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HISTORY AND PHYSICAL IN THE PEDIATRIC PATIENT

Bambang Mulyawan

University of Muhammadiyah School of Medicine Department of Pediatrics

RUANG LINGKUP (KETRAMPILAN)

• ANAMNESIS • DIAGNOSIS FISIS • PEMERIKSAAN PENUNJANG• KEGAWAT-DARURATAN • ( REHABILITATIF )

ANAMNESIS• Beberapa hal khusus pd pasien anak :• Kebanyakan tidak bisa langsung/

alloanamnesis• Sering or-tu tidak dapat menjelaskan geja-

la penyakit anaknya dg baik• Data anamnesis merupakan 80% hal yg

diperlukan dlm penegakan diagnosis

ANAMNESIS (LANJUTAN)

• Sering data anamnesis hanya asumsi dan persepsi or-tu/pengantar (bias), dan berkaitan dg pengetahuan,adat,tradisi, kepercayaan, kebiasaan, faktor budaya.

• Meperhatikan seluruh aspek tumbuh-kembang• Tidak hanya memperhatikan keluhan pasien

saja, “tugas utama dokter bukan mengobati penyakit,melainkan mengobati pasien”.

ANAMNESIS (LANJUTAN)

• Langkah dlm pembuatan anamnesis :• Identitas pasien lengkap• Keluhan utama• Riwayat perjalanan penyakit sekarang• Riwayat penyakit dahulu• Riwayat dlm kandungan,kelahiran, makan-

an, imunisasi, tumbuh kembang, riwayat keluarga.

ANAMNESIS :

• C ------ 3------- B -----2----A• 4. 5. 6.7.8.9. 1.• A : SAAT PEMBUATAN ANAMNESIS

1.KELUHAN UTAMA 2. RIWAYAT PERJALANAN PENYAKIT

• B : AWAL GJL PENYAKIT 3. RIWAYAT PENY.TERDAHULU

• C : SEJAK LAHIR 4. RIWAYAT KEHAMILAN 5. RWY.KELAHIRAN 6. RWY.MAKAN 7. IMUNISASI 8.TUMBUH KEMBANG 9. RINCIAN KEAD.KLG

Contoh kasus :

Contoh kasus

PEMERIKSAAN FISIS• Keadaan Umum pasien dapat diperhatikan

bersamaan waktu anamnesis• Pem.fisis dimulai dg cara yg mudah,tidak

membuat anak takut/merasakan sakit, na-mun pencatatannya logis dan berurutan ( dari kepala kaki ; inspeksi,palpasi, per-kusi, auskultasi )

• Sebaiknya tidak diawali dg penggunaan alat bantu

PEMERIKSAAN FISIS (LANJUTAN)

• ……….URUTAN JALANNYA PEMERIK-SAAN SEDIKIT BANYAK DITENTUKAN OLEH ANAK (PASIEN) DAN BUKAN OLEH DOKTER YANG MEMERIKSA “

Apa yang dimaksud Pemeriksaan Fisik ?

Physical examination is a fundamental examining

method, it is proceeded by the sense organs such as

eyes, ears, nose and hands or simple tools –

stethoscope and plexor.

Empat (4) prinsip utama Pemeriksaan Fisik

• Inspection • Palpation• Percussion• Auscultation“teach the eye to see, the finger to feel, and the ear

to hear”• What is the fifth? Smelling

Peralatan untuk Pemeriksaan Fisik

Required Optional

Stethoscope GlovesTongue blades Gauze padsPenlight Lubricant gelTape measure Nasal speculumSphygmomanometer Turning fork: 128 Hz,512HzReflex hammer Pocket visual acuity cardSafety pins Oto-ophthalmoscope

Persiapan dalam Pemeriksaan Fisik

• Wash your hands, preferably while the patient is watching

• Washing with soap and water is an effective way to reduce the transmission of disease

Aspek penting lainnya

Where does the examiner stand?

