations 342
per rectum 158, 168
per vaginum, history of 340
tendency 482
Blood
flow, direction of 175, 176f
group 338, 339
in stool 161
pressure 44, 47, 169, 346, 365
arterial 233
measurement of 45, 233, 234
Blue lips and nails 342
Blue sclera 58f, 347
Blueberry Muffin’ spots 391
Body
language 15
mass index 122
proportions 120
temperature
measurement of 37
normal 37
Bone 70
marrow aspiration 470
needles 471f
Bordetella parapertussis 195
Botulism 297
Bounding pulse 41, 231
Bowel involvement 273
Bowel sounds 192
Brachioradialis 322
Brachycephaly 51, 331
Bradycardia 228, 228t, 489
causes of 229b
Brain
abscess 268
death 443, 449
assessment of 446
diagnosis of 444, 448b
function, cessation of 446
injury, post-traumatic 271
space occupying lesions of 155
tissues 477
tumors 268
Brainstem 334
evoked response audiometry 424
reflexes 446
tumors 287, 296
Branchial cleft cyst 435
Breast
abscess 102
anatomy of 93, 95f
engorgement of 101
examination of 77
milk 102
composition of 97, 99t
types of 97
Breastfeeding 5, 91, 93, 99, 103
continuation of 104
initiation of 93
schedule of 102
Breath sounds 217
mechanism of 212
Breathing
difficulty in 195, 197t
signs of 44b, 196, 199b
types of 213, 213f
Broca's aphasia 280
Bronchial breathing 213
types of 214
Bronchiolitis 18
Brucellosis 371
Bruckner's reflex 402
Bruckner's test 398, 402f
Brudzinski sign 325, 326f
positive 324, 325
Buccal mucosa 63, 435
Budd-Chiari syndrome 84, 182
Bulbar palsy 296, 297
Bulla 375, 377f
Bullous disorders 391
Bullous impetigo 388
Buphthalmos 53
C
Café-au-lait spots 267
Candida infection 390
Capillary refill time 47, 348
Caput succedaneum 346
Cardiac arrest 498
Cardiac failure, congestive 77, 222
Cardiac murmur 255
mechanisms of 256
Cardiff cards 408
Cardiovascular disorders 221
Cardiovascular malformations 222b
Cardiovascular system 221, 350, 372
examination of 241
Carotid pulsations 252f
Cat scratch disease 435
Cataract 58, 143, 347, 359
bilateral 413f
congenital 397
Catford drum 408
Catheterization technique 469f
Celiac disease 164
Central cyanosis 79
Central nervous system 19, 130, 265, 266b, 372, 402, 445
infection 130, 268, 269
malformations 266
Central venous pressure 237
Cephalic vein 461
Cephalohematoma 346
Cereal-pulse combinations 108
Cerebellar
disorder 311f
signs 277, 326, 327b, 329b
tumors 329
Cerebellitis 275
Cerebral
depression 339
palsy 155b, 273, 274, 296, 333
Cerebrospinal fluid 472
Cervical lymph nodes 79, 80b, 80f
CHARGE syndrome 426
Chemoprophylaxis 103
Cherry red spot 286
Chest
circumference 118, 119f
examination of 203
expansion 208, 209f
indrawing 342, 350
inspection of 205f
movements of 207
pain 198, 198t, 223, 224f
percussion, method of 211f
shape of 204
unilateral retraction of 206f
Cheyne-stokes breathing 43
Child's physical growth 123
Chin 66
Chloroquine 339, 387
Choanal atresia 425
Cholesteatoma 419
Chorea 259, 312
Choreiform movements 224
Chromosomal disorders 331
Chronic sinusitis 202
causes of 202
Circumduction gait 329
Clasp knife spasticity 301
Clavicle 357
Cleft lip 62, 62f
Cleft palate 202
Clinical digital thermometer 31
Clomiphene 339
Club fingers 69f
Clubbing 240, 241, 259
causes of 202b
grades of 202b
mechanism of 201
Coagulation profile 496
Coarctation of aorta 222, 262, 345
Coffin-Siris syndrome 387
Coin test 216
Cold spatula test 431, 431f
Colonic polyp 167
Color vision 283, 285
Colostrum 97
Coma 278, 446
Comedo 380, 380f
Communication skills, nonverbal 4b
Concentration, lack of 281
Confrontation test 284, 285f
Congenital malformations 329, 339, 342
Congestive heart failure 77, 196, 235
signs of 236b
symptoms of 223, 236b
Conjunctiva 57, 396
Connective tissue
diseases 17
disorders 362
Consanguinity 425
degree of 24t
Consciousness 277, 281
Constipation 158, 164
causes of 165b
Contact dermatitis 381
Continuous murmur 257, 258
Convulsions 274, 342
Copper metabolic disorders 275
Cornea 57, 396
Corneal light reflex test 397, 399, 401f
Corneal reflex 288, 446, 449
examination of 447
method of elicitation of 289
Cornelia de Lange syndrome 56f, 387
Corona radiata 334
Corpus callosum, absence of 268
Corrigan's pulse 263
Corrigan's sign 263
Cortical sensations 315, 316b
Corticosteroids 339, 387
Coryza 194
Cough 194, 195, 196t, 446, 447
Cover test 399
Cow's milk
composition of 98, 99t
protein allergy 164
Coxsackie B virus 221
Cracked nipple 102
Cracked pot sign 52, 332
Cranial bruits 53
Cranial nerve 277, 282b, 283, 288, 290, 295, 297
examination 282
Craniofacial abnormality 425
Craniofacial anomalies 295
Craniosynostosis 332
Craniotabes 52
Cremasteric reflex 319
Crepitations 215
Crepitus 430
Cretinism 339
Croup 433
Crust 378, 379f
Cryptotia 422
Cushing's syndrome 387
Cyanosis 78, 223, 236, 259, 349, 350
causes of 79b
Cyst 377, 433
epidermal 377
Cystine 98
Cytomegalovirus 221, 419
infection, congenital 391
D
Danger signs 349, 350b
Deafness 339
Death
cardiac 498
diagnosis of 443
Decerebrate rigidity 301f
Decorticate rigidity 300b, 300f
Deep palpation 179
Deep tendon reflex 277, 318, 319, 321t, 323
grades of 321t
Deep vein thrombosis 462
Degenerative diseases 273
Dehydration 332
assessment of severity of 48t
severe 44
severity of 48
Dementia 281
Demyelinating disorders 419
Depressor angularis oris, congenital absence of 292f
Dermatitis artefacta 381
Dermatoglyphics 88
Dermatomyositis 387
juvenile 366
Dermatophytes 393f
Dermatophytosis, diagnosis of 391
Dermoid 398
cyst 435
Deviated nasal septum 427
Diabetes insipidus, features of 281
Diabetes mellitus 390
gestational 221, 222
Diabetic ketoacidosis 44, 163, 271
Diaphragmatic paralysis 43
unilateral 43
Diarrhea 158, 161, 162, 389
acute 162, 163
causes of 164b
chronic 163
drug induced 164
Diastolic blood pressure 46
Diastolic murmurs 257, 258
Diazepam 339
DiGeorge syndrome 60, 390
Digital clubbing 74f
Digital scale 343
Digital thermometer 32f, 38f
Digital trauma 429
Diphtheria 10, 297, 434
Diplopia 287
Direct ophthalmoscope 408f
Direct ophthalmoscopy, method of 404
Distal extremities, infarction of 467
Distance visual acuity 400
Docosahexaenoic acid 98
Dolichocephaly 51, 331
Doll's eye phenomenon 287
Doppler method 46, 233, 235
Dorsalis pedis, method of palpation of 230f
Dorsiflexion angle 302, 303, 304f
Double vision 272
Down syndrome 35f, 51, 54f, 58, 64, 88, 140, 222, 225, 276, 295, 323, 324, 332, 337
anhidrotic ectodermal dysplasia 386
Drowsy 277
Drug 329
allergy 14
intoxications 491
