Module I: Assessment of the Newborn

STEP/TASK (Some of the following steps/tasks should be performed CASES simultaneously.) Getting Ready 1. Greet the mother and introduce yourself. 2. Tell the mother what you are going to do, encourage her to ask questions and listen to what she wants to say. HISTORY (Ask the following questions if data are not available on the mothers/babys record) Personal Information: 1. What is your name (mothers name), address and phone number? 2. Age of the mother during pregnancy? 3. What is the name and sex of your baby? Perinatal history 1- Prenatal history A- Maternal Obstetric History 1. How many times have you been pregnant (Gravida) and how many children have you got (Para)? 2. How many living children do you have now? 3. Do you have history of abortions/ still births/ neonatal deaths? 4. Are causes of abortion or deaths known? 5. Have you breastfed before? B- Maternal Medical History: 1- Do you suffer from diabetes, hypertension, edema, proteinuria or fits or other relevant diseases during the relevant pregnancy? 2- Did you have any infectious diseases as herpes simplex hepatitis B, or TB? 3- Ask mother for history of fever, rash, lymph nodes (neck nodules), jaundice, cough or other symptoms of trans-placental infections (Toxoplasmosis, CMV, or German measles)? 4- Ask about history of medications? 5- Ask about history of exposure to X rays or radioactive materials? (what is the type of radioactive material?) 2- Natal 1. Duration of pregnancy. 2. When was your baby born? (day and hour) 3. Where was your baby born and who attended the birth? 4. Did you have fever and/or foul smelling water (amniotic fluid) around

the time of delivery? 5. When did your bag of water rupture? (more than 18 hours before the birth is premature rupture of membranes) 6. Was the labour or birth difficult or complicated, Comment on: Fetal distress? Prolonged labour? Caesarean section? (elective or selective) Assisted delivery as Forceps or Ventose extraction? Abnormal position and presentation? Any other complication? 3- Postnatal 1. Did the baby cry immediately after delivery? 2. Did s/he need resuscitation at birth? 3. Did s/he need oxygen 4. Did s/he need any NICU care? 5. Did s/he look bluish (cyanosis) 6. Ask about jaundice 7. Did s/he bleed from any opening or below skin 8. Ask about convulsions EXAMINING THE NEWBORN A- Assessment of Overall Appearance/Well-Being : 1. Wash hands thoroughly with soap and water and dry with a clean dry cloth or air dry. (alternatively you can use antiseptic gel) 2. Place the baby on a clean warm surface or examine him/her in the mothers arms in a well lit environment. 3. Weigh the baby. 4- Gestational age assessment Full term or preterm from: Measurements( Wt, length, OFC) Physical findings (scalp hair, ear lobule, breast nodule, external genitalia, plantar creases) 5- Neonatal reflexes (most important three): (Elicit each and know time of disappearance of each) Moro reflex Grasp reflex Suckling reflex 6- Count the respiratory rate for one full minute 7- Observe whether there is nasal flaring, grunting, retractions and/or chest indrawing. 8Assess and count the heart rate in a full minute using a stethoscope. 9Measure the temperature rectally with a personal thermometer. 10- Observe abnormal colors (cyanosis, jaundice, or pallor)
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11- Observe activity, movements and posture. 12- Assess cry, level of alertness and muscle tone. 13- Examine skin (noting any bruises, abrasions and hemangiomas). B- Head, Face, Mouth, Eyes and Nose: 1. Examine head (for size, shape, fontanels, and abnormal scalp swellings). 2. Examine face, (for abnormal facial features and movements). 3. Examine mouth, (tongue, lips, gums, and palate). 4. Examine eyes, (for corneal cloudiness, cataract, any swelling, redness, or pus draining from them. 5. Perform Doll position 6. Examine nose for signs of distress and patency C- Heart, Chest, Abdomen and Cord, and External Genitalia 1. Examine cardiovascular system, (HR, heart sounds, murmurs and pulses) 2. Examine chest, (shape, gynaecomastia, respiratory movements, auscultation). 3. Examine abdomen (distension, concavity or abdominal wall defects, assess the cord stump and count its vessels, palpation for organomegaly or masses, percussion for free peritoneal fluid and auscultation for intestinal sounds). 4. Examine genitals noting ambiguity and look for patency of the anus. 5. Assess size of penis and examine for descended testes. D- Back and Limbs 1. Examine back, ( for any swellings, lesions, dimples, or hairy patches). 2. Examine all limbs (movements and fractures). 3. Is there Erbs palsy (by Moro reflex). 4. Assess hands and feet for Poly and / or Syndactyly 5. Examine hip joints for limited abduction. 6. Wash hands thoroughly with soap and water and dry them with a clean, dry cloth or air dry (or alternatively use antiseptic gel) . 7. Document all your assessment appropriately.

Module II: Medical History-Taking

STEP/TASK Getting Ready: 1. Introduce yourself with a friendly greeting. 2. Give your name and status. 3. Verify the relationship of the accompanying adult to the child 4. Explain the purpose of the clinical setting. 5. Maintain good eye contact 6. Establish a good rapport with the mother or caregiver, and child. Listen carefully to the mothers complaints. Children above 5 years should be asked to give their history. 7. Ask for background information (personal history) about the patient: Name Age, date of birth Gender Occupation of parents Residence (or address for full file requirements) Order of birth, consanguinity Presenting complaint: 1. Ask the mother/child about the main problems that made her/him went to see the doctor. 2. Allow the mother/child to provide an account of recent events in her/his own words without interruption. Describe onset; course; duration 3. Write down the complaint in chronological order. History of current illness: Analyze the complaint as follows: 1. Ask about the onset, duration and aggravating and relieving factors. 2. Ask about other symptoms of the relevant and relating systems (systemic review) 3. Ask about any investigations and their results if done. 4. Ask about any treatment that have been given Past medical history: Ask about 1. Any similar episodes in the past. 2. Other medical problems or conditions. 3. Previous hospital admissions. History of drug intake: 1. What medications does the patient actually take for any chronic illness? 2. History of drug allergy. Family history:
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CASES