• Stand right side of the bed

• Exam with one’ right hand

Yang harus diperhatikan untuk pasien anak

• Remain calm and appear confident. • You are caring for a whole family. • Honesty is important.• Inform caregiver and child often. • Keep the family together. • Provide hope and reassurance to all.

“Children of any age who are not too big to sit on a parent’s lap

are better examined there than on the examining table.”

Pendekatan dalam pemeriksaan fisik pasien anak

• Head-to-toe sequence for assessing adult clients

• Sequence for pediatric assessments generally altered to accommodate child’s developmental needs

Pencapaian pada pemeriksaan pasien anak

• Minimize stress and anxiety associated with assessment of various body parts.

• Foster trusting nurse-child-parent relationships.

• Allow for maximum preparation of child.• Preserve security of parent-child

relationship.• Maximize accuracy of assessment findings.

Persiapan untuk pasien anak

• Child’s perception of painful procedures• Cooperation usually enhanced with

parent’s presence• Age-appropriate techniques

1) Count respirations FIRST (before disturbing the child)

2) Count apical HR SECOND3) Measure BP (if applicable) THIRD4) Measure temperature LAST

Penilaian Vital Sign pada bayi dan anak

Vitals Respiration

PulseBlood pressure

TempHeight Weight

infants and children

RespirationInfants – rise and fall of the abdomen facilitates

counting

• Rate, regularity and rhythm• Depth• Respiratory Effort

– Retraction (ribs, supraclavicular notch)– Contraction of SCM’s – Flaring of nostrils– Paradoxic breathing

Respiratory / pernafasan • Count for one full minute• May want to do before you wake the infant up• Rate will be elevated with crying / fever

– Pre-term: 40 – 60– Newborn: 30 – 40– Toddler: 25– School-age: 20– Adolescent: 16

Panic levels: < 10 or > 60

Respiration

Age Respirations per minute

Newborn 30-80

1 year 20-40

3 years 20-30

6 years 16-22

10 years 16-20

Clinical Tip

• To accurately assess respirations in and infant or small child wait until the baby is sleeping or resting quietly.

• You might need to do this before you do more invasive exam.

• Count the number of breaths for an entire minute.

Pulse

• Apical pulse– 5th intercostal space in

the midclavicular line

• Femoral pulse– use a point halfway from

the pubic tubercle to ASIS as a guide

Pulse

Age Beats per minute

Newborn 120-170

1 year 80-160

3 years 80-120

6 years 75-115

10 years 70-110

Pulse rates

• Neonate: 70 – 190• 1-year: 80 – 160• 2-year: 80-130• 4-year: 80 – 120• 6-year: 75-115• 10-year: 70-110• 14-year: 65 – 105 / males 60 – 100• 18-year: 55-95 / males 50 - 90

Blood Pressure

• Cuff size (children)– Width should cover ~2/3 of the upper arm or

thigh

Too wide - underestimate BPToo narrow - artificially high BP

http://store.datascope.com/A

ssets/product_images/0998-00-0003-21,22_s164_jpg.jpg

Blood Pressure / Tekanan Darah

• The width of the rubber bladder should cover 40% of the length of upper arm/leg, and the length should encircle 100% of the arm.

• Crying can cause inaccurate blood pressure reading.

• Consider norms for age.

Ukuran manset untuk kelompok umur yang sesuai

• Umur 0 -12 bulan : 2 inci ( 5 cm )• Umur 1 – 5 tahun : 3 inci ( 7,5 cm )• Umur 6 -12 tahun : 4 inci ( 10 cm )• Umur > 12 tahun : 5 inci ( 12,5 cm )

Blood Pressure Cuff / “manset “

Stetoskop

• Gunakan stetoskop binaural ( sisi sungkup dan membran ) , pipa pendek (25-30 cm ), tebal pipa 3 mm, diameter lumen pipa 3 mm.

• Stetoskop pediatrik : diameter membran 3-3,5 cm, bagian mangkuk/sungkup :3 cm.

• Sisi membran utk suara dg nada tinggi, sisi sungkup utk suara dg nada rendah.

