The pediatric history and physical examination


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The pediatric history and physical examination

  1. 1. THE PEDIATRIC HISTORY AND PHYSICAL EXAMINATION By Lewis A. BarnessFrom: Principles and Practice of Pediatrics, Second Edition. Chapter 6. edited by Frank A. Oski et al. J. B.Lippincott Company, Philadelphia © 1994.HISTORYObtaining a complete history on a pediatric patient not only is necessary, but also leads to thecorrect diagnosis in the vast majority of children. The history usually is learned from the parent,the older child, or the caretaker of a sick child. After learning the fundamentals of obtaining andrecording historic data, the nuances associated with the giving of information must beinterpreted.For the acutely ill child, a short, rapidly obtained report of the events of the immediate past maysuffice temporarily, but as soon as the crisis is controlled, a more complete history is necessary.A convenient method of learning to obtain a meaningful history is to ask systematically anddirectly all of the questions outlined below. After confidence is gained with experience,questions can be problem-directed and asked in an order designed to elicit more specificinformation about a suspected disease state or diagnosis. Some psychosocial implications will beobvious. More subtle details often are obtained by asking open-ended questions. Those withorganic illness usually have short histories; those with psychosomatic illness have a longer list ofsymptoms and complaints.During the interview, it is important to convey to the parent interest in the child as well as theillness. The parent is allowed to talk freely at first and to express concerns in his or her ownwords. The interviewer should look directly either at the parent or the child intermittently and notonly at the writing instruments. A sympathetic listener who addresses the parent and child byname frequently obtains more accurate information than does a harried, distracted interviewer.Careful observation during the interview frequently uncovers stresses and concerns thatotherwise are not apparent.The written record is not only helpful in determining a diagnosis and making decisions, but alsois necessary for observing the growth and development of the child. A well-organized recordfacilitates the retrieval of information and obviates problems if it is required for legal review.The following guidelines indicate the information needed. If preferred, a number of printedforms are available, which contain similar material, or forms may be modified as long asconsistency is maintained.General Information
  2. 2. Identifying data include the date, name, age and birth date, sex, race, referral source if pertinent,relationship of the child and informant, and some indication of the mental state or reliability ofthe informant. It frequently is helpful to include the ethnic or racial background, address, andtelephone numbers of the informants.Chief ComplaintAfter the identifying data, the chief complaint should be recorded. Given in the informants orpatients own words, the chief complaint is a brief statement of the reason why the patient wasbrought to be seen. It is not unusual that the stated complaint is not the true reason the child wasbrought for attention. Expanding the question of "Why did you bring him?" to "What concernsyou?" allows the informant to focus on the complaint more accurately. Carefully phrasedquestions can elicit information without prying.History of Present IllnessNext, the details of the present illness are recorded in chronologic order. For the sick child, it ishelpful to begin: "The child was well until "X" number of days before this visit." This isfollowed by a daily documentation of events leading up to the present time, including signs,symptoms, and treatment, if any. Statements should be recorded in number of days before thevisit or dates, but not in days of the week, because chronology will be difficult to retrieve even ashort time later if days of the week are used. If the child is taking medicine, the amount beingtaken, the name of the medicine, the frequency of administration, and how well and how long ithas been or is being taken are needed.For the well child, a simple statement such as "No complaints" or "No illness" suffices. Aquestion about school attendance may be pertinent. If the past medical history is significant tothe current illness, a brief summary is included. If information is obtained from old records, itshould be noted here or may be recorded in the past medical history.Past Medical HistoryObtaining the past medical history serves not only to provide a record of data that may besignificant either now or later to the well-being of the child, but also to provide evidence ofchildren who are at risk for health or psychosocial problems.Prenatal HistoryIf a prenatal interview has been held (see below), this information already may be available.Questions to be answered include those regarding the health of the mother during this pregnancy,especially in regard to any infections, other illnesses, vaginal bleeding, toxemia, or care ofanimals, such as cats, which may induce toxoplasmosis or other animal-borne diseases, all ofwhich can have permanent effects on the embryo and child. The time and type of movements thefetus made in utero should be determined. The number of previous pregnancies and their results,radiographs or medications taken during the pregnancy, results of serology and blood typing of
  3. 3. the mother and baby, and results of other tests such as amniocentesis should be recorded. If themothers weight gain has been excessive or insufficient, this also should be noted.Birth HistoryThe duration of pregnancy, the ease or difficulty of labor, and the duration of labor may beimportant, especially if there is a question of developmental delay. The type of delivery(spontaneous, forceps-assisted, or cesarean section), type of anesthesia or analgesia used duringdelivery, attendance by other family members at delivery, and presenting part (if known) arerecorded. Note this childs birth order (if there have been multiple births) and birth weight.Neonatal HistoryMany informants are aware of Apgar scores at birth and at 5 minutes, any unusual appearance ofthe child such as cyanosis or respiratory distress, and any resuscitative efforts that took place andtheir duration. lf the mother was delayed in seeing the infant after birth, reasons should besought. Jaundice, anemia, convulsions, dvsmorphic states, and congenital anomalies or infectionsin the mother or infant are some of the reasons that viewing or handling of the newborn by themother may be delayed. The time of onset of any of these abnormal states may be significant.Feeding HistoryNote whether the baby was breast- or bottle-fed and how well the baby took the first feeding.Poor sucking at the first feeding may be the result of sleepiness of the baby, but also is a warningsign of neurologic abnormality, which may not become manifest until much