STEP/TASK CASES 1. Ask about Significant illness in relatives 2. Similar disease in family. 3. Comment on consanguinity. 4. If possible plot the family Pedigree SYSTEMIC INQUIRY (inquiry about all the cardinal symptoms in each of the major systems) Cardiovascular symptoms 1. Symptoms of effort intolerance. Dyspnea on effort. Interruption of breast feeding to take breathing. 2. Symptoms of pulmonary congestion. Dyspnea. orthopnea, paroxysmal nocturnal dyspnea or dyspnea at rest. Cough. Hemoptysis. 3. Symptoms of systemic congestion. Edema of lower limb. Pain in right upper abdomen. Dyspepsia 4. Rhythm changes. Palpitation or tachycardia noticed by parents Syncope. 5. Cyanosis (continuous or episodic; history of squatting) 6. Symptoms of low cardiac output. Syncope. Dizziness. Easy fatigability. Cold extremities/blue extremities noted by parents 7. Symptoms suggestive of rheumatic fever, (as arthritis) infective endocarditis, chest pain, mediastinal symptoms (hoarseness of voice, dysphagia, prayers position) Chest and respiratory symptoms 1. Cough; timing and type. a. Dry b. Productive 2. Respiratory difficulty: Dyspnea, fast breathing, or grunting. 3. Wheezing 4. Hoarseness of voice and/or stridor. 5. Chest pain. Site. Duration Radiation. Associated symptoms.
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Character. Precipitating factors. 6. Chocking. 7. Hemoptysis. 8. Cyanosis. 9. Toxemic symptoms. GIT symptoms 1. Appetite: increased or decreased 2. Dysphagia. 3. Abdominal pain: a. Site b. Radiation c. Character d. Duration e. Precipitating factors f. Relieving factors g. Associated symptoms 4. Dyspepsia, vomiting, or heart burn 5. Diarrhea, constipation or tenesmus 6. weight loss / gain. 7. Hematemesis, melena or fresh bleeding per rectum 8. Halitosis 9. Abdominal distension. 10. Jaundice (yellowish discoloration of skin, conjunctival membranes over the sclerae- and mucus membranes) Neurological symptoms 1. Motor= Weakness or paralysis 2. Abnormal movements & convulsions 3. Parasthesia 4. Bladder disturbances 5. Symptoms of increased ICT: Headache, vomiting and blurring of vision 6. Cranial nerve affection a. Anosmia b. Diminution of vision c. Diplopia d. Loss of sensation of the face, difficulty in mastication e. Inability to close eye or deviation of the mouth f. Tinnitus, deafness or vertigo g. Dysphagia, hoarseness of voice and nasal regurgitation h. Dysarthria 7. Abnormal behavior or disorientation 8. Convulsions

STEP/TASK Relieving factors.

CASES

STEP/TASK CASES 9. Hypothalamic manifestations (eating and sleep disturbances) 10.Gait disturbances Endocrine/ reproductive system: 1. Fatigue. 2. Polyuria, polydipsia 3. Weight loss or gain, appetite 4. Heat intolerance / insensitivity. Irritability, constipation, sleep pattern 5. spasms (tetany) 6. Voice change 7. Skin change (pigmentation) 8. Goiter. 9. Menstrual history, amenorrhoea, secondary sexual characteristics: time of onset, genital abnormalities Renal and urinary system: 1. Urine: color (study different colours), quantity (polyuria or oliguria) 2. Nocturia, frequency, dysuria 3. Hematuria 4. Stones, gravel. 5. Renal pain. 6. Colic (site, duration, severity, what increases and what decreases) Skin: 1. Itching 2. Lesions and ulcers 3. Rashes (Types, distribution, time, course and special march if any). 4. Coloration 5. Hair (loss or hirsutism). Musculoskeletal system: 1. Joint pain, stiffness, swelling, and deformity 2. Relationship of symptoms to rest and exercise. 3. Limitations of movement. 4. Bone and vertebral pain. Special points in the pediatric history 1- Developmental history Refer to the schedule of developmental milestones in your Text Ask about and write down all the developmental items chronologically. Compare the results with the childs age Identify whether the child development is normal, delayed or advanced. 2- Dietetic history

STEP/TASK Breast feeding : exclusive or not, (for how long) regular or on-demand, one or both sides how many times per day Bonding and successful procedure Post-feeding satisfaction, Motions, weight gain Any problem of breasts Problems of suckling Maternal drugs during lactation When breast feeding stopped Formula : Type Amount Concentration Frequency Duration of feed How given (cup and spoon, syringe or bottle). Weaning: When started Types of food used (each food and time of introduction, which preferred and which refused) How was it given (method, processing and amount) Any problems during weaning (diarrhea, constipation, vomiting, dysphagia, pain, respiratory or skin allergies, pica, picky nature, anorexia) 24 hours recall (start from 8 am yesterday till just before 8 am today and record type and amount of food given) 3- Vaccination history Refer to the childs health card. If unavailable, ask the mother what the child has received. Determine any missed or due BCG during the first month and inspect for the presence of scar. DPT, oral polio, hepatitis B at 2nd,4th,and 6th months. Oral polio + Vitamin A at 9 months MMR at 1 year

CASES

STEP/TASK Booster DPT and oral polio (MMR at 18th months if not at 1 year). Others. 4- Antenatal, natal, postnatal: refer to newborn module

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Module III: General Examination

STEP/TASK GETTING READY 1. Pre-exam checklist: WIPE: a. Wash your hands and warm them (alternatively use antiseptic gel) . b. Introduce yourself to patient or care giver, explain your task. c. Position patient [on parent's lap if younger than 6 months age]. d. Expose area as needed [parent should undress]. 2. Examine from the Right side of the patient (Left-handed can be on left). General appearance and facies General condition (fair, ill-looking) Posture, body positions. Abnormal Facies (dysmorphic features facies) Dress, hygiene. Alertness, happiness, Any unusual behaviour Crying: (high-pitched vs. normal. , consolable or non consolable) Parent-child interaction, reaction to other accompanying relatives Ask if tenderness anywhere, before start touching them. If asleep, do the heart, chest and abdominal examination first. Vital signs (see specific learning guide) Radial pulse. (Appendix 1) Apical Pulse. (Appendix 2) Other pulses.(Appendix 3) Respiratory rate. (Appendix 4) Blood Pressure. (Appendix 5) Temperature. (Appendix 6) Head and neck and Lymph nodes (Appendix 7 & 8) Colours: o Jaundice o Pallor o Cyanosis (distribution and type) Head circumference (did they have serial records to assess rate of growth). (microcephaly, macrocephaly) (Appendix 12) Head asymmetry, (brachycephaly, scaphocephaly or acrocephaly). Fontanelle, if <18 months: (Full bulging, flat or depressed). Scalp hair abnormalities (alopecia, silky, abnormal colour, fragility) Cases

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STEP/TASK Thyroid enlargement, other lumps. (appendix 8) Neck stiffness. Neck lymph nodes as mentioned (appendix 7) Neck pulsations as mentioned in Cardiac examination Neck veins. (appendix 8) Position of examination: Mother holds child on lap facing forward, one arm encircling child's arms, the other hand on child's forehead Sunken eyes (dehydration) Normal or narrow palpebral fissure Epicanthic folds Direction (normal, mongoloid slanting or antimongoloid slanting) Anatomical location (enophthalmia +/- microphthalmia, exophthalmos, proptosis) Strabismus (Apparent Strabismus is normal before 4-6 months). Lids (ptosis, coloboma, lashes) Pupils: reaction to light. Congenital cataracts. Discharge (purulent or non) Conjunctiva (congestion, injection or suffusion) Photophobia, Sclerae, (blue)

Cases

Eyes

Ears Examination position: same as eye, but child faces the side. Size (Micro or macro-otia) Shape e.g. Bat ears Site (Low set ears) Tags or fistulae Discharge External ear tenderness. Test hearing.

