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Diagnostic methods are a basic way in diagnosis and disease-related information collection.As other clinical disciplines,diagnosis of pediatric diseases also adopts inspection,listening and smelling,inquiring and pulse taking for diagnosis and differentiation.Because of differences from adults in physique,morphological,physiological and pathological aspects,the use of the four diagnostic methods in children are also different.
Inspection in pediatrics should be carried out in the place with plenty of light,with the child quiet,inspection comprehensive and focused,attentive and agile,so the examination results can be improved.
It refers to inspect the facial complexion of children. Shen (spirit 神) is the manifestation of the internal activities of the human body.Every child with shen (full vitality) shows bright eyes,lively expression,clear consciousness,smooth even breath,quick reaction,flexible and coordinately body movements,and otherwise,it is a lack of vitality or no spirit.
a.Normal complexion Normal complexion of Chinese infants is yellowish red and shiny,and the skin of newborns is always soft red,which means qi and blood in harmony.
b.Five colors connecting with the manifestations of diseases When children are ill,their complexion changes are more sensitive than that of adults.Usually,diagnosis is carried out according to the five colors,blue,red,yellow,white and black,which generally meet the following rules.
A bluish complexion indicates patterns of cold,pain,stasis,or fright epilepsy.If an infant with a bluish complexion,the illness is always severe.A red facial complexion indicates a heat pattern; a sallow yellow complexion mostly belongs to spleen deficiency or dampness patterns.Jaundice in newborns is neonatal yellow,physiologically and pathologically.A white complexion belongs to patterns of deficiency and cold; a black face belongs to patterns of cold,pain,stasis or fluid-retention.
It is to observe the body shape and strength,the skin and hair and the static posture so to infer the rise and fall of five zang organs,qi and blood,yin and yang.
a.Body shape In normal developing children there are strong bones and tendons,fullgrown muscles,moist skin,lustrous hair and lively body posture,which indicates that their general well-being is healthy with congenital sufficiency and adequate nourishment.If there is retarded growth,then the bones and tendons are fragile,the muscles are lean and the body is thin and weak with dry skin,lusterless hair,failure of the fontanelle to close at the right age,and dull sluggish gestures.These manifestations all indicate congenital insufficiency and malnutrition.Inspecting the fontanelle: square-shaped head with thin hair and wide fontanelles that fail to close at the right time may be considered as the five retardations; a hollow anterior fontanelle and eye sockets,as well as dry skin are often seen in young children with diarrhea leading to yin damage and body fluid desertion.Inspecting the body: the thoracic cage pointing forward and towering like a chicken’s chest is common in rickets’ rachitic chest or asthma.Inspecting the limbs: muscular relaxation and a sallow yellow skin are manifestations of anorexia,food preferences or repeated cold.Inspecting muscle and skin:an enlarged abdomen and a slim weak body shape with thin hair and visible blue veins on the forehead are common in infantile malnutrition with accumulation.Inspecting the hair: sparse and thin yellow hair or easy falling out commonly indicate qi and blood deficiency.
b.Dynamic state Preferring to lie on the stomach indicates milk and food stagnation.If a child is lying down and curled up,he or she is most likely to have abdominal pain.Convulsions manifest as opisthotonos with a stiff neck,opening and closing of the fingers,and stiffness and spasms of the four limbs.Restlessness and rolling over,crying and covering the abdomen with both hands are generally caused by intestinal colic.Sitting upright with shortness of breath,wheezing and dyspnea usually indicates asthma.Cough with counterflow qi ascent,flaring of the nostrils,and shortness of breath with retracted intercostals are common indications of pneumonia.