later in life. By thesecond or third feeding, even brain-damaged children usually nurse well.If the infant has been bottle-fed, inquire about the type of formula used and the amount takenduring a 24-hour period. At the same time, ask about the mothers initial reaction to her baby, thenature of bonding and eye-to-eye contact, and the patterns of crying, sleeping, urinating, anddefecating. Requirements for supplemental feeding, vomiting, regurgitation, colic, diarrhea, orother gastrointestinal or feeding problems should be noted.Determine the ages at which solid foods were introduced and supplementation with vitamins orfluoride took place, as well as the age at which weaning occurred and the method used to wean.In addition, note the age at which baby foods, toddlers foods, and table food were introduced,the response to these, and any evidence of food intolerance or vomiting. If feeding difficultiesare present, determine the onset of the problem, methods of feeding, reasons for changes, intervalbetween feedings, amount taken at each feeding, vomiting, crying, and weight changes. With anyfeeding problem, evaluate the effect on the family by asking, "How did you manage theproblem?"For an older child, ask the informant to supply some breakfast, lunch, and dinner (supper)menus, likes and dislikes, and response of the family to eating problems.Developmental History
  4. 4. Estimation of physical growth rate is important. Attempt to ascertain the birth weight and theweights at 6 months, 1 year, 2 years, 5 years, and 10 years. Lengths at similar ages are desirable.These data are plotted on physical growth charts. Any sudden gain or loss in physical growthshould be noted particularly, because its onset may correspond to the onset of organic orpsychosocial illness. It may be helpful to compare the childs growth with the rate of growth ofsiblings or parents.Ages at which major developmental milestones were met aid in indicating deviations fromnormal. Some such milestones include following a person with the eyes, holding the head erect,smiling responsively, reaching for objects, transferring objects, sitting alone, walking withsupport and alone, speaking the first words and sentences, and experiencing tooth eruption. Agesof dressing self, tying own shoes, hopping, skipping, and riding a tricycle and bicycle should benoted, as well as grade in school and school performance.In addition, note should be made of the age at which bowel and bladder control were achieved. Ifproblems exist, the ages at which toilet teaching began also may indicate reasons for problems.Behavior HistoryAmount of sleep and sleep problems, and habits such as pica, smoking, and use of alcohol ordrugs should be questioned. The informant should state whether the child is happy or difficult tomanage, and should indicate the childs response to new situations, strangers, and school. Tempertantrums, excessive or unprovoked crying, nail biting, and nightmares and night terrors should berecorded. Question the child regarding masturbation, dating, dealing with the opposite sex, andparents responses to menstruation and sexual development.Immunization HistoryThe types of immunizations received, with the number, dates, sites given, and reactions shouldbe recorded as part of the history. In addition, it is helpful to record these immunizations on thefront of the chart or in a conveniently obvious place with a lot number for future reference whencompleting school physical examinations or when determining need for booster immunizationsor possible reactions.History of Past IllnessesA general statement should be made about the childs general health before the presentencounter, such as weight change, fever, weakness, or mood alterations. Specific inquiry ishelpful regarding the results of any screening tests and regarding any history of roseola, rubeola,rubella, pertussis, mumps, varicella, scarlet fever, tuberculosis, anemia, recurrent tonsillitis, otitismedia, pneumonia, meningitis, encephalitis or other nervous system disease, gastrointestinal tractdisease, or any other illness, as well as specific treatment, results, and residua. The history ofeach past illness should include dates of onset, course, and termination. If hospitalization orsurgery was necessary, the diagnosis dates, and name of the hospital should he included.Questions concerning allergies include the occurrence and type of any drug reactions, foodallergies, hay fever, and asthma. Accidents, injuries, and poisonings should be noted.
  5. 5. Review of SystemsThe review of systems serves as a checklist for pertinent information that might have beenomitted. If information has been obtained previously, simply state, "See history of presentillness" or "See history of past illnesses." Questions concerning each system may be introducedwith a question such as: "Are there any symptoms related to . . .?" Head (e.g., injuries, headache) Eyes (e.g., visual changes, crossed or tendency to cross, discharge, redness, puffiness, injuries, glasses) Ears (e.g., difficulty with hearing, pain, discharge, ear infections, myringotomy, ventilation tubes) Nose (e.g., discharge, watery or purulent, difficulty in breathing through nose, epistaxis) Mouth and throat (e.g., sore throat or tongue, difficulty in swallowing, dental defects) Neck (e.g., swollen glands, masses, stiffness, symmetry) Breasts (e.g., lumps, pain, symmetry, nipple discharge, embarrassment) Lungs (e.g., shortness of breath, ability to keep up with peers, cough with time of cough and character, hoarseness, wheezing, hemoptysis, pain in chest) Heart (e.g., cyanosis, edema, heart murmurs or "heart trouble," pain over heart) Gastrointestinal (e.g., appetite, nausea, vomiting with relation to feeding, amount, color, blood- or bile-stained, or projectile, bowel movements with number and character, abdominal pain or distention, jaundice) Genitourinary (e.g., dysuria, hematuria, frequency, oliguria, character of urinary stream, enuresis, urethral or vaginal discharge, menstrual history, attitude toward menses and opposite sex, sores, pain, intercourse, venereal disease, abortions, birth control method) Extremities (e.g.. weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps) Neurologic (e.g., headaches, fainting, dizziness, incoordination, seizures, numbness, tremors) Skin (e.g., rashes, hives, itching, color change, hair and nail growth, color and distribution, easy bruising or bleeding) Psychiatric (e.g., usual mood, nervousness, tension, drug use or abuse)Family HistoryThe family history provides evidence for considering familial diseases as well as infections orcontagious illnesses.A genetic type chart is easy to read and very helpful. It should include parents, siblings, andgrandparents, with their ages, health, or cause of death. If problems with genetic implicationsexist, all known relatives should be inquired about. If a genetic type chart is used, pregnanciesshould be listed in a series and should include the health of the siblings (Fig 6-1). Figure 6-1. Genetic type chart.
