Physical Exam. In Pedics Flashcards
Physical examination 🧐 Procedure
Differences in Performing A Pediatric Physical Examination Compared to an Adult:
I. General Approach
A. Gather as much data as possible by observation first
B. Position of child: parent’s lap vs. exam table
C. Stay at the child’s level as much as possible. Do not tower!!
C. Order of exam: least distressing to most distressing
D. Rapport with child
1. Include child - explain to the child’s level
- Distraction is a valuable tool
E. Examine painful area last-get general impression of overall attitude
F. Be honest. If something is going to hurt, tell them that in a calm fashion. Don’t lie or you lose credibility!
G. Understand developmental stages’ impact on child’s response. For example, stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult.
II. Vital signs
A. Normals differ from adults, and vary according to age
— See “code card” for charts of age-adjusted normals
B. Temperature
—Tympanic vs.
—oral vs.
—axillary vs.
—rectal
C. Heart rate
—Auscultate or palpate apical pulse or palpate femoral pulse in infants 👶
— Palpate antecubital or radial pulse in older child 🧒
D. Respiratory rate
—Observe for a minute.
Infants normally have periodic breathing so that observing for only 15 seconds will result in a skewed number.
E. Blood pressure
—Appropriate size cuff - 2/3 width of upper arm
—Site
F. Growth parameters - must plot on appropriate growth curve
—Weight
— Height/length
— OFC: Across frontal-occipital prominence so greatest diameter (Occipital Frontal Circumference)
III. Unique findings in pediatric patients (See outline below)
Outline of a Pediatric Physical :
Examination 🧐
I. Vitals - see above 👆
II. General
A. Statement about
—striking and/or important features.
—Nutritional status,
—level of consciousness,
—toxic or distressed,
—cyanosis,
—cooperation,
—hydration,
—dysmorphology,
—mental state
B. Obtain accurate
—weight,
—height and
—OFC ( Occipital Frontal Circumference.
III. Skin and Lymphatics
Birthmarks -
—nevi,
—hemangiomas,
—mongolian spots etc
—Rashes,
—petechiae,
—desquamation,
—pigmentation,
—jaundice,
—texture,
—turgor
—Lymph node enlargement, location, mobility, consistency
—Scars or injuries, especially in patterns suggestive of abuse
IV. Head 👤
Size and shape Fontanelle(s)
1. Size
2. Tension - calm and in the sitting up position Sutures - overriding
Scalp and hair
V. Eyes 👀
General
1. Strabismus
2. Slant of palpebral fissures
3. Hypertelorism or telecanthus
EOM
Pupils
Conjunctiva, sclera, cornea
Plugging of nasolacrimal ducts Red reflex
Visual fields - gross exam
VI. Ears 👂
Position of ears
1. Observe from front and draw line from inner canthi to occiput
Tympanic membranes
Hearing - Gross assessment only usually
V. Nose 👃
Nasal septum
Mucosa (color, polyps) Sinus tenderness
Discharge
VI. Mouth and Throat
A. Lips (colors, fissures)
B. Buccal mucosa (color, vesicles, moist or dry) C. Tongue (color, papillae, position, tremors) D. Teeth and gums (number, condition)
E. Palate (intact, arch)
F. Tonsils (size, color, exudates)
G. Posterior pharyngeal wall (color, lymph hyperplasia, bulging) H. Gag reflex
V. Neck
A. Thyroid
B. Trachea position
C. Masses (cysts, nodes)
D. Presence or absence of nuchal rigidity
VI. Lungs 🫁 /Thorax
A. Inspection
1. Pattern of breathing
a. Abdominal breathing is normal in infants
b. Period breathing is normal in infants (pause < 15 seconds)
2. Respiratory rate
3. Use of accessory muscles: retraction location, degree/flaring 4. Chest wall configuration
B. Auscultation
1. Equality of breath sounds
2. Rales, wheezes, rhochi
3. Upper airway noise
C. Percussion and palpation often not possible and rarely helpful
VII. Cardiovascular
A. Auscultation
1. Rhythm
2. Murmurs
3. Quality of heart sounds
B. Pulses
1. Quality in upper and lower extremities
VIII. Abdomen
A. Inspection
1. Shape
a. Infants usually have protuberant abdomens b. Becomes more scaphoid as child matures
2. Umbilicus (infection, hernias)
3. Muscular integrity (diasthasis recti) B. Auscultation
C. Palpation
1. Tenderness - avoid tender area until end of exam 2. Liver, spleen, kidneys
a. May be palpable in normal newborn 3. Rebound, guarding
a. Have child blow up belly to touch your hand
IX. Musculoskeletal A. Back
1. Sacral dimple
2. Kyphosis, lordosis or scoliosis
B. Joints (motion, stability, swelling, tenderness) C. Muscles
D. Extremities
- Deformity 2. Symmetry 3. Edema
- Clubbing
E. Gait - In-toeing, out-toeing
- Bow legs, knock knee
a. “Physiologic” bowing is frequently seen under 2 years of age and will spontaneously resolve - Limp F. Hips
- Ortolani’s and Barlow’s signs
X. Neurologic - most accomplished through observation alone A. Cranial nerves
B. Sensation
C. Cerebellum
D. Muscle tone and strength E. Reflexes - DTR
- Superficial (abdominal and cremasteric) 3. Neonatal primitive
XI. GU
A. External genitalia
B. Hernias and Hydrocoeles - Almost all hernias are indirect
- Can gently palpate; do not poke finger into the inguinal canal
C. Cryptorchidism - Distinguish from hyper-retractile testis
- Most will spontaneously descend by several months of life
D. Tanner staging in adolescents - See Tanner Staging handouts
E. Rectal and pelvic exam not done routinely - special indications may exist
Hand ✋
Hands
Palm: Palmar erythema, contractures, muscle wasting of the thenar and hypothenar muscles, Palmer parlor, single palmar crease.
Dorsum / back hand 🤚 :
Capillary refill, dorsal gutter, Clubbing (5 stages), splinter haemorrhage, koilonychia, leukonychia,
Pulse rate ( normal for adult is from 60 to 100) ( it defers for children 👧🧒).
BP
Respiratory Rate
you check by observing the chest
But you hold the hand 🤚 of the patient to distract them
SPO2
Skin turgur
Head
Hair
Comment if the hair is evenly distributed or if it is sparsely distributed
If the hair is easily pluck able
The color of the hai
If it is silky or something else
Forehead
Feel for the temperature 🤒
Eyes 👀
Sclerae jaundice
Parlor for general examination