Suhu tubuh

Position for takingaxillary temperature.

Temperature

• Use of tympanic membrane is controversial.• Oral temperature for children over 5 to 6

years.• Rectal temperatures are contraindicated for

anal surgery, diarrhea, or rectal irritation.• Rectal temperature only when absolutely

necessary.

Temperature

• Use of tympanic membrane is controversial.• Oral temperature for children over 5 to 6

years.• Rectal temperatures are contraindicated for

anal surgery, diarrhea, or rectal irritation.• Rectal temperature only when absolutely

necessary.

Anamnesis mempunyai peran yang sangat penting dalam diagnosis dan tatalaksana penyakit anak. Anamnesis (bersama pemeriksaan fisis) juga me-nuntun pemeriksa untuk melakukan pemeriksaan penunjang yang mungkin diperlukan.Pada semua pasien, anamnesis tidak terbatas pd masalah yang berhubungan dengan penyakit se-karang, melainkan juga harus mencakup riwayat pasien dalam kandungan ibu sampai saat dilaku-kan wawancara.Dengan anamnesis, selain diperoleh riwayat yang rinci dan sistematis tentang penyakit sekarang, juga harus tergambar status kesehatan dan status tumbuh kembang anak secara keseluruhan.Biasakanlah membuat catatan kaki pada akhir anamnesis, terutama kesan tentang tingkat keper-cayaan Anda terhadap yang diwawancarai.

PENTING UNTUK DIPERHATIKAN

Tujuan pemeriksaan fisik adl. memperoleh informasi yang akurat tentang tentang keadaan fisis pasien. Karena sifat alamiah bayi dan anak, urutan pemeriksa-an tidak harus ikut sistematika yg lazim pd or. dewasa.Pada bayi dan anak kecil, auskultasi abdomen dan jantung didahulukan, diikuti dg pemeriksaan lain, dan diakhiri dg pemeriksaan yg menggunakan alat.Dalam melaporkan hasil pemeriksaan mulailah dengan identitas ( umur dan jenis kelamin), diikuti dengan kea-daan umum, kesadaran, tanda vital, baru disusul dg hasil pemeriksaan sistemik.Selalu gunakanlah kedua sisi stetoskop, dahulukan sisi sungkup ( untuk suara bernada rendah dan sedang ) kemudian sisi diafragma untuk suara bernada tinggi.

Persiapan Asepsis and reducing the risk of infection

• Good hand washing

• Good hand drying

• Aseptic technique

• Good observation and questioning of the client

Pemeriksaan abdomen

• Pada bayi dan anak kecil pemeriksaan abdomen sering kali didahulukan daripada pemeriksaan bagian tubuh lain

• Urutan pemeriksaan : inspeksiauskultasi palpasi perkusi. Maksud urutan tsb. adalah agar interpretasi hasil auskultasi tidak salah, karena setiap manipulasi pada abdomen akan mengubah bunyi peristaltik usus.

Secquence of Abdominal Examination

Examination secquence inspection, auscultation, palpation , percussion Recording secquence inspection, palpation, percussion, auscultation

Abdom

inal A

rea: Four regions

right upper quadrant

right lower quadrant

left upper quadrant

Left lower quadrant

Abdom

inal Area:

Nine regionsright hypochondriac

region

left hypochondriac

regionepigastric region

umbilieal region

hypogastric region

right lumber region

left lumber

region

right iliac region

left iliac region

Nine regions &

P

rojectionspleen

stomach

gallbladdertransverse colon

ascending colon

small intestine

sigmoid colon

urinary bladder

ileum

The Chest

• Inspection• Palpation• Percussion• Auscultation

Inspection• Shape• Scars• Lesions• Resp rate• Resp depth• Mode of breathing• Abnormal inspiratory movements• Abnormal expiratory movements• Asymmetry of movement

Chest wall

1.Pectus carinatum

3.Barrel chest,”toraks emfisematikus”

2.Pectus excavatum

: bulat seperti tong

Palpation

• Chest expansion• Tactile vocal fremitus

Percussion

• Illicit resonance• Compare both sides• Map out abnormal area

Percussion technique

• Place left hand on chest wall, palm downwards with fingers separated

• 2nd phalanx over area of intercostal space• Right middle finger strikes the 2nd phalanx

producing hammer effect• Entire movement comes from wrist

Rumple-Leede Test (1)

• Tourniquet Test

• Rumple-Leede Capillary Fragility Test


• Suatu metode diagnostik klinis untuk mengetahui tendensi/kecenderungan adanya perdarahan pada seorang pasien.