  6. 6. (Circle, female, square, male.) 1, maternal grandmother, 67 years old, living and well; paternal grandmother, 66living and well. 2, Maternal grandfather, died at 62 of heart disease. 3, Paternal grandfather, 71, living and well. 4,Single horizontal line, married. 5, Double horizontal line, consanguineous marriage. 6, Mother, 39 years old, living,diabetic. 7, Father, 41 years old, living, hypertensive. 8, Stillbirth. 1968 (x, died). 9, Male sibling, 14 years old,living, hay fever. 10, Patient, 12 years old (note light circle). 11, Brother, 10 years old, living and well. 12, Female,died at 2 days old of respiratory distress (year can be included).Family diseases, such as allergy; blood, heart, lung, venereal, or kidney disease; tuberculosis;diabetes; rheumatic fever; convulsions; skin, gastrointestinal, behavioral, or mental disorders;cancer; or other disease the informant mentions should be included. These diseases may have aheritable or contagious effect. Pertinent negatives should be included also.Social HistoryDetails of the family unit include the number of people in the habitat and its size, the presence ofgrandparents, the marital status of the parents, the significant caretaker, the total family incomeand its source, and whether the mother and father work outside the home. If it is pertinent to thecurrent problems of the child, inquire about the familys attitude toward the child and towardeach other, the type of discipline used, and the major disciplinarian. If the problem ispsychosocial and only one parent is the informant, it may be necessary to interview the otherparent and to outline a typical day in the life of the child.Prenatal HistoryIt is desirable, if feasible, to interview the mother and father before the child is born. Not onlycan some necessary data be obtained, but also the parents can become acquainted with the doctorwho will be seeing them shortly after the arrival of their newborn. The health of the mother,whether she will nurse or bottle-feed the baby and whether the husband supports her choice, thepreparation for the baby on arrival home, and whether help will be available can be ascertained.
  7. 7. Because the father may feel bypassed by the pregnancy except for the initial event, it isimportant to direct some questions to him, such as, "Do you want your son circumcised?," and toget the family history of diseases first from him.History From the ChildEven young children should be asked about their symptoms and their understanding of theirproblem. This also provides an opportunity to determine the interaction of the child with theparent. For most adolescents, it is important to take part of the history from the adolescent aloneafter asking for his or her approval. Regardless of your own opinion, obtain the historyobjectively without any moral implications, starting with open-ended questions related to theinitial complaint and then directing the questions.PHYSICAL EXAMINATIONExamination of the infant and young child begins with observing him or her and establishingrapport. The order of the examination should fit the child and the circumstances. It is wise tomake no sudden movements and to complete first those parts of the examination that require thechilds cooperation. Painful or disagreeable procedures should be deferred to the end of theexamination, and these should be explained to the child before proceeding. For the older childand adolescent, examination can begin with the head and conclude with the extremities. Theapproach is gentle, but expeditious and complete. For the young, apprehensive child, chatter,reassurance, or other communication frequently permits an orderly examination. Some childrenare best held by the parent during the examination. For others, part of the examination mayrequire restraint by the parent or assistant.When the complaint includes a report of pain in a certain area, this area should be examined last.If the child has obvious deformities, that area should be examined in a routine fashion withoutundue emphasis, because extra attention may increase embarrassment or guilt.Because the entire child is to be examined, at some time all of the clothing must be removed.This does not necessarily mean that it must be removed at the same time. Only the part that isbeing examined needs to be uncovered and then it can be re-clothed. Except during infancy,modesty should be respected and the child should be kept as comfortable as possible.With practice, the examination of the child can be completed quickly even in most criticalemergency states. Only in those with apnea, shock, absence of pulse, or, occasionally, seizures isthe complete examination delayed. Although the method of procedure may vary, the record ofexamination should be in the same format for all children. This provides easy access to neededinformation later. The description that follows is the usual way of recording the examination andnot necessarily its required order. When diseases are given with a sign, these are examples andnot a complete differential for that sign. The significance of a previous examination cannot beoverstressed. A murmur that was not heard a year ago but now is easily audible has far differentsignificance than does a similar murmur heard many years before.
