This document provides guidance on performing a head to toe examination in children. It describes examining the head, hair, scalp, fontanelles, face, eyes, mouth, tongue, ears, nose, neck, limbs, chest, spine, abdomen, and genitalia. For each body part, common abnormalities are listed such as flat or prominent occiput, microcephaly, cephalhematoma, strabismus, low set ears, cleft palate, delayed dentition, goiter, lymphadenopathy, and neck stiffness. The document provides details on assessing each body part and common clinical findings to note during a pediatric examination.

1. Head to foot
examination
Anees Kurikkal
2008 MBBS

2. Includes Examination of
 Head
 Hair
 Scalp
 Fontanelle
 Face
 Eyes
 Mouth
 Tongue
 Ears
 Nose
 Neck
 Limbs
 Chest
 Spine
 Abdomen
 Genitalia
 Skin

3. HEAD
 Flat or prominent occiput ? ( in trisomy 21 and 18
resp)
 Shape of skull
 Fontanels
 Size of head

4.  Microcephaly
 When HC is 3SD below normal
 two types
 Primary
 secondary

6.  Macrocephaly
 HC >2SD above normal
 Familial macrocephaly
 Hydrocephalus – congenital or acquired
 Achondroplasia
 Cerebral giantism
 Fragile X syndrome
 Widening of suture in rickets, thalassemia

8. Fontanels
 6 at birth
 Only anterior and posterior palpable
 Anterior fontanelle -size 2.5 X 2.5 cm, AP direction
upto 4cm
 Soon after delivery AF narrow(moulding) and then
increases in size
 Examined with child quiet and upright
 Closes by age 9-18 months
 Pulsation of AF normal

9.  Closed/open ?
 Pulsatile / non pulsatile
 Normal /depressed / bulging ?

12.  Types
 Dolychocephaly
 Brachycephaly
 Cephalic index = head width x 100
head length
 <76 dolichocephaly
 76-80 normal
 ≥ 81 Brachycephaly

13.  Dolichocephaly
 Increased AP diameter
 Sagittal suture close early
 Skull cannot grow laterally
 Growth only in AP diameter
 Also called Scaphocephaly

14.  Brachycephaly
 Premature fusion of coronary suture
 Head cannot grow in AP diameter
 Transverse diameter is more
 Occiput flat as in down’s syndrome

15. SCALP
 Scalp swellings
 Dermoid
 Histiocytosis
 Osteoma
 Organized cephalhaematoma
 Secondary deposits
 Traumatic
 Seborrhoeic dermatitis of the scalp
 Yellow crusted plaques in the scalp

16.  Cephalhaematoma
 Sub periosteal collection of blood
 Elevated periosteum
 Does not cross suture line unlike caput succedaneum
 Maximum size by third day
 Parietal bone commonly involved
 Disappears by 3-6 weeks or may get calcified

17.  Caput succedaneum
 Diffuse soft bogy swelling of scalp
 Loose areolar layer of scalp
 Seen at birth
 Crosses suture line
 Disappears by 1-2 days

18.  Cranial bossing
 Prominence of central parts of frontal and parietal
bones
 Early manifestation of rickets
 Hydrocephalus
 Congenital syphilis
Frontal Bossing

19.  Craniotabes
 Ability of indentation under pressure of skull bones
near suture and springing back to normal
 Normal in new born
 In rickets- elicited beyond newborn period

20.  Head tilt and torticollis
 Due to
 Local painful reasons
 Compensation for visual defect
 Herniation or cerebellar tonsil
 Torticollis-Occiput tilted to one side and chin deviated
to opposite side
 Head tilt-Both occiput and chin deviated to same side

22.  Scalp hair
 White hair- as in albinism
 Sparse, straight thin easily pluckable – as in
malnutrition
 Alternately pigmented and depigmented hair called
flag sign indicates alternate periods of abnormal and
normal nutrition – seen in kwashiorkor
 Alopecia
 Congenital ectodermal dysplasia
 Treatment for malignancy
 Alopecia areata- autoimmune
 Trichotillomania- localized hair loss

24.  Hypertrichosis
 Cushing's syndrome
 Precocious puberty
 Drugs like minoxydil, androgens
 Can be familial
 Low hair line
 Extending below spine c4
 Low hair line in the back – turners, Klippel feil
syndrome, due to short neck
 Low hairline in the Front – hypothyroidism

25. FACE
 Moon face
 Cushing's syndrome or due to prolonged use of steroids
 Puffy face
 Nephrotic syndrome
 Hypothyroidism