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STEP/TASK Nose Nasal Bridge Discharge Nares patency Nasal flaring. Mouth (Appendix 9) Throat (see also Appendix 9) Tonsils: size, signs of inflammation, follicles of pus or membrane. Posterior pharyngeal wall Diaper, genitalia, anus (permission is asked verbally) Only perform when indicated. Diaper: o Inspect contents. o Inspect napkin area Male:
o

Cases

Size of penis, Circumcision o Epispadius/hypospadius? o Testes descent, hydrocele o Hernias

Female: Vulva, clitoris. 2 openings Both sexes: o Tanner stage. o Discharge. o Abnormalities. Anus inspection: o Hemorrhoids, fissures, prolapse. o Peri-anal inflammation. Extremities and Back Test for hip dislocation in newborn and early infancy ( hip abduction in infants with knees flexed especially in girls). Feet abnormalities (as Talipes deformities or rocker-bottom feet). Deformitis of bones or joints Poly and or Syndactyly, Arachnodactyly
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STEP/TASK

Cases

Simian Creases Rudimentary middle phalanx of the little finger Ape-line, Separation or overlying toes, or hand clenching Nails Pallor Clubbing Hemorrhages Spooning White spots Hypoplasia Pits Spine: deformity (kyphosis; scoliosis, lordosis) masses, tenderness, limitation of movement, spina bifida and pilonidal dimple.

Skin Rashes, using proper terminology. Skin colour, Skin consistency, Hydration (skin elasticity, dryness). Subcutaneous fat. Oedema, Bruises and petechiae. caf-au-lait spots, hemangiomas and nevi,(their size and location). Body Measurements at the end of exam Height (length below 2 years), weight, skull circumference and MAC (Appendices 10-13)

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STEP/TASK Measure and plot on appropriate centile chart.

Cases

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Appendix 1: Measuring Radial Pulse

STEP/TASK Cases Getting Ready: 1. Prepare equipment: Watch or clock with a counter for seconds. 2. Explain the procedure to the patient. 3. Assist the patient to pronate and slightly fix the forearm. 4. Wash the hands Procedure: 1. Locate the radial artery just medial to the distal radius and proximal to the patients wrist on the thumb side. 2. Place the tips of the index, middle & ring fingers just proximal to the patients wrist on the thumb side, orienting them over the vessel. 3. Push lightly at first, gradually adding pressure till you feel the pulse. 4. Repeat procedure with other arm to assess equality on both sides 5. Compare with the apical pulse. Post Procedure: 1. Wash the hands. 2. Discuss the findings with the patient. 3. Record the results as beats / minute and comment on regularity and volume. During palpation, note the following: Rate: Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and multiply by 2. If the rate is particularly slow, fast or irregular, it is probably best to measure for a full 60 seconds in order to minimize error in recording over shorter periods of time. Rhythm: Is the time between beats constant? so it may be : (1- Regular. 2- Regular irregularity 3- Irregular irregularity). if the pulse is irregular; verify the rate by listening over the heart (apical pulse). Volume: (i.e. the subjective sense of fullness). Normal. Big. Small Variable volume. Special character: Comment if there is a special character as Water hammer pulse .

Appendix 2: Measuring Apical Pulse

STEP/TASK Getting Ready: 1. Prepare equipment: Watch or clock with a counter for seconds. 2. Explain the procedure to the patient. 3. Assist the patient to a comfortable position (supine or semi-sitting ). Cases

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4. Stand to the right of the patient. 5. Expose chest well. 6. Wash the hands Procedure: 1. By inspection: look tangentially, from the side of the patient for apical pulsation. 2. Palpate the apex by palmer surface of the hand. 3. Localize the apex (the lowermost outermost visible palpable powerful pulsation) with the tip of your index finger. 4. Auscultate the apex with the bell of the stethoscope. Post Procedure: 1. Discuss the findings with the patient. 2. Wash your hands. 3. Record the results as beats / minute

Appendix 3: Assessment of Peripheral pulses

STEP/TASK Getting Ready 1. Greet the patient respectfully and with kindness. 2. Tell the patient you are going to examine the different pulses 3. Position the patient as suitable for each pulse. 4. Wash hands thoroughly and dry them 5. Put on new examination or high-level disinfected surgical gloves on both hands. 6. Exposure: Ask the patient to remove all clothing covering the examination areas Assessment of Peripheral Arterial pulses: 1. Femoral artery: 1. Lay the patient supine 2. Partially flex the knee 3. Abduct and externally rotate the hip 4. Using the tips of your fingers 5. Feel the pulse below the mid-inguinal point 6. Compare both sides. 2. Popliteal artery: 1. The patient to lie supine and partially flex the knees 2. Feel the pulse with the fingers encircling and supporting the knee on both sides. 3. Alternate method: Ask the patient to lie prone Using the tips of your fingers pressing against the femur Feel along the line of the artery Compare both sides. 3. Posterior tibial artery: Cases

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1. The patient to lie supine 2. Using the tips of your fingers 3. Feel the pulse in the groove between the medial malleolus and tendo-achilles. 4. Compare both sides. 4. Dorsalis pedis artery: 1. Using the tips of your fingers 2. Feel the pulse lateral to the extensor hallucis longus tendon and proximal to the 3. 5. 1. 2. 3.

first metatarsal space. Compare both sides. Brachial artery: Partially flex the elbow Using the thumb Feel the pulse over the elbow just medial to the biceps tendon.

Appendix 4: Measuring the Respiratory Rate

STEP/TASK Getting Ready: 1. Prepare equipment: Watch or clock with a counter for seconds. 2. Assist the patient to a comfortable semi-sitting position 3. Wash the hands. Procedure: 1. Do not explain the procedure to the patient, 2. Pretend you are measuring the radial pulse, while inspecting and counting the elevations of the chest wall in 60 seconds. 3. If you could not count the respiratory rate easily because of clothes or any other reason, let the patient lie flat and pretend that you are measuring the apical pulse or performing cardiac examination while counting the respiratory rate. Post Procedure: 1. Wash your hands. 2. Record the results as breathes/ minute and comment on regularity and difficulty. Cases

Appendix 5: Measuring Blood Pressure

STEP/TASK Getting ready: 1. Greet the child and parents. 2. Explain the procedure and attempt to gain the childs and parents confidence before approaching the child. 3. Explain that the procedure will not hurt. 4. Put the patient in a supine or sitting position with back supported for 5 minutes and legs uncrossed, feet flat on the floor and patient relaxed. 5. Prepare equipment (stethoscope and sphygmomanometer)
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Cases