  8. 8. Completion of the history can be accomplished during the physical examination. Talking to theparent frequently reassures the child. Praising the young child, explaining the parts of theexamination to the older child, and reassuring the adolescent of normal findings facilitates theexamination. Usually, if the examiner enjoys the spontaneity and responsiveness of children, theexamination will be easier and more thorough.Measurements (Vital Signs)Temperature is taken in the axilla or rectum in the young child and by mouth after 5 or 6 years ofage, when the child can understand how to hold the thermometer. Electronic thermometer probesinserted as usual or in the ear canal give rapid, accurate determinations. Elevated temperatureoccurs with infection, excitement, anxiety, exercise, hyperthyroidism, collagen-vascular disease,or tumor. Decreased temperature occurs with chilling, shock, hypothyroidism, or inactivity.Temperature may be decreased after taking certain drugs, with hypocortisolism, or withoverwhelming infection.The pulse rate can be obtained at any peripheral pulse (femoral, radial, or carotid) or by palpationover the heart. The normal rate varies from 70 to 170 beats per minute at birth to 120 to 140shortly after birth, and ranges from 80 to 140 at 1 to 2 years, from 80 to 120 at 3 years, and from70 to 115 after 3 years. The sleeping pulse after the age of 2 years normally is about 20 beats perminute less than the awake pulse, but does not decrease with rheumatic fever or thyrotoxicosis.For each degree of temperature rise, the pulse rate increases about 10 beats per minute. The pulserate is elevated with excitement, exercise, or hypermetabolic states, and is decreased withhypometabolic states, hypertension, or increased intracranial pressure. Irregularity may becaused by sinus arrhythmia, but can indicate underlying heart disease. Absence of the femoralpulse is a cardinal sign of postductal coarctation of the aorta.Respiratory RateThe respiratory rate should be determined by observing the movement of the chest or abdomenor by auscultating the chest. The normal newborn rate is 30 to 80 breaths per minute; the ratedecreases to 20 to 40 in early infancy and childhood and then to 15 to 25 in late childhood andadolescence. Exercise, anxiety, infection, and hypermetabolic states increase the rate; centralnervous system lesions, metabolic abnormalities, alkalosis, depressants, and other poisonsdecrease the rate.Blood PressureThe blood pressure should be measured with a cuff, with the bladder completely encircling theextremity and the width covering one half to two thirds of the length of the upper arm or upperleg. The pressure should be recorded and compared with normal readings (Figs 6-2 through 6-7).High systolic pressure occurs with excitement, anxiety, and hypermetabolic states. High systolicand diastolic pressures occur with renal diseases, pheochromocytoma, adrenal disease, arteritis,or coarctation of the aorta.
  9. 9. Figure 6-2. Age-specific percentiles of blood pressure (BP) measurements in boys--birth to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP.(American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.) Figure 6-3. Age-specific percentiles of blood pressure (BP) measurements in boys--1 to 13 years of age; Korotkoff phase IV (K4) used for diastolic BP
  10. 10. (American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.) Figure 6-4. Age-specific percentiles of blood pressure (BP) measurements in boys--13 to 18 years of age; Korotkoff phase V (K5) used for diastolic BP
  11. 11. (American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)Figure 6-5. Age-specific percentiles of blood pressure (BP) measurements in girls--birth to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP
  12. 12. (American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.) Figure 6-6. Age-specific percentiles of blood pressure (BP) measurements in girls--1 to 13 years of age; Korotkoff phase IV (K4) used for diastolic BP
  13. 13. (American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)Figure 6-7. Age-specific percentiles of blood pressure (BP) measurements in girls--13 to 18 years of age;Korotkoff phase V (K5) used for diastolic BP
  14. 14. (American Academy of Pediatrics. Task Force on Blood Pressure. Pediatrics 1987;79:1.)Height, Weight, Head CircumferenceTo obtain height and weight recordings, measure the infant supine up to the age of 2 years, andstanding thereafter. Measure head circumference in all infants less than 2 years of age and inthose with misshapen heads. Record height, weight, and head circumference measurements withpercentiles on a chart (Figs 6-8 through 6-15).Figures 6-8 through 6-15 are in PDF format and were downloaded from the National Centerfor Health Statistics (NCHS) Web site ( Additional figures,information, and statistics are freely available from this site. Figure 6-8. NCHS percentiles of physical growth in girls--birth to 36 months. Figure 6-9. NCHS percentiles of physical growth in girls--2 to 20 years of age. Figure 6-10. NCHS Girls Weight-for-Stature percentiles. Figure 6-11. NCHS percentiles of physical growth in boys--birth to 36 months. Figure 6-12. NCHS percentiles of physical growth in boys--2 to 20 years of age. Figure 6-13. NCHS Boys Weight-for-Stature percentiles. Figure 6-14. Head circumference, boys. Figure 6-15. Head circumference, girls.
  15. 15. Shortness may be caused by malabsorption, chronic illness, or syndromes with dwarfism.Gigantism may be the result of pituitary abnormalities. Compare sitting height and total height indwarfs to standard measurements to determine the type of syndrome present.Decreased weight can be caused by conditions similar to those that cause decreased height. Instates of malnutrition, weight percentile is less than height percentile; head circumferenceremains normal unluess the condition is severe and persists. Overweight usually is exogenousand associated with increased height until epiphyseal closure. Overweight resulting fromendocrine disorders is associated with decreased linear growth.Skin Fold MeasurementsSkin fold measurements are useful in determining obesity and in identifying and followingmalnutrition. Skin fold calipers are applied over the mid-triceps.General AppearanceA statement should be recorded about the alertness, distress, general development, and nutritionof the child. Mental status, activity, unusual positions, or apprehension or cooperativeness maydirect one to consider an acute or chronic illness or no illness at all. The child who lies quietly,staring into space, may be gravely ill. The child who lies quietly but becomes irritable when heldby his mother (paradoxic irritability) may have meningitis or pain