Orifices refer to the mouth,tongue,eyes,nose,ears,genital organs and anus.
a.Eyes The pupils and irises of the eyes are equally round and the eyes are bright,and the eyeballs are flexible with smooth opening and closing,which reflects sufficient qi and blood of the liver and kidney.Pale color of conjunctiva is related to blood deficiency; if the white part of the eyes is yellow,this is jaundice; painful red and swollen eyes are caused by wind-fire attacking upwards.Swelling eyelids indicates intermingling of wind and water; if there are sunken eye orbit sockets and the child is crying without tears,this is a sign of yin and body fluid exhaustion.If the eyelids are too weak to open and close,this indicates that the original qi is deficient or exhausted.Sleeping with open eyes indicates kidney deficiency.If the eyes look dull and the eyeballs move slowly,this indicates kidney essence insufficiency; if the eyes look straight ahead and stare with little movements,this is caused by liver wind stirring internally; if the pupils are contracted,dilated or vary in size,and have no reaction to light,this indicates a critical condition.
b.Nose If there is nasal congestion with a clear discharge,this is an affection of exotenous wind-cold; if the nasal discharge is yellow and thick,this is wind-heat attacking the lung; if the nasal discharge is thick with a putrid smell like rotten fish over a long period of time,this is lung channel heat constraint; if the nasal discharge is clear with repeated sneezes when getting up or against wind,this indicates wind-phlegm accumulated in lung; if there is a bloody nose with bright red blood,this is lung heat forcing the reckless flow of blood; if the nostrils are dry,this is lung channel dryness-heat damaging yin; flaring nostrils accompanied by shortness of breath and wheezing indicates lung qi stagnation and blockage; frequently sniffing,blinking and grinning indicates excessive wind of liver channel.
c.Mouth Red lips is caused by heat; reddish-purple lips indicates and the intermingling of heat and stagnation; light red lips indicates deficiency-cold; pale lips indicates qi and blood insufficiency; light blue lips is a prodrome of infantile convulsion; when there are flushed cheeks but the area around the mouth is pale,this is one of the manifestations of scarlet fever.
Oral cavity ulceration and erosion result from accumulated heat in the heart and spleen.Red oral herpes is affected by exogenous pathogens; white scaly patches inside the mouth may occur as a result of thrush.Small red spots with off-white pinpoint centers on the inside of the cheeks are the manifestations of a measles mucous patch.
Delayed teeth development is associated with kidney qi insufficiency; gum bleeding and pain is common in patterns of stomach fire flaming upwards; red swollen gums are caused by stomach heat fumigating.New-borns often have small white patches on the gums which are known as “horse teeth” and are not diseased.
A red pharynx,fever and aversion to cold are the signs of an external contraction pattern; a red pharynx and tonsillitis with swelling and pain are due to externally contracted wind-heat or lung and stomach fire flaming upwards; tonsillitis with pus indicate heat accumulation with fragments of dead tissue;enlarged tonsils without redness are common when there is an incomplete clearance of stasis heat or deficient qi fails to astringe fluids.A slightly red,sore throat with a soft gray membrane formed across the throat that is not easy to wipe away is a manifestation of diphtheria.A red or even rotten pharynx,with punctiform rashes or bleeding points on the soft palate,is known as a mucosal eruption,commonly in scarlet fever.
d.Tongue A normal healthy tongue of a child is soft,flexible,light red and moist,with a moderately moist and thin coating on the top.A child’s tongue body is more tender and red than that of an adult.Newborn infants have a red tongue without coating,and breastfed babies have a milk-white coating that is considered as normal.
Tongue body A fat and tender tongue indicates spleen qi insufficiency; a swelling,dark purple tongue indicates qi and blood stagnation and stasis; a distending and red tongue indicates excessive heat in heart and spleen; a prickly tongue indicates the pattern of heat entering nutrient-blood; a crazing tongue indicates yin-fluid damage and exhaustion.
Tongue proper A pale white tongue indicates qi and blood insufficiency due to deficiency and cold; a red tongue indicates patterns of heat; a red and dry tongue indicates yin-fluid damaged by heat; a red tip indicates warm diseases of upper-energizer or heart fire flaring up; red margins of a tongue indicate heat in liver and gall; soft-red accompanied with dryness indicates heat and yin deficiency; a crimson tongue indicates heat entering nutrient-blood,intermingling of stagnation and heat; dark purple-red indicates stagnation of blood and heat; dark purple indicates stagnation of qi blood stasis.