STEP/TASK 6. If the pulses are equal, use right arm. 7. If unequal, use arm with the strongest pulse. 8. Take off the sleeve of the identified arm. 9. Arm should be abducted, supinated & at the level of the heart (if sitting, use arm support). 10.Choose the correct size of the width of the cuff. The bladder at least40% of the circumference of the midpoint of the upper arm and the length 80% of the upper arm. TAKING THE BLOOD PRESSURE 1. Place the cuff around the upper arm with the lower edge of the cuff, with its tubing connections one inch above the antecubital space across the inner side of the elbow. 2. Wrap the cuff snuggly around the inflatable inner bladder centered over the area of the brachial artery. 3. Close the valve of the pump. 4. Inflate the cuff while palpating the radial pulse. Inflate the cuff rapidly to 70 mmHg then 10 mmHg at time till the pulse will no longer be felt (the pulse obliteration pressure). This is the approximate systolic BP. 5. Deflate the cuff 6. Mentally Add 20-30 mm Hg to previously measured number to know the maximum inflation level (MIL). 7. Place the earpieces of the stethoscope into ears, with the earpiece angles turned forward toward the nose. 8. Palpate the brachial artery. 9. Apply the diaphragm of the stethoscope over the brachial artery, just below but not touching the cuff or tubing. 10. Close the valve of the pump. 11. Inflate the cuff rapidly to the MIL previously determined. 12. Open the valve slightly and maintain a constant rate of deflation at approximately 2mm per second. 13. Allow the cuff to deflate 14. Listen throughout the entire range of deflation until 10mm Hg below the level of the diastolic reading. The first loud beat will be the systolic recording, the sudden reduction of sound will denote the diastolic reading. 15. Fully deflate the cuff by opening the valve. 16. Remove the stethoscope earpieces from the ears. 17. Write down the systolic and diastolic readings to the nearest 2mmHg. 18. Deflate cuff completely, 19. If the sound were not heard clearly or the blood pressure recording is high raise arm above head level for one minute then lower arm and repeat exam.

Cases

Appendix 6: Axillary Temperature Using a Mercury Thermometer

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STEP/TASK Getting Ready: 1. Prepare equipment (thermometer tray, tissue paper and thermometer) 2. Tell the mother what is going to be done and encourage her to ask questions. Procedure: 1. Place the baby on her/his back or side on a clean, warm surface. 2. Shake the thermometer until it is below 35C. 3. Place the tip of the thermometer high in the apex of the axilla with thermometer parallel to long axis of the body and hold the arm continuously against the body for at least two minutes. 4. Remove the thermometer and read the temperature by holding it at eye-level and rotating the stem until the mercury is clearly seen Post Procedure: 1. Wipe the thermometer with a disinfectant solution after each use (better use a thermometer for each child). 2. Record results on a notepad NB: Rectal temp is the most accurate one.

Cases

Appendix 7: Examination of Lymph Nodes

STEP/TASK Getting Ready 1. Greet the patient respectfully and with kindness. 2. Tell the patient you are going to examine the lymph nodes and their sites. 3. Position the patient according to each group of lymph nodes 4. Wash hands thoroughly and dry them 5. Exposure: Ask the patient to remove all clothing covering the examination areas Internal Waldayer Ring (see mouth exam) External Waldayer Ring 1- Inform the patient or parent what are you going to do 2- Examine both from front and back using both hands 3- Examine for submental LN in midline below chin 4- Examine for submandibular LN on both sides below the mandible 5- Do bimanual palpation with a gloved fingers to differentiate between LN and salivary gland (technique needs to be described) 6- Palpate for the jugulo-digastric LN on both sides below the angles of the mandible. One at a time to avoid bilateral carotid pressure and syncope? 7- Pre-auricular LN 8- Mastoid LN 9- Occipital LN 10- Give the following comments a. Size b. Site c. Tenderness d. Consistency (soft, firm)
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e. Matting f. Attachments to overlying and underlying tissue g. Associated lymphangitis h. Catchment area evaluation. Cervical LN 1- Inform the patient or parent what are you going to do 2- Inspect and palpate 3- Examine from front and back 4- Determine whether upper or lower (Transverese line dividing neck) 5- Determine whether anterior or posterior (in relation to sternomastoid) 6- Determine whether superficial or deep to sternomastoid 7- Make the previously mentioned comments Axillary LN 1- Inform the patient or parent what are you going to do 2- Examine the patient from the front: 3- Examine each axilla with your opposite hand 4- Rest the patient forearm on your forearm 5- Examine for apical, anterior, posterior, medial, lateral groups of LNs 6- You can palpate the posterior axillary fold from behind 7- Give the full description for each group on both sides Mediastinal LN 1- Inform the patient or parent what are you going to do 2- Auscultate the back in midline and slightly around for bronchial breathing below the level of carina (below 2nd thoracic in infants, below 3rd thoracic in children and below 4th thoracic in adults) Para-Aortic LN Mesentric LN Lymph Nodes in the Inguinal Region 1. Inform the patient or parent what are you going to do 2. Fully expose the inguinal region 3. Lay supine 4. Flex the contra-lateral knee 5. Palpate above and below the inguinal ligament 6. Examine both sides 7. Examine lower limbs for a cause. Epitrochlear Lymph Nodes Post-procedure Remove gloves/ wash hands after examination Inform parent/patient of findings Thank patient/ parent

Appendix 8: Examination of the Neck

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STEP/TASK Getting Ready 1. Greet the patient respectfully and with kindness. 2. Tell the patient you are going to examine the neck. 3. Ask the patient to sit on the examining table with arms at sides. 4.Wash hands thoroughly and dry them 5. Put on new surgical gloves on both hands. 6. Exposure: Ask the patient to remove all clothing down to the nipple line. PROCEDURE Inspection: Observe the contour of the neck and notice any abnormalities Ask the patient to swallow and notice any masses moving with deglutition Define the anatomical site of any observed swelling Notice any neck pulsations, dilated veins, scars

CASES

Allow patient to recline at 45 degrees, this makes normal neck veins visible just above clavicles with their characteristic pulsations Comment on: o Arterial pulsations(suprasternal and or prominent carotid pulsations) o Venous pulsations; congestion, pulsations and their relation to inspiration o How to differentiate between venous and arterial pulsations o Thyroid swelling o Other swellings o Webbing of the neck

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Palpation: Advise the patient to sit on a stool Stand behind the patient Instruct the patient to relax the neck muscles so as to allow you to move the head in any direction Hold the head with one hand and flex it gently to one side while palpating the front of the neck with the other hand Flex the patients head towards the side that is being palpated Palpate the trachea and its position Examine the relationship of any masses detected to: o The trachea: Notice the movement of the mass with swallowing o The hyoid bone: Notice the movement of the mass with protrusion of the tongue Palpate the cervical lymph nodes (revise LN) Palpate both carotid arteries for equality and thrill; one at a time Comment on: Thyroid gland: is there thyroid gland swelling (goiter) (The normal thyroid is not visible & is often not palpable). o size o shape o tenderness o mobility o consistency Lymph node enlargements Pulsations and thrill Percussion : Tap with the index finger over the manubrium sterni in order to rule out any retrosternal extension of the thyroid gland, which will elicit a dull note Auscultation: Listen over the thyroid gland for any bruit or murmur. Listen over both carotid arteries for any bruit or murmur.

