Paediatrics 2

Pediatrics: Examination

1. Environment, general appearance
2. Arms, vital signs
3. Heart, lungs
4. Abdomen
5. Diaper, genitalia, anus
6. Legs, feet
7. Integumental
8. Nervous
9. Head and neck, eyes, ears, nose, throat
10. Height, weight
11. Examination tips

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.

PEDIATRIC ASSESSMENT: FOCUS ON PHYSICAL ASSESSMENT

 

Pediatric Assessment:   The Major Focus

· Major differences between children and adults

· Specific approaches and techniques to physical exam

· Normal findings, variations and common pathological conditions

· Interpretation of exam results

Major Concepts in Pediatric Physical Assessment

· Children are not little adults

· Understanding differences from adults  is important

· Differences relate to both growth and development patterns

· Differences exist in motor skills and coordination, and in physiologic, psychosocial, behavioral, 

temperamental, language, and cognition areas

Skills Utilized in Working with Children

· Knowledge of growth and development

· Communication skills with children and their parents

· Understanding of family dynamics and parent-child relationships

· Knowledge of health promotion and anticipatory guidance

Major Concepts for Assessment and Health Promotion 

· Development

· Medical history

· Nutritional status

· Growth and vital sign measurements

· Physical assessment

· Guidelines for well child supervision

· Anticipatory guidance

· Immunizations2

Exam Settings

· Outpatient (office, clinic emergency room)

· Well child check

· Illness visit

· Inpatient 

· Moderate to severe illness

· Anxiety and stress

· School setting or health office

· Children usually healthy

· Illness visits primarily common acute problems and some chronic illness issues

· Health screenings

Environmental Setting

· Safety is primary

· Pleasant, comfortable settings are helpful

· Accessible toys for young children are distracters and may reduce anxiety

· Age appropriate literature or items for teens and older children provide diversion in waiting areas

Standard Measurements

· Weight

· Height

· Head Circumference

· Chest Circumference

· Vital Signs

· Temperature

· Pulse, Heart Rate

· Respiration

· Blood Pressure

· Gestational Age Assessment and Intrauterine Growth Charts

Sensory Issues

· Smell:  usually not tested;  observe for unusual odors from child

· Taste:  usually not tested; infants often prefer sweet tasting foods

· Touch:  well developed in infant; if stimulated can invalidate other sensory tests

· Vision: right eye (OD), left eye (OS), both eyes (OU)

· Hearing:  correlates with language development; localization requires both ears

Specific Evaluations

· Development

· Vision

· Hearing

· Language3

Key Points to Assessment Procedure

· Head to foot exam is most orderly 

· Vary sequence according to child’s response

· Examine young children in parent’s lap

· Do intrusive examinations last

Approach to Physical Exam

· Consider age and  developmental level; observe for “readiness” clues

· Take time to get “acquainted”

· Use play techniques for infants and young children

· Determine best exam place ( table, parent’s lap, examiner’s lap)

· Use systematic approach; but be flexible to accommodate child’s behavior

· Examine least intrusive areas first (i.e., hands, arms)

· Examine sensitive, painful or intrusive areas last (i.e. ears, nose, mouth)

· Determine what exam you want to complete before possible crying (i.e. heart, abdomen)

Age Groups

· Neonate/Newborn Birth to 28 days 

· Pre-term Gestational age <37 weeks

· Term Gestational age 37-42 weeks

· P o s t-term Gestational age > 42 weeks

· Infant Birth to 1 year

· Young, Immobile Birth to 6 months

· Older, Mobile 6 to 12 months

· Young Child 1-5 years

· Toddler 1-3 years

· Pre Schooler 3-6 years

· School Age or Older Child 6-12 years

· Adolescent 13 to 18/21 years

· Pre-Adolescent 10-12 years

Approach to Infants

Birth to 6 months:  If baby is comfortable and stress free, exam can be conducted on  table.  Sensory 

methods, such as voice, noise makers, toys to see or touch, or skin touch attract babies.  They like a 

smiling human face.   Do quiet things first, then head to toe.

6 to 12 months:   Consider exam in parent’s lap due to separation or stranger anxiety (up to 4 years).  

“Warm up” more slowly with play techniques.  Object permanence and ability to anticipate develops, 

so provide comfort measures after unpleasant procedures.  Increased mobility leads to additional safety 

measures and limit-setting concepts , which continue with each age group.4

Approach to Toddlers

Exam in parent’s lap, due to need for parent security.  Play games.  Do least intrusive things first. 

