A toddler boy is lying on the bed, conscious and comfortable. He is in respiratory distress and on oxygen support. A physical examination will assess vital signs, growth parameters, general appearance, and specifically examine the head, eyes, mouth, nose and ears for any abnormalities. Examinations of young children require developmentally appropriate techniques to establish rapport and avoid distress.

1. DR. FARHAD SHAKER
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INTRODUCTION TO PEDIATRIC
EXAMINATION

2. OBJECTIVES
• 1. To understand how the general approach to physical
examination of the child will be different compared to
that of an adult patient, and will vary according to the
age of the patient.
• 2. To observe and demonstrate physical findings unique
to the pediatric population, and to understand how these
findings may change depending upon the age of the child.

3. COMPETENCIES
• 1. To obtain accurate vital signs (Temperature, HR, RR,
BP) in a pediatric patient in different age groups and to
be able to evaluate these vital signs compared to age-
adjusted normal. To understand the normal variation in
temperature depending on the route of measurement.
• 2. To complete a thorough physical examination on a
pediatric patients in different age groups.

4. GENERAL APPROACH
• Gather as much data as possible by observation first
• Stay at the child’s level as much as possible. Do not tower!!
• Order of exam: least distressing to most distressing
• Rapport with child 1. Include child - explain to the child’s
level 2. Distraction is a valuable tool.

5. • Examine painful area last-get general impression of overall
attitude
• Be honest. If something is going to hurt, tell them that in a
calm fashion. Don’t lie or you lose credibility!
• Understand developmental stages’ impact on child’s
response. For example, stranger anxiety is a normal stage of
development, which tends to make examining a previously
cooperative child more difficult.

6. EXAMINATION PARTS
• 1. vital signs
• 2. Anthropometry data
• 3. General examination

7. VITAL SIGNS SIGNS
• Vital signs in pediatrics include
• Temperature
• Heart rate
• Blood pressure
• Respiratory rate

8. 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.

9. 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

10. 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.

11. 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

12. 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

13. METHODS OF TAKING TEMPERATURE
• Rectal 36 to 37.5 c
• Axillary 1c Lower
• Oral 0.5 Lower
• Infrared same as rectal
• For the appropriately clothed child a fever is considered
38 rectal.
• 3 months of age and less always take temperature
rectally.

14. 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.

16. 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

17. ANTHROPOMETRY
• The following measurements are very important & should
always be done.
•
• Height, weight, and head circumference should be plotted
on a growth curve graph.

18. WEIGHT
• 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).

20. 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).

22. 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).

24. GENERAL INSPECTION
• A comment should be made about the patients general
appearance.
• 1. Age estimation
• Some diseases are more common in certain age group like
Nephrotic syndrome is more common in between 2-8 years
while Nephritic syndrome is more common between 5-15
years.
• 2. Gender of the child
• Some disease is more common in female child like
Autoimmune disease and X-linked disease like Hemophilia
is more common in male child.

25. • 3. Resting position either Lying on bed or Sitting position
or On mother lap And others.
• 4. Conscious level either conscious or
• 5. General well-being Either is looking ill or well
Is important to know for the severity of disease

28. • 6. Hydration status
• Generally look for signs of dehydration
• 7. Nutrition and growths
• Ask to plot on growth charts
• 8. Respiratory status
• Look for signs of respiratory distress

29. • 9. look for clinical syndrome or dysmorphic features like
Downs syndrome
• 10. look for equipment and environment like 0₂ mask, O₂
bottle, nebulizer machine, Foley's catheter ……..

30. SUMMARY
• A toddler age boy, lying on bed, conscious, comfortable,
looks well, not dehydrated, well nourished, he is in
respiratory distress, no dysmorphic features, there is a
cannula in right hand, he is on O₂ mask.

31. 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.

32. • • 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.

33. • 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.

34. • • 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.

35. 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.
• Look to conjunctiva for pallor, jaundice, inflammations
• Look to periorbital for periorbital edema

36. MOUTH
• 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 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).

37. • 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.

38. • Examine the teeth for dental caries, color of the teeth,
number of teeth and for dental occlusion.

39. NOSE
• Look for deformities, obstruction of the airway, color
of the mucosa, discharge, and tenderness.
• • Check the nose for foreign bodies (beans, carrots,
crayons).
• • 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.

40. 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

41. NECK
• Look for swelling of the neck- It may be seen in
Diphtheria, Mumps or Cellulitis.
• • Look for enlargement of the neck veins.
• • Webbing of the neck may be seen in girls with turners’
syndrome
• • Look for abnormal venous pulsations.
• • Palpate the lymph nodes in both the anterior and
posterior triangles of the neck.
• • Look for enlargement of the thyroid gland or any other
abnormal swellings in the neck.

42. 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.

43. • • Any deformities or extra digits should be noted.
• • Range of motion, swelling, erythema, and warmth should
be noted any joint.
• • Check for signs of contusions, abrasions, and edema
which are common signs of trauma.

44. 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).

45. • • Range of motion should be preformed and any joint
swelling, erythema, and warmth should be noted.
• • Hips are routinely examined in infants.
• • Foot abnormalities are common in infancy but not in
later life.
• • The peripheral pulses, especially the femoral pulses.