Tongue coating Thin coating indicates a normal or light condition,e.g.the beginning of exogenous diseases; thickness indicates illness in the interior or severe condition,e.g.dyspepsia and dampness-phlegm pattern;moist,dampness stagnation; dry,fluid damage; sticky and greasy,phlegm dampness; rotten curd-like,the turbid in stomach;white,normal condition or cold-dampness;thin and white,affection of exogenous windcold or beginning of wind heat; white and greasy,internal accumulation of phlegm dampness; thin and yellow,wind heat affecting exterior or wind-cold transforming into heat or pathogenic heat entering interior; yellow and greasy,dampness-heat in spleen and stomach or phlegm heat; gray and moist,retention of phlegm dampness; pale and bulgy,qi deficiency of spleen and stomach;little and geographical,qi-yin insufficiency of stomach.
When observing the tongue coating,attention should be paid to its dynamic changes.If a light red tongue is changing to red or crimson,it indicates a heat syndrome moving from a shallow level to the interior.If the tongue coating turns from white to yellow or to gray,it indicates a heat syndrome turning from a mild condition to a severe one.If the tongue coating starts to reappear after being absent,it indicates that stomach qi is gradually recovering.If the tongue coating turns from thin to thick,it indicates aggravation of a food accumulation and damp-stagnation pattern.If the tongue coating turns from thick to thin,it indicates that food accumulation and damp-stagnation are gradually disappearing.
e.Ears Pain inside the ears accompanied with oozing pus is the symptom of exuberant fire in the liver and gallbladder; mumps manifests as painful cheeks with general swelling centering on the earlobes.
f.Genital organs and anus A tight and steady scrotum is a symptom of health while a loose and lighter colored scrotum is a sign of morbid state.A swollen scrotum is an indication of a hydrocele; various sized shapes moving around inside the scrotum are the signs of an inguinal hernia which may contain parts of the bowel.If the vulva is flushed,hot and itchy,it is usually caused by dampheat pouring downward; if the anus of an infant is red,painful and moist,it is a common sign of diaper dermatitis,also known as“diaper rash”.If the anus drops in the rectum from its normal position,it is a rectal prolapse due to sinking of middle qi; anal cracks and bleeding are mostly caused by constipation.
Maculae and rashes are skin conditions.They are signs of a systemic disease reflected in the body surface,more common in pediatrics.
a.Maculae A macula is a relatively large spot that forms a continuous extended area without protruding from the skin; it does not fade when pressed.If the maculae are bright red,neither respond to touch nor fade when pressed,it is common in heat toxin exuberance affecting nutrient-blood; if the maculae are pale purple with pale complexion,cold limbs and thready pulse,it is common when qi fails to control blood,and blood oozes from orifices.
b.Rashes A rash is an abundance of relatively small spots which protrude from the skin and fade when pressed.If measles mucous patches appear in the mouth or on the inside of the cheeks 3–4 days after a fever with small rashes about the size of sesame seeds,this is measles; small reddish rashes with a slight fever is likely to be rubella; if there is a high fever with red skin and a densely widespread scarlet rash accompanied by a crimson strawberry-like tongue,it is usually scarlet fever; papulae and herpes scabs existing together with clear fluid inside the blisters is common in chickenpox; herpes in palms,toes and throats is commonly seen in hand-food-mouth disease; maculopapular rashes in different sizes with unbearable itching appear and disappear like clouds,which is commonly seen in urticaria.