Save ears, nose, throat for last.  Avoid “no” responses or choices they can not make.  Offer simple 

acceptable choices.  Let them touch equipment.Approach to Pre-Schoolers

Keep parent close.  Some will cooperate with exam on table.  Protect modesty.  Use dolls, animals 

or parents to “examine” first.  Magical thinking may cause fearfulness or thinking equipment is 

alive.  Let them play with equipment.  Use familiar, safe, non-frightening words and approaches.

Approach to School-Age Child

Do a head to toe exam.   Respect modesty. Address questions more directly to child.  Explain in 

concrete terms.   Medical diagrams or teaching dolls are helpful. Elicit their active participation in 

history, exam and care plan.  Answer questions honestly.

Approach to Adolescents

Confidentiality, privacy, protection of modesty are important.  Explain confidentiality parameters.  

Offer to examine alone, without parent present.  Address questions to patient.

Keep in mind, depression is more common in adolescents, especially girls.  More common 

concerns among girls include body-image distortion, loss of appetite & weight, & lack of 

satisfaction.  More common concerns among boys include irritability, social withdrawal & drop in 

school performance.  A health promotion system such as GAPS, Guidelines for Adolescent 

Preventive Services can be useful

An Additional Growth and Development Handout is Available to Download

This is a 5-page summary, including one chart and additional summaries of pertinent growth and 

development theories

General Assessment:  Key Points

· Note general appearance

· State of wellness

· Degree of illness or distress

· Behavior

General Assessment:  

· Body: Symmetry, nutrition, build, hygiene, breath, odor, posture,  movement,               

coordination, facial expression

· Behavior: Development, attitude, affect, responsiveness/awareness,

cooperation, speech, LOC (person, place, time), thought process, attention span, 

concentration, memory

· Distress: Posture, (flexion/extension), pain, facial grimace, respiration5

Skin, Hair and Nails:  Skin – Key Points

· Color: Jaundice, pallor, cyanosis, erythema, ecchymosis

· Texture & Turgor: Degree of hydration or dehydration

· Edema: Periorbital (crying, allergies, renal disease, juvenile hypothyroidism)

Dependent (renal or cardiac disease)

· Birth Marks

· Pigmentations: Hyperpigmentation (endocrine, growth dis turbance); hypopigmentation

· Infectious lesions: Viral, bacterial,  fungal (erythema, macule, papule, vesicule, pustule)

· Capillary bleeding: Petichiae and purpura usually indicate serious conditions 

· Infestations: Pediculosis, scabies, insect bites

· Pruritis : Dry skin, allergy, eczema, contact dermatitis, hepatic, renal, lesions

· Trauma: Scars, ecchymosis, signs of abuse

· Hand: Dermatoglyphic variations associated with syndromes

Common Skin Variations in Newborns and Infants

· Thin, transparent skin, especially premature

· Color Variations

· Vascular Markings

· Pigmentations

· Lanugo (downy hair) more prominent in premature

· Original hair may shed at 4-8 weeks, and be replaced

Skin Color Variations

· Jaundice: Pathologic in first 24 hrs. physiologic after 24 hrs. 

· Acrocyanosis  Cyanotic, cool  extremities; warm, pink trunk

· Cutis marmorata  Bluish mottling due to chilling or stress 

· Erythema toxicum  Papules, vesicles on erythematous base @24-48 hrs.

· Harlequin color change  Lower side of body red, upper side pale – change reverses it 

· Milia  White papular epidermal cysts with sebaceous retention

· Miliaria  (4 types) Obstruction of sweat ducts from head and humidity

· Neonatal acne, prickly head Miliaria – crystallina, rubra, pustulosa, profunda

· Pallor  Anemia or anoxia

· Plethora Erythematous flush, due to polycythemia

Skin Vascular Markings

· Capillary hemangiomas (telangiectasia or telangiectataic nevus or

nevus simplex --- “stork bites,” “angel kisses”) --- usually fade

· Nevus flammeus (“port wine stains”), nevus vasculosis ---not likely to fade

Can be associated with Sturge-Weber Syndrome 

· Strawberry hemangioma:  bright red, lobulated tumor 6

· Cavernous hemangioma:  bluish red, more vascular than strawberry

Skin Pigmentations

· Mongolian spots in darker pigmented infants 

· Pigmented nevi, 

· Café au Lait (<3cm and <6 in # are WNL – larger size or more spots associated with

Neurofibromatosis , or Von Recklinghausen Disease) – an autosomal-dominant disorder, with 

tumors on peripheral or cranial nerves

Yellow Skin Color

· Jaundice: Observed in sclera, skin, fingernails, soles, palms & oral mucosa .

