Examination in Paediatric Dr. Varsha Atul Shah Senior Consultant
Physical Examination Perform physical examination from head to toe on a pediatric patient. You may need to alter the order of the examination for patient compliance for uncooperative or hyperactive patients. Do not force a child to do something that may be frightening or uncomfortable to them. When examining an infant, toddler, or school-aged child it is suggested to have a parent or guardian in the room with you.
Physical Examination Examination of an infant or toddler may be preformed on the lap of the patient. With an adolescent, it may be more appropriate not to have the parent in the room with you, this may allow the patient to feel that they can be more candid. To avoid possible legal issues, a male doctor may want a female staff member to be in the examination room. The doctor should verify confidentiality laws in their particular state.
Vital Signs Vital signs in pediatrics include temperature, heart rate, blood pressure, respiratory rate, weight, length, and head circumference.
Weight Height, weight, and head circumference should be plotted on a growth curve graph. Decrease in weight percentile may be due to decreased intake (malnutrition, central nervous system abnormality), malabsorption (cystic fibrosis, IBD, celiac disease, parasitic infestation), or an increased metabolic rate (hyperthyroidism, congestive heart failure). Increase in weight is most commonly exogenous but may also be associated with certain genetic syndromes (Prader- willi).
Height A child’s length (lying flat on a table) is measured until 2 to 3 years of age; after that it is measured as height (standing). Decrease height may be familial, or may be seen in conditions affecting weight or independent of weight (Turner syndrome). Increase height may be familiar or associated with certain genetic and endocrine abnormalities (Cerebral gigantism).
Head Circumference Head circumference is routinely measured until 2 to 3 years of age. Microcephaly may be part of a syndrome (Rett syndrome), congenital infection (CMV), or the result of abnormal brain growth (schizencephaly). Macrocephaly may be familiar or may represent a pathologic state (Hydrocephalus, Canavaan disease, AV malformation).
Blood Pressure Blood pressure must be measured with a cuff wide enough to cover at least 1/2 to 2/3 of the extremity and its bladder should encircle the entire extremity. A narrow cuff elevates the pressure, while a wide cuff lowers it. Systolic hypertension is seen with anxiety, renal disease, coarctation of the aorta, essential hypertension, and certain endocrine abnormalities. Diastolic hypertension occurs with endocrine abnormalities and coarctation of the aorta. Hypotension occurs in hypovolemia and other forms of shock.
Blood Pressure The level of systolic blood pressure increases gradually throughout infancy and childhood. 2years 96/60 112/78 6years 98/64 116/80 9years 106/68 126/84 12years 114/74 136/88
Pulse An elevated heart rate is seen in infections, hypovolemia, hyperthyroidism, and anxiety. A rule of thumb is that the heart rate increases by 10/minute for each 1 degree of temperature Centigrade. Bradycardia is seen in hypertension, increased intracranial pressure, certain intoxications, or other hypometabloic states. It is best to examine an infant’s heart first during the exam.
Heart Rate Birth 140 1 - 6 months 130 6 - 12 months 115 1 - 2 years 110 2 - 6 years 103 6 - 10 years 95 10 - 14 years 85 14 - 18 years 82
Respiration Tachypnea is seen with increased activity, hypermetabolic states, fever, or respiratory distress. A decreased respiratory rate is seen with conditions affecting the central nervous system, including medications/toxins, congenital malformations, and other lesions. A variable respiratory rate, known as periodic breathing, is commonly seen in neonates but more than a 20 second pause is always abnormal. Cheyne-Stokes breathing is seen with brainstem abnormalities.
Respiratory Rate Newborn 30 - 75 6 - 12 months 22 - 31 1 - 2 years 17 - 23 2 - 4 years 16 - 25 4 - 10 years 13 - 23 10 - 14 years 13 - 19 15 + same as adult
Temperature Temperature may be elevated with infections, tumors, hyperthyroidism, autoimmune disease, environmental exposures, certain medications, or increased activity. Temperature may be decreased with infections (especially in neonates), hypothyroidism, certain medications, environmental exposures, shock, or CNS disease affecting the hypothalamus. Control of heat production and heat loss is maintained by the thermoregulatory center in the hypothalamus.
Methods of Taking Temperature Rectal 96.8* to 98.6* F Axillary 2* F Lower Oral 1* F Lower Infrared same as rectal For the appropriately clothed child a fever is considered 100.4* F rectal. 3 months of age and less always take temperature rectally.
General Inspection A comment should be made about the patients general appearance. Activity level and whether the patient is ill, is interacting with the surroundings, and level of distress, if any. Comment about unusual odors.