26.  Coarse facies
 Does not look cute
 Bloated cheeks and protruding tongue
 Seen in
 Hypothyroidism
 Mucopolysaccharidosis
 gangliosidosis

27.  Mask like facies
 Wilsons disease or other disease affecting extrapyramidal
system
 Tranquilizer overdose
 bilateral facial nerve palsy (GBS)
 Potter’s facies
 Small lower jaw
 Depressed nose

28.  Mongoloid facies

29.  Depressed nasal ridge
 Downs syndrome
 Congenital syphilis
 Late stage leprosy
 Micrognathia
 Cri-du-chat syndrome
 Di George syndrome
 Foetal alcohol syndrome
 Russell silver syndrome

30.  Prognathism
 Angelman syndrome
 Acromegaly
 Fragile X syndrome

31. EYES
 Lid oedema
 Nephritic
 Nephrotic syndrome
 Cardiac failure
 Kwashiorkor
 Severe cough
 Conjunctivitis
 stye
 Angioedema
 Hypothyroidism
 IM
 Microphthalmos
 Congenital infections like- CMV, Rubella, toxoplasmosis
 Cornea
 Megalocornea- glaucoma
 Cloudy cornea- Mucopolysaccharidosis

32.  Colaboma
 Developmental defect in some portion of the eye
 Eyelash, iris, lens, retina affected
 Red eye
 Bacterial blepharoconjunctivitis
 Circum corneal congestion- as in acute uveitis
 Ptosis
 Congenital ptosis
 Occulomotor palsy
 Horner's syndrome
 Myasthenia gravis
 Oedema of the lid

33.  Proptosis
 Malignancies- neuroblastoma, leukemia,
retinoblastoma
 Non-malignancies- Cavernous hemangioma, Optic
nerve glioma
 Hyperthyroidism- exopthalmos

34.  Epicanthic fold
 Crescent shaped fold of skin originating below eye and
sweeps upwards to blend with upper lid
 Inner canthus covered
 Classic of down’s syndrome
 Seen in Chinese race
 Mongoloid slant
 Upward slant= slanting from medial to lateral
 Racial, down’s syndrome, prader willi syndrome

35.  Antimongoloid slant
 Downward slanting
 Turner’s syndrome
 Edward syndrome ( trisomy 18)

36.  Hypertelorism
 Distance b/w medial canthi of 2 eyes more than width
of each eye
 Turner’s syndrome. Down’s syndrome
 Canthal index= distance b/w inner canthi/ distance
outer canthi >0.38  hypertelorism

37.  Conjunctiva
 Xerosis- dryness, wrinkled appearance
 Bitot spots- grey, rough dry areas on temporal side of
conjunctiva

38.  Cataract
 Congenital cataract- transmitted as autosomal
dominant, recessive or X linked
 Intrauterine infections- rubella
 Metabolism cause- galactosemia( oil drop cataract),
Wilson's disease (sunflower cataract)
 Chromosomal anomalies- trisomy 13, 18, 21
 Trauma, radiation, drugs( long term steroids)

39.  Buphthalmos
 Congenital glaucoma
 Cornea usually cloudy cornea due to corneal oedema
 Enlarged orbital globe (bulging eyeballs)
 Blepharospasm
 Epiphora
 Strabismus
 Non parallelism of visual axes
 Due to
 Refractory error
 Medial rectus stronger than lateral rectus
 Concomitant – constant deviation
 In paralytic type deviation is not constant

40.  Kiesel fiescher ring
 Periphery of cornea as golden yellow, greenish or
brownish ring
 Deposition of copper
 There is no space between limbus and ring
 Wilsons disease

41. EAR
 Low set ears
 Superior attachment of pinna to the side of head must be at
or above line joining 2 inner canthi in normal child
 Below- low set ears
 Downs syndrome
 Di George syndrome
 Turners
 Examine from front with child’s head erect and eyes facing
directly forward
 large prominent ears
 Fragile X syndrome, marfan’s

42.  Deformed pinna
 Down’s syndrome
 Treacher Collin's syndrome
 Bat ear
 Protruding ear with poorly formed fold of helix
 Tragus sign
 Otitis externa
 Pressing of tragus causes pain
 Deafness
 Sequelae of neonatal kernicterus
 Intrauterine rubella infection
 Recurrent otitis media
 Aminoglycosides
 Ear wax
 Tympanic membrane trauma

43. MOUTH
 Outer edge of lips should fall on a perpendicular line drawn
from centre of either pupil with eyes
 When edge of lip falls outside- macrostomia. inside-
microstomia
 Large mouth
 Goldenhar syndrome
 William syndrome
 Angular stomatitis
 Riboflavin deficiency
 congenital syphilis