Does not blanche with pressure over chest or nose areas

Is associated with liver disease, hepatitis, red cell hemolysis, biliary 

Obstruction & sever infection during infancy.

· Carotenemia: Observed in palms, soles, face, skin 

(not in sclera or mucous membranes)

Blanches easily to pressure over chest or nose

Occurs in older infants, with eating yellow vegetables 

· Renal Disease: Yellowing of exposed skin areas (not sclera or mucous membranes)

May be associated with chronic renal disease

Hemolytic Jaundice of Newborn:  Biirubin above 5ml/dl

· Pathologic: Occurs first 24 hrs of life.

Bilirubin increases faster than 5ml/dl/day

· Physiologic: Onset after 24 hrs, with peak from 72-90 hrs.

Declines at  4 to 7 days

· Breast Feeding: Early onset: Onset at 2 to 4 days.  Peak at 3 to 5 days

Late onset: Onset at 5-7 days.  Peak at 10 to 15 days.

May remain jaundiced for 3 to 12 weeks

Hair:  Key Points

· Assess for dis tribution, color, texture, amount, quality and for infestations

· Course, dry, brittle or depigmented  hair may indicate nutrition deficiency or thyroid disorder

· Alopecia may be related to tinea capitus, hair pulling or persistent positioning

· White eggs (nits) attached to hair shafts indicate pediculosis

· Hair tufts on spine or buttocks may indicate spina bifida

Nails:  Key Points

· Inspect for color, shape, condition, nail biting and infection

· Clubbing may indicate chronic hypoxia (respiratory or cardiac dis ease)

· “Spoon” nails may indicate iron deficiency anemia

· Pitted nails may indicate psoriasis

· Splinter hemorrhages under nails may indicate trauma or endocarditis7

HEENT:  Head & Neck:  Eyes:  Ears:  Nose, Face, Mouth & Throat

· Head: Symmetry  of skull and face

· Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes

· Eyes: Vision, placement, external and internal fundoscopic exam

· Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane

· Nose: Exam of nose and sinuses

· Mouth: Structures of mouth, teeth and pharynx

Head:   Key Points

· Head Circumference (HC): Frontal Occipital Circumference (FOC)

· Fontannels/sutures: Anterior closes at 10-18 months, posterior by 2 months

· Symmetry & shape: Face & skull

· Bruits: Temporal bruits may be significant after 5 yrs

· Hair: Patterns, loss, hygiene, pediculosis in school aged child

· Sinuses: Palpate for tenderness  in older children

· Facial expression: Saddness, signs of abuse, allergy, fatigue

· Abnormal facies: “Diagnostic facies” of common syndromes or illnesses 

Head:  Variations

· Neonates: Molding (suture overlap) resolve  2 days 

Capput succedaneum (scalp swelling) resolve 2 days 

Cephalohematoma (subperiosteal hemorrhage) resolve wks/months

· Fontannels: Tense and bulging with increased intracranial pressure (ICP)

Depressed with dehydration

· Large HC/ICP: Increased HC due to increased ICP (before suture closure), 

 tense & bulging fontannels, dilated head veins,  “sunset sign.”

Head may tranilluminate.

May indicate hydrocephalus, intraventricular hemorrhage, trauma, 

meningitis or tumors.  

In older child, after cranial sutures close, ICP increases are more like 

adult signs ( headache, vomiting, BP increases, change in LOC)

· Small HC: May indicate microcephaly or craniosynostosis

· Craniosynos tos i s : Asymmetric head shape due to premature closure of sutures.

Surgical separation corrects defect.

· Craniotabes: “Ping-pong” effect with pressure over temporo-parietal-occipital 

areas.  May be WNL, or result of hydrocephaly, rickets or infection

· Macewen’s sign: “Cracked pot” sound with tapping over parietal bone.

May be WNL in infants, or associated with ICP & suture separation

(i.e. lead encephalopathy, tumor)

· Chevostek’s sign: Spasm of facial muscle with percussion over zygomatic bone in front of

ear.  May be associated with hypocalcemic tetany and tetanus.

· Flattened head areas: Especially occipital flattening with hair loss, may indicate persistent 

placement of baby in same position.8

Eyes:  Key Points

· Vision:   Red reflex & blink in neonate

Visual following at 5-6 wks

 180 degree tracking at 4 months

E chart & strabismus check for preschool child

Snellen charts for older children

· Irritations & infections

· PERRLA

· Amblyopia (lazy eye):  Corneal light reflex, binocular vision, cover-uncover tes t

· EOMs:  tracking 6 fields of vision

· Fundoscopic exam of internal eye & retina

Eyes:   Variations

· Placement & symmetry: Wide set:  hypertelorism – Down syndrome

Close set:  hypotelorism

Epicanthal folds or upward slants – ethnicity, Down s.