Head In an infant the size and topography of the anterior fontanel should be noted. Ant. Fontanel is the largest 4 to 6 cm and closes between 4 and 26 months. Post. Fontanel is 1 to 2 cm and closes by 2 months. Bulging of the fontanel may indicate increased intracranial pressure found in infections, neoplastic diseases of the central nervous system, or obstruction of the ventricular circulation. Depression of the fontanel is found in decreased intracranial pressure and may be a sign of dehydration.
Head Symmetry should be examined from various perspectives: Plagiocephaly: is characterized by flattening of the occipital skull. Scaphocephaly: describes an elongated head with flattening of the bones in the temporoparietal regions. Cephalhematoma: term applied when there is bleeding over the outer surface of a skull bone elevating the periosteum. Caput succedaneum a localized pitting edema in the scalp that may overlie sutures of the skull, usually formed during labor as a result of circular pressure of the cervix on the fetal occiput. Craniosynostosis refers to premature fusion of one or more of the sutures of the cranial bones, and should be considered in any neonate with an asymmetric cranium.
Head Craniotabes is a term for softening of the skull bones, with pressure the skull may be momentarily indented before springing out again. The major clinical significance is with congenital rickets. Rarely, osteogenesis imperfecta or congenital hypophosphatasia may be causes. Pressure to skull makes a sound “Crack” like a ping pong ball. Macewen’s Sign: is characterized by a “Cracked pot” sound when the cranium is percussed with the examining finger. A positive Macewen’s sign may be evident until fontanel closure.
Head The shape of the head can reveal much about the baby’s trip through the birth canal. Palpate suture lines for abnormalities. Palpate for any bumps or points of tenderness. Examine the hair and eyebrows for texture, quantity, and pattern. Abnormalities in hair may be associated with systemic disease or abnormality. Dry, course and brittle hair may be associated with congenital hypothyroidism. Alopecia Areata: well circumscribed areas of complete or almost complete hair loss, the scalp is smooth w/o signs of inflammation. Hair loss usually begins suddenly, and total loss of scalp and body hair may develop.
Head Tinea Capitis is a fungal infection of the scalp characterized by a patch of short broken off hairs and the patches of hair loss may be scaly or they may be marked with inflammation, bogginess, and pustules called “kerion.”
Eyes The shape and position of the eyes should be noted. Any abnormal eye movement and the ability to focus on the examiner are important to note. Hard to examine because of the bright lights.
Nose Look for deformities, obstruction of the airway, color of the mucosa, discharge, and tenderness. Check the nose for foreign bodies (beans, carrots, crayons) younger children often putting foreign objects into the various orifices of the body and they often get stuck their. A green, foul smelling, purulent discharge from only one side of the nose is common with a foreign object being left in the nose. Purulent discharge bilaterally indicates infection. Delivery can give nasal obstruction due to displacement of the septal cartilage.
Nose Flaring of the nostril almost always shows respiratory distress. Mucosal Assessment: Red: Acute infection Blue and Boggy: Allergy Gray and Swollen: Rhinitis Maxillary and Ethmoid are developed in infancy. Frontal sinus developed by 5 years of age. The size, shape and symmetry of the nose should be noted. A horizontal crease may be seen in the skin on the surface of the nose, this signifies repetitive wiping of the nose commonly seen in allergic rhinitis.
Ears The size and any aberration in shape of the external ear (Pinna) should be noted. A low position (below the level of the eyes) or small deformed auricles may be an indication of a brain defect or congenital kidney abnormality, especially renal agenesis. Inspection of the auricle and pariauricular tissues can be done by checking the 4 D’s: Discharge Discoloration Deformity Displacement
Ears Discharge: from the ear canal can be a result of otitis external or chronic untreated otitis media. Discharge may be thick and white, it may accompany a bright pink or red canal. To differentiate between otitis externa and otitis media, pull on the pinna, if this elicits pain, it is most likely otitis externa. Prolonged moisture in the ear canal promotes bacteria and fungal growth which predisposes the child to otitis externa (swimmers ear). Equal mixture of alcohol and vinegar used as a rinse will keep the ears dry and keep bacteria from growing.
Ears If the discharge is accompanied with perforation of the tympanic membrane, otitis media is suspected. The presence of a foreign bodies in the ear is common and if left in the ear for a period of time may cause an inflammatory response which may produce a foul- smelling purulent discharge. Discoloration in the form of eccymosis over the mastoid area is called “Battle Sign”, and is associated with trauma and should be considered an emergency.
Ears Deformity of the ears may develop from intrauterine positioning or could be the results of hereditary factors. These deformities are of minor concern unless gross deformities are present. Gross deformities of the external ear are often associated with anomalies of the middle and inner ear structures. Displacement of the auricle away from the skull is a distressing sign associated with mastoiditis, other signs of mastoiditis are erythema and tenderness over the mastoid and pinna, fever, and purulent discharge. Other conditions associated with displacement of the auricle are parotitis, primary cellulitis, contact dermatitis, and edema.
