The examination of an infant or child by a physician or nurse practitioner can accomplish several goals simultaneously. With children, as opposed to adults, the physical examination is often the first direct contact between the examiner and the patient, the history having been obtained primarily from a parent. Therefore one of the crucial outcomes of the examination is the relationship between the physician and the child. The quality and quantity of care plans and the child’s future attitude in medical settings will depend in part on this relationship. This chapter emphasizes approaches to examining children of different ages that will enhance the physician-child relationship.
The physician-parent relationship, which is initiated when the history is taken, can be strengthened during the physical examination if the practitioner takes a relaxed, gentle approach toward the child and, no less important, performs a thorough examination appropriate to the setting and the chief complaint. Parents develop trust in physicians in several ways, not the least of which is the consideration the practitioner shows for the child’s fears and the parents’ concern about a particular symptom or sign. For each organ system discussed in this chapter, the common symptoms for which physicians are consulted are linked to a suggested level of detail in performing a physical examination.
The physician must be sensitive to the potential for iatrogenic concerns initiated by the patient’s or the parent’s comments during the examination and should anticipate the child’s wondering, “What’s wrong with me?” and the parent’s worrying, “What did I do wrong?” Reactions such as these are very common. A thorough grounding in the normal stages of growth and development of the organ systems and the body as a whole allows the examining physician to respond to such questions by emphasizing the normal physical findings, as well as by interpreting abnormal findings in the context of normal developmental patterns. The description of each organ system in this chapter begins with important stages of growth and development, particularly specific steps that can be monitored by serial physical examinations. The characteristics of common physical abnormalities will be linked whenever possible to the child’s age and stage of growth. The physical examination has limited value as a screening mechanism for occult disease. Physical Examination as a Screening Tool) and has proved to be much less productive in detecting problems in schoolchildren than, for instance, a comprehensive history. In general, the physical examination of children confirms abnormalities suggested by the history, as well as normal growth and development. When the child is examined in the presence of one or both parents, the physical examination can provide strong clues about the strength and characteristics of the parent-child relationship.
Each portion of the physical examination is discussed according to the special characteristics of each of five age groups: (1) newborn period, (2) infancy (1 week to 12 months), (3) early childhood (1 through 5 years), (4) late childhood (6 to 12 years), and (5) adolescence (12 to 18 years).
The clinical examination is relatively inexpensive and requires little equipment. The two components of the clinical examination—the history and physical examination—can be completed almost anywhere, and repeated examinations can be done easily. The evaluation of clinical disorders emphasizes the importance of the history and physical examination as the most important diagnostic tools the clinician has available. A diagnosis can often be made with the clinical examination without further laboratory testing. If necessary a directed laboratory investigation can be made based on information gathered in the history and physical examination. The history and physical examination should be used to formulate a diagnosis with appropriately guided laboratory evaluation used to verify the diagnosis.
A good pediatric physical examination requires great observation skills, flexibility, and attention to detail. The examination begins as soon as the physician enters the room and gains a snapshot of the child. Immediate impressions of activity, color, mental status, respiratory distress, and interactions with the family and environment begin the overall assessment. During the history, observations can be made concerning developmental level and parent-child interactions. Examination of the child should be in a well-lighted and warm room so that the child is not uncomfortable without clothing. For comfort, the infant or toddler should be examined while being held in the parent’s lap. The physical examination begins by direct observation of the cranial nerves, tone, movement, response to environment, color, and respiratory pattern, as well as the presence of rashes, birthmarks, and dysmorphic features. Least invasive examinations should be accomplished first, such as examination of the heart and lungs. Flexibility in the order of the examination is important to maximize comfort of the child, moving to different parts of the examination if the child shows fear or discomfort, and returning later to complete the examination. The toddler may frequently be frightened by direct eye contact during the examination. A gentle, progressive approach while avoiding direct eye contact may be more successful. Having the parent aid in the examination may reassure and calm the fearful child. Observing the child play, draw, or participate in games often gives the examiner information about cognitive skills, fine- and gross-motor function and coordination. The examiner must often be creative in producing an environment where parent and child are at ease and maximal information can be obtained. On occasion, subsequent and serial examinations are necessary to elucidate the clinical problem.