in motion. Note any unusualodor, which may suggest the presence of a foreign body in one of the orifices or certainmetabolic diseases or toxins.SkinIn examining the skin, record its color and turgor, the type of any lesions, and the condition ofbody and scalp hair and nails.Normal color of the skin is the result of the presence of melanin; depigmented areas are vitiligo:absence of pigment occurs in albinism. Cyanosis is caused by unsaturation of or abnormal formsof hemoglobin; jaundice is caused by excessive bilirubin deposited in the adipose tissue. Notethe size and borders of nevi, which usually are darkly pigmented areas, and café-au-lait spots,which are brownish areas that may signal neurofibromatosis. White spots shaped like a leafsuggest tuberous sclerosis. Ecchymoses or petechiae and scars may indicate abuse.Swelling may be caused by edema. Lack of turgor occurs with dehydration or recent weight loss.Describe any rashes, many of which are characteristic of viral or bacterial infection.Head and FaceRecord the shape, symmetry, and any defects of the head; the distribution of hair; and the sizeand tension of fontanelles. A large head may be an early sign of hydrocephalus or an intracranialmass. A small head may be a result of early closure of sutures or lack of brain development. Forany deviation from normal head size, frequent measurements are necessary. The fontanelles
  16. 16. normally are flat. The posterior fontanelle closes by 2 months of age, and the anterior fontanellecloses by 12 to 18 months of age. Unusual hair whorls are associated with severe intracranialabnormalities.The face may appear distinctive for a number of syndromes. For example, unilateral facialparalysis may be associated with congenital heart disease. Coarse facies occur with storagediseases. Epicanthal folds occur in a number of syndromes, including Down (5trisomy 21.)EyesTest vision grossly in the young child with brightly colored objects. In the older child, test withSnellens E chart. Evaluate for strabismus by noting the position of the reflection of light on thecornea from a distant source. Evaluate the range of eye movements and the presence ofnystagmus. Both eyelids should open equally. Failure to open is ptosis and may be caused byneurologic or systemic diseases. Upward slanting of the palpebral fissures with covering of theinner canthus (epicanthal folds) is a sign of Down syndrome. The conjunctivae should be pink,but not inflamed; the sclerae should be white. Examine the cornea for haziness (a sign ofglaucoma) or opacities. Record the size and shape of the pupils, the color of the iris, and theresponse of the iris to light and accommodation. In the fundoscopic examination, use a zero lensand note the presence of a red reflex, or hemorrhages or pigmented areas, and the size of theveins compared to the arteries. Any obstruction, such as corneal or lenticular cataract willobliterate part or all of the red reflex. The disc borders should be sharp. They are blurred withincreased intracranial pressure. The macula may not be clear, which is a sign of degenerativediseases. Obtain the corneal reflex by lightly touching the cornea with a piece of cotton. Failureto blink indicates trigeminal or facial nerve injury.EarsNote the position of the ears and abnormalities of the external ear, the pinna. Low-set ears maysuggest the presence of renal agenesis. Tags and deformities frequently are associated with otherminor or major anomalies. Grossly evaluate hearing, then proceed with examination of the innerear. Pull the earlobe up and anteriorly. Grasp an otoscope equipped with a bright light so that theholding hand rests on the childs head and moves with any movement of the head, and use thelargest speculum that will fit into the canal. The canal should be clear, and the drum should bepearly gray in color and concave. A cone of light, the malleus, and sometimes the incus will beidentified. If the bones are not visualized, the drum is not gray in color or is infected, or the drumis not concave, fluid may be in the inner ear, which is diagnostic of otitis media.NoseRaise the tip of the nose and look up the nose with a bright light. Deformities of the septum,bleeding, or discharges should be recorded. The normal nasal mucosa is light pink in color. Tapon the maxillary and frontal sinuses for tenderness. Feel for air egress from both nares.Mouth and Throat
  17. 17. Examination of the mouth and throat usually is the most resistant part of the examination andshould be performed near the end of the examination. The child should be sitting so that thetongue is less likely to obstruct the pharynx. Deformities or infections around the lips arerecorded. Count the number and note the condition of the teeth. Similarly, note the condition andcolor of the tongue, buccal mucosa, palate. tonsils, and posterior pharynx. Normally, these arepink in color. Exudate indicates infection by bacteria, viruses, or fungi, but etiology usuallycannot be determined by physical examination alone. Note also the presence of the gag reflexand the voice or cry. If the child seems hoarse, question the parent concerning the normal voice.Laryngitis can lead to airway obstruction. After the age of 2 years, children should not drool.Chronic drooling may suggest mental deficiency, but acute onset of drooling is a grave sign ofepiglottitis or poison ingestion.NeckFeel in the neck for lymph nodes, which normally are nontender and up to 1 cm in diameter inboth the anterior and posterior cervical triangles. Larger or tender nodes occur with local orsystemic infection or malignancies. Feel the trachea in the midline. The thyroid may not bepalpable. Other masses may be present and are always abnormal. Flex the neck. Resistance toflexion is a cardinal sign of meningitis, except in infancy, but this also occurs with severeinfections around the neck or dislocation of the cervical vertebrae.Lymph NodesIn addition to the lymph nodes in the neck, palpate inguinal, epitrochlear, supraclavicular,axillary, and posterior occipital nodes. Normally, inguinal nodes may be up to 1 cm in diameter:the others are nonpalpable or less than 5 mm. Larger or tender nodes hold significance similar tothat described for abnormal cervical glands.ChestObserve the chest for shape and symmetry. The chest wall is almost round in infancy and inchildren with obstructive lung disease. Respirations are predominantly abdominal until about 6years of age, when they become thoracic. Note suprasternal, intercostal, and subcostalretractions, which are signs of increased respiratory work. Swelling at the costochondraljunctions is an indication of rickets. Edema of the chest wall occurs in children with superiorvena cava obstruction. Asymmetry of expansion occurs with diaphragmatic paralysis,pneumothorax, or other intrathoracic abnormalities.BreastsBreasts normally are hypertrophied at birth; they regress within 6 months and develop with theonset of puberty. Development during adolescence is staged. Breast development in both boysand girls usually begins asymmetrically. Palpate for nodules, which may be cysts or tumors.Redness, heat, and tenderness usually indicate infection.Lungs
