OnExam

Inspection

Important part of exam is simply gathering an impression of the child to determine their clinical status

  • Activity and alertness
  • Position, body habitus and shape
  • Crying
    • Pitch, volume, and character
  • Skin colour
    • Cyanosis, jaundice
  • Child-caregiver interactions
  • Signs of neglect (e.g., inappropriate dress or hygiene, malnutrition)

Body Measurements

Use reproducible technique and, ideally, the same equipment

Plot information on WHO growth charts to compare the patient with others of his/her age and identify individual growth trends.

Weight

  • Use an infant scale until child able to stand on own
  • Infants should be naked or clothed in only diaper/underpants
  • Children should follow their “percentile” curve, but are allowed to cross one percentile curve without major concern
  • Dropping more than two quartiles or a weight below fifth percentile is considered failure to thrive
  • It is important to follow the growth charts over time noting any changes
    • If height is normal but weight is low, suspect chronic disease
    • If weight is normal and height is low, suspect endocrinopathy
    • If everything is low, suspect chromosomal abnormality

Height

  • Less than two years old, use supine measuring board/tray, making sure that the child is fully extended
  • Greater than two years old, use a wall or scale-mounted sliding ruler.
    • If only a wall with marked ruler available, place a board or other flat surface against the child's head

Head Circumference

  • Routinely measure head circumference until child is two years old and thereafter only if there are concerns with growth
  • Use a flexible tape measure placed over the occipital, parietal, and frontal prominences to record the maximum circumference
    • Even skilled examiners sometimes need to take several measurements before noting the largest one

Vital Signs

Remember that the normal vital signs for the pediatric population are age and size dependent. Consult a table of normal vital signs before suggesting there is an abnormality present.

  • Blood Pressure
    • Distressed children will often have elevated blood pressure—be friendly in your approach and explain every step (“the blood pressure cuff is just going to give your arm a great big hug”)
    • Properly-sized cuff: covering 2/3rds of the upper leg or arm
  • Pulse
    • In younger children, pulse rate can be difficult to measure in squirming/distressed infants, therefore heart rate is easier to assess by auscultation for 15-30 s in this situation
    • Femoral and brachial pulses are easiest to find and maintain
  • Respiratory Rate
    • Count respirations when patient not crying
    • Rate may vary widely; measure over a longer period of time (30 s to 1 min)
  • Temperature
    • Fevers are common in paediatric population
    • Tympanic thermometers preferred method for screening
    • Less than two months: rectal temperatures preferred method

Skin

  • After the first year of life, pediatric integumentary exam is very similar to that performed in adults (see Integumentary System)
  • Acrocyanosis
    • Blue-tinged hands and feet, especially when exposed to cold
    • Severe acrocyanosis can be an indication of cyanotic congenital heart disease
  • Café-au-lait spots
    • Pigmented light brown benign lesions that can occur anywhere on the body
    • More than five spots are associated with neurofibromatosis
  • Capillary hemangioma
    • Bright red protuberant lesion caused by a collection of capillaries
    • May grow in the first year of life, usually regress and involute
  • Erythema toxicum neonatorum (“Red Rash of the Newborn”)
    • Very common and normal
    • May present anywhere except the palms and soles
    • Not present in the first day of life, presents after 24 hours
    • Characterized by reddish macules over an erythematous base
    • Can become blisters and pustules
    • Lesions are possibly migratory on the body
  • Harlequin dyschromia
    • Well demarcated cyanosis of one half of the body or one extremity that quickly resolves (within seconds)
  • Jaundice
    • Can be either physiologic or pathologic
    • Detection is often aided by blanching the skin with a bit of pressure
  • Lanugo
    • The fine, downy hair found over most of a newborn's body
    • Prominent in premature babies
  • Milia crystallina
    • White pustules without reddened base
    • Rupture easily
    • Clears up spontaneously within weeks
  • Milia rubra
    • Obstructed sweat glands and ducts resulting in scattered vesicles on an erythematous base
    • Clears up spontaneously within weeks
  • Mongolian spots
    • A dark or bluish-grey pigmentation usually over the inferior lumbar and buttocks areas but may appear anywhere
    • Clearly demarcated, does not fade into the surrounding skin
      • Important characteristic when differentiating from bruise
      • Be sure to document Mongolian spots on chart
    • More common in darker skinned ethnic groups
    • Usually fade: months to a year or two
  • Pemphigus neonatorum/staphylococcal scalded skin
    • May be present in the first day of life
    • Pustules over erythematous base
    • Nikolsky’s sign: skin easy to peel off if scraped or rubbed
    • Babies look ill, toxic appearance
    • May become septic
  • Spinal cord defects
    • Sometimes presents as a midline tuft of hair over the lumbosacral spine
    • Meningocele: protrusion of meninges through a defect in the vertebral colu
  • Vernix caesosa
    • A cheesy white material that covers the body of newborns (normal)