Appendix 9: Examination of the Mouth

STEP/TASK Getting Ready 1. Greet the patient respectfully and with kindness. 2. Tell the patient you are going to examine the mouth. 3. Ask the patient to sit on the examining table with arms at sides. 4. Wash hands thoroughly and dry them (alternatively use antiseptic gel) 5. Put on new surgical gloves on both hands. CASES

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STEP/TASK 6. Prepare a good light source and spatula PROCEDURE 1. What about mouth odor? 2. Inspect the buccal mucosa and lips 3. Depress the tongue to look at fauces (throat), tonsils and pharynx 4. Inspect angles of mouth for fissures 5. Examination of the cheeks: Inspect the interior of the cheek for pigmentations, ulcers, swellings, Koplicks spots Inspect the orifice of the parotid duct. 6. Examination of the teeth: Inspect for shape, color, dental cares and rough or broken edges. Count their number 7. Examination of the gum: Evert the lips fully to inspect the gums Look at the color, the crenated edges, the relation to the necks of the teeth, pigmentation, ulcers, swellings 8. Examination of the tongue: (Inspect the tongue color and surface as well as undersurface) o Assess the mucous membrane; (dry or moist, clean or furred) o Protrusion of the tongue o Note if there is any swellings, ulcers or fissures 9. Examination of the fauces (throat) and palate Tilt the head slightly backwards and open the mouth to full extent Inspect the movement of the palate when patient says (AAH) Inspect for cleft palate and palpate for submucosal cleft Depress the tongue with a spatula and illuminate the throat; inspect the tonsils, pillars of the fauces and the posterior pharyngeal wall.

CASES

Appendix 10: Measurement of the Height of a Child above 2 Years

Getting ready: 1. Use a measuring device e.g. studiometer or wall- mounted measuring ruler. 2. Introduce yourself to the mother 3. Explain the task for the patient or care giver 4. Ask the mother/child to remove shoes and socks. Procedure 1- Ensure the correct positioning by beginning at the feet and working upwards. 2- Place the feet together flat on the ground with heels touching the zero point. 3- Ask the child to stand as straight as possible with the heels, buttocks and shoulders touching the measuring device/wall 4- Be sure the knees are fully extended 5- Put the head carefully in the neutral position with the lower margins of the
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orbit in the same horizontal plane as the external auditory meatus 6- Record the reading and plot it on a growth chart.

Height below 2 years (length) : Put the infant on the special scale for length measurement.

Appendix 11: Measurement of the Weight of an Infant Below 2 Years

STEP/TASK Getting Ready: 1. Prepare a clean scale and a disposable piece of Paper. 2. Put a light cloth or blanket on the scale pan to avoid chilling of the Infant. 3. Adjust the scale to the zero point. 4. Introduce yourself to the mother and explain the steps. 5. Instruct the mother to remove the child's cloth leaving the least possible. Procedure: 1. Place the child gently on the center of the weighing Scale 2. Wait till the scale display stops flashing (digital scale), or the pointer settles (mechanical scale). In case you use a beam scale, move the weight on the main scale beam away from the zero point until the indicator settles at the center (The child must not touch the table and the mother must not support his body). 3. Take the child off the scale and repeat the previous Step 4. Record the average of both readings Post procedure: 1. Return the child to his mother and instruct her to dress it him 2. Record the weight and plot it on a growth chart. Recording weight on the growth chart (plotting measurements) 1. Write the month of birth in the box below the first vertical column )the first box which has thick lines around it). Near the box, write the year of birth. 2. Beginning with the month of birth, write out the following months of the year in the following boxes. When you reach January, write the year near that box exactly as you wrote the year of birth near the box for the month of birth. 3. Carefully calculate the child's age to the nearest month. 4. Record the weight by putting a big dot on the line corresponding to that weight in kilograms. For example, if the weight is 6 kg in a given month, find the horizontal line representing 6 kg and put a dot at the point on that line where it meets the column for the month in which the weight is being taken. Use a straight edge to draw a horizontal line from that point until the vertical line. CASES

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5. Adjust the position of the dot within a column. If the child is being weighed

early in the month, put the dot towards the left side of the column. Put the dot in the middle of the column if the weight is being taken in the middle of the month. If the weight is being taken late in the month, put the dot towards the right side of the column. 6. Follow the above instructions each time you record the weight on a chart. Join subsequent dots by a line. This is the growth curve Interpreting the growth line (revise your Text) Counseling the mother about her child's growth 1. Tell the mother the difference in her child's weight compared to the previous month. Is this normal or less(malnutrition)or excess (overweight or obesity) 2. Ask the mother open-ended questions (related to her child's feeding practices) and write down your notes. 3. Compliment the mother for what she is doing correctly and counsel her on any problems identified during the diagnosis. Urge the mother to continue the things she is doing correctly and change faulty behaviours. 4. Ask the mother what things that would make it difficult for her to follow the advice that she is given and help the mother to work through any obstacles. 5. If the child has been ill, talk about prevention or management of the illness. 6. Verify that the mother understands the advice asking her to mention the key things that she should stop doing and the things she should continue to do. Weight above 2 years: standing undressed (underwears) on a calibrated scale

Appendix 12: Measurement of the Head Circumference

STEP/TASK Getting Ready: 1. Prepare a non-stretchable measuring tape 2. Introduce yourself to the mother 3. Ask her permission to examine the child Procedure: 1. Patient position? Preferably sitting supported by mother if necessary CASES

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2. Pass the tape on the forehead along the plane midway between the eyebrow and the hairline, to the occipital prominence at the back of the head. 3. Take care of kinks or obliquity. 1. Measure to the nearest millimeter 2. Repeat three times and take the average Post procedure: Record measurement on head circumference chart

Appendix 13: Measurement of Mid-Arm Circumference

STEP/TASK Getting Ready: 1. Prepare the following tools: A non-stretchable measuring tape A water removable skin marker 2. Introduce yourself to the mother 3. Ask her permission to examine the child 4. Ask the mother to undress the child exposing the left shoulder and arm. 5. Help the child put the arm in an extended relaxed position Procedure: 1- Identify the mid-point between the acromion and the olecranon on the lateral side of the left arm. 2- Pass the tape around the arm at the identified plane, perpendicular to the long axis of the arm 3- Measure to the nearest millimeter Post procedure: Record the reading interpretation CASES