Particular attention should be paid to vital signs and growth parameters, especially plotting serial growth points on appropriate growth curves. Vital signs are a screening tool, giving information at a single point in time and serving as a frame of reference for subsequent clinical changes. Plotting growth data is important for monitoring long-term growth patterns and observing deviations from normal growth velocity. Specific growth charts should be used for individual clinical indications such as Down syndrome, Turner syndrome, and other disorders. These ongoing data-collection points constitute the surveillance that is critical for detecting subtle developmental, growth, and medical problems at early stages. In fact, a physical examination uninformed by history or such indicators has an otherwise low yield.
Listening to the patient’s concerns, as William Osler declared, is unspoken caring. Gentle touching with the examination enhances bonding between physician and patient. Thorough, unrushed explanation of findings of the clinical evaluation reassures and comforts the family. If further evaluation is necessary, then explanation of the process based on the clinician’s evaluation provides a foundation of confidence and trust.
The clinical examination of the child demands skill, patience, gentleness, and compassion. It is the beginning not only of the patient’s evaluation, but also more importantly of the physician-patient relationship. It is the cornerstone of clinical medicine.
THE PEDIATRIC HISTORY
I. General principles
Smile. Introduce yourself. Shake hands with parents, child if old enough. Try to help family feel comfortable, establish rapport.
II. Identifying information: name of patient, date of birth, gender, date of interview. Identify source of history.
III. Chief Complaint: ask the patient or parent, use their own words if possible.
IV. History of Present Illness:
- What are the symptoms?
- How long have they been present?
- Who else is sick? (family members, daycare contacts)
- Has this patient ever had a similar illness?
- What treatments have been tried for this problem?
- Include pertinent ROS and past medical history.
- Past Medical History
maternal history: mother’s age, gravida, para (term, preterm), abortions (spontaneous or elective).
pregnancy: LMP, EDC, onset of prenatal care, weight gain, complications (bleeding, preterm labor, infections, medications, gestational diabetes), rubella immunity status, RPR, PPD, hepatitis B, drugs, alcohol, tobacco use.
labor and delivery: spontaneous or induced, duration, duration of rupture of membranes prior to delivery, complications, medications or anesthesia, vertex or breech presentation, vaginal or c-section, meconium staining of amniotic fluid.
neonatal: birth weight, estimated gestational age, Apgar score, resuscitation in delivery room, problems in nursery (e.g. jaundice, feeding difficulty, respiratory distress), length of stay, reasons for prolongation of stay.
B. Previous hospitalizations age, length of stay, reason, location
C. Childhood illnesses or exposures age, complications, treatment recent exposures, date, nature of exposure travel to other locations, animal exposure
D. Previous surgery/ transfusions age, reason for procedure, complications
- E. Trauma/ injuries/ ingestions, burns age, circumstances surrounding event, treatment, complications
The Pediatric History, page 2 Past medical history, continued
medications – name of medication, timing of reaction, signs and symptoms, who made the diagnosis of allergy.
- other allergies – signs and symptoms, therapy
current or recent, include OTC meds, dosage, frequency indications and reactions, timing of most recent dose
infants – breast or formula, frequency, amount, problems
toddlers – introduction of baby foods and cereal, milk intake
when did transition from formula/breast to cow’s milk occur’
problems, peculiar eating habits (pica) ‘
older children – good appetite or “picky eater”, special
diets, milk intake, “junk foods”, concerns about weight
I. Immunizations and reactions Don’t rely on memory; ask to see shot record.
|2 mo||hepatitis B2||DTP1||Hibl||OPV1||
|6 mo||hepatitis B3||DTP 3||Hib3||
- J. Growth
weight, height, head circumference, rate of growth, concerns, puberty, menarche
- K. Development
- Gross motor milestones
- Fine motor milestones
- Social interactions, behavior
- Speech and language development
- School performance
- Hearing, vision
The Pediatric History, page 3
VI. Family history
Ask about parents, siblings, grandparents and extended family. Focus on Inherited diseases, diseases that “run in the family”, miscarriages, infant or childhood deaths, congenital anomalies, developmental delay, mental retardation, seizures, early cardiovascular diseases, sickle cell disease, consanguinity, any family members with similar problems to patient’s current complaint.