rectal administration of 455
withdrawal syndrome 339
Dry tap 472
Duchenne muscular dystrophy 226, 309, 330, 333
Dugdale's index 122
Dull aching 161
Dysarthria 280, 327, 329
Dysdiadochokinesia 311, 327, 328
Dysentery 164, 167
Dysmetria 311f, 327, 328
Dysmorphism 86, 259
Dysphagia 198, 281, 431
Dysphonia 280, 433
Dysplasia 86, 87
Dyspnea 199, 223, 258
grades of 223b
inspiratory 199
Dystonia 313, 334
Dysuria 161
E
Ear 33
examination 60, 417, 420
method of 421f
foreign body of 418
hemangiomas 422
itching of 418
pain, causes of 418
tag 422
Earache 269
Ectodermal dysplasia 56f
Ectopic kidney 494
Edema 83, 170, 259
abdominal wall 178
angioneurotic 62, 63f, 64
causes of 85b
Edinger-Westphal nucleus 285
Edward syndrome 69f, 225
Elbow 117
Electrocardiogram 226
Electroencephalogram 449
Electrolyte imbalance 482
Ellis-van Creveld syndrome 226
Encephalitis 275, 296, 297
Encephalopathy 268, 274
Endocardial fibroelastosis 222
Endophthalmitis 397
Endothrix invasion 393f
Endotracheal intubation 486
Endotracheal tube 447, 487
Energy requirements 28t
Enophthalmos 53, 287
Enteral feeding 478
Enthesitis-related arthritis 366
Epidermoid tumor 474
Epigastric pulsations 246
palpation for 246f
Epigastrium 159
Epiglottitis 434
Epilepsy 155, 268, 271
abdominal 158
Epileptic encephalopathies 271
Epiphora 59, 429
Episode, duration of 267
Epistaxis 428
causes of 429b
Epstein pearls 349
Epstein-Barr virus 397
Erosion 378
Erythema marginatum 259
Erythema multiforme 70, 381, 390
Erythema toxicum 349
Erythematous skin rash 347
Esophageal perforation 478, 480
Esophageal stricture 478, 480
Esophagus, foreign body in 432f
Estrogen 222
Ethylene diamine tetra acetic acid 474
Eustachian tube dysfunction 418
Evoked otoacoustic emissions 424
Excessive sneezing 429
Excoriation 378
Exophthalmos 287
Extensor pollicis
brevis 310f
longus 310f
External auditory canal 422
atresia of 419
External ear anomalies 60
External genitalia 175
External jugular vein 456, 461
puncture 463
Extracardiac murmurs 260
Extremely low birth weight 337
Eye 33, 53, 143, 169
anatomy of 396, 396f
discharge 396
examination of 347, 357, 395
external evaluation of 401f
itching of 397
screening 397
age appropriate methods of 399t
methods of 397
slanting of 54
Eyeballs, size of 53
Eyebrows 55, 56f
Eyelashes 55, 56f
Eyelids 55, 415
drooping of 55
vicinity of 397
F
Face 53
Facial dysmorphism 34
Facial nerve 290
motor function 291f
palsy 292f
Failure to thrive 158
Fallot's tetrad 257
Febrile seizures 18, 268
Fecoliths 187
Feeding twins 95f
Femoral vein puncture 464
Fetal scalp 339
Fetor hepaticus 171
Fever 194, 241, 270, 340
acute rheumatic 363
history of 417
of unknown origin 482
Fibrosis, cystic 202
Filariasis 83
Fine motor
development 135
milestones 137t
Fine-needle aspiration biopsy 498
Finger
abductors 310f
adductors 310f
Finger-finger and finger-nose test 309, 311f
Fingertip patterns 88
Fix and follow test 399
Flat chest 206f
Flexion creases 89
Flexor digitorum
profundus 310f
sublimus 310f
Flexor pollicis
brevis 410f
longus 310f
Floating spots 272
Fluid
overload 238
thrill 191
demonstration of 192f
Flush method 46, 233, 234
Follicular hyperkeratosis 73f
Fontanels 50
Food poisoning 164
Foot 68
dorsiflexion angle of 146, 303
Football holding method 95f
Fossa tumor, posterior 297
Frankfort's horizontal plane 115, 121
Friedreich ataxia 333
Frontal lobe dysfunction 281
Fundoscopy 59
Fundus
evaluation 407, 408f
examination 240, 283, 286, 286f
normal 406f
Fungal infection 417
Funnel chest 206f, 207f
G
Gag reflex 296
Gait 277
ataxia 327
broad based 330
disturbances 266
examination 329
hemiplegic 329
Galactosemia 103
Galeazzi's sign 356, 356f
Gallop rhythm 350
Gangliosidosis 59f, 286
Gastric
aspirate test 478
lavage 480
perforation 480
volume, measurement of 478
Gastroesophageal reflux disease 21, 195, 196
Gastrointestinal bleeding 166
Gastrointestinal system 157
Gastrointestinal tract 167b
Gaucher disease 182, 296
Genetic syndromes 155
Genitalia 74, 348
Genitourinary system 157
Genodermatoses 373
Geographic tongue 65f, 381
Gestational age
adequate for 337
large for 337
small for 337, 348
Gianotti-Crosti syndrome 381
Giardiasis 164
Giddiness 266, 420
Glabellar tap 354
Glasgow coma scale 277, 278, 278t
Glaucoma 272
Glossopharyngeal nerve 295
Glucose 6 phosphate dehydrogenase deficiency 18
Glycogen storage disease 226
Gower sign 309
Gram's stain 485
Granuloma annulare 381, 384f
Graphesthesia 316
Grasp reflex 130
Great arteries, transposition of 222
Great vessels, transposition of 261
Gross motor milestones 131, 132t
Growth 33, 259
assessment of 111, 226
based on
height 115
weight 112
charts 123
pubertal acceleration of 112
Guarded prognosis 440
Guillain-Barré syndrome 275, 287, 292, 297, 301, 329, 331, 486
Gums 64, 435
Gynecomastia 171
H
Hackett's grading 184, 185f
Haemophilia
A 429
B 429
influenzae 10, 275
Hair 386
color of 387
Hairpins 116
Hairy pinna 347
Haloperidol 339
Hand 68
and feet, cyanosis of 348
dorsum of 458f
muscles 310f
Hand-foot-and-mouth disease 377f
Hand-to-mouth reflex 137
Hansen's disease 381, 383
Harrison's sulcus 205, 207f
Head 346
and neck injury 478
circumference 115
examination of 49
injury 296
history of 272
shape of 331
size of 332
Headache 224, 266, 268, 269, 269b, 270, 273, 274, 416, 474
causes of 269b
cluster 269
during fever 269
in migraine 270
Hearing 131, 143
assessment 293, 424
deficit 295b, 360
loss 143, 155, 345, 418
causes of 419t
conductive 419
family history of 425
Heart
block, congenital 222
defect, congenital 222, 224
disease
congenital 221, 224
cyanotic 348
rate 40, 169, 226, 345
sound
abnormal 253t
first 251
fourth 254
second 252
third 252
Hemangioma 64, 386f, 398, 434
capillary 347
Hematemesis 158, 161, 167
Hematochezia 168
Hematoma 427, 472
Hematuria 158, 161, 168, 169, 496
Hemiballismus 334
Hemiparesis 273
Hemiplegia 273
Hemoglobin level 22
Hemoglobinuria 169
Hemopericardium 498
Hemophilia 365
Hemophilic arthropathy 364
Hemoptysis 198
Hemorrhage 268
intracranial 266, 271
intraventricular 342, 477
Hemorrhoids 167
Hemothorax 486
Henoch-Schönlein purpura 71f, 365, 366, 372
Hepatic encephalopathy 171, 271
Hepatitis
B 10, 22, 23, 342
vaccines 342
C virus 22
chronic 482
Hepatobiliary system 157
Hepatoblastoma 182
Hepatocellular failure, signs of 171b
Hepatojugular reflux 238
Hepatomegaly 237
causes of 182b
Hepatosplenomegaly 241
Hernia, inguinal 348
Herpes simplex 62
virus 221
