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

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