Throat Examine the external mouth for symmetry, such as drooping of the corner of the mouth. The lips and mucous membrane should be examined for evidence of cyanosis. The tongue should be palpated for movement and strength of suck, this evaluates the function of the glossopharyngeal, vagus, and hypoglossal nerves The soft palate should be examined for presence of the gag reflex, evaluates the vagus nerve. The hard palate should be evaluated for structure, absence of clefts, and alignment of the arch. A high arched palate may possibly indicates future dental problems associated with insufficient space for teeth ( high arched palate may indicate syndromes like Marfan syndrome).
Throat The color of the oropharynx should be noted, the size of the tonsils and tonsillar pillars and any discharge should be noted. Cobblestoning of the posterior pharyngeal wall is a sign of chronic allergic disease. The quality of the patient’s voice should also be noted. The tongue should be examined for size, shape, color, and coating. A coated tongue is nonspecific A smooth tongue is found in avitaminosis A strawberry or raspberry tongue is seen in specific stages of Scarlet Fever. A geographic tongue is a common finding.
Throat Examine the oral mucosa may have creamy white reticular plaques commonly seen with thrush caused by Candida Albicans. A gray/white, sand grain sized dots on the buccal mucosa opposite the lower molars, called Koplik Spots are seen with Rubeola. Examine the teeth for dental caries, color of the teeth, number of teeth and for dental occlusion. Examine the neck for masses, enlarged glands, tracheal tugging, carotid bruits, mobility, and webbed neck.
Thorax and Heart Note the symmetry of the chest, asymmetric expansion may be seen with pneumothorax or diaphragmatic paralysis. Also note any abnormal shapes (Pectus Excavatum or Pectus carinatum. Barrel-shaped chest are sometimes seen in patients with chronic obstructive pulmonary disease(chronic asthma or cystic fibrosis). A rechitic rosary may be seen or palpated in rickets. Widely-spaced nipples may be a sign of Turner Syndrome. Note the pubertal development of the breast (Tanner staging) in females. Note any masses, tenderness, or discharge of the breast and describe in detail. Breast buds are commonly seen in neonates. The integrity of the clavicles should be noted in newborns Males sometimes develop unilateral or bilateral breast hypertrophy during puberty, called gynecomastia, with milk production may or may not be present.Approximately 40% of all males between the ages of 10 and 16.
Thorax and Heart Female breast usually develop asymmetrically. Inspect the thorax for color, respiration, type of breathing. Auscultate breath sounds (rate, ease, depth, rhythm). Palpate thorax (tenderness, respiratory excursion, vocal or tactile fremitus, and areas of abnormality) Measure chest circumference at nipple line. Auscultate the heart (murmurs, rubs, clicks, or gallops) should be noted.
Thorax and Heart A history of excessive perspiration and difficulties in feeding are two of the most common complaints of early congestive heart failure. Important questions to ask the parent: How has the infant been feeding? Does he or she get out of breath or appear exhausted? Has the child’s growth pattern changed recently? Does the child tire easily, with eating or with playing? Does the child perspire excessively, especially with efforts such as feeding? Does the infant breathe rapidly, even at rest.
Upper Extremity Examination of the upper extremities should include inspection for normal anatomy and limb position, palpation for structural integrity, and joint range of motion. The extremities should be examined for clubbing, cyanosis, and edema. Acrocyanosis is a common finding in neonates, characterized by cyanotic discoloration, coldness, and sweating of the extremities, especially the hands. Any deformities or extra digits should be noted. Range of motion, swelling, erythema, and warmth should be noted of any joint. Check for signs of contusions, abrasions, and edema which are common signs of trauma.
Upper Extremity Check for muscle tone and strength of the upper extremity. Evaluate all range of motion of each joint.
Abdomen Inspection is the most important first step. The order of examination has been changed slightly in that palpation is done last. It is a good idea, before performing abdominal examination, to ask the child if they need to use the restroom. For the examination of the infant or toddler the knees may be bent in order to relax the abdomen and the child’s arms down at their sides. Inspect for rashes, scars, lesions, or discoloration. Observe overall contour and symmetry. Inspect the umbilicus for shape, signs of inflammation or hernia
Abdomen Auscultation of the abdomen should be done before palpation or percussion since the latter may alter the frequency and quality of bowel sounds. Listen to the 4 quadrants noting the frequency and quality of the bowel sounds. Abnormal sounds: gurgles clicks growls Frequency of sounds is from 5 to 34 times per minute.
Abdomen An increase in frequency or pitch of bowel sounds may be associated with intestinal obstruction or diarrhea. Decreased or absent sounds may be associated with paralytic ileus or peritonitis. To be certain that bowel sounds are absent listen for 2 minutes in the area just inferior and to the right of the umbilicus. Percussion in the pediatric patient is the same as the adult patient. Because children tend to swallow a lot of air when eating or crying the stomach and intestines has a great amount of air in them.