Herpes zoster 381, 382f
High stepping gait 330
Hind milk 98
Hip 357
circumference 119
congenital dislocation of 358f
developmental dysplasia of 356
examination of 357f
Hirschsprung's disease 341
Hissing sound ceases 46
Hodgkins tumor 435
Hoffman sign 323
Holt-Oram syndrome 226
Homocystinuria 58
Homonymous hemianopia 281
Hormonal therapy 339
HOTV matching cards 411f
Human immunodeficiency virus 22
Human milk
components of 99
composition of 98
immunological components of 100t
Hurler's syndrome 202, 226
Hyaline membrane disease 342
Hydration, assessment of 47, 352f
Hydrocele 348
Hydrocephalus 51f, 155, 268271, 329
Hydroxychloroquine 416
Hygroma, cystic 435
Hyperbilirubinemia 425
Hyperesthesia 313
Hypernatremia 268, 271
Hypertelorism 347
Hypertension 229, 269, 365, 467
pregnancy-induced 340
severe uncontrolled 494
Hypertensive encephalopathy 271
Hyperthermia 350
Hyperthyroidism 312, 387
Hypertonia 301
types of 301
Hypertrichosis 386, 387b
Hypertrophic obstructive cardiomyopathy 222, 231
Hypocalcemia 140, 266, 268
Hypoglossal nerve 297
Hypoglycemia 130, 266, 268, 271
Hypokalemia 165
Hypokinetic pulse 42, 232
Hypomagnesemia 266, 268
Hyponatremia 268, 271
Hypoproteinemia 482, 486
Hypothalamic dysfunction 281
Hypothermia 342, 350, 445
Hypothyroidism 36f, 165, 332
Hypotonia 301, 323, 327, 339
Hypotonic cerebral palsy 323
Hypoxia 489
Hypoxic ischemic encephalopathy 130, 266
I
Ichthyosis, congenital 347
Icterus 78, 348
Iliac crest 470
Immaturity 143
Immotile cilia syndrome 202
Immune thrombocytopenic purpura 428
Immunization 14
history 16, 27, 342
Impetigo 379f, 388
In utero infection 419, 425
Indian Academy of Pediatrics classification 128
Infantile tremor syndrome 18
Infantometer 113f, 343
Infection 271, 429, 467, 472, 486, 489, 498
Infective endocarditis 372
signs of 241b
symptoms of 241b
Inflammatory articular diseases 363
Inflammatory bowel disease 164, 365, 366
Infrared thermometer 38f
Injury 434, 489
Innocent murmurs 257
Intellectual disability 273
Intelligence quotient 277
Intensive care units 449
Intention tremor 312, 327
Internal jugular vein puncture technique 464f
Intertrigo 381
Intestinal laceration 482
Intestinal obstruction 165, 478
Intestinal perforation 482
Intra-articular ligaments 370
Intradermal injection 454
Intramuscular injection 452
sites for 453f
Intraosseous cannulation technique 460f
Intraosseous infusion 459
Intrauterine growth retardation 338, 339
Intrauterine infections 391
Inverted syringe technique 100, 101f
Iris 58, 396
Iron deficiency anemia 75f, 275
Irritable bowel syndrome 164
J
Janeway lesions 241
Jaundice 57, 78, 158, 161, 166, 259, 339, 342, 349
acute 166
Jaw
abnormalities 434
jerk 290
Joint 70, 240
capsules 370
examination 370
involvement, distribution of 372
pain 223, 366, 370
position, sense of 315
swelling 161
Jugular vein puncture, position for 463f
Jugular venous pressure 237, 238f
Juvenile idiopathic arthritis 362, 366
systemic onset 364, 366
Juxta-articular bones 370
K
Kanawati index 122
Kangaroo mother care 94f
Kartagener syndrome 202
Kawasaki disease 18, 63, 74, 223, 224, 292, 364, 355, 366, 379, 387
Kayser-Fleischer ring 58f
Keratosis pilaris 381
Kernicterus 130
Kernig sign 324, 325, 326f
Kidney
bimanual palpation for 186f
horseshoe shape 494
palpation of 184
Kiesselbach's plexus 428
Knee
asymmetry of 356f
extensors, testing power of 308f
flexion 308f
flexors, testing power of 308f
jerk 319, 322
elicitation of 320f
joint 365
Koilonychia 74, 75f, 387
Koplik spots 63
Korotkoff sound 45, 46
Kuppuswamy scale 29
modified 29t
Kyphoscoliotic chest 206f
L
Labyrinthine function 293
Lacrimal glands 59
Lacrimal sac, distention of 398
Lactation, physiology of 95
Lactiferous ducts 93
Lactose intolerance 164
congenital 103
Landau reflex 355
Language
development 138, 139t
loss of 280
Laparotomy 491
Laryngeal edema 434
Laryngeal examination 436
Laryngeal web 434
Laryngitis, acute 434
Laryngomalacia 434
Laryngoscope 433, 486
blade, position of 488f
Laryngotracheobronchitis 195, 433, 434
Lea symbols 410f
Lead
encephalopathy 329
poisoning 271
Left axillary BCG adenitis 82f
Left bundle branch block 253, 254
Left hypochondrium 159
Left iliac fossa 160
Left kidney 186
Leishman's staining 392
Lens 58, 396
Lenticular opacity 58
Leprosy 381
Lethargy 342
Leukemia 77, 182, 429, 435
Leukocoria 143, 397
Lichen planus 381
Lichenification 378
Limb 68
length 72
Lipomas 435
Lips 62, 435
swelling of 63f
Little's area 428
Liver
abscess 467
biopsy 482
cirrhosis of 482
failure 429
infarction 467
lower border of 179
palpation of 179, 180f
upper border of 180
Lobar pneumonia 210, 216
Lobe functions 280
Local pain 472
Logmar chart 408
Loud murmurs 258
Low Apgar score 425
Low birth weight 295, 337
Low pulse volume 77
Lower limb 461
hypertonia of 299
scissoring of 305f
Lower motor nerve palsy 292
Lower motor neuron 333
disease 333t
facial palsy 291
lesion 291
localization of 335t
Lower respiratory tract infections, recurrent 222
Ludwig's angle 204
Lumbar puncture 472
position for 473f
Lumbar regions 160
Lumbosacral meningomyelocele 358f
Lumbricals 310f
Lump, abdominal 187
Lurching gait 330
Lyme disease 419
Lymphadenitis
acute 435
inguinal 82f
Lymphadenopathy 79, 170, 259
significant 81
Lymphangiectasis 83
Lymphangioma 64
M
MacEwen sign 52, 332
Macrocephaly 332
causes of 51b
Macroglossia 64
Macula lutea 407
Macular means spot 374
Macule 374
over face 375f
Magnesium sulfate 339
Magnetic resonance imaging 265
Malformation syndromes 87
Malignant tumors 435
Malnutrition 27, 124
grades of 128
moderate 128
severe 128
Mandible 66
Mantoux test 454
Marasmus 34f
Marfan syndrome 58, 225, 276
Mass
abdominal 187b
lesions 397
around eyelids 398t
Massive ascites 192f
Massive edema over face 84f
Mastitis 102
Mastoid abscess 419f
Maternal endocrinal disorders, history of 338
Maternal rubella 419
McCune-Albright syndrome 77
Measles 419
mumps, rubella 454
rubella vaccine 9
vaccine 275
Measuring digital clubbing 200, 201f
Mechanical ventilation 425
Meckel's diverticulum 167
Median cubital vein 456
Mediastinal structures 472
Megaloblastic anemia 77
Melena 158, 167
Membrane's temperature 39
Memory 277, 279
Meningeal irritation, signs of 277, 324
Meningism 324
Meningitis 287, 292, 324
acute bacterial 19
Meningococcal meningitis 275
Meningococcal vaccine 275
Meningococcemia 71f
Meningoencephalitis 269, 271
Menke's syndrome 275
Mercury clinical thermometer 38f