The stools of breastfeeding infants are frequent,egg-yolk yellow,loose and thin with a sour odor and little-undigested milk clots; the stools of goat or cow’s milk fed children are dry and pale yellow with more undigested clots.Stools mixed with a sticky reddish-white jelly are common in dysentery due to damp-heat stagnation; stools of infants like fruit jam accompanied with bursts of crying often indicate intussusceptions; stools that are thin,loose and mixed with white curds are common when there are internal food and milk damage; grayish white but not yellow stools are commonly due to biliary block; difficult bowel movements accompanied by vomiting,abdominal pain,and palpable masses may often indicate obstruction of colon.Stools that are pale yellow,dry and hard are often caused by excess internal heat or fluid consumption due to dryness-heat;thin and loose stools with bubbles and slight smell are the intestine contracted by windcold; stools that are thin and loose,yellow and smelly indicate that there is damp-heat in intestines; thin and odorless stools indicate yang failing to warm the spleen and the spleen failing to transport and transform due to spleen qi deficiency; diarrhea with undigested food is due to spleen and kidney yang deficiency.
Urine that is clear and excessive is common in cold patterns,including external pathogenic cold or internal cold due to yang deficiency; urine that is yellow with a little volume is common in heat patterns,including fluid damaged by pathogenic heat or internal heat due to yin deficiency.Dark yellow urine stagnated heat accumulating internally; yellowish-brown urine like strong tea is due to jaundice with a damp-heat pathogen.If the urine is red or shows erythrocytosis under a microscope,it is hematuria,which may be caused by a variety of diseases.If crimson and freshred,it is blood heat moving recklessly; if light red,it is qi failing to control blood; if brownish-red,it is stagnated heat accumulating internally; if dark red,it is yin deficiency and blood heat.
The finger venule refers to the superficial veins of the radial arm of the index finger.Infant skin is thin and tender and finger venules are relatively clear and visible,so venule observation is often taken as part of the inspection for children under 3 years old.The finger venules are classified into three“passes” which are called the wind pass,the qi pass and the life pass.From the hǔ kǒu (虎口) at the root of the index finger to its tip,the first section from the root is the wind pass,the second section is the qi pass,and the third section (to the tip) is the life pass.When observing the finger venules,carry the child to a well-lit area.If observing the child’s right hand,the practitioner uses the index finger and the middle finger of his left hand to grip the child’s wrist joint,and uses his left thumb to fix the child’s index fingertip; to reveal the venules for observation,the other thumb pushes and gently presses from the finger life pass to the wind pass.If the left hand of the patient is diagnosed,it is contrary to the above.
Usually,the normal condition of the infantile finger venules is slightly purplish and faintly visible below the wind pass.If there are diseases,especially in critical conditions,then the finger venules can show the disease changes reflected in the colors at both superficial and deep levels at the different regions.Therefore,the finger venules has a certain reference value for the diagnosis and differentiation of diseases.
Chen Fei-xia pointed out in The Grand Compendium of Pediatrics (Yòu Yòu Jí Chéng ,幼幼集成) that superficial or deep one corresponds with exterior or interior patterns; red or purple colors indicate heat or cold; light or dark-stagnant venules reflect deficiency or excess patterns; the three passes indicate the severity of a disease.
Superficial or deep one corresponds with exterior or interior patterns: superficial means the finger venules are visible at the surface,which indicates that the pathogens are at the exterior.Deep means the finger venules are hiding inside and are not displayed at the surface,which indicates that the pathogens are interior.
Red or purple colors indicate heat or cold:Red venules are mostly due to cold patterns while purple venules to heat patterns.
Light or dark-stagnant venules reflect deficiency or excess patterns: Light-colored finger venules which move easily and smoothly when pushed indicate deficiency patterns;purple stagnated venules that respond slowly when pushed and slowly return to fullness indicate excess patterns.
The three passes indicate the severity: Finger venules appearing in the wind pass indicate that the pathogens have just arrived at the exterior and the disease is a mild one;when finger venules reach the qi pass,it indicates that the pathogens have entered the interior and the disease is more serious; when finger venules reach the life pass,it indicates pathogens have gone deep inside and the disease has become exacerbated; when finger venules reach the index finger tip with visible veins extending through all the passes towards the nail,the disease is critical.
The method of finger venules diagnosis has certain diagnostic significance in a clinic.When the finger venule manifestations are not in agreement with the pattern,then the presenting symptoms should take precedence.Changes in the finger venules are not generally notable when the disease is mild; in these cases,it is also possible to disregard the state of the finger venules and follow the symptoms pulse images.