  18. 18. Examination of the lungs includes observation, palpation, percussion, auscultation, and, ifindicated, transillumination.ObservationNote the type and rate of the childs breathing. The rate of respiration varies, as describedpreviously. Rapid rates, known as tachypnea, are associated with infection, fever, excitement,exercise, heart failure, or intoxicants. Slower rates are characteristic of intracranial lesions,depression caused by sedative drugs, heart block, or alkalosis. Cheyne-Stokes breathing, which ischaracterized by periods of deep, rapid respirations followed by slow, shallow respirations, iscommon in premature and newborn infants, and in those with intracranial or metabolicabnormalities. Dyspnea, or distress during breathing, is associated with flaring of the intercostalspaces and nares. Inspiratory dyspnea is more common with obstruction high in the respiratorysystem and expiratory dyspnea is more common with lower respiratory diseases.PalpationFeel the entire chest with the palms and fingertips. Note masses or areas of tenderness. Tactilefremitus, a vibratory sensation during crying or speaking, normally is felt over the entire chest.Fremitus is absent if the airway is obstructed.PercussionEither direct percussion (tapping the chest wall directly with either the index or middle fingers)or indirect percussion (placing a finger of one hand firmly on the chest wall and tapping thatfinger with the index or middle finger of the opposite hand) may be used in children. The entirechest wall is percussed anteriorly, posteriorly, and along the midaxillary line. A resonant soundwill be obtained over most of the chest except over the scapulae, diaphragm, liver, and heart,where dullness is elicited. Dullness detects consolidation in the lungs, as well as the size andposition of the liver and heart. Scratch percussion, which involves tapping the chest wall with afinger while listening with a bell stethoscope over the heart and liver, is especially useful indetermining heart and liver size. Increased resonance is found with increased trapped air,emphysema, or air in the pleural space (pneumothorax).AuscultationTo auscultate the lungs in children, listen with a small bell in small children and with thediaphragm in older children. Normal breath sounds are bronchovesicular and inspiration is twiceas long as expiration in young children; breath sounds are vesicular and inspiration is three timesas long as expiration in older children. Breath sounds are decreased with consolidation or pleuralfluid in the young child and increased with pneumonia in the older child. Fine crackles either ininspiration or expiration (rales) indicate foreign substances, usually fluid, in the alveoli orsmaller bronchi, as occurs in bronchitis, pneumonia, or heart failure. Coarse extraneous sounds(rhonchi) are the result of foreign substances in the larger airways, as in crying or upperrespiratory infection. Musical extraneous sounds (wheezes) are caused by airflow throughcompromised larger airways, as in asthma.
  19. 19. TransilluminationIf pneumothorax is present, the chest will transilluminate. This is especially useful in thenewborn.HeartIn addition to the hearts rate (pulse) and rhythm, and the blood pressure, note the size, shape,sound quality, and presence of murmurs when examining the heart.Precordial bulging is a sign of right-sided enlargement. A cardiac impulse may not be noted in ayoung child, but in a thin, active child, it may suggest the size and position of the heart. An apexbeat outside the midclavicular line in the fifth interspace indicates cardiomegaly, which is asignificant sign of heart disease or heart failure. Palpation and percussion are described above.Auscultate both in the sitting and the supine position. Determine the heart rate and rhythm if thiswas not done previously. Auscultate initially over the apex (mitral area), then over the lowerright sternal border (tricuspid area), the second left intercostal space at the sternal edge(pulmonary area), and the second right intercostal space at the sternal edge (aortic area). Next,proceed to the remainder of the precordium, the axillae, back, and neck. Note heart sounds andany arrhythmia. A loud first sound at the apex occurs with mitral stenosis, a loud second sound atthe pulmonary area occurs with pulmonary hypertension, and a fixed split-second sound in thepulmonary area occurs with an atrial septal defect. Innocent murmurs are systolic, musical, orvibratory and of low intensity, and usually are heard at the second left Interspace, just inside theapex, or beneath either clavicle. The latter is a venous hum that may be continuous and thatdisappears when the patient is supine. Diastolic murmurs are almost always significant.Significant systolic murmurs may be stenotic and are loudest in mid-systole over the aortic orpulmonary areas. Regurgitant murmurs begin immediately after the first sound. Over the mitralor tricuspid area, they indicate valvular insufficiency. A continuous or uneven systolic murmuralong the upper left sternal border indicates patent ductus arteriosus.AbdomenObserve the shape of the abdomen. A flat abdomen may indicate diaphragmatic hernia; adistended abdomen may indicate intestinal obstruction or ascites. Auscultate before percussing orpalpating. Normally, peristaltic sounds are heard every 10 to 30 seconds. High-pitched frequentsounds occur with obstruction or peritonitis; absent sounds indicate ileus. Next, palpate gently,beginning in the left lower quadrant and proceeding to the left upper, right upper, right lower,and midline areas. Then palpate more deeply in the same areas and follow with palpation in thesame areas with the unused hand, pushing toward the front hand from the childs back. Feelespecially for the liver in the right upper quadrant and the spleen in the left upper quadrant, andestimate their size. Any other masses are abnormal. Determine tenderness and attempt to locatethe maximum point of any tenderness, which may indicate intra-abdominal infection such asperitonitis, cystitis, or appendicitis, or rapid enlargement of organs, as occurs with enlargementof the liver in heart failure. Percuss to verify findings. Feel in the costovertebral angles todetermine kidney size. Tenderness usually indicates pyelonephritis.