Mesomelia 72
Metabolic acidosis 44
Metabolic disorder 155, 360
Metabolism, inborn error of 44, 140, 163, 266, 268, 271
Metastasis 435
Microcephaly 332
Micromelia 72
Micronutrient deficiency
clinical signs of 85
diagnostic signs of 85b
Microphthalmos 53
Microtia 419, 421f
Micturition disturbances 281
Middle ear infection 292
Midline neck swelling 68f
Mid-upper arm circumference 117, 118
Migraine 269
abdominal 158
Migratory arthritis 362
Milia 347, 349, 381
Miliaria rubra 376f
Milk ejection reflex 96, 97f
Milk production reflex 96f
Mitochondrial disorders 331
Mitral regurgitation 41, 229, 263
Mitral stenosis 263
Mitral valve prolapse 223, 224
Mongolian spots 349
Monocular vision assessment 411f
Monoparesis 273
Moro reflex 152f, 352, 353, 355f
asymmetric 353
exaggerated 353
incomplete 352
reverse 353
Morphine 339
Motor deficits 273
Motor system 277
examination 298
components of 298b
Mouth 62
Movement disorders 273
Mucopolysaccharidosis 36f, 54f, 165
Mucosa 431
Multinucleate giant cells 392
Mumps 222, 419
Murmurs 255b
conduction of 256b
radiation of 256b
Muscle 335
bulk 298, 304
nutrition 304
power 277, 298, 306
grades of 306t
tone 277, 298, 299, 301, 345
wasting 304
weakness 273
Muscular disorders 155
Muscular dystrophy 329
Musculoskeletal pain 198
Musculoskeletal system 356, 362
examination 363
pediatric regional examination of 369
Myasthenia gravis 55f, 292
Mycobacterial lymphadenitis 435
Mycobacterium tuberculosis 478
Myocarditis 264
Myoclonus 313
Myoepithelium 96
Myoglobinuria 169
Myopathy 273, 329
N
Nail 70, 74, 241, 387
clubbing of 387
pitting 387
Narcotic withdrawal syndrome 339
Nasal
blocks 270
cavity 61, 430
discharge 270
fractures 429, 478
intubation 429
itching 429
necrosis 480
obstruction 425, 429
patency 431
polyps 427
regurgitation 296
septum 430
Nasogastric tube 429, 478, 479f
Nasolacrimal system 415
Nasopharyngeal carcinoma 435
Nasopharynx 426f
Nausea 270
Neck 67
masses, causes of 435t
rigidity 324
stiffness 324
swellings 435
vessels 259
Necrotizing enterocolitis 342, 467
Neonatal
death 337
disorder 339, 339t
hepatitis 482
hyperbilirubinemia 295
intensive care unit 2, 341, 425
jaundice, history of 341
reflexes 150t, 352, 353t, 355f
septicemia, diagnosis of 478
Nephrotic syndrome 14, 18, 77
Nerve roots 335
involvement 273
Nervous system 265
Neuroblastoma 329, 331
Neurocutaneous syndromes 268
Neurodegenerative disorders 155, 296, 419
Neurofibroma 435
Neurofibromatosis 268
Neurologic system 351
Neurological deficits 241
Neurological lesion, localization of 333
Neutral thermal environment 344
Nevus
achromicus 383
sebaceous 381
over scalp 384f
Niacin 86
Niemann-Pick disease 182, 286
Nikolsky sign 391
Nipples, inverted 99
Nitrofurantoin 339
Nodular rash 365
Nodules 70, 374, 433
over scalp 376f
Nonaccidental injuries 416
Nonarticular pain 370
Non-Hodgkins tumor 435
Nonpitting edema 35f
Noonan syndrome 35f, 55, 225
Nose 33
examination of 61, 417, 429
foreign body in 427f
method of examination of 430f
Nuchal rigidity 324, 325f
Nutrient gap 108
Nutrition 33, 109
assessment of 118
Nutritional status 123t
assessment of 124
Nystagmus 327, 328
O
Obesity 27, 281
Obstruction 434f
Obstructive lung diseases 199
Occipital lobe dysfunction 281
Ocular media opacities 415
Ocular movements 402
Oculocephalic reflex 287
Oculocephalic response 445, 448
Oculomotor nerve
Edinger-Westphal nucleus 285
palsy, manifestations of 287b
Oculovestibular response 445, 448
Oilgoarticular juvenile arthritis 371
Olfactory nerve 282
Oligoarticular idiopathic arthritis 372
Ophthalmoplegia 272
Ophthalmoscope 32f, 286f, 344
Opisthotonus 299f
Opponens pollicis 310
Optic nerve 283
atrophy 286
examination of 283b
head 405
pathway of 283
Optic neuritis 272
Optimum nutrition 90
Oral cavity 169
examination of 62, 435
Oral mucosa 381
Oral poliovirus vaccines 9, 23
Orchidometer 75f
Organophosphorus poisoning 486
Oropharynx, examination of 435
Ortolani's tests 357
Oscillometer method 46, 233, 235
Osler nodes 241, 259
Ossicular disruption 419
Ossicular malformations 419
Otitis externa 418
Otitis media 418, 419
acute 418
acute suppurative 417, 423, 423f
chronic suppurative 417, 423, 424f
Otoscope 32f
Otoscopic examination 61
Ototoxic drug 295, 425
Oxycephaly 51, 331
Oxygen saturation 48
Oxytocin 96, 339
reflex 97f
P
Pain 364, 417, 493
abdominal 157, 158, 161t
character of 160
esophagitic 198
nature of 160
radiation of 160
site of 158
types of 160
Palate 64, 435
Pallor 77, 241, 348, 349
Palmar erythema 171, 241
Palmar grasp 150, 353, 354, 355f
Palpable heart sounds 243
Palpable lymph nodes 79
Palpatory method 45, 234
Pansystolic murmur 257, 258
Papilledema 286, 406f
Papillitis 407
Papillomatosis 433, 434
Papular urticaria 70, 389
Papule 374
Paracentesis, abdominal 481
Parachute reflex 356
Paralytic ileus 478
Paraparesis 273
Paraphimosis 76f
Paraplegia 273
Parasternal heave, palpation for 245f
Parental diarrhea 164
Paresthesia 273
Paronychia 387
Parotid gland 292
Parotid swelling 171
Paroxysmal hypertension 331
Patau syndrome 225
Patch 374
Patellar clonus, elicitation of 323f
Patellar jerk 322
Patent ductus arteriosus 41, 221, 222, 260, 342
Pathologic signs 349
Pectus carinatum 206f
Pectus excavatum 207f
Pedal edema 236f
demonstration of 179f
Pediatric
intensive care unit 2
ophthalmologist 415t
Pedigree chart 26f
typical 25f
Pellagra 381
Pendred syndrome 419
Pendular knee jerk 327, 328
Pentavalent vaccine, doses of 9
Perforated tympanic membrane 424f
Periarticular pain 370
Pericardial friction rub 255
Pericardial knock 255
Pericardial pain 198
Pericardial rub 260
Pericardiocentesis 496
sites for 497f
Pericarditis 223, 224
constrictive 233
Perinatal asphyxia 295
Perinatal birth asphyxia 23
Perinatal mortality rate 337
Perinatal period 221, 337
Perinephric hematoma 496
Periodic breathing 43
Perioral dermatitis 381
Peripheral cyanosis 79
Peripheral intravenous access 456
Peripheral nerves 335
Peripheral nervous system 372
diseases of 486
Peripheral pulsations 40, 227, 230
Peripheral pulses 365
Peritoneal dialysis 490, 492f
Peritonitis 482, 491, 493
Peritonsillar abscess 431
Pernicious anemia 387
Persistent diarrhea 163
Persistent neonatal jaundice 36f
Pertussis 10, 163
Petechial spots 16, 71f
Pethidine 339
Pharyngeal reflex 446, 447
Pharynx 66
Phenobarbitone 339, 339f
Phenytoin 222, 329, 339, 387
Pheochromocytoma 331
Philtrum 63
Photophobia 270
Phrynoderma 73, 73f, 381, 383f