Head and Neck

Skull/Scalp/Neck

In infants:

  • Examine the sutures and fontanelles for size, molding, and depression/bulging
    • Anterior fontanelle closes between 4-26 months of age
    • Posterior fontanelle closes by 2 months
  • Asymmetry, microcephaly, macrocephaly, plagiocephaly, and other visible abnormalities of the head
  • Micrognathia, abnormal palpebral fissures, paralysis, wide philtrum, and other visible abnormalities of the face

In older children and adolescents:

  • Same as adult head and neck examination (see: Head and neck examination)
  • Neck: thyroid enlargement and presence of cysts, cervical lymphadenopathy
  • Check for neck stiffness and meningeal signs such as Kernig's and Brudzinski's.

Eyes

Newborns and infants:

  • Conjunctiva: swelling and redness, discharge, crusting
  • Sclera and pupils
    • Colobomas, Brushfield spots, subconjunctival hemorrhages
  • Pupillary reaction and accommodation
  • Lacrimal sac, medial canthus-swelling, redness, discharge indicating dacryocystitis
  • Visual milestones
    • Birth: can blink, may fix on faces
    • 1 month: can fix on an object
    • 2 months: coordinated eye movement
    • 3 months: eyes converge, baby can reach towards objects
    • 12 months: acuity of approximately 20/50
  • Ophthalmoscope: check the red retinal reflex
    • Cloudiness in the cornea: associated with cataracts
    • Leukocoria or white retinal reflex: associated with retinoblastoma

Older infants:

  • Principal goals are to check acuity and gaze
  • Acuity may be difficult to check in children less than three years old and even then only with an eye chart that uses pictures or symbols
  • Development of acuity should be symmetric and follows approximate milestones:
    • 3 months: eyes converge, baby can reach towards objects
    • 12 months: acuity of approximately 20/50
    • <4 years: 20/40
    • >4 years: 20/30
  • Gaze should be tested with the cover-uncover test

Ears

In infancy:

  • Inspect ear to ascertain normal position, shape, and features
  • Exam of tympanic membranes and ear canal is aided by pulling the auricle downward rather than upwards and backwards as in older children and adults
  • Gross signs that an infant can hear include
    • 0-2 months – Startles/blinks to a sudden noise (assess using clap test)
    • 2-3 months – Change in facial expression/movement in response to sound
    • 3-4 months – Turning eyes and head to localize sound
    • 6-7 months – Turning to listen to voices and conversation

In older children and adolescents

  • See Head and Neck section for adult ear exam
  • Inspect the auditory canal for cerumen, discharge, or signs of infection
  • Check for tenderness on movement of the pinna and tragus
  • Examine the tympanic membrane for bulging, erythema, effusion, perforation, scarring or lack of movement with pneumatic otoscope
  • Hearing can be tested grossly in the office by whispering at a distance of ~three metres, but formal acoustic screening should be arranged at least once.

Nose, Mouth, and Pharynx

  • Nose: patency, septum midline, nasal polyps
  • Sinuses: develop gradually, usually developed/palpable after six years old
  • Mouth: supernumerary teeth, thrush, tongue tie, protruding tongue, and Epstein's pearls
  • Teeth
    • Number, condition, alignment
    • New primary teeth erupt between 5-30 months and permanent teeth begin appearing after the sixth year
  • Pharynx
    • Infants: best examined when patient is crying, palpate hard palate
    • Tonsils: size, shape, and exudates
    • Uvula: lateral displacement
  • Breath odour

Thorax and Lungs

  • Follow adult respiratory examination for general guidelines
  • Inspection
    • Pectus carinatum/excavatum, scoliosis, or other deformities
    • Signs of respiratory distress: tracheal position, accessory muscle use, tracheal tug, nasal flaring, chest indrawing, central cyanosis/pallor, difficulty with fluid speech
    • Observe for spells of apnea or periodic breathing
  • Palpation
    • Tactile fremitus
  • Percussion
    • Percuss for dull and resonant areas as in the adult respiratory exam
  • Auscultation
    • Listen without a stethoscope for audible breath sounds such as grunting, wheezing, stridor, or prolonged expiratory phase
    • Findings are generally similar to those of adult patients, but sounds are louder, harsher, and may be more difficult to localize or distinguish