  20. 20. GenitaliaAverage adolescent development in girls proceeds as follows: 1. breast development at 10.5 years of age, 2. pubic hair at 11 years of age, 3. increase in height velocity at 12 years of age, 4. menarche at 12.5 years of age 5. axillary hair at 13 years of age.Average development in boys proceeds as follows: 1. testicular enlargement at 11.5 years of age, 2. pubic hair at 12.5 years of age, 3. increase in height velocity at 14 years of age, 4. facial and axillary hair at 14.5 years of age.Variations in order of development suggest hormonal abnormalities. Modesty of the child shouldbe respected during the examination, especially of the genitalia.Inspect the genitalia for urethral discharges, which are always pathologic and indicate infectionanywhere in the genitourinary systems.In a girl, vaginal bleeding after the newborn period and before puberty may be the result ofinjury or foreign body. Fused labia minora usually part with hygiene. Imperforate hymen causeshydrocolpos before puberty and hematocolpos after menarche. Vaginal discharge may be theresult of injury or foreign body in a young girl, usually is normal at the start of puberty, andsuggests infection in an older girl. Adolescents with vaginal discharge, dysuria, lower abdominalpain, irregular bleeding, or sexual activity require a complete vaginal examination. The uterus ina younger child is palpated for size, shape, and tenderness with one hand over the lowerabdomen and a finger of the other hand in the rectum. For an older child, the cervix is visualizedwith a vaginoscope or small speculum, and cultures are obtained.In boys, testes should be in the scrotum after birth, although active cremasteric reflexes mayempty the scrotum temporarily. The meatal opening should be slit-like and the urinary streamshould be strong. Hydroceles, which do not reduce and do transilluminate, and hernias, whichreduce but do not transilluminate, enlarge the scrotum. Testicular tenderness suggests torsion ofthe testis or epididymitis.RectalInspect the anus for fissures, inflammation, or lack of tone. The latter may indicate child abuse.The rectum is not examined routinely, but is examined in all children with abdominal orgastrointestinal complaints, including diarrhea, constipation, or bleeding from the rectum.Extremities and Back
  21. 21. Asymmetry, anomalies, unusual size, pain, tenderness, heat, and swelling deformities of theextremities and back must be distinguished from congenital malformations, osteomyelitis,cellulitis, myositis, or, rarely, rickets and scurvy. Joint heat, tenderness, swelling, effusion,redness, and limitation or pain on motion may indicate arthritis, arthralgia, synovitis or injury, orseptic arthritis (which is a medical emergency). Observe as the child walks for the presence of alimp. Clubbing of the fingers is a sign of chronic hypoxemia, as in congenital heart or chronicpulmonary diseases.The spine should be straight with mild lumbar lordosis. Kyphosis, scoliosis, masses, tenderness,limitation of motion, spina bifida, pilonidal dimples, or cysts may be caused by injury,malformation, infections, or tumors.Weakness, tenderness, or paresis of the muscles suggests inflammatory muscle disease,congenital or metabolic neuromuscular diseases, or central nervous system abnormalities.Neurologic ExaminationMental status and orientation help determine the acuteness of a childs illness, depending on theenvironmental conditions. Position at rest and abnormal movements such as tremors, twitchings,choreiform movements, and athetosis are characteristic of hyperirritability of the central nervoussystem. Incoordination of gait usually indicates cerebellar dysfunction. Kernigs sign (inability toextend the leg with the hip flexed) and Brudzinskis sign (flexing the neck with resultant flexionof the hip or knee) are indications of meningeal irritation.Cranial nerves can be tested. Dysfunction of olfactory nerve 1 results in anosmia. Nerves II, III,IV, and VI are described briefly under "Eyes" in Chapter 34, and nerve VIII is discussed under"Ears" in Chapters 36.6 and 36.7. Dysfunction of the trigeminal nerve V results in lack ofsensation of the face and tongue. With peripheral facial nerve VII paralysis, neither the foreheadnor the face moves. With nuclear VII paralysis, the forehead moves. Difficulty in swallowingand loss of pharyngeal reflexes are caused by dysfunction of the glossopharyngeal nerve IX orthe vagus nerve X. Patients cannot contract the sternocleidomastoid or trapezius muscles withinvolvement of the spinal accessory nerve XI. The tongue protrudes to the involved side withhypoglossal nerve XII lesions.Examination of tendon reflexes (biceps, triceps, patellar, and Achilles) is less important than isobservation of general activity. Hyperactive reflexes indicate an upper motor neuron lesion orhypocalcemia. Decreased reflexes are seen in lower motor neuron lesions or the musculardystrophies.NEWBORN EXAMINATIONIn the delivery room, a minimal examination is needed. The general appearance is noted and, at 1and 5 minutes of age, an Apgar score is assigned (Table 6-1). A score of 7 or less indicates thatan infant is at risk.
