This document provides guidance on examining pediatric patients. It emphasizes establishing rapport, keeping exams non-threatening, and tailoring the approach based on a child's age and development. Key points include observing the child first before interacting, explaining procedures, using distraction, and examining painful areas last. Practice is emphasized to improve skills in communication, examination techniques, and handling different age groups in a developmentally-appropriate manner. The goal is to make exams as comfortable as possible for children.

1. Examination in Paediatric Medicine
Dr.Varsha Atul Shah
SC Neonatal and Developmental Medicine, Singapore General Hospital
VC, Dept. of Child Development, KKH

2. Soft skills in Pediatrics,
orientation, planning for
exams

7. I. General Approach
 Gather as much data as possible by observation first
 Position of child: parent’s lap vs. exam table
 Stay at the child’s level as much as possible. Do not tower!!
 Order of exam: least distressing to most distressing
 Rapport with child, do baby talk while engaging, smile, make funny
faces
1. Include child –explain to the child’s level
2. Distraction is a valuable tool
 Examine painful area last-get general impression of overall attitude
 Be honest. If something is going to hurt, tell them that in a
calmness

8.  Practice!!!!!
 Spend time in wards and clinics
 Get exposure at the wards
 Time yourselves
 Ask each other to present the cases
and discuss
 Practice alone on dolls and in front
of mirror

9. 1. Maternal history (Pre-natal)
2. Birth history (Natal)
3. Post-natal history
4. Nutritional history
5. Vaccination
6. Growth and development
7. Family history
8. Social history

10.  The predominant impact of the chronic
disease may be on growth and development
(syndromes, Chronic illness).
 Physiological norms are more constant in
adults, variable with age in infants and
children( HR, RR)
 Clinical signs of the disease may differ from
those of adults (Liver is palpable in infancy).

12.  The examination of infants and children
is an art, demanding qualities of understanding,
sympathy and patience, observation is important
 Heart rate, Respiratory rate, BP, liver size, heart size
varies with age
 Keep disturbing or painful procedures to the end
 It is not necessary to be systemic in your examination ,
but should be complete

13.  • Arms to be bare below the elbow
 • No jewellery on hands or wrists except for
wedding rings/bands.
• Cut nails short, do not paint
• An acceptable form of dress would be a
conventional short-sleeved shirt/blouse
• For a long-sleeved shirt/ blouse to have the
sleeves rolled up
• Tee-shirts and polo shirts are not acceptable dress
• Girls- beware of low neckline when kneel down
• Tie hair, pin it

14. 1. Red yarn pom pom (4 cm diameter) with string and dangling,
2. Bright colour 12 cubes 2.5 cm,
3. Rattle with narrow handle
4. Raisins or cheerio's or honey stars or M and Mms
5. Cup, spoon
6. A 4 size paper
7. Big size color pencils
7. Picture cards, multiple picture books (like bird, fish, dog, bus
etc., fruits etc.) on same page,
8.Tennis ball
9. Small doll, hand puppet
10. Bell
11. Stickers, sweets for rewards
12. Paediatric Stethoscope
13.Tendon tapper
14. Key or orange stickers
15.Torch light
16.Tongue depressor
17. Ruler and measuring tape both

15. Pre-exam checklist: WIPE5:
 Wash your hands or scrub them with alcohol then
rub hands, [warming them]. Compulsory.
 Introduce yourself to patient or parents, explain
what going to do. Wipe stethoscope with alcohol
swab after introducing and shaking hands
 Position patient and yourself on right side of
patient [+/- on parent's knee].
 Expose area as needed [parent should undress]
and Examine, Eyeball. USE EYES, EARS,
ENGAGE, (Always do general inspection of
significant followed by system asked).

16.  Look around the room & surroundings
 Look at the child (!)
 Do as much as you can before approaching
 Leave child with parents
 Get your knees dirty
 Interaction with child throughout exam
 Observe, may talk with child with baby
language, may sing for them rhymes etc,
good boy good girl etc
 Do what you can, when you can
 Generally, systems based relevant inspection
findings
 Distraction is a valuable tool

17.  Dress, hygiene
 Examine from the Right side of the patient.
 Posture, body positions, body shape.
 Skin colors (pale, jaundice( lemon or greenish), blue
(cyanosed), plethoric, bronze)
 Hydration.
 Alertness, happiness, eye gaze

18.  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.

19.  Can establish rapport while checking cyanosis,
 dyspnoea, and cough.
 Can examine teddy bear first.
 Best examination method by age:
 Neonates, very young infants: on examining table
 Infant, toddler: On mothers shoulder if crying or
 anxious
 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.