- Draw a family tree.
VII. Social History
- ONE OF THE MOST IMPORTANT COMPONENTS OF THE HISTORY1
Observe interactions between the family and child. Seek information about the home environment which will impact how the child and family cope with illness. Find out what resources are available for support for the child, mother, family. Find out if there are underlying concerns that have not yet been brought out (e.g. an neighbor died from a brain tumor, and the mother fears that this child’s headache is a sign of a tumor.) Typical questions may include:
- Who lives at home?
- Who is the primary caregiver or disciplinarian?
- Does the child attend school, daycare or a babysitter?
Who helps the mother? In the outpatient setting, important questions may include:
- Do you have a way to pay for this prescription?
- Do you have transportation to return if your child gets worse?
VIII. Review of Systems
Similar in general to adult patients with a few important differences:
A. General: include fever, weight loss, etc. as in adults, but also include patient’s activity level, playfulness, appetite, sleep habits, days of school missed.
B. HEENT: include recent or past history of ear infections if not already included in PMH.
C. GI: diarrhea, vomiting, constipation, etc. Young children will not complain of nausea. Encopresis.
D. GU: change in urinary pattern such as enuresis in previously toilet trained child.
E. Hydration status: tears, wet diapers, details of p.o. intake, details of losses (frequency of diarrheal stools, volume, frequency of emesis), activity level.
Algranati, PS. The Pediatric Patient: An Approach to history and Physical Examination. Williams & Wilkins, 1992.
Report of the Committee on Infectious Diseases 22nd ed. American Academy of Pediatrics, 1991.
PEDIATRIC PHYSICAL EXAMINATION
Wash your hands. Introduce yourself. Say something nice, or compliment the child/parents (at the end of the session as well).
The .order of the exam can be individualized. Start by observation, introduce instruments and let the child check them out, keep invasive or painful parts for the end. Explain everything you will be doing. Use age-appropriate non-threatening terms. Give feedback. In the newborn, observe, auscultate and palpate first.
The child has to be undressed for the exam, but this can be done gradually. Exam has to be thorough, even in the uncooperative child.
Special focus of the pediatric exam: Growth and Development. Points of special relevance to the newborn are in boldface.
Axillary- T° is 2° below rectal, oral is 1° below rectal.
BP cuff should cover 1/2 to 2/3 of arm span.
Heart rate and repiratory rate.
Height and weight. Head circumference. Chest and abdominal
circumference if indicated. Plot them on charts.
Skin fold thickness.
Nutritional status. Cleanliness. Posture. Reluctance to move. Alertness, interest in surroundings, playfulness, cooperation. Distress, consolability (paradoxical irritability). Hydration status. Development. Cry or speech. Gross abnormalities. May include a note about the family.
Color, pigmentation. Jaundice. Cyanosis (acrocyanosis). Mottling.
Pallor. Birthmarks (nevus flammeus, salmon patch). Texture.
Scars. Rashes (erythema toxicum). Ecchymosis (color and age).
Craddle cap. Capillary refill. Edema.
Milia. Vernix caseosa. Desquamation. Mongolian spot.
Cyanosis, clubbing. Pitting. Capillary refill.
Lanugo. Alopecia (including occipital alopecia). Lice or nits.
Pubic hair and Tanner stage.
LYMPH NODES ‘ •
Size and symmetry. Circumference. Sutures. Fontanelles, size (AT measured perpendicular to sides), bulging or depression, pulsatility. Caput succedaneum. Cephalhematoma. Craniotabes. Transillumination. Sinuses.
Paralysis. Asymmetry. Anomalies, coarseness of features. Edema.
Vision, visual fields. Scleral color. Strabismus (paralytic, non-paralytic). Nystagmus. Conjunctivitis, discharge. Hemorrhages (subconjunctival hemorrhages). Reaction to light. Iris (absence-). Ophthalmoscopy (red reflex, retinal hemorrhages, macula).
Position, shape. Discharge. Tenderness. Auricular pits or tags.
Otoscopy (use the bigger speculum). Hearing.
Discharge, obstruction, polyps (use otoscope). Bleeding. Flaring.
Drooling. Teeth (map, hygene). Cysts. Palate (cleft). Thrush.