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Module IV= System Examination (see Appendices 14, 15, 16 and 17) 1-Abdominal Examination
GETTING READY 1. Greet the patient respectfully and with kindness. 2. Explain the procedure to the patient. 3. Ask the patient or care giver to undress from the nipple line to the midthigh, and cover with a clean sheet. If this is embarrassing, examine the genitalia first and then cover them before examining the rest of the abdomen. 4. Wash hands thoroughly and dry them (alternatively use antiseptic gel). 5. The patient's position: ask the patient to lie flat on his back with the legs extended. Older children need to flex the hips to 45 and the knees to 90. (In very young infants you can examine the infant in the mothers lap). INSPECTION: 1. Look from end of the bed and tangentially and observe: a. Abdominal movements with respiration f. Divercation of recti b. Breasts g. Scars or pigmentations c. Pulsations (Epigastric h. Veins. pulsations) i. Visible peristalsis. d. Hernias j. Genitalia Tanner stage e. Umbilicus PALPATION: 1. Stand by the right side of the patient (unless you are left handed) 2. Make sure that your hand is warm and ask the patient to flex the hips and knees in order to relax the abdomen. (not needed in very young) 3. Ask the patient whether there is a painful area or a mass. Always start palpation in the region diagonally opposite to any lesion or pain, and proceed systematically to other regions approaching the affected area last of all. 4. Begin in the left iliac fossa and proceed to left lumbar, left hypochondrium, epigastrium, umbilical, suprapubic, right iliac fossa, right lumbar and lastly right hypochondrium . Then palpate more deeply in the same areas. Superficial palpation: a. Tenderness: b. Rigidity: c. Swelling: (relation to diaphragm and if intra or extra abdominal)
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d. Hernia orifices: Examine the anatomical sites of hernia for swelling

(repeat while standing) e. Dilated veins: Determine the direction of the flow by placing two fingers on the vein, sliding one finger along the vein to empty it and then releasing one finger Deep palpation: Start palpation of the normal solid viscera (the liver, the spleen and the kidneys): NB: Liver, spleen: <6 years may palpable up to 2cm below costal margin. A.Palpation of the liver: - Place your right hand on the right iliac fossa (MCL) resting transversely parallel to the costal margin - Ask the patient to take a deep breath. - Keep your hand still during inspiration - As the patient to expire, slide the hand a little nearer to the right costal margin till you palpate lower border of the right lobe of the liver. - Put your hand in the midline and repeat the above steps till you palpate the lower border of the left lobe of the liver. - Percussion is done to get the upper border of the liver. Is liver ptosed? Record the findings: o The degree of enlargement (span in cm between upper and lower borders in MCL) o The character of the border (sharp or rounded). o The surface (smooth or nodular) o The consistency(soft like a lip, firm like a nose, hard like a bone or heterogeneous) o The presence of pulsations o The presence of tenderness o Hepatojugular (abdominojugular) reflux B. Palpation of the spleen: Start palpation from the right iliac fossa with the tips of you hand directed towards the left axilla, and moving toward the left hypochondrium until you feel the spleen Record the findings: The consistency The degree and direction of enlargement The character of the border (sharp or rounded), the presence of notch The surface (smooth or nodular) Tenderness C. Palpation of the kidneys:

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1- Bimanual palpation of both kidneys Put your hand behind the patient's loin Lift the loin and the kidney forward. Put the other hand on the lumbar region and ask the patient to take a deep breath. During expiration push your hand deeply but gently and keep it still during inspiration Repeat as the patient takes his breath. 2- Ballottement is done to confirm renal origin of a swelling (by pushing renal angle upwards, and palpate the kidney by the other hand Comment on: 1- Mass or fullness 2- Tenderness D. Palpate for other Abdominal Swellings: Differentiate intra abdominal from parietal swellings: o Relation to the costal margin. o Behavior on contraction of the abdomen. PERCUSSION: Rub your hands together and warm them up before placing them on the patient Percuss for ascites and over any masses. In the abdomen only light percussion is necessary. Start from resonant to dull in the midline A. Percussion of the liver (span of the liver): Determine the upper border of the liver by heavy percussion starting from the 2nd intercostal space opposite the sternocostal junction Percuss down along each inter-costal space in the MCL and when you reach the dullness ask the patient to take a deep breath and hold it Percuss again, ((tidal percussion), if it became resonant this will denote infra diaphragmatic cause (liver). If it remain dull, this will denote supra diaphragmatic cause(pleural effusion) Measure the distance between the upper border (by percussion) and lower border (by palpation) in the right mid- clavicular line, this is the span of the liver. B. Percussion of the Spleen: Percussion of the Traube space {Area defined by the anatomical apex (5th ICS in MCL), left sixth and eighth ribs superiorly, the left midaxillary line (9th, 10th&11th ICS) laterally, and the left costal margin inferiorly}. If Traube area is dull: the spleen may be enlarged, full stomach, pulmonary or pleural disease or cardiac dullness.

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C. Percussion for Ascites (Shifting Dullness) Instruct the patient to lie in the supine position Place your fingers parallel to the flanks. Start percussion from the region of the umbilicus down to the flank till you elicit a dull tone. On detecting dullness, ask the patient to turn to the opposite side, while keeping the examining hand over the exact site of dullness. Keep your hand in position till the patient rests on the opposite side. Repeat percussion; if the flank returns a resonant note and percussion at the umbilicus returns a dull note, that indicates the presence of moderate free ascites. Testing for MINIMAL ascites in the knee elbow position: (If shifting dullness is negative ) Percuss around the umbilicus while the patient is kneeling in the kneeelbow position. In case of MASSIVE ascites: 1-Detect ascites by FLUID THRILL: Instruct the patient to lie in the supine position Place one hand flat over the lumbar region on one side Get the patient (or assistant) to put the edge of the hand in the midline of the abdomen Tap or flick the opposite lumbar region: A thrill will be felt in the other hand 2- Detect organomegaly by DIPPING method: Place your hand in the right hypochondrium and push the abdominal wall downwards by a quick pushing movement from the wrist. An enlarged liver will rebound and hit your hand. Place your hand in the left hypochondrium and push the abdominal wall downwards by quick pushing movement from the wrist. An enlarged spleen will rebound and hit your hand. AUSCULTATION: for intestinal sounds It is performed before percussion or palpation as vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus bowel sounds. Exam is made by gently placing the pre-warmed (accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20 seconds. Practice listening in each of the four quadrants. Normally, peristaltic sounds are heard every 10 to 30 seconds. Comment on presence intestinal sounds EXAMINATION OF THE BACK Ask the patient to sit Inspect for any swellings, deformities or scars Palpate for edema over the sacrum Palpate for tenderness over vertebrae
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EXAMINATION OF GENITALIA AFTER PERMISSION Comment on descended testes and if any ambiguity

Chest Examination
STEP/TASK CASES Getting Ready: 1. Wash your hands. 2. Stand to the right of the patients bed 3. Prepare your stethoscope with bell (cone) and diaphragm 4. Explain the procedure to the patient. 5. Be sure that your hands are warm if not, rub your hands. 6. Put the patient in sitting position first. 7. Ensure good lighting. Position of the Trachea by Inspection and Palpation: Place the patients chin in neutral position. Examine from the front. Gently thrust the index or the middle finger into the suprasternal notch exactly in the midline and try to feel both the sides of the trachea. NB.(If the finger moves more easily to one side than the other; it means that the trachea is shifted to the opposite side). Examination of the Chest Anteriorly: Inspection: 1. Put the patient in supine position. 2. Expose the chest well. 3. Always compare both sides. 4. Examine the chest wall from front, sides (tangentially) and from foot end. Comment on: o Respiratory rate o Shape of the chest o Symmetry of the chest wall o Respiratory movements during deep breathing o Contraction of accessory muscles of respiration (alae nasi, sternomastoids, scalenii, trapezii and intercostal muscles). o Breasts; Tanner stage. o Swelling at the costochondral junctions or elsewhere. Palpation: 1. Ask the patients to take deep breath. 2. Ask patient to repeat four-four in Arabic or Nine -Nine in English.