20.  History is given by second person.
 The parents may place their own
interpretation on events(any fever may be
called tonsillitis).
 The cooperation of the child cannot be
guarantied
 The expression of the disease may be
influenced by the child’s developmental
status(apnea may indicates convulsion in
newborn)

21.  The predominant impact of the disease may
be on growth and development (UTI, Chronic
illness).
 Physiological norms are more constant in
adults, variable with age in infants and
children( HR, RR)
 Clinical signs of the disease may differ from
those of adults (Liver is palpable in infancy).

22.  Maternal history (Pre-natal)
 Birth history (Natal)
 Post-natal history
 Nutritional history
 Vaccination
 Growth and development
 Family history
 Social history

23.  The examination of infants and children is an
art, demanding qualities of understanding,
sympathy and patience
 Heart rate, Respiratory rate, BP, liver size,
heart size varies with age
 Keep disturbing or painful procedures to the
end
 It is not necessary to be systemic in your
examination , but should be complete

24.  Practice!!!!!Practice and Practice
 Get exposure on the wards
 Time yourselves
 Spend time in wards and clinics
 Ask each other to present and discuss

25. • Infant is learning to regard the
environment, especially faces.
• No stranger anxiety until late in this phase.
• Nonverbal communication is key
 Facial expressions
 Tone of voice
• Parents warm to medical personnel who
treat their children as babies, not patients.
Make faces and talk baby talk!

26. • Stranger anxiety!Try to keep the child
with a caregiver.
• Communication is still mostly nonverbal
but talk to the child anyway.
• Development in motor skills is often
faster than communication skills
• Use stimulating objects to catch
attention for distraction or assessment.
• Use toe to head approach

27. • More explorative but still shelter with parents.
• Will understand more words than they can say.
• Constantly moving.
• Play and curiosity are big motivators.
• Use your tools and toys.
• Toe to head approach.
• Try not to hold them down but don’t wait forever for
cooperation with exam.
• Toilet training often includes lessons about modesty
and improper touching. Respect these lessons;
uncover child selectively for exam.
• Distract them

28. • Usually a great age to work with.
• Learning to explore and be independent.Very curious!
• Can be very talkative and verbally enthusiastic.
• Are starting to understand about being hurt or sick
and that people will try to help them.
• Are starting to understand the concept of “the
future”.
• May misinterpret words they hear.
• Have “magical thinking”.
• Worry about being in trouble.
• Like to have choices.
 Please don’t ever threaten a child with a shot or a
doctor’s visit if they’re not behaving right.This
is sabotage!

29. • Fear failure, inferiority.Want to be treated as “big kids” but
may feel “baby” insecurities.
• Want to be accepted and blend in
• Body-conscious and modest
• May feel pain intensely
• Feel comfort with touching
• Question the child directly and in simple but not babyish
terms.
• Use common interests to build trust.
 Sports
 TV and movie characters
• Treat them with respect
 Offer limited choices.

30.  Don’t embarrass them in front of peers.
 Don’t tell them not to cry!
 OK to touch in comfort.
 Respect their modesty.

31.  Identity and peer relationships are the key issues at
this age.
 Body image and future deformities and
dysfunctions are very important.
 Reactions can be under- or over-exaggerated.
 Regressive behavior is common
 Respect modesty and privacy.
 Avoid embarrassing the child.
 Direct yourself to the child as you might to an adult,
with an adjustment in language.
 Make eye contact but don’t force it unless you need
to make a point.

32.  Respect modesty and privacy.
 Avoid embarrassing the child.
 Direct yourself to the child as you might
to an adult, with an adjustment in
language.
 Make eye contact but don’t force it
unless you need to make a point.

33.  The hardest part of taking care of kids is
usually dealing with their parents and
guardians
Whenever you’re caring for a child, you must
consider the family members to be your
patients too.
enever you’re caring for a child, you must consider the family members to be your patients t

34.  Learn and use their preferred name.
 At least get the sex right!
 Keep children as physically and
emotionally comfortable as possible.
 Basic and advanced pain management is
important.
 Try to relieve fear and anxiety as early and
as much as possible.

35.  Treat every child as if they were the most
special, beautiful, smartest child in the
world. A compliment to a child is a
complement to their parents.
 Listen to what the child has to say, even if it
sounds like nonsense.
 Every child has something you should
honestly be able to complement them on,
even if it’s just that they have such good lungs
for them to be able to scream so loudly…

36.  Infants less than about 6 months can be touched
anywhere first, but go to the most painful place last.
 For children with stranger anxiety, offer your hand or a
tool for them to touch and explore first. Go for their heads
and trunks and any painful parts last
 Touch school-agers in a playful fashion. “High five” is
often a good way to start.
 Tickling is good in young school-agers but don’t do it until
you’ve gotten your assessment.
 Once a school-ager trusts your touch, try to maintain
some contact while getting info from the parent.

