Pediatrics Examination ( Part 2 )

Physical Examination - Pediatrics Section

You must check the following given below in order to perfom your examination.

Environment

• Nebulizers, drugs on dresser.
• Special food, including sugar-free (DM).
• Mobility-assisting devices.
• Hospital equipment.

General appearance

• Pre-exam checklist: WIPE:
  • Wash your hands [thus warming them].
  • Introduce yourself to pt, explain what going to do.
  • Position pt [+/- on parent's knee].
  • Expose area as needed [parent should undress].
• Examine from the R side of the pt.
• Posture, body positions, body shape.
• Skin colors. See Skin Colors Exam ( find this thread in STEP - 3 )
• Hydration.
• Dress, hygiene.
• Alertness, happiness.
• Crying: high-pitched vs. normal.
• Any unusual behavior.
• Parent-child interaction, reaction to someone new walking entering the room (child abuse).
• Ask if tenderness anywhere, before start touching them.
• If asleep, do the heart, lungs and abdomen first.

Arms, vital signs

• Nails: See Nails Exam ( find this thread in STEP - 3 )
• Hands:
  • Clinical hand signs.
  • Color, warmth.
• Radial pulse.
• Femoral pulse.
• BP.
• Temperature.
• See Taking Pediatric Vital Signs Exam ( find this thread in STEP - 3 )
• Axillary lymph nodes.

Heart

• Inspection:
  • Precordial bulge.
  • Apical heave.
• Palpation:
  • Apex beat location.
  • Thrills, heaves.
• Auscultation:
  • Site, radiation.
  • Pitch, quality, character.
  • Intensity, rhythm, duration.
  • Changes with respiration, posture.
  • Carotid bruits.
• See Pediatric Heart Exam ( find this thread in STEP - 3 )

Lungs

• Inspection:
  • Spinal curvature.
  • Tanner stage (female). See Tanner Stages Exam ( find this thread in STEP - 3 )
  • Accessory muscles of respiration [respiratory pattern is abdominal <6yrs].
  • Intercostal respiration (respiratory obstruction).
• Palpation
  • Fremitus
• Percussion:
  • Dull and resonant areas.
• Auscultation:
  • Crackles.
  • Wheeze.

Abdomen

• Inspection:
  • Shape.
  • Visible swellings, hernias.
  • Umbilicus, veins.
  • Visible peristalsis.
• Percussion [often optional]:
  • Fluid wave, shifting dullness.
  • Liver, spleen.
• Palpation:
  • Masses.
  • Areas of ternderness, rebound, guarding.
  • Liver, spleen: <6 years may palpate up to 2cm below costal margin.
  • Kidneys, bladder.
• Auscultation:
  • Bowel sounds.

Diaper, genitalia, anus

• Only perform when indicated.
• Diaper:
  • Inspect contents.
  • Have MSU bottle ready if indicated.
• Male:
  • Testes decent, hernias.
  • Circumcision, testes, hydrocele.
• Female:
  • Vulva, clitoris.
• Both sexes:
  • Discharge.
  • Abnormalities.
  • Tanner stage.
• Anus inspection:
  • Hemorrhoids, fissures, prolapse.
  • Sphincter tone, tenderness, mass.
  • PR exam isn't done on children.

Legs, feet

• Infants: hip abduction in infants with knees flexed.
• Feet abnormalities, such as rocker-bottom feet.
• Similar signs as seen in hands, nails.

Nervous

• Can often skip these, as should already have good idea by now.
• Abnormalities during play.
• Limbs: movement, tone, limp, Gower's sign.
• Head control.
• Reflexes:
  • Moro and tonic neck reflexes <3months.
  • Babinski's sign positive <12-15 months.
  • Hypertonicity commonly is normal infants, but hypotonicity is abnormal.
  • Other reflexes: grasp, suck, root, stepping and placing.
• Meningitis signs if indicated: Kernig, Brudzinski.

Integumental

• Rashes, using proper terminology.
• See Hallmark Rashes Exam ( find this thread in STEP - 3 )
• See Skin Lesion Terminology Exam ( find this thread in STEP - 3 )

Head and neck

• Head circumference, rate of growth.
• Head asymmetry, microcephaly, macrocephaly, other visible abnormalities.
• Fontanelle, if <18 months:
  • Full vs. flat vs. depressed.

• Thyroid enlargement, other lumps.
• Neck stiffness.
• Neck lymph nodes: location, size in cm, tenderness, consistency.

Eyes

• Exam position: mother holds child on lap facing forward, one arm encircling child's arms, the other hand on child's forehead.
• Pupils: reaction to light, accommodation.
• Strabismus [aka squint].
  • Strabismus is normal before 4-6 months.
• Photophobia, proptosis, sclerae, conjunctivae, ptosis, congenital cataracts.
• Fundoscopy. See Eye Exam ( find this thread in STEP - 3 )

Ears

• Exam position: same as eye, but child faces the side.
• Discharge, canals, external ear tenderness.
• Test hearing.
• Otoscope to examine ear drums.

Nose

• Nares patency, septum, nasal flaring.
• Discharge, mucous membranes, sinus tenderness.

Throat

• Breath odor.
• Lips: color, fissures and dryness.
• Tongue.
• Teeth: number, arrangement, dental caries.
• Gums: color, hypertrophy (phenytoin)
• Throat: epiglottis
• Tonsils: size, signs of inflammation.

Height, weight

• Measure and plot on appropriate centile chart.

Examination tips

• Can establish rapport while checking cyanosis, dyspnea, cough.
  • Can examine teddy bear first.
• Best examination method by age:
  • Neonates, very young infants: on examining table
  • Up through preschool: lying sit on mother's lap
  • Adolescent: without family present.
• Parent, not examiner, should undress a small child.
• Kids are impatient, so a systematic full examination may get difficult. Examine the most pertinent area first.
• Record respiratory rate first, before crying starts.
• In child, breath sounds are easier to hear, but harder to localize.
• ENT exam more likely to induce a cry so these go last.
• Opportunism:
  • If child dozes, auscultation heart.
  • While parent removes shirt, examine shoulder/arm movement, head control.
  • If child kicks examiner, observe hip range of motion.
  • If cries, the deep breaths between each cry can reveal rales with stethoscope.