• Test ini menilai fragilitas dinding kapiler dan digunakan untuk mengidentifikasi adanya trombositopeni.

• WHO : salah satu alat yg diperlukan untuk diagnostik DHF.


• Cara : Cuff/manset tensimeter dipasang dan dipertahankan pada posisi tekanan darah antara diastolik dan sistolik selama 5 menit.

• Hasil positif : terdapat 20 petechiae pada daerah volar lengan seluas diameter 1 inch ( +/- seluas uang logam Rp.100,- lama )

Selamat Belajar

T e r i m a K a s i h

Clinical Outcomes

3. Enhanced support services to maintain family cohesion, sense of control, satisfaction with care, and informed decision making.

4. Facilitation of transitions from settings of care due to progression of condition.

5. Advanced preparation and support of families when end-of-life care becomes imminent.

Financial Outcomes

1. Prevent unnecessary Emergency Room and Hospital admissions.

2. Facilitate earlier discharges from hospitals into home care.

3. Perform some treatments and procedures, such as chemotherapy, at home.

Financial Outcomes

4. Supporting families to provide end-of-life care at home rather than the hospital, as appropriate.

5. Providing “hospice in the hospital” when it is appropriate for a terminal admission.*********(not covered under Florida’s Model)

Eligibility:• Children 0-21 years of age • have a life-limiting condition as

certified by their PCP • who wish to receive PIC services• are enrolled in the CMSN.

Program Sites: PensacolaGainesvilleJacksonvilleSt. PeteFt. MyersWest Palm BeachMiami

New: July 2007 Ft. Lauderdale

Sarasota

PIC/PACC SERVICES

Pain and Symptom Management

Therapeutic Counseling

Expressive Therapies (music, art, play)

Respite

Specialized Nursing

Specialized Personal Care

Enrollment Trends

Current Enrollment as of December 2006: 226 children

Majority of Children are in Midstage: Children who are 4 months or more post-diagnosis and who are on active treatment and/or intervention.

Top five ranked diagnoses: Congenital Anomaly/GeneticBrain Injury/developmentLeukemiaMuscular DystrophyCerebral Palsy

2005-2006 Surveys

CMS Nursing Directors

Hospice Directors

Family

Child

Summary and Conclusions

CMS Survey Results

•How children are identified and referred :The variability across the sites in how children are

identified and referred to the PIC Program has been address during the Technical Assistance and Monitoring Visits.

•Training


Hospice Survey Results

•How families are approached

•How Care Plans are developed

•Ongoing care coordination activities between CMSN staff and the hospice staff is conducted.


Parent Survey Results

•Survey length is acceptable, but changes are needed to avoid duplicative questions and to include responses for non applicable questions.

•Questions will be added:Satisfaction with the assigned hospice nurse, social workerSatisfaction with the PIC Program in generalParent questions to address:

enrollment experiencesservices they and their children are receiving

unmet needs


Child Survey Results

Children had difficultly answering the survey questions •Questions will remain the same but answer choices will be modified.

•Open ended question about their experiences with the program and the services they received will be added.

2006-2008Activities and Focus

Evaluation Cost EffectivenessTitle V OfficesImplement quality assurance monitoring toolSite visitsChart reviewsCreate best practicesReapplication of the waiverThe addition of 2 new program sites; Broward

Sarasota

“There are risks and costs to a program of action. But they are far less than the long-range risks

and costs of comfortable inaction.”

John F. Kennedy

Health Care for Children with Special Needs

Making A Difference

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