Listening and smelling is a diagnostic method using auditory and olfactory senses,including two aspects: listening to the voice and smelling odors.
a.Crying Crying is the language of a baby and is a physiological instinct.Crying can be a physiological expression,a physical discomfort,and a variety of pathological manifestations.It is normal for an infant to cry loudly with sound and tears several times a day.Hunger,diaper wetting,excessive bandaging and other improper nursing care may lead to crying,so crying is not necessarily a morbid state.Diseases-caused crying is often sharp,suddenly slow and suddenly urgent,intermittent regardless of day and night.
b.Breathing sounds Normal children breathe evenly and smoothly.Coarse and strong breathing reflects excess-type external contraction or phlegm-heat accumulated in the lung; short breathing with wheezing sounds in the throat indicates phlegm blocking the airways; shortness of breath or even flaring of the nostrils with frequent coughing is due to a lung qi blockage and constraint;distressed breathing with a choking cough and a blue face without coughing is common when a foreign body is blocking the airways.The stethoscope can be used to listen to the breathing sounds instead of hearing with the ears.
c.Coughing Cough is one of the major symptoms of lung diseases.Dry coughs without phlegm or with scant thick sticky phlegm are mostly caused by dryness invading the lung or lung yin damage; clear and high pitched coughs with the noises of a blocked nose are mostly due to external contraction attacks; frequent coughs with thick and difficult to expectorate phlegm and gurgling with sputum are commonly due to phlegm-heat in the lung or a lung qi blockage; a hoarse cough like a dog barking is commonly seen in diphtheritis and acute laryngitis; constant coughs mostly at night,and coughing and vomiting accompanied by an echoing sound is typical of whooping cough.
Eructation with sour rotten odor is commonly due to infantile food stagnation; bad breath is usually due to retention of heat in the spleen and stomach; fishy and bloody breath is often seen in gum bleeding,or lung and stomach bleeding; fishy and foul snot with pus is mostly due to thick rhinorrhea;stools with sour foul odor are due to impairment by overeating; urination that is clear and long without an odor is due to spleen-kidney yang deficiency; sour and foul vomit is commonly due to food stagnation transforming into heat; if the vomit smells like stools,it is mostly due to qi blockage leading to stool ascending counter-flow.
Pediatric respondents to the inquiry are mostly parents,nursing staff or elderly children,and so attention should be paid to the following aspects.
1.Age It is very important to know the exact age of the children: exact days for newborns,exact months for children under the age of 2,exact years and months for children over two.
2.Pathogenetic Condition It includes the symptoms,the duration,changes during the process,any possible causes and treatments of the disease.Except main symptoms and concomitant symptoms,inquiry should also cover the child patient’s diet,urine and stools,sleeping.Chen Xiu-yuan of Qin Dynasty summed up the inquiries into “Song of Ten Inquiries”: Inquiry involves ten aspects — cold and fever,sweating,head and body,urine and stool,food and drink,chest and abdomen,deafness,thirsty,old illness and its causes.In addition to drugs and variation of a disease,women must be asked about the menstruation including menstruation delay,early menstruation,amenorrhoea,and hypermenorrhea.For child patients,inquiry should also cover whether they have the smallpox and measles.
3.Personal History Personal history includes the prenatal and birth history,feeding,growth and development,and vaccination.Prenatal and birth history mainly involves times of pregnancy and delivery,whether the delivery is full term,natural or difficult,whether there is the experience of abortion,delivery method,birthplace,the conditions at birth,as well as the mother’s nutritional and health condition during pregnancy.Feeding history includes feeding methods,supplementary food,weaning and conditions after weaning.For the elder infants,the inquiry should include habit of taking food and appetite.Growth and developmental history includes physical development and mental development,such as the time of being able to sit,stand,speak and walk as well as tooth eruption,fontanel closure,and also the weight and length growth.As to the elder children,the inquiry extends to cover the progress of psychology,behaviors and study.Inquiry of vaccination history means to ask when and what kind of vaccina-tions have been received,and the effect of these vaccinations.Besides,inquiry should also include the past medical history and relevant family history.