Character of eyebrows

· Eyelids: Ptosis, lid lag, blepharitis (stye), swelling

Dacryocystitis (blocked tear duct) may cause rednnes, 

swelling and discharge

“Allergic shinner” (dark circles) may indicate allergy

Perorbital edema may indicate renal problems

Sunken eyes may indicate dehydration

· Conjunctive: Inflammation,  pallor (anemia), 

Cobblestone appearance may indicate allergy

· Sclera: Jaundice (liver disease),  injection (conjunctivitis),

Hemorrhage, blue color (osteogenesis imperfecta)

· Cornea: Smooth, mo ist,clear (not injected with conjunctivitis red eye)

· Pupil & Iris: Brushfield’s spots (light speckling of iris) seen in Down s.

Coloboma (notch at outer edge or iris) may indicate visual 

field defect.

· Othalmoscope: Partial or dark red reflex  indicates pathology, various retinal 

anomalies or opacities of cornea, anterior chamber or lens

(i.e. cataract)

White retinal reflex indicates pathology (i.e., retinoblastoma,

Retinal detachment  chorioretinitis)

Retinal hemorrhage is pathological, associated with a variety 

of causes:  Is a specific diagnostic criteria in “shaken baby” 

syndrome.

Papilledema of increased ICP more likely in olde child, with 

closed cranial sutures9

Ears:  Key Points

· Exam last In younger children

· Restrain Young children in lap, head braced against parent’s chest

· Hearing: Especially if language delay or  frequent otitis media

· Otoscope exam: Pull auricle down & back for infants, toddlers, preschoolers

Pull auricle up &back for school aged & adolescents

Cerumen removal may be necessary

Use pneumatic otoscopy

· Tuning fork: Weber & Rinne tests to differentiate conductive vs  sensorineural 

hearing loss are not effective with younger children

Ears:  Variations

· External: Malformed auricle/pinna, or low-set or obliquely-set ears may be 

Associated with many syndromes, or genitourinary & chromosomal 

abnormalities.

· Otitis externa: Pain with movement of auricle or tragus, discharge in canal, occurs 

More often in summer (“swimmer’s ear”)

· Otitis media: Proper position & holding of otoscope facilitates comfortable

As middle ear pressure or fluid increases, the tympanic membrane 

(TM) becomes less mobile with pneumatic otoscopy. 

 Exam of TM:

TM: Dull, gray, retracted, loss of light reflex, landmarks may be 

more difficult to see, with possible superior injection near 

short process of malleus is associated with blocked or 

obstructed eustachian tubes.

TM: Dull, bulging, gray or with some injection is associated with 

pressure, fluid or pus accumulating in the middle ear.

TM: Red, dull/thick/bulging, with landmarks not visible is 

associated with acute otitis media.

TM: Orange-amber color, with/without bubbles/fluid lines is 

associated with serous otitis media with effusion, often 

associated with viral URIs, or pressure changes, such as diving 

or flying.  TM may be retracted, with landmarks easier to see.

Nose: Key Points

· Exam nose & mouth after ears (after crying from ear exam)

· Observe shape &  structural deviations

· Nares: ( check patency, mucous membranes, discharge, inferior turbinates, bleeding)

· Septum: (check for deviation)

· Infants are obligate nose breathers

· Nasal flaring is associated with respiratory distress10

Nose:  Variations

· Allergy: Pale, boggy mucous membranes & interior turbinates, watery 

discharge, mouth breathing & “allergic salute” line across nose.

· Infection: Erythematous, edematous mucous membranes, with purulent yellow 

or green nasal discharge

· Foreign body: Foul odor or unilateral discharge

· Excoriation: Irritating discharge, frequent wiping or nose picking

· Structure variations: Observe flattened nose or nasolabial folds that may indicate 

congenital anomolies.  

Asymmetry of nasolabial folds may indicate facial nerve impairment or 

Bell’s palsy.

Sinuses:  Key Points

· Palpate maxillary & frontal sinus areas for tenderness of sinusitis in older children

· Development of facial sinuses and location of sinus pain is listed below:

Sinus Pain Location Age of Development

· Maxillary cheek & upper teeth present @ birth

· Ethmoid medial & deep to eye present @ birth

· Frontal forehead & above eyebrow approximately 7 years

· Sphenoid deep behnd eye in occiput adolescence

Mouth & Pharynx:  Key Points

· Inspect lips for color, symmetry, moisture, swelling, sores, fissures

.