Pigeon chest 206f
Pinna 420
congenital deformities of 422b
Pityriasis alba 381, 383, 389
over face 385f
Pityriasis rosea 379f, 381
Pityriasis rubra pilaris 381
Pityriasis versicolor 375f, 381, 383, 391
Plantar grasp 353, 354, 355f
Plantar reflex 319
elicitation of 318f
Plaque 374
Platynychia 74, 75f
Plethora 349
Pleural effusion 208, 210, 218
Pleural rub 216
Pleuritic pain 198
Pleuroperitoneal communication 491
Pneumococcal meningitis 275
Pneumococcal vaccine 275
Pneumonia 164
Pneumoperitoneum 482
Pneumothorax 208, 210, 211, 219, 486, 489, 498
Poliomyelitis 275, 297, 301, 486
Polycystic ovarian disease 77, 68f
Polycythemia 348
Polydactyly 69f
Polymorphous light eruption 381
Pompe disease 64, 226
Ponderal index 122
Popliteal angle 302, 303
Porphyria 169
cutanea tarda 387
Portal hypertension, severe 482
Portal vein, thrombosis of 467
Positron emission tomography 449
Postextubation stridor 489
Postinflammatory hypopigmentation 383
Postlumbar puncture 269
Postnasal drip 195
Postparacentesis shock 482
Postpartum psychosis 103
Poststernotomy, post-thoracotomy of 242
Post-tussive vomiting 163
Postural hypotension 331
Post-viral cerebellitis 329
Potassium hydroxide 391, 393f
Preauricular sinus 422f
Preauricular skin tags 60f
Precordial pulsations 243, 259
Precordium 242, 259
Preferential looking test 408
Premature birth 419
Prepregnancy health status 338
Primaquine 339
Primary microcephaly, causes of 50t
Primitive reflexes, evaluate for 147
Progesterone 222
Prolactin reflex 95, 96f
Prone position 132
Propranolol 339
Protection of Children from Sexual Offences Act 438
Protein
energy malnutrition 165, 275
requirements 28t
Proximal finger 41
Pruritis 390
Pseudobulbar palsy 296
Pseudostrabismus 401f
Psoriasis 381
vulgaris 376f, 381, 383f
Ptosis 55f
Puddle sign 189, 189f
Puffy face 84f
Pulmonary artery 223
hypertension, severe 237
Pulmonary aspiration 480
Pulmonary edema 491
unilateral 486
Pulmonary stenosis 222, 254, 262
Pulmonary valve obstruction 223, 224
Pulse 40, 227
abnormal 231
apex deficit 229
examination of 40
oximetry, advantages of 49
rate 40, 226, 228
volume 365
Pulsus
alternans 231
bigeminus 231
paradoxus 42, 233
causes of 233b
tardus 232
trigeminy 231
Punctuate erythematous spots 331
Pupil 58
examination of 446
white reflex in 397
Pupillary examination 399, 402
Pupillary light reflex 449
Pupillary reaction 283, 285
Pure tone audiogram 425
Purpuric spots 16
Pustule 375
Pyloric stenosis, congenital hypertrophic 162
Pyoderma 347
Pyridoxine 86
Q
Q-T syndrome, prolonged 224
Quinine 339
R
Radial artery 469f
catheterization 468
method of palpation of 230f
Radiofemoral delay 41, 229
Radioradial delay 41, 229
Raised intracranial pressure 19, 52, 163, 268, 269, 273275
Raised jugular venous pressure, causes of 238b
Rao's index 122
Rattling sounds 214
Reactive arthritis 362, 365, 366
Rectal temperature 39
Red eye 397
Red flag signs 34b
Red reflex 359f
examination 399, 403f
test 359t, 398
Red-colored urine, causes of 169b
Reflex 277, 319, 321, 322
abdominal 317f, 319
examination of 316
response 345
superficial 277, 317, 319t
Refractive errors 269, 359
Regional lymphadenopathy 388
Renal biopsy 494
Renal bruit 192
Renal failure, acute 44
Renal infarction 467
Renal lump 186, 187b
Renal tenderness 186
Respiration 42, 200, 345
depth of 44
muscle of 44
rate 42, 169
types of 43
Respiratory diseases 216
Respiratory distress syndrome 16, 342
Respiratory signs 197t
Respiratory sounds 44t
Respiratory system 194, 350, 372
Responsive feeding 109
Retina 402, 407
Retinal detachment 272, 397
Retinal hemorrhage 286
Retinal infarcts 286
Retinal vessels 405
Retinoblastoma 359
Retinopathy of prematurity 342, 416, 416
Retractions 197, 199
Retropharyngeal abscess 433f, 434
Rheumatic activity, signs of 259
Rheumatic chorea 224, 273, 301
Rheumatic fever 18, 241f
Rheumatoid arthritis, juvenile 365
Rheumatologic disorder 369
Rhinitis 429
allergic 202
Rhinorrhea 429
Rhizomelia 72
Rhonchus 214
Rhythm 40, 228
Rickets 86, 165, 332
Rifampicin 339
Right bundle branch block 253
Right cardiac border 248
Right heart failure 238
Right hypochondrium 158
Right iliac fossa 160
Right kidney 184
Rigid direct laryngoscopy 436
Rinne's test 294, 294f
Risus sardonicus 54f
Rocker-bottom feet 69f
Romberg sign 327, 328f
positive 327
Root pain 273
Rooting reflex 150, 353, 354
Roth's spots 241, 407
Rubella 58, 222, 419
congenital 295
syndrome 226
S
Salbutamol 312
Salicylates 339, 491
Salivary gland disorders 435
Salmon patches 347
Sarcoidosis 372
Scabies 70, 381, 388
Scale 378, 379f
Scalp 381
hairs, loss of 389
veins of 456
Scaphocephaly 51, 331
Scaphoid abdomen 173
Scar 378
Scarf sign 146, 302, 304
Schönlein purpura 158
Schwabach test 294
Scissoring gait 330
Sclera 57
Sclerosis 379
Scrotal swelling 158, 168
Scurvy 86, 364
Seborrheic dermatitis 381, 389
Secondary microcephaly, causes of 50t
Sedation 451
Seizures 265, 266, 268b, 339, 350
causes of 266b, 268b
history of 341
types of 267
Select appropriate growth chart 124
Sensorimotor system 415
Sensorineural hearing loss 419
Sensory
extinction 316
loss 314t
system 277, 313
Sepsis 425
Septate hyphae 393f
Septic arthritis 362, 365, 372
Septicemia 342
Shakir tape 118
Shock 77
Sickle cell disease 185, 365
Simian crease 72f, 89
Single photon emission computed tomography 449
Sinus
bradycardia 40
tachycardia 40
Sinusitis 269, 270
Sjögren's syndrome 59
Skeletal deformities 259
Skeletal system, examination of 367b
Skin 16, 34, 240, 347
appendages of 386
elasticity 47
examination of 373, 386
lesions 73b
pain 198
scars 174
striae 173
tests 454
turgor 47, 73
Skinfold thickness 120
Skull 277
abnormal shapes of 51b, 331b
examination of 331
frontal bossing of 52
Sleep disturbances 266, 281
Slipped upper femoral epiphyses 18
Smell, loss of 281
Snake bite 271
Snellen chart 408, 412f
Soft palate 436
Sore nipple 102
Sore throat 194, 223
Spasmodic cough 195
Spastic gait 330
Spatula 344
Speech 131, 277, 280
functional disorder of 280
Spherocytosis 185
Sphygmomanometer method 45, 233
Spider angioma 171
Spinal accessory nerve 297
Spinal cord 273
involvement 273
Spinal nerve roots 321, 322
Spinal shock, features of 335
Spine 277, 357
examination of 333
Spinomuscular atrophy 298, 330
Spleen 187b
bimanual palpation of 183f
differentiation of 183
palpation of 181
size of 184
Splenomegaly 240
causes of 185b
Splinter hemorrhage 241
Spondyloarthropathy, juvenile 362