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3. Use the palm of the hand. 4. Palpate all areas sequentially (three levels anteriorly; infraclavicular, mammary and inframammary and two areas laterally; upper axilla and lower axilla). 5. Compare the corresponding area of the opposite side. Comment on: o Chest movement and expansion o Palpable wheeze o Chest expansion o TVF(tactile vocal fremitus); Percussion: 1. Place your left hand on the right side of the chest wall with pleximeter parallel to the border being percussed. 2. Strike the center of the second phalanx of the middle finger (plessor) sharply with the tip of the pad of the right middle finger with the movement coming from the wrist joint 3. Start from resonant to dull area. Comment on: Any area of dullness(dull or stony dull) or hyperresonance over the lung fields Auscultation: 1. Use the bell (cone) in small children and with the diaphragm in older children. 2. Ask the patient to breathe deeply with his/her mouth kept wide open. 3. Auscultate all areas of the lungs anteriorly and laterally. 4. Always compare both sides. 5. Ask patient to cough during auscultation. 6. Ask the patient to say four four in Arabic repeatedly (VR) or nine nine in English. 7. Auscultate all areas sequentially. 8. Immediately compare the corresponding area of the opposite side. Comment on: Type of breath sound (bronchovesicular or bronchial) Adventitious sounds as rub or rhonchi (sibilant or sonorous) Normal, increased or decreased vocal resonance. Presence of bronchophony, whispering pectoriloquy NB: Normal breath sounds are bronchovesicular and inspiration is twice as long as expiration in young children; breath sounds are vesicular and inspiration is three times as long as expiration in older children. Examination of the chest posteriorly: Inspection:
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Comment on: as mentioned anteriorly + Deformity of the spine (kyphosis, lordosis or scoliosis) Palpation: Comment: as mentioned anteriorly Percussion: Comment: as mentioned anteriorly Auscultaion: Comment: as mentioned anteriorly Post procedure: 1- Wash your hands or use antiseptic gel 2- Explain results to the patient if appropriate 3- Record them on a notepad

Cardiac Examination
STEP/TASK CASES Getting ready: 1- Wash your hands or use antiseptic gel. 2- Stand to the right of the patients bed. 3- Explain procedure to the patient 4- Prepare a stethoscope with bell and diaphragm 5- Be sure your hands are warm, if not, rub your hands 6- Put the patient is in supine position or semi sitting if he is orthopenic . 7- Ensure good Light. 8- Expose the patient's chest well and neck. Inspection of the precordium: 1. Look tangentially from the foot end of the patient for precordial bulge. 2. Look tangentially, from the side of the patient for apical pulsation and other pulsations in: Suprasternal area, Aortic area, Pulmonary area, Parasternal area, Epigastrium 3. Comment on: Precordial bulge or any other thoracic cage abnormalities Site of apex beat Other pulsations : as Pulmonary area Parasternal area Epigastrium Palpation of the precordium: 1. Palpate apex by palmar surface of the hand. 2. Localize the apex (the lowermost outermost powerful pulsation) with the tip of your index finger.

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3. Palpate other cardiac areas 4. Comment on:

A- Apex: Site Character Thrill Palpable gallop Dullness outside the apex as a sign of pericardial fluid B-Palpable diastolic shock C-Parasternal thrill or heave D-Epigastric pulsations E- Carotid pulsations and thrills Auscultation of the precordium: 1. First auscultate mitral area= apex (fifth left intercostal space). 2. Then auscultate at the axilla. 3. Then auscultate at tricuspid area (lower left sternal border). 4. Then auscultate at the left sternal border. 5. Then auscultate at the second aortic area (third left intercostal space). 6. Then auscultate at the pulmonary area (second left intercostal space). 7. Then auscultate at the first aortic area (second right intercostal space). 8. Move the stethoscope to the neck 9. Move the stethoscope to the interscapular region Some tips 1. Detect timing with the carotid pulse. 1. 2. 3. 4. 2. Use the diaphragm for high pitched sounds (S1, S2, MR, AR and rub). 5. 6. 7. 8. 3. Use the cone (bell) for low pitched sounds (S3, S4 and MS). 9. 10. 1. 2. 1 1 4. Ask the patient to roll onto his left side and auscultate the apex with the 13.ii.iii. i. bell. 5. Ask the patient to sit up, lean forward, exhale completely and hold iv. v.vi. ii. v breath in expiration. Listen to aortic areas down the left sternal border to the apex. 6. While the patient is sitting evaluate the splitting of the second sound inviii.ix. x.xi. the pulmonary area (second left intercostal space) Comment on: A- First and second heart sounds B- Additional sounds (third and forth heart sounds, opening snap of mitral stenosis, ejection click of aortic stenosis; midsystolic click of mitral valve prolapse). C- Presence of murmur. If present comment on: Timing : systolic or diastolic
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Character: early systolic, pansystolic, decrescendo, ejection Site of maximum intensity Propagation Pitch: soft, harsh, musical Intensity and grade