44.  Philtrum
 Long nose leads to short philtrum and a short nose
leads to wide philtrum
 Long philtrum – William's syndrome
 Short philtrum- cohen syndrome
 Smooth philtrum- foetal alcohol syndrome
 Uvula
 Bifid uvula
 Apert syndrome
 Di George syndrome
 Treacher’s syndrome

45.  Palate
 Cleft palate
 Trisomy 13,18
 Pierre robin syndrome
 Foetal hydantoin syndrome

46.  Painful ulcer of hard palate- herpes zoster
 Painful ulcer of oropharynx, soft palate- herpangina
 Rash in mucous membrane due to exanthematous
fever
 Drooling
 Normal during teething
 Stomatitis
 Acute epiglottitis/ diphtheria
 Pseudobulbar palsy
 Dry mouth
 Dehydration
 Mouth breathing
 antihistamine

47.  Oral thrush
 AIDS
 Antibiotics
 Steroids
 Hypoparathyroidism
 Look for enlarged salivary glands

48. TEETH
 Delayed dentition
 No teeth beyond 13th month
 Hypothyroidism
 Hypopituitarism
 Rickets
 PEM
 Discoloured teeth
 Poor oral hygiene
 Tetracycline therapy( brown)
 Enamel hypoplasia ( brown)
 Kernicterus (brown)
 Porphyria(reddish)
 Iron therapy(black)
 Chalky white patches(Fluorosis)

49. Tongue
 Macroglossia
 Congenital hypothyroidism
 Down’s syndrome
 Cystic hygroma
 Hemangioma
 Foote’s sign
 Rhythmic protrusion of tongue in new born may suggest
intracranial haemorrhage or cerebral oedema
- Coating of tongue- poor oral hygiene, typhoid fever, uremia
- Smooth bald tongue without papillae- vit B12 deficiency

50. Neck
 Short neck
 Turner’s syndrome
 Down’s syndrome
 Klippel feil deformity
 Noonan’s syndrome
 Hypothyroidism
 Goiter
 Puberty
 Hashimoto’s thyroiditis
 Iodine deficiency
 Grave’s disease

51.  Thyroid gland best appreciated when child extends
neck or when child swallows
 Thyroglossal cyst- moves with protrusion of tongue
 Webbed neck
 Turner’s syndrome
 Noonan’s syndrome
 Lymphadenopathy
 Localized- any infection in draining area
 Generalized- >2 non contiguous lymphnodes
 Viral infection- IM, HIV, Rubella
 Bacterial-TB
 Malignancy- lymphoma, leukemia
 Drugs- phenytoin

52.  Warm tender gland- infection
 Soft fluctuant gland- suppuration
 Matted gland- chronic inflammation(TB)
 Hard nodes- malignancy
 Neck stiffness
 Meningitis (stiffness on flexing neck but not on lateral
movement)
 Sub arachnoid haemorrhage
 Meningism- upper lobe pneumonia, tonsillitis
 Herniation of brain as in Space Occupying Lesion
 Local causes- retropharyngeal abscess, painful cervical
adenitis

53.  Opisthotonus
 Tetanus
 Meningitis
 Kernicterus
 And local causes- retropharyngeal abscess

54. Chest
 Absence of clavicle- cleidocranial dystosis
 Pre sternal oedema- mumps
 Widely spread nipple- turners
 Shield chest- turners
 Absence of pectoralis muscle- polland’s syndrome

55.  Pectus excavatum

56.  Pectus carinatum

57.  Gynaecomastia
 Transient during puberty
 Obesity
 Cirrhosis liver
 digitalis
 Oestrogen secreting tumour
 Klinefelter’s syndrome

58. SPINE
 Loss of normal curvature in cervical region is seen in
Juvenile rheumatoid arthritis
 Loss of curvature in Lumbar region- ankylosing
spondylitis
 Scoliosis
 Lateral curvature of spine
 Non fixed- corrected on lifting axilla or bending down
 Fixed- not corrected on bending
 Gibbus
 Prominent at apex of kyphosis
 Due to underlying collapsing vertebrae
 Commonest cause- TB spine

59. UPPER LIMB
 Cubitus valgus
 Forearm distal to elbow directed away from the body
 Cubitus varus
 Forearm distal to elbow directed towards the body

60. Fingers
 Clinodactyly
 Shortened middle phalanx of little finger
 More pronounced in radial aspect
 Little finger curved inwards
 Down’s syndrome and some normal children

61.  Camptodactyly
 flexion deformity of 5th finger
 seen in downs syndrome
 Bifid thumb
 due to chromosomal anomaly

62.  Arachnodactyly
 unduly long fingers
 seen in marfan's syndrome and homocystinuria
 Thumbs sign: thumb protrudes the ulnar border when
it is brought across the palm.
Present in marfan's syndrome, absent in
homocystinuria.