Cardiovascular

  • Cardiac exam is very similar to adult examination
  • Inspection
    • Central cyanosis: inside the mouth, underneath the tongue, and in the conjunctivae.
    • Noncardiac findings of cardiac disease: tachypnea, hepatomegaly, clubbing, irritability, and failure to thrive
    • Precordial bulge of cardiomegaly
  • Palpation
    • Peripheral pulses: brachial, femoral, temporal, dorsalis pedis, posterior tibial
      • Note asymmetries
    • Coarctation of the aorta: at least once, measure the BP in both arms and a leg, and palpate femoral pulses, note any brachiofemoral delay.
    • Feel for thrills, heaves, and the point of maximal impulse
  • Auscultation
    • Listen to the rhythm and rate (children often have premature atrial or ventricular beats)
    • Listen for S1 and S2 heart sounds noting any extra heart sounds (S3 frequently heard and generally normal, S4 rarely heard in children)
    • A split S2 is generally normal in children
    • Characterize any murmurs: site, radiation, timing, pitch, intensity, quality, and changes with respiration, Valsalva, or posture
    • Note that many, but not all, pediatric heart murmurs are benign and resolve during childhood.
    • Clinical features that suggest structural heart disease include: poor feeding, failure to thrive, cyanosis, syncope or near syncope, diaphoresis, poor exercise tolerance, and chronic cough
    • Lungs should be auscultated for crackles which may indicate pulmonary congestion associated with congenital heart disease

Pediatric Heart Murmurs

When evaluating for evidence of structural heart disease, a history and physical examination including vital signs, child’s general appearance should first be obtained

Red Flags of pathological murmurs:
  • Holostylic murmur
  • Grade 3 or higher, harsh quality
  • Abnormal S2, maximal intensity at the upper left sternal border
  • Systolic click
  • Diastolic murmurs
  • Change in intensity when standing or squatting
  • Change in intensity with passive leg elevation
Patent Ductus Arteriosis
  • Continuous murmur in the upper left sternal border (crescendo in systole and decrescendo in diastole)
  • Soft systolic ejection murmur at left upper sternal border may be due to a closing patent ductus arteriosis during the newborn period
  • Can cause easy fatigue, CHF and respiratory symptoms, often asymptomatic
Ventricular Septal Defect
  • Small defect: usually asymptomatic, loud holosystolic murmur at LLSB
  • Medium-large defect: increased right to left ventricular impulse, thrill at LLSB, split or loud S2, holosystolic murmur at LLSB without radiation
  • Can cause CHF, bronchial obstruction symptoms and frequent respiratory infections
Atrial Septal Defect
  • Usually incidentally found on echo, large defects can present with CHF
  • Systolic ejection murmur best heard at the upper left sternal border, with a wide fixed split S2, no thrill
Coarctation of the aorta
  • Systolic ejection murmur over interscapular region with normal heart sounds, associated with decreased or delayed femoral pulse
  • Older children have leg pain or are asymptomatic, infants may present with CHF

Benign Murmurs
  • Innocent murmurs are produced by normal flow through the heart and vessels, and should vary with positioning. Prompt the child to push out their abdomen against your hand, listen for a normal S1 and S2.
  • Features of innocent murmurs include
    • Systolic murmurs
    • Soft sound, short duration
    • Musical or low pitch
    • Varying intensity with change in respiration or posture
    • Murmurs that become louder with exercise, anxiety or fear
Peripheral pulmonic stenosis
  • Caused by stenosis originating from the branch pulmonary arteries
  • Early systolic murmur loudest over both axillae and the back
Still's murmur
  • Musical vibratory, early-midsystolic murmur
  • Loudest at LLSB
  • Associated with carotid bruit
Venous hum
  • Soft, hollow, holosystolic
  • Heard best under clavicle
  • Eliminated by position changes
Carotid bruit
  • Early systolic, usually louder on left
  • Eliminated by carotid compression

Abdomen

Newborns and infants:

  • Shape and general appearance of the abdomen
    • Scaphoid abodmen, diastasis recti
  • Inspect the umbilical area for any cord abnormalities
    • Erythema, edema, or hernias
  • Veins and visible peristalsis are often easily noticed
  • Auscultation for bowel sounds
  • Percussion to determine size of organs or masses
  • Feel for the liver, spleen, and kidneys, noting shape, size, and consistency
    • The spleen extends no more than 1-2 cm below the costal margin in children
    • The liver span in children ranges from 3.6 cm at age 2 to 5.5 cm at age 10
    • Liver span can be assess using the scratch test (link: Scratch test)
  • Palpate all four quadrants, noting any abnormal masses and their size, consistency, mobility, and associated tenderness
  • Older children and adolescents

Musculoskeletal

Newborns and Infants

  • Inspection
    • Thoroughly inspect the spine and sacral dimple looking for any pigmented areas, tufts of hair, or pits indicating neural tube defects
  • Palpation
    • Palpate each clavicle looking for any signs of birth trauma
    • Perform the Ortolani test for congenital hip dysplasia and the Barlow test to look for an unstable or dislocatable hip
  • See adult Musculoskeletal Physical Exam section for more details.