Stahl's ear 422
Staphylococcal scalded skin syndrome 70f, 381
Staphylococcus aureus 388
Status epilepticus 271
Stepping reflex 151, 353, 355f
Stereognosis 315, 316
Sternomastoid tumor 347, 435
Sternum 470
Steroid toxicity 84f
Stethoscope 32f, 250, 343
Stevens-Johnson syndrome 381, 391
Stool, consistency and color of 163
Strawberry tongues, white and red 64f
Streptomycin 339
Stress 15
Stridor 197, 296, 433
causes of 434t
types of 434f
Stroke, cerebrovascular 224, 271
Stupor 278
Sturge-Weber syndrome 268
Subconjunctival hemorrhage 57f, 347f
Subcutaneous nodules 241f, 259
Subglottic stenosis 434
Subhyaloid hemorrhage 407
Sublingual temperature 39
Subscapular skinfold 120
Sucking reflex 150, 353355
Sun-setting sign 51f
Superficial veins, abdominal 189f
Suprapubic bladder
aspiration 489
puncture technique 490f
Suprapubic region 160
Suprasternal pulsations 247
palpation of 247f
Swollen breast 102
Sydenham chorea 312
Sydney crease 89
Symmetrical edema 128
Symmetrical tonic neck reflex 354
Syncope 223, 224
Syndactyly 69f
Synovial fluid 370
Syphilis, congenital 70, 347, 391
Systemic lupus erythematosus 17, 18, 222, 362, 365, 366, 387, 397
Systolic murmur 256
grading of 256t
T
Tache cerebrale 331
Tachycardia 77, 228, 228t, 350
Tachypnea 44, 196, 197, 199, 345, 350
cut-off for 43t
Tactile vocal fremitus 217
Takayasu arteritis 228
Tandem walking 327
Taurine 98
Tay-Sachs disease 59f, 286
Tears 59
Telangiectasia 380
Telemedicine, concept of 439
Teller acuity chart 408, 409f
Temporal artery thermometer 39
Temporal lobe dysfunctions 281
Tenderness 177, 430
abdominal 340
Tenesmus 164
Tense
abdomen 177
ascites 482
Tension 41, 229
headache 269
Teratoma 77, 435
Tetanus 10, 54f, 299f, 486
toxoid vaccination 338
maternal status of 342
Tetralogy of Fallot 254, 261
Thalassemia 182, 185, 339
Therapeutic hypothermia, use of 445
Therapeutic substances, administration of 478
Thermometers 38f
Thoracocentesis 483, 484f
Thrills 243, 247
Throat
examination of 417
pain 431
Thrombocytopenia 339, 391, 429
Thromboembolism 467
Thrombophlebitis 462
Thrombosis 493
Thyroglossal duct cyst 435
Thyroid
disorders 331
tumors vascular malformations 435
Tibia 470
Tics 312
Tinea
capitis 381, 390
corporis 381, 390
cruris 381
versicolor 390
Tinnitus 420
Toe walking 330
Tongue 64, 434, 436
fasciculation of 298
spatula 31, 32f
Tonic neck reflex 353, 355f
Tonsillitis, acute 432f
Tonsils 66, 436
Tooth 56f, 66, 435
Topognosis 316
TORCH infection 339, 391
Toxic epidermal necrolysis 391
Toxic look 16
Toxins 271
Tracheal position 208
Tracheal reflex 446, 447
Tracheoesophageal fistula 21
Trachoma 57
Traction response 351, 352f
Transient pustular melanosis 347
Transient tone abnormalities 155
Transillumination test 332
Trauma 269, 297, 365, 419
Traumatic cataract 397
Traumatic ulcer 65f
Treacher Collins syndrome 55, 387
Tremors 312, 328
Triceps
muscles 307f
skinfold 120
Trichotillomania 387
Tricuspid
atresia 262
stenosis 238
Trigeminal nerve 288
Trigonocephaly 331
Trisomy 13 225
Trisomy 18 225
Trisomy 21 88, 222, 225, 337
Trivandrum development screening chart 140f
Trochlear nerve palsy 288
Truncal ataxia 326
Trunk 381
Tuberculoma 268
Tuberculosis 342, 371
Tuberculous arthritis 362
Tuberculous meningitis 268, 269, 271, 273, 297, 299f
Tuberous sclerosis 268, 387
Tumors 428
benign 435
Tuning fork test 424
Turner syndrome 55, 83, 225, 276
Turricephaly 51
Tympanic membrane 423
appearance of 423t
malformations 419
perforation 419
Tympanic thermometer 39
Tympanometry 425
Tzanck cells 393
Tzanck smear 391
U
Ulcer 378
Umbilical artery catheterization 467
Umbilical catheter 466f
Umbilical cord 466f
Umbilical hernia 36f, 174, 175f
Umbilical vein 466f
catheterization 465
Umbilicus 173, 174
Unconsciousness 274, 278
Undescended testes 76f
Unilateral facial palsy, causes of 292
Upper gastrointestinal tract bleeding, assessment of 478
Upper limb 461
Upper motor neuron 291, 333, 333t
facial palsy
bilateral 292
unilateral 292
lesion 291
Upper respiratory tract infection 196, 270
history of 417
Uremia 163
Uremic encephalopathy 271
Urinary bladder 187
perforation of 482
Urinary tract infection 163
Urticaria 377, 378f
Usher syndrome 419
Uvula 436
V
Vague psychiatric disorders 281
Vagus nerve 295, 296
Valproic acid 339
Varicella 454
vaccine 275
Vascular thrombosis 268
Vasculitis 362
Vasovagal reactions 498
Veins, superficial 173, 456
Vena cava obstruction, superior 238
Ventricular septal defect 222, 226, 260
Ventricular tap 476
Ventricular tapping 477f
Ventriculitis 477
Vertigo, benign paroxysmal positional 420
Very low birth weight 337
Vesicle 374
Vesicular breathing 213
Vessel
perforation 467
wall, condition of 230
Vestibular function 293
Vestibulocochlear nerve 293
Vestibulo-ocular reflex 446
Vibration sensation 315
Viral arthritis 362
Viral infection 163, 195, 221, 372, 391
Viral meningoencephalitis 268
Vision 59, 155
assessment 409f
disturbances 266, 272
field of 283
screening method 407, 408
Visual acuity 283, 415
Visual aura 270
Visual behavior 415
Visual field defects 272
Visual hallucination 281
Visual milestones 413
Vitamin
A 105
deficiency 57, 59, 73f, 85, 86b
B
complex 105
deficiency 85
B1 85, 105
B11 105
B12 86, 105
B2 85, 105
B3 105
B6 105
C 105
deficiency 86
D 105
deficiency 86
signs of 62
E 105
deficiency 86
K 339
dependent bleeding manifestations 339
Vitiligo 375f, 381, 382f, 384
Vocal cord
disorder of 280
paralysis 434
Vocal resonance 215
Voice
hoarseness of 296, 433
nasal quality of 296
Vomiting 158, 161, 162, 266, 270, 273, 274, 342
causes of 163t
contents of 162
types of 162
von Willebrand disease 429
W
Waddling gait 330
Waist-hip ratio 122
Water hammer pulse 42, 231, 232f
Watering eye 59
Weber test 294, 295f
Weighing machine 31, 32f
Weight loss 342
Weight-for-age 122, 126f
Weight-for-height 128
Wernicke's aphasia 280
Wheeze 197, 214
William syndrome 87, 226
Wilms tumor 168
Wilson disease 18, 58f, 275
Wood's lamp 383
World Breastfeeding Week 91
World Health Organization 395, 443
Wound infections 462
Y
Yellow sclera 57
Yellow white papules 347
Z
Ziehl-Neelsen stain 485
Zinc deficiency 389
×
Chapter Notes

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Communication and Counseling in Pediatric PracticeChapter 1

MMA Faridi
 
INTRODUCTION
A famous saying is that sword and words have the same letters; strangely they also have the same effect if not handled properly.