Abdomen A distended abdomen may signify an obstruction, infection, celiac disease, ascites, or an abdominal mass. Palpation will reveal masses (note size and location) hepatosplenomegaly, and any sources of pain. If the liver is felt below the costal margin (it commonly is 1 cm below the margin) its span in the midclavicular line should be percussed. Danforth’s sign is right shoulder pain with RUQ palpation (represents an irritated diaphragm) is strongly suggestive of liver injury. Kehr’s sign is left shoulder pain with LUQ palpation (represents an irritated diaphragm) is strongly suggestive of splenic injury.
Abdomen Rovsing’s sign is RLQ pain with LLQ palpation is suggestive of appendicitis. McBurney’s point is 2/3 of the way from the umbilicus to the anterior superior iliac crest in the RLQ and tenderness there is also suggestive of acute appendicitis.
Rectum A chaperone may be necessary. The anus should be inspected for position (an imperforated anus is associated with a host of other anomalies; an abnormally places anus can also be associated with constipation or encopresis, depending on the position of the orifice with respect to the sphincter). Any fissures, trauma, or parasites should be noted. A rectal prolapse may be seen with many conditions including malnutrition, constipation, and cystic fibrosis. The rectal exam is mandatory for any child complaining of abdominal pain, encopresis, constipation, hematochezia, or melena.
Rectum A lubricated small finger is used to palpate for any masses, tone of the sphincter, and any focal pain, as may be seen with appendicitis. The stool should be tested for occult blood. Rectal examination on infants and young children should be performed in the supine position.
Genitalia Patient’s should always be examined is the presence of a parent or a caretaker or in the case of a pre-teen or teenager with a staff member present. It is not common for Doctors of Chiropractic to do female genitalia or pelvic exam. It is common for the D.C. to give a hernia examination and Tanner Staging for school or sports physicals. Tanner Staging is the measurement for sexual maturation.
Lower Extremity Visually inspect the lower extremity for abrasions, contusions, rashes, edema, cyanosis, clubbing, and discoloration. Visually inspect for any abnormalities or deformities (any extra digits should be noted). Measure the extremity as to circumfrencial measurements, actual leg length (ASIS to Medial malleolus) and apparent leg length (Umbilicus to Medial Malleoolus). A way to determine true leg length is to take a Scanogram (this is a x-ray procedure where three views are taken of the extremities the first is through the head of the femurs, the second is through the knees, and the third is through the ankles) using a Bell Thompson Ruler.
Lower Extremity Range of motion should be preformed and any joint swelling, erythemia, and warmth should be noted. Hips are routinely examined in infants (see orthopedic sect.) Foot abnormalities are common in infancy but not in later life. The peripheral pulses, especially the femoral pulses.
Orthopedic Testing Infant orthopedic testing should include all rang of motion testing, static and motion palpation. Ortolani’s Test is a common test performed on the infant. It is a reduction test. With the baby relaxed in the supine position, the hips and knees are flexed to 90*, the examiner grasp the baby’s thigh with middle finger over the greater trochanter and lifts the thigh an simultaneously gently abducting the thigh, thus reducing the dislocation and a “clunk” will be observed
Orthopedic Testing Barlow’s Test is a provocative test (dislocation) also called Reverse Ortolani’s test. Barlow’s Test is performed to discover any hip instability. The baby’s thigh is grasped with the middle finger along the baby’s thigh adducted and with a gentle downward pressure. Dislocation is palpable as the femoral head slips out of the acetabulum.
Orthopedic Testing Allis’ or Galeazzi’s Sign is another orthopedic test used to test for a dislocatable hip and is preformed by flexing the child’s knees and hips placing feet on the table the lower one the femoral head lies posterior to the acetabulum. Another test for a dislocated hip, shortening of the thigh will bunch up the soft tissue and will accentuation of the skin folds. Telescoping of the thigh is elicited because the femoral head is not contained within the acetabulum. Trendelenburg’s Test with the child standing with weight on the affected side the normal hip drops down, indicating weakness of the abductor muscles of the affected side.
Neurological Testing Much of the neurologic exam comes from observation of the child. Any limitation in the use of the hands, legs, or pupillary light response. Babinski Reflex the baby’s foot is stroked from heel toward the toes. The big toe should lift up, while the other toes fan out: absence of the reflex may suggest immaturity of the CNS, defective spinal cord, or other problems. This reflex may be seen up to age 12 to 24 months. Then it will reverse with toes curling downward. Doll’s Eye while manually turning baby’s head, his eyes will stay fixed, instead of moving with the head. While normally vanishing around one month of age, if it reappears later, there may be damage to the CNS.