· Inspect buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding, 

lesions.

· Inspect tongue & frenulum for movement, size & texture

· Count teeth & inspect for caries, malocclusion and loose teeth.

20 deciduous teeth, begin eruption at 6 months & continue adding approximately 1/month

32 permanent teeth, erupt from 6 to 25 years, with molar eruption from 1to 25 years

· Inspect uvula for symmetrical movement or bifid uvula (indicating cleft palate or WNL

· Observe for quality of voice

· Observe infants for rooting and sucking reflexes, Epstein pearls & thrush

· Observe breath for halitosis11

Mouth & Pharynx:  Variations

· Newborn cysts: White retention epitheleal cysts occur in the newborn:

Epstein’s pearls occur along midline of palate.

Bohn’s nodules occur along gum line, resembling teeth.

· Vesicular eruptions: Can occur on lips, buccal mucosa & tongue, due to viral infections,

such as herpes simplex cold sores or aphthous stomatitis.

· Fissure/cracked lips: May be due to harsh climate or vitamin deficiencies.

· Color variations: Central cyanosis can be observed in lips & mucosa..

Pallor may indicate anemia.

Cherry red coloration may be seen in acidosis.

· White patches: White ulcerated sores on mucosa ae cankers, related to mild trauma, 

viral infection, mild trauma or local irritants .

Koplik’s spots, small white, red rimmed eruptions on buccal mucosa 

next to first & second molars, appear and disappear before the onset of 

Measles (rubeola) rash. 

White curdy patches that cannot be scraped away, may be oral 

candidiasis (thrush), and is common in infants, especially following 

antibiotic therapy.

· Tongue variations: A smooth, red tongue may be related to vitamin deficiencies

.

“Strawberry” and “Raspberry” tongue are seem in scarlet fever.

A short frenulum with inability to touch tongue to upper gum ridge

(“tongue tie” or ankyloglossia) may lead to later speech problems.

· Palate & uvula: With gag reflex, deviation of uvula to one side suggests either

Glossopharyngeal or vagus nerve involvement or infection of 

peritonsillar or retropharyngeal abcess.

An absent or bifid (notched) uvula may indicate submucosal or soft 

palate cleft.

· Tooth markings: Brown & black spots may indicate caries.

“Baby bottle” caries appear on teeth at gum line and are

due to babies taking a bottle to bed, and milk pools around the teeth.

Brown-white mottling may indicte excessive fluoride intake.

Green & black staining may indicate oral iron intake contacting teeth

An increase in tooth decay or evidence or eroded enamel may indicate 

frequent, self-induced vomiting, especially in adolescent girls.  Callous 

marks on fingers/knuckles might also be observed12

· Pharynx: Large tonsils, due to developmental lymph tissue hypertrophy

Are common in school aged children & adolescents

Large red tonsils covered with white exudate are suggestive of 

streptococcal tonsillitis, especially if palatal  petichiae & red uvula are 

present.

Thick, gray exudate may indicate diptheric tonsititis

A gray, necrotic discoloration of tonsillar tissue may suggest infeftious 

mononucleosis .

A unilateral, red, enlarged tonsil suggests peritonsillar abcess.

· Voice quality: Nasal voice may indicate enlarged adenoids

Hoarse cry may indicate croup, cretinism or tetany.

Shrill, high-pitched cry may indicate increased ICP, such as 

head injury or meningitis.

Neck: Key Points

· Check for position, lymph nodes, masses, cysts or fistulas/clefts

· Suppleness & Range of  Motion (ROM)

· Check clavicle in newborn

· Head control in infant

· Trachea & thyroid in midline

· Carotid arteries (bruits)

· Torticollis

· Webbing

· Meningeal irritation

Neck: Variations

· Head lag: Significant lag after 6 months may indicate cerebral palsy

· Torticollis: “Stiff neck” with resistance to lateral head turn as result of injury to

sternocleidomastoid muscle, more often seen in newborn

· Clavicle: Check for fracture in newborn, associated with shortening, break in contour, 

Crepitus at fracture site, and decreased motion of arm

· Webbing: Feature of “Turner’s syndrome” or other congenital abnormalities

· Meningeal: Irritation indicated by nuchal rigidiy, opisthotonos, tripod position with sitting, 

Positive Brudzinski’s sign (with patient supine, neck flexion produces pain and 

flexion of hips and knees).

Positive Kernig’s sign (with patient supine, hip & knee flexed, extension of knee 

Produces pain & resistance

· Node s : Lymphadenopathy common with infection in older children, upper neck areas, 

and below angle of jaw, usually bilateral.  Should not be deep cervical or 

clavicular.13

· Mumps: Parotitis produces swelling over angle of jaw,  usually unilateral, 

with redness & swelling of  Stensen’s parotid duct in mouth & pain with

sour tastes.