Disease is an entity comprising of some physiological disturbances frequently coupled with anatomical changes and histopathological derangement that manifests in the form of symptoms and signs. Patient on the other hand is an individual who feels pain, and agony; needs help and support for self and personal care, and requires careful evidence-based measures to diagnose the disease and institution of rational therapy for cure or palliation. Patient is not alone in this hour of disease and discomfort but there are family and friends, and healthcare providers around. It is easy to prescribe medicines and surgical interventions to the patient; changes in lifestyle and diet can also be very easily advised. However, acceptance of the reality, gravity and long-term prognosis of the ailment by the patient and the family, and coming to terms with the social impact of the disease and quality of life may differ from person to person and family to family. This may add many dimensions to the disease management. Treating a patient and treating a disease is, therefore, not same. It is easy to treat disease but extremely difficult to treat a patient.
An infant or child patient throws some more peculiar challenges. If their capacity to react to disease insult is limited, then more often it is stereotypic to many serious illnesses. Initially parents may not consider signs and symptoms serious as they continue to “play” and behave “normally” till the disease is well entrenched with complications; it is late. Often parents feel guilt and are inconsolable seeing their child in serious and grave situation.2
Once a child patient is admitted in the health facility, the mother remains the main caregiver except in the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU). The routine of the entire family gets disturbed, parents do not get enough rest, and absence of facilities for basic comfort and unfamiliar and not-so-friendly hospital rules and regulations make the parents and other relatives jittery and frustrated. This sets the milieu for patient/family dissatisfaction and aggressive behavior and results into accusations and complaints landing in the consumer court.
Active communication with the patient and family may mitigate some of the concerns and anxiety of the parents including ethical dilemma and social issues. Counseling is the way of working with the people. Counseling truly reflects empathy towards the patient and the family and empowers them to understand the disease, its treatment and prognosis and to take most appropriate decision best suited to their situation. Spending some time with the patient and family gives big dividends to the treating physician and nurses. This helps building trust between the patient/family and the healthcare providers and gives confidence to them to follow treatment plan and advice. A good rapport and communication also enhance early recovery and well-being of the patient and ensures timely follow-up.
However, it is important that doctors should have detached empathy with the patient and are not involved sentimentally. Otherwise, it may lead to “burn out” and “sympathetic” actions which are perceived irrational. This may also lead to insinuations and doubts by the patient, family and friends later on. The attributes of active communication are described in Box 1. Counseling is to give professional help and recommendation to someone. There are three components of counseling (Flowchart 1).
zoom view
Flowchart 1: Components of counseling.
 
COMPREHENSION AND UNDERSTANDING SITUATION
It is extremely important to first find out sociocultural background, economic status, education level, religious beliefs, community practices, and past experience of the patient/family before offering any help and support regarding the present disease and its sequelae. The learning of the above aspects may be facilitated by a set of steps, described in Box 2.
 
MAKING APPROPRIATE AMBIENCE AND PRESENTATION
Active communication and counseling should be done at a quiet and reasonably comfortable place. All family members—parents, grandparents, friends, and distant relatives—present at the time of counseling should be invited, greeted, and seated in the chair. Pediatrician/senior resident/junior resident should also sit in the chair without any table between the doctor and the attendees to remove any barrier. Doctor should introduce himself and then ask all the person their name and relationship with the patient.
Maintain social distance while talking to the patient/family; neither too close nor too far. Always look towards the person you are talking. It is a common mistake that while talking to the patient or her relative, the doctor is busy with the papers/case sheet or calling other staff for some work or attending phone.4
Never look towards the watch while in conversation. This indicates that you are in a hurry and do not have enough time for them. Always show to the patient and the family that you have plenty of time for them and that you enjoy talking to them. When patient talks or family shares some facts then show response by nodding, smiling or saying “achha”, “un hoon” or exclaiming “oh my dear” or “is that so”, etc. Touch and patting are a great gesture and shows respect, friendship, and bonding. Doctor can appropriately touch and pat the patient and relatives else you can touch the child. But be careful of the societal values. In our culture, male doctor touching a woman is generally not appreciated but with time once you command faith then you can gently pat the mother/father on the shoulder assuring her/him of your availability for any clarification or consultation any time. The above measures are also referred as nonverbal communication or body language. The nonverbal communication skills are summarized in Box 3.
Adequate measures should be taken for privacy and confidentiality. For eliciting history of HIV and some hereditary disease, it is better to talk one to one or in front of a person whom patient or family is comfortable with. Do not show anger and make such gestures which amount to disapproval or inappropriateness. Always end the conversation with saying thank you and reassurance of your availability and support anytime.
 
ASKING OPEN OR FACTUAL QUESTIONS
Questions are of two types, open question and closed question. An open question is one which elicits a response from the patient/family. It is very useful in taking history and learning situation of the patient/family in shorter time and without speaking much.5
Table 1   Examples of closed and open questions.
Closed questions
Open questions
  • Do you wash hands before taking meals?
  • Can you donate blood?
  • Can you look after this baby at home?
  • How do you ensure hygiene before taking meals?
  • How will you arrange blood?
  • Who will look after this baby at home?
It allows more time to the patient/family to speak and encourage them to share more information. The open question starts with when, how, why, where, etc. The closed question elicits answer as yes or no. Patient does not feel like telling details and is frequently leading type and ends up with judging words. For example, is your child well? It is a closed question because answer to the question will be either yes or no. Here “well” is a judging word that may make mother confused as to what exactly you mean by “well”. If you ask an open question, then judging word will disappear. How is your baby?
If you want to know whether mother is breastfeeding? You may ask the mother “are you breastfeeding?” The answer may be, yes, I am breastfeeding, or I am not. It does not tell anything more. But if you ask the mother how are you feeding your child? The answer may be, I am breastfeeding but sometimes my child cries more in the evening, so I give powder milk by a bottle. I do it two to three times in a week. So, mother gives more information about feeding the child. Factual question is a type of closed question, but it is asked when factual information is required, e.g. what is your age? how many children do you have? are you pregnant? etc. Example of closed and open questions are in Table 1.
 
PARAPHRASING OR REFLECTING BACK WHAT THE PATIENT/FAMILY SAYS AND THINKS
Listen to the patient/family patiently. In order to know more about a point or narration, patient is making or expressing his/her opinion. It is advisable to repeat the same or paraphrase the sentence said by him/her. Reflecting back encourages the parents and patient to tell more about their concerns and apprehensions and reassures them that doctor is listening to them and that healthcare provider is responsive and interested.6
Example, mother says “I do not have enough breast milk that is why I give cow's milk twice a day, in the morning and night, as my son is 4 months old now”.
Doctor can say “you think you do not have sufficient breast milk” or “how did you get this idea?” or simply “you think so”.
Mother will now give reasons and tell more about why she thinks her milk is not enough for the child. She may inform you that she has to join job next month and she wants that child is able to feed on the animal milk while she is away in the office. She further informs that her sister says it is better to start bottle feeding at least a month before joining duties as child can learn to take top feed. Thus, reflecting back on the patient or parents helps you understand the situation. It will now be easy for the doctor to give information on the signs of insufficiency of breast milk and offer suggestions as to how a woman can breastfeed when she is away from her child.