Neurologic Examination
Getting Ready: Establish rapport with the patient Explain the procedure to the patient Ask the patient to tell if any pain or embarrassment is caused by the examination Ask the patient to expose the area of examination Compare opposite sides Compare distal and proximal sites Record findings at the end of the procedure Wash hands and maintain proper infection prevention practices. Prepare hammer, pin and cotton piece I- Mental Status Examination A. Appearance: B. Movements: (gait, posture, coordination, eye movement and facial expression) C. Level of Alertness: Apply Glasgow Coma Score( modified one for children) D. Orientation (Awareness of the Environment) E. Speech: II- Sensory Examination (In a young child or uncooperative patients, it is often only possibly to comment that the patient could appreciate pain at the tested dermatomes (Bear in mind the sensory segmental dermatomes). 1. Superficial sensation A. Pain 1. Use a suitable object to test "sharp" or "dull" sensation ( an object that has a sharp part and a dull part as a sharp pin with large head 2. Compare both sides 3. Compare from above down (sensory level) 4. Examine around the trunk or limb in levels B. Touch C. Temperature 2. Deep sensation A. Pressure Sense B. Vibration Sense C. Joint sense (joint movement and joint position): With the patient's eyes
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closed ask the patient to identify the direction you move the toe/finger 3. Cortical Sensation: Tactile Localization, Tactile Discrimination and Stereogenesis {Tactile Localization: Ask the patient to localize one point of pin prick} {Stereogenesis: Ask the patient to close eyes. Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.). Ask the patient to tell you what it is} III- Motor Examination 1. Examine and observe: Muscle state involuntary movement or fasciculation 2. Examination of the muscle tone: Ask the patient to relax and not attempt active movement (Wait till a young or uncooperative patient is relaxed and not fighting you) Flex and extend the patient's fingers, wrist, elbow, and shoulder. Flex and extend patient's ankle, knee & hip. There is normally a small, continuous resistance to passive movement Elicit postural reactions: Traction response, vertical and horizontal suspension in young infants Observe for decreased (flaccid) or increased (rigid/spastic) tone Comment on trunkal and appendicular tone and distribution of tone changes. 3. Examination of the muscle power: Test strength by having the patient move against your resistance Examine power of muscle around all joints 4. Deep reflexes a. Ensure that the patient is relaxed and positioned properly before starting b. Reflex response depends on the force of your stimulus. c. Reflexes are either normal, hypo or hyper d. Examine the following reflexes The brachioradialis reflex (C5,6) The triceps reflex (C6,7) 1. Support the upper arm and let the patient's forearm hang free 2. Strike the triceps tendon above the elbow with the broad side of the hammer 3. If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest 4. Watch for contraction of the triceps The biceps reflex (C5,6) 1. The patient's arm should be partially flexed at the elbow (120 degree)

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with the palm down 2. Place your left index finger firmly on the biceps tendon 3. Strike your finger with the reflex hammer 4. You should feel the response even if you can't see it The knee jerk reflex (L2, L3, L4) 1. Ask the patient to allow the leg to hang down, or to cross the leg to be examined over the other leg (thighs must be exposed). 2. Alternatively, Support the half bent knee on your left arm, while the patient is supine 3. Tap the tendon of the quadriceps just below the patella with the hammer 4. Note contraction of the quadriceps and extension of the knee The ankle jerk reflex (S1, S2) 1. Put ankle over the other leg with slight ankle dorsiflexion and eversion (with the other hand). 2. With the hammer in the other hand & swing it to hit the Achilles tendon 3. Watch and feel for plantar flexion at the ankle The ankle clonus (S1, S2) 1. Support the knee in a partly flexed position 2. With the patient relaxed, quickly dorsiflex the foot 3. Observe for rhythmic oscillations of the patient's foot 5. Superficial reflexes Insure that the patient is relaxed before starting Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth) Use a blunt object such as a key or tongue blade The abdominal skin reflex (T8, T9, T10, T11, T12) 1. Strike the abdominal skin rapidly and not too hard with a needle from the side to the middle at three levels 2. Note the contractions of the abdominal muscles and deviation of the umbilicus towards the stimulus (degree and symmetry). The Planter reflex (S1, 2) 1. Expose the patients feet 2. Press the lower leg against the table. 3. With a blunt object strike the lateral edge of the sole of the foot from the heel to the base of big toe, heavily, steadily and slowly 4. Note movement of the toes, normally flexion (withdrawal) 6. Tests for coordination (Occasionally in a young or uncooperative patient you can only comment on presence of tremor on reaching for objects). Standing: Check whether he could remain straight with eyes opened then with eyes closed.

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 Walking: comment on type of gait

Finger-to-nose test 1. Ask the patient to stretch one arm out 2. Ask the patient to close his\her eyes 3. Ask the patient to bring the index finger to the tip of the nose knee-heel test IV- Cranial Nerves Examination 1- Olfactory nerves (CN 1)(may not be needed and difficult in very young patients) 2- Optic nerve (CN 2) (you can get the help of an ophthalmologist in some cases) Visual acuity: Visual field Stand 50 cm in front of the patient and at the same level Ask the patient to look directly and fix his eyes into your eyes Cover non-tested eyes Use small object (or index finger) and place it half distance between you and the patient and beyond limits of field of vision Advance the object (while moving) from outwards inwards Test the four quadrants (upper nasal, lower nasal, upper temporal, and lower temporal) Repeat for the other eye Pupillary reflex Shine a bright light obliquely into each pupil in turn Look for the change of pupil size in the same eye (direct reflex) Record pupil size and any asymmetry or irregularity 3- Oculomotor, trochlear and abducent nerves (CN 3, 4 and 6) Look for ptosis Squint Nystagmus Pupillary reflex 4- Trigeminal nerve (CN 5 ): Organize your approach into three categories: Motor 1. Palpate the temporalis and massetter muscles bilaterally 2. Ask the patient to open his/her mouth then against resistance from your hands placed below the chin 3. Notice any deviation of the mandible Sensory: facial sensation Reflexes: Jaw jerk 1. Ask patient to hang the jaw freely (while eyes are closed). 2. Place your left index finger on the chin of the Patient

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3. Tap your finger by a hammer 4. Look for jaw closure 5- Facial nerve(CN 7) (In young or uncooperative patients you may only be able to

comment on the facial weakness or asymmetry) Organize your approach into two procedures: Motor 1. Inspect the face for symmetry 2. Ask Patient to do the following, note any lag, weakness, or asymmetry: Close both eyes tightly against resistance Smile Show teeth Blow his cheeks Sensory 6- Acoustic nerve (CN 8) Organize your approach into three procedures: Hearing testing: Voice test 1 Stand beside the patient at a distance of about 50 cm 2. Whisper at very low voice 3. Ask the patient to repeat what is said 4.Compare both sides 7- Glossopharyngeal and vagus nerves= 9, 10 Comment on voice Comment Deglutition Palatal reflex 1. Advance the torch with the tongue depressor in the patient mouth so that you press the tongue and see the pharynx clearly 2. Notice the position of the uvula if it is central or deviated to one side Gag reflex 1. With the other tongue depressor in your left hand touch the posterior pharyngeal wall 2. Comment if the patient gags or not 8- Accessory nerve= 11 Examine trapezius and sternomastoid 1. Stand behind the patient while he is sitting on a chair 2. look for atrophy or asymmetry of the trapezius muscles 3. Place your hands over both shoulders 4. Ask the patient to elevate shoulders against resistance, and palpate the trapezius in both sides 5. Place your hands so that the right hand is pushing the right side of the
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patient mandible, and the left hand is palpating the patient's right sterno- mastoid muscle 6. Ask the patient to push against you right hand and test the muscle for power 7. Replace hands, to test for the other sternomastoid muscle 9- Hypoglossal nerve =12 Ask the patient to protrude the tongue and observe deviation

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