· Thyroid Ascends with swallowing (not normally palpable in young child).

Check bruits, nodules or goiter (& accelerated growth, staring eyes)

Lymph Nodes:  Key Points

· Inspect & palpate lymph nodes for size, color, location, temperature, consistency, tenderness, 

firmness & mobility.

· Nodes are proportionately large in older children & adolescents, and smaller in the elderly.

· Lymphadenopathy in the head & upper neck area are common with various infections:

(Occiptal, pre & post auricular, superficial anterior cervical, posterior cervical, tonsillar, 

submandibular, submaxillary, submental, sublingual)

· Inguinal lymphadenopathy may be observed in some diapered children, but not usually 

otherwise.

· Deep cervical, supraclavicular, infraclavicular, axillary & epitrochlear lymphadenopathy may 

indicate pathology.

Thorax & Lungs:  Key Points

· Structure:  Observe for shape, symmetry & posture

· Chest deformities: can be WNL, but significance varies with severity  etiology

· AP diameter: round chest or 1:1 ratior during infancy, with transverse diameter

increasing, with AP:lateral ration 1:2 during school age years.

· Pectus carinatum or pigeon breast: concavity of sternum

· Pectus excavatum or funnel chest  protrusive sternum

· Harrison;s Groove:  horizontal ression groove of lower ribs with lower rib flarring,

may indicate vitamin D deficiency (richets)

· Beading  or richitic rosary:  protrusive deformities along costochondral junction s ,

may indicate vitamin D defenciency (richets)

Breast:  Key Points

· Inspection: size, color, symmeetry, color,  nipples/accessory nipples, dimpling

· Palpation: masses, consistency, elasticity,  nipple discharge

· Male gynecomastia

· Self Exam

Tanner Stages for Female:

I Prepubertal, elevation of papilla only

II Breast bud, elevation of breast & papilla as small mount, enlargement of areola

III Further enlargement of breast & areola, no separation of contours

IV Areola projected as secondary mound

V Mature, recession of areolar mound to breast contour, projection of papilla only14

Lungs & Respiratory Status:  Key Points

· Symmetry of expansion, decreased expansion (pneumonia, pneumothorax, FB)

· Prolonged expiratory phase

· Resp rate (>40 at rest, after neonate period = respiratory distress)

· Color: cyanosis or mottling

· Clubbing

· Nasal flaring

· Grunting (expiratory)

· Stridor (inspiratory):  croup

· Snoring (expiratory):  upper airway obstruction, allergy, enlarged lymph tissue

· Retractions

· Respiratory movement: males abdominal, females thoracic-costal,

elderly shallow, infants abdominal

· Dyspnea

· Orthopnea

· Fremitus: Increase: pneumonia, atelectasis, mass

Decrease: asthma, pneumothorax or FB

· Dullness to percussion:  fluid or mass

· Quality: vesicular (bronchioles, alveoli)

bronchovesicular (bronchi)

bronchial (trachea)

· Adventitious (adventiginous) sounds

· Crackles (rales)

· Rhonchi (course breath sounds)

· Wheeze

· Pleural friction rub

Cardiovascular:  Key Points

· Vital signs: compare with normal/age values

· Peripheral pulses: apical, carotid, radial/brachial, femoral, pedal

· Rate, rhythm:  compare cardiac rhythm with pulse

· Peripheral vascular:  color, temperature, edema, skin texture/changes

· Capillary refill:  immediate

· Peripheral pulses:  femoral pulses absent or diminished in aortic stenosis

· Deep vein thrombosis:  Homan's sign

· Skin:  pallor, cyanosis  (lips, nail beds, ear lobes)

· Clubbing

· Pulsating neck vessels (JVD)

· Bulging chest

· Elevated BP

· Thrills

· Bruits15

Heart

  

· Rate, rhythm, heart sounds

· Size, PMI

· Auscultation:  sitting, lying, left recumbent & bending forward

· PMI: Lt. ventricular contraction during systole

· location & size of heart: midclavicular 5th intercostal space (4th/infant)

Stethoscope

Diaphragm: high pitch, S1

Bell: low pitch, S2

S1: Mitral & Tricuspid AV valves close  (ventricles are full,

prior to ventricular contraction--systole begins,

best at apex

S2: Aortic & Pulmonary semilunar valves close  -- ventricles eject--

after ventricular contraction--diastole begins, atrial filling begins

S2: may be split--widens during inspiration (increase venous return--

increase filling time--delayed pulmonic closing)