You will appreciate that disagreeing with the mother or questioning her on her decision of top feeding or telling her about the dangers of top feeding in the beginning will vitiate the atmosphere and make mother/father unwilling to follow your advice and suggestions. However, one should be careful that while you are reflecting back you do not sound sarcastic or judgmental or insensitive.
 
EMPATHIZING WITH THE PATIENT/FAMILY WHAT HE/SHE FEELS AND EXPERIENCES
Empathy is an essential component of counseling and active communication. It means expressing to the patient/parents that you understand their concerns and agony and respect their feelings. Try to find out occasions, while talking to the patient/parents, where you can show empathy. Using empathy is a great skill which makes the person comfortable from inside that doctor understands his/her worries and concerns. If you empathize then parents may share several things and enrich patient's history by telling things without being asked.7
If a child patient with respiratory distress comes to casualty and you show empathy to the parents by saying “I can understand you are quite worried about the child”. Father may tell you in chocked voice that “he lost elder child with similar complaints 2 years ago”. You can imagine the kind of feelings and apprehension this family has which you do not know when patient walks in the emergency room. You can identify with the pain and anguish of the family by saying “loosing child is always very painful to parents”. This is empathy. If you say “it was so bad, God willed that way”. This is sympathy and this does not sooth the traumatized feelings of the parents. So do not show sympathy and sentiments.
The next important step in counseling is building confidence and checking understanding of the patient/parents. It is very important that you must assess what patient/family has understood about the disease and its treatment at the end of conversation. The steps as mentioned in Box 4 can help in building the confidence with parents.
 
ACCEPT WHAT PARENTS THINK, BELIEVE OR FEEL
It has been seen that disagreement during conversation with a person on a mistaken idea makes him/her annoyed, resistant and possessive of his/her ideas and opinion. In turn he/she often loses confidence and does not accept suggestions. Agreement with a mistaken idea is vulnerable because then one cannot offer suggestions for correction later on. Therefore, one should neither agree nor disagree with the parents or patient if they harbor a wrong and unscientific idea; instead a neutral response should be given. The neutral statement could be in the form of reflecting back or empathy.8
A mother says “my 1-month-old daughter cries in the night and wants breastfeed too often. She perhaps remains hungry as my milk is not enough for her”. Doctor can say that mother's milk is never in short supply. Child feeds two hourly in early infancy throughout the day including night and circadian rhythm of the infant is such that he/she gets up in the night and more playful; your baby is alright. These statements are scientifically correct but smell of disagreement. Mother may not be satisfied with this response. Rather she may lose confidence as she may feel she does not know physiology of her child. However, if doctor says to the mother that “you are obviously worried about your child”, “both of you then are not able to sleep”, “I understand you are worried about breast milk supply” he is seen polite and gives feelings of being sensitive towards the mother. These statements are showing empathy and giving neutral response to the mistaken idea expressed by the mother. Another example, a mother comes with her daughter to the Well Baby Clinic. The nurse advises immunization to the child, but she refuses citing that it will cause pain and fever. What will you say?
  • No, you should not refuse immunization. It will prevent many diseases.
  • There will be some pain and fever, but benefits outweigh these.
You are concerned with the discomfort the immunization will cause? Is that so? Accept what the person thinks and feels in a neutral fashion.
 
IDENTIFY WHAT PARENTS/PATIENT ARE DOING RIGHT AND PRAISE FOR THAT
Praising is liked by every individual. This boosts the morale of the person, enhances confidence, makes him to do same thing again and again if appreciated for that and encourages him/her to accept suggestions given by the person who praises him/her. Doctors have to learn praising as a communication skill. They have to find out something being done right by the parents or the patient himself/herself and praise them for even in worst scenario.
A mother brings 1-year-old child to the OPD with the complaints of loose motions and fever. Child is feeding on diluted cow's milk by bottle from the age of 3 months and is malnourished. Mother is carrying old patient record including discharge ticket given at birth. A doctor generally becomes judgmental in this situation and accuses the mother for being responsible for this sorry state of her child. Remember mother will never harm her child. So how can a doctor praise the mother in this situation? See mother is carrying old patient record and a discharge ticket indicating birth weight and other information. Doctor can praise the mother that old patient record will be very helpful in understanding the situation and managing the patient. It will boost her morale and she will feel happy.9
 
GIVE RELEVANT INFORMATION
Doctors are busy persons. They should use communication skills that encourage parents/patient to tell history correctly and convey the message that doctor is sensitive and empathic. It is very important that doctor gives relevant information about the disease and treatment in one sitting. One or more sittings may be arranged depending on the course of the disease and situation. A mother comes to Well Baby Clinic for immunization of her 6 weeks old infant. Mother may be given information about the three doses of pentavalent vaccine, oral poliovirus vaccines (OPV) and Rota virus vaccine which will be administered at 6, 10, and 14 weeks of age. Pneumococcal and fractionated inactivated polio vaccine will be administered at 6 and 14 weeks of age. Child may have some fever for which medicine (paracetamol) will be given. Breastfeeding should continue. There is no need to tell about Measles-Rubella (MR) vaccine at 9 months and then booster doses of diphtheria-pertussis-tetanus (DPT), etc. at this time. This is relevant information.
The relevant information should be in positive manner. Negative information is perceived as threatening and may down the confidence of the parents/patient if they are doing that. For example, information on excessive viewing of the mobile by the child can be given by two ways:
  • Spending less time on mobile chatting enhances school performance. Exclusive breastfeeding till 6 months of age makes the baby grow strong and healthy. This are relevant information in a positive manner.10
  • If you spend more time on mobile chatting, you will fail in the examination. Mixed feeding or top feeding will cause diarrhea and pneumonia. These are relevant information albeit in negative frame.
The information should be provided as a scientific fact in general terms and not specifically addressing the patient or the parents. The language should be simple and comprehensible by the nonmedical person. Remember, even well-literate people do not understand medical terminology.
 
MAKE FEW SUGGESTIONS NOT COMMANDS
Doctors are trained to give orders. Even the prescription paper begins with R. This tells “I order in the name of God” the following medicines. Command or order is not liked by any person. Commands are not generally adhered to. Alternatively, suggestions do make a difference. Suggestion gives a person choice and authority to carry it out or not. How one will feel if somebody says, please close the door or will you please close the door? Former is an order to close the door; there is no choice. But later statement gives a choice to the person to say no if he does not want to close the door. Former is a command and later is a suggestion. After giving primary immunization to a 6 weeks child, the nurse tells the mother to come after a month for second dose without looking at her and busy in writing records in the register. Obviously, immunization coverage is not satisfactory. If nurse says to the mother that three doses of pentavalent vaccine will prevent diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae meningitis (use local language for the diseases) in the child. You are a good and responsible mother that you were on time for first vaccination. The next immunization will be after a month say on January 29. Can you come for immunization? Now mother will think for a moment and can say yes. It is possible she may say “no, I have parent child meeting (PTM) in my elder son's school or there is family function. I cannot come on January 29”. Now nurse may give mother other suggestions like immunization can be done after 4 weeks. So, nurse can suggest that she can come on January 28, for immunization. It is important to give suggestions and not commands for carrying out treatment and taking informed consent. This is a very useful communication skill which is immensely appreciated by the parents and the patient.11
 
CHECKING UNDERSTANDING OF THE PATIENT/PARENTS
It is not enough to give relevant information and suggestions. The parents/patient has to understand the disease, its implications, treatment modalities and long-term effects including adverse effects of the drugs and nutritional rehabilitation. Doctor should always determine that parents have learnt and internalized the whole conversation about the disease. It should be done in a manner that it does not sound like appearing in an examination. Doctor can start by saying, well we have discussed many things today. Can we revise or recollect what we have discussed? Now information may be elicited and supported and completed by the doctor. He may finish the session by assuring the parents that at any time, something is not clear they can approach him.