Pediatrics Physical Examination

Pediatrics Physical Examination

History - Pediatrics

Introductory information

• Introduce, establish rapport.
• Name, age, gender.
• Person giving the history (parent, etc).
• Origin.

Presenting complaint

• Description of the presenting complaint, in chronological order.
• Including whether came in through casualty or admitted by GP.

History of presenting complaint

• SOCRATES:
• Time course: seasonal or diurnal fluctuation.
• Exacerbating factors: foods.

• Referral by GP vs. came in through casualty.
• Relevant negatives.
• If using slang, ask for clarification.

Past medical, surgical history

Birth history

• Length of gestation.
• Age and parity of mother at delivery.
• Any maternal insults [alcohol, smoking] or illnesses during gestation.

• Where born: city, hospital.
• Birth weight, mode of delivery, difficulties in delivery.
• Resuscitation, intensive care requirement at birth.

• Cyanosis, pallor, jaundice, convulsions, birthmarks, malformations, feeding or respiratory difficulties.
• Apgar score at birth if known.

• How baby was fed in first few days.
• Whether child went home with mother.

Nutritional history

• Breast-fed vs. bottle-fed
• When breast started, stopped.
• If formula: type, amount, pre-mixed vs concentrate [and dilution used].
• Vitamin supplements.
• Age when beikost started.
• Appetite and growth.
• Current diet.

Immunization history

• See Immunization Schedule Reference.
• Get dates of each.

Illnesses and operations

• Past illnesses, operations.
• Childhood illness, obs/gyn.
• Tests and treatment prescribed for these.
• Problems with the anesthetic in surgery.

Developmental history

• Gross motor.
• Fine motor.
• Vision, speech, hearing.
• Social.
• See Developmental Milestones Reference.

Education history

• Start of school attendance.
• Where attend school.
• Special needs requirements.
• Impact of symptoms: absent school days.

Family history

• The current complaint in parents/ siblings: health, cause of death, age of onset, age of death.
• Parents/siblings: age, health, where living.
• Height and weight of parents.
• Hereditary dz suspected: do a family tree.

Social, personal history

• Age, occupation of parents.
• Race and migration of parents [if relevant].
• Any others at daycare/ school with same complaint.
• Travel: where, how lived when there, immunization/ prophylactic status when went.
• Does the child live at home, and with whom [include siblings].
• Smokers in the home.
• Pets in the home.
• "Is there some things that worry you about the symptoms you child is having?"

Drug history

• Prescriptions currently on: dose, when started, what for.
• OTCs.
• Alternative medications.
• Allergies, and reaction of each:
• Eczema, asthma, hay fever, hives.
• Drugs, foods, dyes.

Systems review

• See Systems Review below.

History tips

• Use "the father" or "the mother" instead of "your husband" or "your wife", as current spouse may not be the genetic parent, also avoids issue of a divorce/separation.
• Parents may use slang. Ask "do you mean..." for clarification as needed.
• Ask if the temperature was actually measured, and if so, what it was.

Examination - Pediatrics

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 Reference.
• 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 Reference.
• Hands:
• Clinical hand signs.
• Color, warmth.
• Radial pulse.
• Femoral pulse.
• BP.
• Temperature.
• See Taking Pediatric Vital Signs Reference.
• 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 Reference.

Lungs

• Inspection:
• Spinal curvature.
• Tanner stage (female). See Tanner Stages Reference.
• 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 Reference.
• See Skin Lesion Terminology Reference.

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.

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.

Systems Review - Pediatrics

Cardiovascular

• Chest pain, pressure
• Shortness of breath, exertion required
• Lie flat or use pillows, how many pillows
• Awoke breathless at night
• Noticed heart racing, aware of heartbeat
• Ankle swelling
• Cold/ blue hands, feet

Pulmonary

• Sore throats, earaches
• Cough: sputum, blood
• Shortness of breath, wheeze
• Snore loudly, apnea
• Fever, night sweats
• Recent chest X-ray

Alimentary

• Weight, appetite changes
• Abdominal pain or discomfort
• Bloating, distention
• Indigestion
• Nausea, vomiting: contents
• Bowel habits: change, number
• Incontinence, constipation/ diarrhea
• Stool: colour, blood/ black, consistency, mucous

Nervous

• Headaches
• Dizziness, vertigo
• Faints, seizures, blackouts
• Weakness, numbness
• Sleep disturbances
• Limp, ataxia, tremors
• Concentration, memory

Genitourinary

• Enursesis
• Changes to urine quantity, colour
• Blood in urine
• Genital rashes, lumps
• Sex life problems
• Pain, bleeding in periods

Endocrine

• Prefer hot or cold weather
• Sweating
• Fatigue
• Hand trembling
• Neck swelling
• Skin, hair, voice changes
• Thirst

Integumental

• Itchy
• Rashes
• Bruising
• Swelling
• Colour changes

Hematological

• Bruise easily, difficulty stopping bleeds
• Lumps under arms, neck, loin
• Clots in legs, lungs
• Fevers, shakes, shivers

Rheumatoid

• Joints: pain, stiffness, swollen
• Variation in joint pain during day
• Fingers painful/ blue in cold
• Dry mouth, red eyes
• Skin rash
• Back, neck pain

Is patient their regular self?
Anything else you think I should know?

Source: www.doctorshangout.com