37.  Touch teens only as needed for your
exam, unless further touch is clearly
welcome.
 Try to always have a witness when
with a teen, especially a teen of the
opposite sex, in case one of your
gestures is misinterpreted.
 Watch your facial expressions with
teens! If you look like you don’t
believe them, you lose them.

38. I. General Approach
 Gather as much data as possible by observation first
 Position of child: parent’s lap vs. exam table
 Stay at the child’s level as much as possible. Do not tower!!
 Order of exam: least distressing to most distressing
 Rapport with child, do baby talk while engaging, smile, make funny faces
1. Include child –explain to the child’s level
2. Distraction is a valuable tool
 Examine painful area last-get general impression of overall attitude
 Be honest. If something is going to hurt, tell them that in a calmness

39.  Sex
 Age
 Social statement (the most important, relevant
social factoid)
 Past history (of relevance only)
 Onset
 Presentation
 Jones is a 12 year old overweight boy with a past
history steroid resistant Nephrotic syndrome, who
presents with the diagnostic problem of the sudden
onset of abdominal pain with fever and sore throat.

40. Short Cases:Always communicate if you are giving running commentary of
summary at the end of examination in short cases
 Hakim is 6 years old Malay boy, who is well or not sick, not
dysmorphic/syndromic, well thrived, not malnourished or underweight, or
short, but I would like to confirm my findings on gender specific
progressive percentile charts forWeight, Height and
OccipitoFrontalCircumferece. He is alert and oriented and has conjugate
eye gaze.
 Cheerful, fretful, anxious, social, not oriented, not socially aware, drowsy,
active, passive,
Long cases: Name, Age, Sex, Race, Social statement (the most important,
relevant social factoid)
 Past history (of relevance only),Onset, Presentation
 Irfaan is a 12 year old Malay boy with a past history steroid resistant
Nephrotic syndrome, who presents with the diagnostic problem of the
sudden onset of abdominal pain with fever and sore throat.
 List the problems list
 Do include social, emotional, financial problems

41.  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.

42.  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.

43. Vital signs in pediatrics include (TPR BP)
 T:Temperature,
 P: Pulse/heart rate,
 RR: respiratory rate,
 BP: blood pressure)
Growth Percentiles:
 Weight,
 length/Height,
 head circumference (Occipitofrontal circumference).

44.  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).

45.  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).

46.  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).

47.  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.
 A rule of thumb is that the heart rate increases by 10/minute
for each 1 degree of temperature Centigrade.

48.  Rectal 96.8* to 98.6* F
 Axillary 2* F Lower
 Oral 1* F Lower
 Infrared same as rectal
 normal 37°C or 98.4°F
 For the appropriately clothed child a fever is considered
100.4* F rectal.
 3 months of age and less always take temperature rectally.

49.  Neonates 98.6-99.9 F 37-37.7 C
 3 years 98.5-99.5 36.9-37.7
 10 years 97.5-98.6 36.4-37
 16 year 97.6-98.8 36.4-37.1
 Anything above 37.5 and above is fever


50.  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.

51.  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

52.  Tachypnea is seen with respiratory distress, increased
activity, hyper metabolic states, fever
 A decreased respiratory rate is seen with conditions
affecting the central nervous system, 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
 Kussumaul breathing is seen in metabolic acidosis

53.  Newborn 30 – 60
 6 - 12 months 20 - 30
 1 - 2 years 17 - 23
 2 - 4 years 16 - 25
 4 - 10 years 20 - 28
 10 - 14 years 12 - 20
 15 + same as adult

54.  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.

55.  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

56.  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.

57.  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.

58.  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.

59.  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.

60.  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.

61.  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.”

62.  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.

63.  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.

64.  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.

65.  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

66.  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.

67.  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.

68.  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.

69.  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).

70.  The color of the oropharynx should be noted, the size of
the tonsils and tonsillar pillars and any discharge should
be noted.
 Cobble stoning 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.

71.  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.

72.  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 ofTurner 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.

73.  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.
 The point of maximum impulse is at the forth intercostal
space until about age 7

74.  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.

75.  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

76.  Check for muscle tone and strength of the upper extremity.
 Evaluate all range of motion of each joint.

77.  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

78.  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.

79.  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.

80.  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.

81.  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.

82.  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.

83.  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.

84.  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.

85.  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 BellThompson Ruler.

86.  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.

87.  Infant orthopedic testing should include all rang of motion
testing, static and motion palpation.
 Ortolani’sTest 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

88.  Barlow’sTest is a provocative test (dislocation) also called
Reverse Ortolani’s test.
 Barlow’sTest 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.

89.  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’sTest 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.

90.  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.

91.  Do give some stickers to children, thank
parents, child, wave them bye bye