  • Feet
    • The feet are often turned inward, but the examiner should be able to easily correct to a neutral position
      • If unable to correct with manipulation suspect talipes equinovarus (clubfoot)
      • Observe gait, looking specifically for “in-toeing” or “out-toeing”
    • Look for “in-toeing” or “out-toeing”
      • Most will resolve spontaneously during growth
  • Genu varum (bowlegged)
    • Frequently seen for 1-2 years after child begins to walk
  • Genu valgum (knock-knees)
    • May follow genu varum in children 2-4 years of age
  • Inspect true leg length by measuring from the anterior superior iliac spine to the medial malleolus

Genitourinary and Reproductive

Males

Inspection:

  • Stage of sexual maturity
  • Foreskin
    • Should completely cover the glans
    • Not fully retractable at birth
  • Shaft of the penis
    • Chordee: the penis is fixed in a downward bowing position
  • Urethral meatus
    • Hypospadias: the urethral meatus is located on the ventral surface of the penis
    • Epispadias: the urethral meatus is located on the dorsal surface of the penis
  • Scrotum
    • Slight scrotal edema is normal due to maternal estrogens
    • Significant edema or swelling should be further investigated to rule out hydrocele and inguinal hernia

Palpation:

  • Palpate the testes
    • Begin palpation in the external inguinal ring proceeding downward to the scrotum
    • Testes should measure ~10mm in width and ~15mm in length
  • If a testicle is palpable in the inguinal canal, gently attempt to milk the undescended testicle to the scrotum
    • Cryptorchidism: testicle fails to descend during development

Females

Inspection:

  • Stage of sexual maturity
  • Inspect for rashes
  • Inspect the clitoris and labia majora noting their size and colour
  • Separate the labia majora: inspect the urethral orifice , labia minora and hymen
  • Inspect for signs of sexual abuse
  • Due to the effects of maternal estrogens there may be a milky blood tinged vaginal discharge present during the first weeks of life

Neurological

The adult neurological exam can be performed in developmentally-normal children and adolescents. A modified approach must be used in infants, young children, and those with developmental delays who are unable to follow commands.

Newborn or infant:

  • Mental status
    • Observe for extreme irritability, lethargy, and level of alertness
    • Note the volume and pitch of the infant’s cry
  • Cranial nerves
    • Check for pupillary reflexes
    • Extraocular movements can be assessed by getting the infant to fix on and follow a toy or interesting object
    • Observe the symmetry of the face when crying
    • Does the infant startle with loud noises
    • Does the palate move symmetrically with crying
  • Motor
    • Observe the position of the infant, which is normally slightly flexed
    • Are all limbs moving symmetrically
    • Assess peripheral tone by passively manipulating the limbs, assess axillary tone with vertical suspension and central tone with ventral suspension
    • Assess for head lag by pulling the infant to a sitting position
  • Reflexes
  • Older Children

Developmental Milestones

Assess for developmental milestones.

References

  1. Swartz MH. Textbook of Physical Diagnosis: History and Examination. 6th ed.Philadelphia: W.B. Saunders Company; 2010.
  2. Bickley LS, Szilagyi PG. Bates' guide to physical examination and history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009.
  3. Rourke L, Leduc D, Rourke J. Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance. Canadian Pediatric Society Website. http://www.cps.ca/english/statements/CP/Rourke/RBRNational.pdf. Last updated July, 2011. Accessed on December 20, 2011.
  4. Behrman RE, Kliegman, RM, Jenson HB. Textbook of Pediatrics. 17th edition. Saunders; 2003.
  5. Wedro B. Pediatric Vital Signs. eMedicine Health. http://www.emedicinehealth.com/pediatric_vital_signs/article_em.htm. Last updated March 10, 2008. Accessed December 20, 2011.
  6. Rosen DS, Goldenring JM (January, 2004). Getting into adolescent heads: An essential update. Contemporary Pediatrics, 21(1), 64-90.
  7. Kleigman, R., Stanton, B., Schor, N., Behrman, R. Nelson Textbook of Pediatrics, Saunders, 2011