Gums. Tongue. Palate. Tonsils. Postnasal drip.
Stridor, hoarseness, cry (weak, high-pitched). Vocalization,
Position, motility, webbing. Nodes, masses. Neck stiffness,
Inspection,”palpation, percussion, ausculation.
Pectus (carinatum, excavatum). Harrison’s groove.
Respiratory rate, chest expansion, symmetry, retractions,
paradoxical breathing. Grunting. Flaring, use of accessory
muscles. Cough (characteristics, frequency).
Breast size, milk discharge, symmetry, Tanner stage.
Rate and rythm (sinus arrythmia). Inspection, palpation,
Inspection, palpation, percussion, ausculation.
Shape (scaphoid, pot-belly). Circumference. Umbilicus (cord
stump), umbilical hernia. Diastesis recti. Gastric waves. Liver,
spleen, masses. Unimanual palpation of the kidneys. Bladder. Superficial reflexes. Inguinal areas, femoral pulses, lymph nodes.
Penis size, meatus location, circumcision, testicles (Tdescended), hydrocoele, r^rnia, cremasteric reflex. In girls, labia minora prominent in the newborn. Discharge, adhesions. Diaper rash. Tanner stage.
Anus (patency), anal wink, fissures, fistula, prolapse,
hemorrhoids, masses, stools, Guaiac. Diaper rash.
EXTREMITIES AND MUSCULOSKELETAL.
Posture, asymmetry, extra digits, clubbing, temperature, swelling. Hands and dermatoglyphics. Nails. Feet (clubbing). Genu valgum, gait, hips (dislocation). Spine, scoliosis, sacral pit or hair tuft. Pulses. Joints range of motion, arthralgias, arthritis. Kernig’s sign.
State of consciousness. Spontaneous movements, abnormal movements. Tone and strength. Superficial reflexes, deep tendon reflexes. Suck, root, grasp, Moro, tonic neck, Babinski, stepping, placing, Landau, parachute reflexes.Sensations. Coordination, cerebellar signs. Cranial nerves. Gait. Development (Denver Screening Test). Meningeal signs.
Head and chest
Includes arms and lower legs
Includes hands and feet
BILI LEVEL (mg/dl)
6-12 8-16 10-18 ‘ 15-20+
ECCHYMOSES COLOR AGE (days)
Infancy 3-4 mo
L. A. Barness. Manual of Pediatric Physical Diagnosis. Sixth ed.
Mosby Yearbook, 1991.
STAGES OF PUBERTY (TANNER STAGES) Female breast.
- I. Preadolescent. The breast has an elevated papilla (nipple) and a small flat areola.
II. Breast bud. The papilla and areola elevate as a small mound, and the diameter of the areola increases.
III. The breast bud further enlarges. The areola continues to enlarge. No separation of breast contours is noted.
- IV. The areola and papilla separate from the contour of the breast to form a secondary mound.
V. Mature. The areolar mound recedes into the general contour of the breast. The papilla continues to project.
I. Preadolescent. No pubic hair.
II. Sparse distibution of long,
slightly pigmented hair at the base of the penis
III. The pubic hair pigmentation
- increases; it begins to curl and spread laterally in a scanty distribution.
- IV. The pubic hair continues to curl and become coarse in texture. An adult type of distribution is attained, but with fewer hairs.
V. Mature. The pubic hair attains
- an adult distribution, spreading to the surface of the medial thigh. Pubic hair grows along the linea alba in 80% of males.
Preadolescent. No pubic hair. Sparse distibution of long, slightly pigmented straight hair appear bilaterally along the medial border of the labia majora. The pubic hair pigmentation increases; it begins to curl and spread sparsely over the mons pubis.
The pubic hair continues to curl and become coarse in texture. The number of hairs continues to increase.
Mature. The pubic hair attains an adult feminine triangular pattern, with spread to the surface of the medial thigh.
Male genital development.
II. The testes enlarge. The scrotum enlarges, developing a reddish hue and altering in skin texture. The penis enlarges slightly.
III. The testes and scrotum continue to grow. The length of the penis increases.
IV. The testes and scrotum continue to grow; the scrotal skin darkens. The penis grows in width, and the glans penis develops.
V. Mature. The testes, scrotum, and penis are adult in size and shape.
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