Physical Examination of Pediatric

Physical Examination

The purpose of a physical examination is to identify any health issues by using the senses of sight, hearing, smell, and touch. It is done to gather factual information and compare it against opinion.

A thorough examination from head to toe is crucial for a precise diagnosis.

Equipment

• Clean gloves
• Scale
• BP cuff
• Tape
• Snellen chart
• Otoscope
• Speculum
• Pediatric stethoscope
• Growth chart
• Pen

Physical Examination Started from:

Vital Signs

• Temperature: Axillary temperature is more common and safe method for all stages unless specific indication for another method to measure temperature in children.
• Pulse: Palpate antecubital or radial pulse for an older child and auscultation in apex for heart beats in very young baby or palpate femoral pulse for a young baby or palpate femoral pulse for a young baby (infant). Count pulse for full minutes.
• Respiration: Count respiration for full minute by observing the movement of the abdominal wall while infant/ young baby is in mother's lap.
• Blood pressure: Measure blood pressure with cuffs completely encircling the extremity (upper/lower) and the width covering one-half or 2/3 of the length of the upper arm/leg.

Measurements

• Head circumference: Measure head circumference of all children less than 2 years of age with the history relating to neurological disease. Head circumference (occipio-frontal circumference: OFC) is measured across frontal (above the Eyebrow) - Occipital prominence which is the greatest diameter.
• Chest circumference: Measure chest circumference in a young child in the level of a nipple.
• Height weight: Measure the weight of infants/children using digital infant scale or Beam balance scale or Electronic weight machine. Measure length up to 2 years of age in the supine Position by using Infantometer or a measuring tape and standing height thereafter using Stadiometer or height scale.

General Appearance

Observe general appearance of child's that include body position, posture, evidence of pain, crying, alertness, irritability, distress, hygiene, nutritional status, mental status, behavior pattern, general development, speech, fear, anxiety, cyanosis, malformation, and dehydration.

Skin: Examine skin for color, pigmentation, lesions, jaundice, cyanosis, scar, superficial vascular condition, moisture, edema, a condition of mucous membrane, presence of birthmarks, navi, hemangioma tenderness, masses, texture, turgor, elasticity, rash, patches, subcutaneous nodules etc.

Lymph nodes: Observe and palpate the lymph nodes for enlargement, tenderness, pain.

Hair: Observe color and distribution of hair on the head, back and other parts of the body, alopecia.

Nail: Cyanosis, pallor, capillary filling time, capillary pulsation, koilonychia and leukonychia in growing nails.

Regional Examination

Head and neck

Skull: shape, a condition of the scalp, hair, swelling, alopecia, impetigo, nits, fontanels (up to 2 years of age), suture, movement of the head, head holding.

Face: Shape, coarse, puffy, positioning and shape of eyes, mouth, ear and nose, parotid glands, nose bridge, tenderness over sinuses.

Eye: Observe for discharge, eyelids, eyelashes, conjunctiva, sclera, pupil, cornea, visual field test, a distance between the eyes, distributions of eyebrows, epicanthic fold, exophthalmos, conditions of pupils, cataract, corneal opacities, squint, nystagmus, hemorrhage, blockage of the nasolacrimal duct.

Ear: Shape, size, position, low-set ear, deformities, discharge, tenderness over mastoid bone and hearing abilities, wax, furuncle etc. For examination pull pinna down and back in less than 3 years old baby and pull up and back on 3 and more than 3 years old baby.

Nose: Examine nose for shape, size, discharge, nostrils flaring, bleeding, deviated septum, depressed nasal bridge, nasal polyp, foreign body, nasal mucosa, para- nasal sinuses, tenderness patency etc.

Mouth and Throat

Mouth: Examine the color of lips, lesions at the corners of the mouth, cleft, teeth, caries, shape, gum bleeding, hypertrophy of gum, mucosal congestion, petechia, kopilks spots, tongue, and pharynx; a presence of any infections, tonsillitis gag reflex, a condition of a vulva.

Neck: Shape, size, movement, swallowing, tenderness prominent veins supra-sternal in drawing, a location of the trachea, tenderness, thyroid etc.

Chest

Observation: Shape, symmetry, circumference, Harrison’s groove, sternal angle, expansion, subcostal or intercostals in-drawing, position of nipple, breast development, fullness of intercostals space, prominent veins, special impulses, pre-cordial pulsation, spinal deformities, superficial swelling, skin condition, type and rate of respiration chest wall configuration- pigeon chest).

Palpation and Percussion: Upper border of liver dullness, intercostals spaces, cardiac dullness detect any tenderness swelling thrill. Through, palpation and percussion not possible in small baby and also not that much significant. In a case of older children, it is done as in an adult.

Auscultation: Strider, wheeze, rhonchi, crackles, heart sound; murmur over the pericardium and inter- scapular region.

Note: Auscultation should be done before palpation and percussion.

Abdomen

Inspection: Size, shape, distended prominent veins, peristalsis, umbilicus, swelling, scar, cleanliness, any congenital anomalies such as a hernia, co of skin etc.

Palpation: Tenderness, rigidity, doughy feeling, skin turgor flow of blood in prominent veins, fluid thrill, superficial or visceral swelling mass, lesions rebound tenderness inguinal lymph nodes etc.

Percussion: Upper margin of liver dullness, spleen dullness, shifting dullness, full bladder, tympanic etc.

Auscultation: Peristaltic sounds ( notes: auscultation before palpation and percussion).

Genitalia

Sex determine, sexual maturity, inguinal lesions.

Male: Examine for urethral opening and its abnormalities, (Hypospadias, epispadias), phimosis, hydrocele, hernia, undescended testis, a size of penis etc.

Female: Labia major, minora, vaginal and urethral opening, discharge, cleanliness, infections, swelling of bartholin’s glands in adolescence.

Anus and rectum: Examine for potency, presence of fissures or fistula, rectal prolapsed, etc. (Rectal and pelvic examination are not performing routinely).

Musculoskeletal

Back: Assess spine for its curvature, sacral dimple, gasping or other congenital deformities, kyphosis-lordosis etc.

Limbs: Examine for any deformity, asymmetry, hemi- hypertrophy, bow legs, knock- knees, edema, any swelling or limitation of movement of the joints, paralysis, clubbing of fingers, number of fingers and toes ( syndactyly, polydactyly), creases on the palms and soles, changes in the nails, deformity of the feet, any infections, tenderness, swelling, cleanliness etc.

Hips: Ortolani’s and Barlow’s signs for dysplasia of the hip.

Neurological

Observe and examine cerebral functions (memory, cognition, and language), cranial nerve function, deep tendon reflex, muscle tone, gait balance, coordination, sensory and motor function.

Points to Remember

• Can build rapport while assessing for cough, dyspnea, and cyanosis.
• Can first inspect the teddy bear.
• Age-appropriate assessment technique:
• On the exam table were neonates and extremely young babies.
• From kindergarten on: lying occupy the mother's lap.
• Adolescent: absent from family.
• A parent should undress a young kid, not an examiner.
• Children are impatient, so a thorough, methodical examination may be challenging. Examine the area that matters the most first.
• Before crying begins, take a respiratory rate reading.
• Children's breath sounds are simpler to hear but more difficult to locate.
• ENT exams are more prone to make people weep, thus these are done last.
• Opportunism.
• Heart auscultation if a child doses.
• Examine shoulder/arm movement and head control while the parent removes the shirt.
• If a young person kicks the examiner, look at the hip range of motion.
• If cries, a stethoscope can pick up rales from the deep breaths between each cry.