  22. 22. The infant is placed in a warmer. A small catheter is passed through both nares. Secretions areaspirated, and the tube is continued into the stomach and the stomach contents are aspirated.Easy passage of the catheter indicates patency of both nares. Passage into the stomach obviatesblind pouch types of tracheoesophageal fistula. The infant may urinate or defecate, indicatingpatency of these orifices. The mouth is inspected for cleft palate. Gestational age is assessedbased on neurodevelopmental signs. Newborn care then is given and further examination isdeferred to the nursery. Table 6-1. Apgar Score Rating 0 1 2 Appearance Pale or blue Body pink, extremities blue Pink all over Pulse Absent 100 100 Grimace None Weak Strong Activity (tone) Limp Some flexion Spontaneous movement Respiratory effort Absent Hypoventilation, gasping Coordinated, vigorous cryPreferably within the first few hours of birth, an admission newborn examination is performed inthe presence of the parents. The examiner should develop a routine for the newborn examinationso that critical areas are never omitted. In the first few hours of life, the newborn usually isawake, but after 4 hours, he or she may be sleepy. The pressing question to be answered in thefirst examination is: "Is my child normal?" Although the order of the examination may vary, aswith the history, a stereotyped order of recording should be initiated for easy retrieval ofinformation if it is needed later.Vital SignsVital signs include temperature, heart rate, respiratory rate, blood pressure (using an apparatusfor newborns) in an upper and a lower extremity, weight, length, and head, chest, and abdominalcircumferences. In addition to recording these, it is essential that they also be plotted on a chart(see Figs 6-8, 6-11).General AppearanceWithin a few moments, observe the movement of the four extremities, the appearance of thehead and neck, body symmetry, and any gross abnormalities.SkinThe skin may be covered by a white, greasy, easily removable material called vernix caseosa.Note skin color, consistency, and hydration. Cyanosis, jaundice, eruptions, edema, bruises,petechiae, and pallor are significant abnormalities. Note also hemangiomas and nevi, their sizeand location. Mongolian (brown) spots over the back are not suggestive of disease, but café-au-
  23. 23. lait spots, if they are numerous, may be a cardinal sign of neurofibromatosis. Papules andpustules must be identified as either normal eruptions or infections.Head and NeckThe fontanelle size and head circumference are variable on the first day because of molding.Scalp edema (caput succedaneum) crosses the midline and may be present; this is distinguishedfrom cephalhematoma, which does not cross the midline and is caused by subperiosteal bleeding.Unusual facies suggests dysmorphic syndromes. Peripheral facial nerve palsies are common.Edema of the eyelids is a result of birth processes or reaction to silver nitrate prophylaxis. Sub-conjunctival and retinal hemorrhages are found frequently. Red reflex from the fundus, if notvisible, indicates some obstruction in the preretinal chambers. Malformation of the pinnae of theears often is accompanied by severe congenital malformations. If the nose was not found to bepatent in the first examination, it should be examined at this time by passing a catheter throughboth nares. The mouth should be reexamined for cleft palate. The neck should be examined forshortening (as in Klippel-Feil syndrome), redundant skin folds (as in gonadal dysgenesis),vertebral anomalies, cysts, sinuses, and limitation of motion (torticollis).ChestThe chest normally is barrel-shaped and smooth at birth, and expands symmetrically with noretractions. Unequal expansion or asymmetry suggests intrathoracic pathology such as cardiacenlargement, pneumothorax, or diaphragmatic hernia. The respiratory rate normally is less than60 breaths per minute. Occasional irregularities with apnea up to 10 seconds can be normal.Auscultation may reveal adventitious sounds for the first 4 to 6 hours. Percussion is resonantthroughout. Maximal cardiac impulse is felt in the fourth interspace close to the sternum. Thrills,if they are present, usually indicate cardiac abnormalities. Murmurs are present in 60% of normalnewborns, but the lack of a murmur does not eliminate a diagnosis of congenital heart disease.Brachial and femoral pulses, if they are not of equal intensity, suggest vascular anomalies suchas coarctation of the aorta. If chest expansion is unequal, transilluminate the chest.Transillumination occurs with pneumothorax and occasionally with diaphragmatic hernia.AbdomenDistention of the abdomen occurs with sepsis, intestinal or urinary system obstruction, ascites,tumors, or pneumoperitoneum. Scaphoid abdomen suggests a diaphragmatic hernia. Palpategently. The livers edge usually is felt 1 to 2 cm below the costal margin and the spleen tip isbarely palpable. The bladder, if it is palpable, should be reexamined after voiding. Palpation ofthe costovertebral angle with ballottement helps to determine the size of the kidneys. Theumbilical cord contains two arteries, which are small and thick-walled, and one vein, which islarger and thin-walled. A single umbilical artery is associated with an increased incidence ofcongenital anomalies. Erythema at the base of the cord suggests omphalitis. Note the patency ofthe urethral meatus by observing voiding and the patency of the anus either by observing thepassage of meconium or by inserting a small rubber catheter.
  24. 24. ExtremitiesAsymmetric posturing requires careful palpation of the clavicles, shoulders, and extremities forfractures or brachial plexus injuries. Anomalies of the hands and feet such as webbing,polydactyly, and clubfoot are noted. Abduct both legs to determine any limitation of movementor instability of the hips, which is characteristic of dislocated hips. Read Barlow and Ortolanitests.GenitaliaTestes normally are in the scrotum of term infants. Determine the position and size of theurethral meatus. The newborns penis is greater than 2cm in length. An enlarged clitoris can beconfused with a small penis and requires evaluation for chromosomal sex and otherabnormalities of the genitourinary system. The vaginal opening is inspected, and mucosal tags,imperforate hymen, and ambiguous genitalia are sought.Neurologic ExaminationAssess muscle tone and strength. Extremities normally recoil spontaneously when they areextended from a flexed position and thrash about when irritated. Moros reflex, which is obtainedby loud noise or sudden motion, involves abduction of the upper arms and legs, and extension atthe elbows and knees, followed by flexion. Absence of this reflex indicates central nervoussystem depression. Asymmetry suggests extremity fracture or peripheral nerve injury.