63.  Trident sign – Achondroplasia
 Divergence of 3rd and 4th fingers.
 Thumb and 1st two fingers & the last two fingers stand
out as separate giving a trident appearance
 Polydactyly
 congenital with no apparent reason
 occasionally familial

64.  Syndactyly
 fused fingers
 trisomy 13
 Absent thumb
 fanconii anaemia
 Osler's Nodes
 transient, small, pea sized, tender nodule in pulp
of finger and toes
 infective endocarditis, vasculitis syndrome

65.  Janeway lesions
 painless erythematous patches over palms and
soles
 Phocomelia
 congenital absence of limbs due to use of
thalidomide in 1st trimester

66. NAILS
 Koilonychia
 soft, thin, brittle, flattened, concave nails.
 Seen in iron deficiency anaemia
 White nail
 anaemia
 hypoalbuminemia
 Red nail – polycythemia
 Black nail – addisons disease
 Splinter haemorrhage – infective endocarditis

67.  Splinter haemorrhage

68.  Clubbing
 normal angle between nail and nailbed is lost
 Normally there is a gap when nails are placed in
opposition, which is lost in clubbingshamroths
window test
 causes:
 Cardiac- cyanotic heart disease, IE, TOF, Eisenmenger
syndrome
 Pulmonary- bronchiectasis, lung abscess, empyema
 GIT – Inflammatory Bowel Disease, cirrhosis

69.  Cyanosis
 -bluish discolouration when reduced Hb more
than 5gm%
 causes:
 Cardiac- congenital cyanotic heart disease, Eisenmenger
syndrome
 Pulmonary- interstitial pneumonia, severe pneumonia,
ARDS
 Methaemoglobinemia

70.  Palmar crease – Simian crease seen in downs
syndrome is a transverse palmar crease

71. LOWER LIMBS
 Coxa valga- angulated away from the hip joint
 Coxa vara- angulated towards the hip joint
 Genu valgum (knock knees)- commonly seen
in rickets and congenitally. Distance between
the medial malleoli is more than 5cms
 Genu varus (bow legs) – seen in
achondroplasia and rickets. distance between
medial condyle is more than 5cms

72.  both genu varum and genu valgus are physiological in
children of 1 ½ to 2 yrs of age
 genu recurvatum
 seen in poliomyelitis
 There is hyper extension of the knees
 pes planus- flat foot, seen physiologically in 1 ½ to 2yrs
 pes cavus-claw foot, seen in poliomyelitis
 talipus equino varus- foot adducted downwards,
inwards and with medial concavity

73. ABDOMEN
 Look for abdominal masses to exclude
 hepatosplenomegaly
 kidney mass(hydronephrosis)
 faecal mass
 intussusceptions
 malignancy
 umbilical hernia(imperfect closure of the umbilical
ring, protrudes during straining)

74. GENITALIA
 Hernia
 Undescended testes
 Precocious puberty
 Hydrocele
 Micropenis
 length less than 1.5cm
 normal length of penis- 4cms.
 Seen in
 hypopituitarism,
 Klinefelter's syndrome,
 noonans syndrome
 Micro orchidism- seen in hypopituitarism, hypothalamic disorders,
Lawrence moon beidl syndrome
 Macro orchidism- seen in testicular tumours, fragile x syndrome

75. SKIN
 Look for changes suggestive of PEM
 Flaky paint dermatosis
 Crazy pavement dermatosis
 Keratomalacia

76.  Neurocutaneous markers
 Hypopigmentation/hyper
 Molluscum contagiosum
 Pyoderma
 Scabies
 Fungal infections
 Skin turgor
 Rash
 Mongolian spots
 Haemangioma
 Spider naevus
 Port wine stain

77.  Molluscum contagiosum

78.  Mongolian blue spots
 Grey blue pigmented macule over lumbosacral region
 Benign & it fades in months to years

79.  Haemangioma
 Salmon patches- pale pink macule
 Site – neck eyelid face
 Present at birth
 Spider naevus
 Main vessel is an arteriole
 Seen in chronic liver disease

80.  Port wine stain
 Present at birth
 Fade with age but does not disappear
 Associated with surge weber syndrome
 It can be masked by cosmetics

81. THANK YOU