S3: can be functional sound in childhood

S4: not normally audible, associated with cardiac abnormalities

Murmurs:may be systolic, diastolic or continuous 

(timing, location, quality (course, harsh, blowing, high pitched)

GRADE: I   - faint, may not be heard sitting

II  - readily heard with stethoscope

III - loud, no thrill

IV  - loud with stethoscope, thrill

V   - loud with stethoscope barely to chest, thrill

VI  - loud with stethoscope not touching chest, thrill

Functional Murmurs:

Change or disappear with position change (usually loudest supine)

Low grade, soft or musical

Intensity range from I-III/VI

Systolic (never diastolic)

Do not radiate

COMMON FUNCTIONAL MURMURS: 

Cardiac murmurs occurring in absence of significant heart disease or structural 

abnormality

· Still’s Murmur: 2 years  – adolescence;  midway between apex & LLSB, 

Grade I-II/VI, mid-systolic, soft, low pitched, louder in supine position; may be

Louder with fever or tachycardia

· Basal systolic ejection murmur: high pitched, blowing, systolic, best

heard in pulmonic area, in supine position16

· Physiologic peripheral pulmonic stenosis, or pulmonary outflow

murmur: disappears during infancy as pulmonary arteries enlarage; short 

systolic, grade I-II/VI, heard best in axillae

· Venous hum:  usually after 3 yrs, UR&LSB & lower neck, continuous musical 

hum Grade I-III/VI; heard best in infra & supraclavicular areas; loudest in sitting 

position & decreases in supine position or with turning child’s head or  

occluding jugular vessels

Organic Murmurs & sounds:

· Diastolic murmurs: always organic

· Systolic murmurs: may be functional or organic

· Friction rubs

· Before 3 yrs, usually congenital

· After 3 yrs often acquired 

· Rheumatic fever

· Kawasaki disease

Abdomen:  Key Points

· Contour

· Peristalsis

· Skin:  color, veins

· Umbilicus

· Tenderness

· Ridigity

· Tympany

· Dullness

· Hernias:  umbilical, inguinal, femoral

· Masses - size, shape, dullness, position, mobility

· Liver

· Spleen

· Kidneys

· Bladder

Genitourinary and Reproductive:  Key Points

Breast:  as previous

Female Genitalia

· External genitalia:  Pelvic 16-18 years or when sexually active

· Mons pubic, prepuce (clitoral hood), clitoris, labia minora/majora,

vagina, Skene's & Bartholin's ducts, anus

· Size, color, skin integrity, masses

· Redness, swelling, labial adhesions/fusion, lesions, discharge (foul-smelling)17

Tanner Stages

I Prepubertal. No true pubic hair

II Sparse growth of slightly pigmented, downy hair, slightly curled, along labia

III Increas in hair, courser, curled, darker

IV Adult-type hair, but limited area.  No spread to thighs

V Adult distsribution & quantity with spread to thighs

Male Genitalia

· Penis:  Size, color, skin integrity, circumcision

· Urethral meatus:  Shape, placement, discharge, ulceration, discharge

meatal stenosis, hypospadias, epispadias

· Scrotum: Color, size, symmetry, edema, masses, lesions, tenderness,

· testes descended bilaterally

· Pubic hair

Tanner Stages

I Prepuberal, no true pubic hair, testes, scrotum, penis childhood size

II Sparse, slightly curled, downy hair (base of penis/along labia

Enlargement of testes & scrotum, scrotal skin reddens & coursens

III Hair courser, curled, darker.  Enlargement of penis (length), 

further growth  scrotum/ testes

IV Adult type hair, no spread to medial thighs. Enlargement of penis 

(width/length), enlargement of glans, scrotal skin darkens

V Adult hair distribution (triangle) & adult genital development 

Musculoskeletal:  Key Points

· Alignment, contour, strength, weakness & symmetry 

· Limb, joint mobility:  ROM, stiffness, contractures -

Neck, shoulder, elbow, wrist, hip, knee, ankle, foot

· Digits

· Dermatoglyphics

Problem Areas

· Spinal changes:  scoliosis, kyphosis, lordosis

· Scoliosis: pre-adolescent growth

lateral curvature

contralateral hip hump

prominent scapula

asymmetry: shoulder, arms, hips

· Congenital hip dislocation or dysplasia:  check hip abduction & symmetry 

· asymmetrical hip abduction

· asymmetrical thigh & gluteal folds

· Ortolani's click

· Barlow's test

· Trendelenburg gait

· Allis' sign

· Trendelenburg sign & gait:  indicates hip disease in ambulatory child

· Asymmetries or weaknesses18

· Limp

· Legg-Calve` Perthes:

peak age 7 years: boys > girls

Hip or knee pain

May have history of trauma

+ Trendelenburg

· Slipped Capital Femoral Epiphysis

Adolescents: boys > girls

Obese

Hip or knee pain

· Joint  infection

· Feet/legs: Variations may begin in feet, tibia or upper let & hip area

Feet  turning in:  varus

Feet turning out:  valgus

· Legs:

Bowleg (genu varum -- knees 2 inches apart)

Knock-knee (genu valgum -- ankles 3 inches apart)

· Movement limitation: 

crepitus  with joint movement

meningeal signs, such as stiff neck, opisthotonous

· Muscular dystrophy

Progressive muscular weakness (Gower’s sign)

· Cerebral palsy or other muscular disease

Pes equinus (weight bearing on toes)

Short heel cords

Neurological Evaluation:  Key Points

· Cerebral Function:

· "Mental status" appearance, behavior, cooperation

· LOC, language, emotional status, social response, attention span

· Cerebellar Function

· Balance, gait & leg coordination, ataxia, posture, tremors

· Finger to nose (fingers to thumb)  3-4 yrs

· Finger to examiner's finger  4-6 yrs

· Ability to stand with eyes closed (Romberg)  3-4 yrs

· Rapid alternations of hands (prone, supine)  school age

· Tandum walk   4-6 yrs

· Walk on toes, heels   school age

· Stand on one foot   3-6 yrs

· Motor Function:  Gross motor & fine motor movements

· Muscle size, symmetry, strength, tone, movement

· Involuntary movements, posture

· Developmental maturation19

· Sensory function

· Tested in cranial nerves

· Sharp-dull

· 2 point discrimination

· Stereognosis

· Graphesthesia

· Infants: responsive to touch, vision, hearing, smell

Present only one sensory stimulation at a time, if testing

· Reflexes

Deep tendon: Biceps   C5, C6

Triceps  C6, C7, C8

Brachioradialis  C5, C6

Patellar  L2, L3, L4

Achilles  S1, S2

Superficial: Cremasteric   T12, L1, L2

Abdominal   T7, T8, T9, T10, T11

Infant Automatisms:  Primitive Reflexes

· Cranial Nerves

C1 Smell

C2 Visual acuity, visual fields, fundus

C3, 4, 6EOM, 6 fields of gaze

C5 Sensory to face: Motor--clench teeth,

Corneal reflex---is C5 & C7

    C7 Raise eyebrows, frown, close eyes

tight, show teeth, smile, puff cheeks,

Taste--anterior 2/3 tongue

C8 Hearing & equilibrium

C9 "ah"  equal movement of soft palate & uvula

C10 Gag, Taste, posterior 1/3 tongue

C11 Shoulder shrug & head turn with resistance

C12 Tongue movement

· Infant Reflexes:  Most disappear between 4-6 months of age

· Blink (dazzle)

Blinks to bright light, 1

s t

 year of life, absence indicates blindness

· Root

Turns direction cheek is stroked, disappears 3-4 months, may persist longer, absence 

indicates neruologic disorder

· Suck

Sucks in response to stimuli, may persist during infancy, weak or absent reflex

indicates developmental/neurological disorder

· Extrusion

Tongue extends out when t ouched, disappears at 4 months, persistent extrusion may 

indicate Down’s

· Moro & Startle

Arms & legs extend symmetrically & arms return to midline, when stimulated by 

position change or sudden noise, disappears by 4-6 months,  absence or asymmetry of 

responses indicate injury, neurological disorder or hearing loss20

· Galant's (trunk incurvation)

Back moves toward paraspinal side stimulated, present for 4-8 weeks, absence

may indicate spinal cord lesions

· Dance or step

Feet withdraw or step up, when foot touched to surface, present  4-8 weeks,

persistence indicates neurological problem

· Palmar grasp

Finger’s curve around object placed in palm or palmar aspect of fingers, disappears 3-4 

months, persistence indicates neurologic disorder

· Tonic neck

Fencing position: head turn-arm extend, leg extend to same side & all reverse with 

change to opposite side, appears strongest at 2 months & disappears by 6 months, 

persistence indicates neurological problem

· Neck righting

When supine, shoulders, trunk  pelvis turn to direction head is turned, absence or 

persistence beyond 6 months indicates neurological disorder

· Crawling

Symmetrical crawling movements when prone, asymmetries indicate neurological

disorder

· Babinski

+ for toe fanning, present until child walks well, or at 2 years of age21