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UPSC MainsMEDICAL-SCIENCE-PAPER-II20185 Marks
Q10.

Which physical examination findings would help you to arrive at diagnosis in this child?

How to Approach

This question requires a systematic approach to outlining the key physical examination findings that would aid in diagnosing a pediatric case. The answer should be structured around a head-to-toe examination approach, detailing what to look for in each system. It's crucial to link each finding to potential diagnoses, demonstrating clinical reasoning. The response should be comprehensive, covering vital signs, general appearance, and specific system examinations.

Model Answer

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Introduction

A thorough physical examination is the cornerstone of pediatric diagnosis. Children often present with non-specific symptoms, making a detailed and systematic examination crucial for identifying underlying pathology. The examination should be age-appropriate and tailored to the presenting complaint, but a complete assessment from general appearance to neurological function is often necessary. This response will outline the key physical examination findings, organized by system, that would be helpful in arriving at a diagnosis in a pediatric patient.

I. General Appearance & Vital Signs

The initial assessment begins with observing the child’s general appearance. This includes assessing their level of consciousness, distress, nutritional status, and any obvious signs of illness. Vital signs – temperature, heart rate, respiratory rate, and blood pressure – are fundamental. Deviations from normal ranges can indicate significant pathology.

  • Level of Consciousness: Altered mental status (lethargy, irritability, confusion) suggests neurological issues, infection, or metabolic disturbances.
  • Respiratory Distress: Nasal flaring, retractions, grunting, and cyanosis indicate respiratory compromise.
  • Nutritional Status: Evidence of malnutrition (wasting, stunting) can point to chronic illness or inadequate intake.
  • Temperature: Fever suggests infection; hypothermia can indicate sepsis or exposure.
  • Heart Rate: Tachycardia can be due to fever, dehydration, or cardiac issues; bradycardia may indicate hypothermia or certain medications.
  • Respiratory Rate: Tachypnea suggests respiratory distress; bradypnea can indicate central nervous system depression.
  • Blood Pressure: Hypotension can indicate shock; hypertension may suggest renal disease or coarctation of the aorta.

II. Head, Eyes, Ears, Nose, and Throat (HEENT)

A detailed HEENT examination can reveal clues to various conditions.

  • Head: Palpate for fontanelles (if present) – bulging or sunken fontanelles can indicate increased intracranial pressure or dehydration, respectively.
  • Eyes: Assess pupillary response to light (PERRLA), conjunctival pallor (suggests anemia), scleral icterus (suggests jaundice), and fundoscopic examination (to evaluate the optic disc and retina).
  • Ears: Otoscopic examination to assess the tympanic membrane – redness, bulging, or effusion suggests otitis media.
  • Nose: Assess for nasal discharge (color, consistency), nasal flaring (respiratory distress), and patency of nasal passages.
  • Throat: Examine for pharyngeal erythema, tonsillar enlargement, exudates (suggests streptococcal pharyngitis), and presence of ulcers.

III. Cardiovascular System

Auscultation of the heart is crucial.

  • Heart Sounds: Murmurs can indicate congenital heart defects or valve abnormalities. Gallops (S3 or S4) suggest heart failure.
  • Pulses: Assess the strength and symmetry of peripheral pulses (radial, femoral, dorsalis pedis). Weak or absent pulses can indicate peripheral vascular disease or shock.
  • Capillary Refill: Prolonged capillary refill (>2 seconds) suggests poor perfusion.
  • Precordial Bulge: Suggests cardiomegaly.

IV. Respiratory System

Auscultation and observation are key.

  • Breath Sounds: Wheezes suggest asthma or bronchiolitis; crackles suggest pneumonia or pulmonary edema; diminished breath sounds suggest airway obstruction.
  • Work of Breathing: Observe for nasal flaring, retractions, and use of accessory muscles.
  • Percussion: Dullness to percussion suggests consolidation (pneumonia) or pleural effusion.

V. Abdomen

Palpation and auscultation are important.

  • Palpation: Assess for tenderness, guarding, rigidity, and organomegaly (hepatomegaly, splenomegaly).
  • Auscultation: Bowel sounds – absent or diminished bowel sounds suggest ileus; hyperactive bowel sounds suggest gastroenteritis.
  • Masses: Palpable abdominal masses require further investigation.

VI. Neurological System

A comprehensive neurological exam is essential.

  • Mental Status: Assess level of consciousness, orientation, and cognitive function.
  • Cranial Nerves: Test cranial nerve function (e.g., pupillary response, facial symmetry, gag reflex).
  • Motor Strength: Assess muscle strength in all extremities.
  • Sensory Function: Assess sensation to light touch, pain, and temperature.
  • Reflexes: Test deep tendon reflexes (biceps, triceps, patellar, Achilles).
  • Cerebellar Function: Assess coordination and gait.

VII. Skin

Skin findings can be diagnostic.

  • Rash: Characterize the rash (type, distribution, morphology) – can indicate viral or bacterial infections, allergic reactions, or autoimmune diseases.
  • Jaundice: Yellowing of the skin and sclera suggests liver disease or hemolysis.
  • Petechiae/Purpura: Small, non-blanching red or purple spots suggest thrombocytopenia or vasculitis.
  • Dehydration Signs: Poor skin turgor, dry mucous membranes.

Conclusion

In conclusion, a systematic physical examination, encompassing vital signs, general appearance, and a thorough system-by-system assessment, is paramount in pediatric diagnosis. Each finding must be carefully interpreted in the context of the child’s history and age. The findings outlined above provide a framework for identifying potential diagnoses and guiding further investigations. A skilled clinician will integrate these observations to formulate a differential diagnosis and initiate appropriate management.

Answer Length

This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.

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Additional Resources

Key Definitions

Jaundice
Yellow discoloration of the skin and sclera caused by elevated bilirubin levels in the blood. It can be physiological (normal in newborns) or pathological (indicating underlying liver disease or hemolysis).

Key Statistics

Approximately 1 in 2000 babies are born with congenital heart defects (CHD) annually in the United States.

Source: Centers for Disease Control and Prevention (CDC), 2023 (Knowledge Cutoff)

Globally, pneumonia is the leading infectious cause of death in children under 5 years of age, accounting for nearly 15% of all deaths in this age group.

Source: World Health Organization (WHO), 2024 (Knowledge Cutoff)

Examples

Kawasaki Disease

A child presenting with fever, rash, conjunctivitis, strawberry tongue, and swollen lymph nodes should raise suspicion for Kawasaki Disease, requiring prompt diagnosis and treatment to prevent cardiac complications.

Frequently Asked Questions

▶What is the significance of clubbing of the fingers in a child?

Clubbing of the fingers (increased angle of the nail bed) is often associated with chronic hypoxia, such as that seen in congenital heart disease or cystic fibrosis.

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