Pulse-taking and palpation are important methods for diagnosis of pediatric diseases.
Pulse-taking in children is different from that of adults.
● Methods: Because cùn kǒu (site for taking wrist pulse,寸口) is too short for three adult fingers,finger veinlet inspection with finger-feeling of pulse is used instead of pulse-taking for children under 3 years old.That is,the practitioner uses his or her thumb or index finger to press the three passes of cun , guan and chi under light,moderate and heavy strength of the finger to distinguish the variations of pulse: floating,middle or deep.
● Healthy children of different age groups have different pulse rates.The younger the age,the faster the pulse.Pay attention to moods which may have an effect on the pulse.
● The basic pulse manifestations of the infants are floating,deep,slow,rapid,forceful and forceless pulses which can be used to differentiate the exterior or interior,cold or heat,deficiency or excess syndrome of the disease.
● The clinical significance of pulse diagnosis should be treated according to different conditions of different age.When the pulse does not conform to the symptoms,the presenting symptoms should take precedence.
a.Head and fontanelle If a child’s fontanelle has delayed closure or the skull is not hardened enough with an elastic feeling when pressed,it is due to kidney qi insufficiency and a manifestation of poor development as is often seen in rickets; sunken fontanel is commonly caused by severe vomiting and diarrhea,loss of fluids and essence; a bulging fontanelle with a tense feeling is known as a bulging fontanelle,which is due to wind-fire and phlegm-heat moving upwards,ascendant hyperactivity of liver fire,and excessive heat generating wind.If the sutures of the skull are loose and the head is enlarged with a wide fontanelle,it is known as the metabolism,usually due to congenital kidney qi insufficiency or postnatal marrow heat bloating.
b.Neck and axilla In normal children,there are a few small green-pea-sized nodes(lymph nodes),which are movable without a tender feeling or pain,located in the neck and armpits.If the node enlarges with a hard texture and forms in a group of clusters,but it is pain and unmovable when pressed or there is tumefaction and scorching hot,it is due to phlegm-heat accumulation; if there is no pain when pressed,it is scrofulid.If the cheeks below the ears become swelling and painful,accompanied with masticatory obstacle,it is parotic swelling (mumps).
c.Chest and abdomen A forward protrusion of the breastbone with no pain when pressed is known as the pigeon chest; excessive outward curvature of the spine without pain when pressed is called tortoise back. Xū lǐ (虚里) is an ancient name for the heat apical-impulse on the left side of the chest and is the place where the pectoral qi assembles.Too strong and irregular impulse indicates pectoral qi leakage,and the condition is serious; too faint and not very obvious impulse indicates internal pectoral qi deficiency; too fast impulse accompanied with shortness of breath and flaring of the nostrils indicates an insufficient flow of pectoral qi and the condition is critical.
d.Four limbs Cold limbs often belongs to pattern of yang deficiency; feverishness in palms and soles usually belongs to internal heat due to yin deficiency and,or internal damage due to infantile dyspepsia; feverishness in dorsum of hands and the whole body are common in exterior patterns of external contraction; cold limbs during high fever is excessive heat causing cold; cold limbs with a pale complexion and pale lips usually belongs to patterns of deficiency-cold; cold limbs with red lips and red tongue are usually the heat pattern with pseudo-cold symptoms.
e.Skin Cold skin and profuse sweating is due to yang qi insufficiency; hot skin without sweating is due to heat retention in the interior; hot skin with profuse sweating is due to heat evaporation outside; dry skin without elasticity is due to fluid consumption by vomiting or diarrhea; skin that is swollen but follows the finger upward and returns to the initial state when pressed belongs to yang edema; skin that is swollen but cannot return to the initial state when pressed is yin edema.
The clinical significance of the data obtained by palpation should be determined according to the age characteristics.If the child is so young that it keeps crying during palpation,the signs obtained are inaccurate,which needs identifying.