6. PHYSICAL EXAMINATION PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

1. Pediatric physical examination

2. Introduction Children and infants are not small adults, they are significantly different physiologically Knowledge of pediatric anatomic and physiologic differences will aid in recognizing normal variations found during the physical examination. The knowledge will aid in understanding the different physiologic responses children have to illness and injury The sequence and approach to the examination varies by age. Provide a comfortable atmosphere for the examination with privacy so that modesty is respected. Explain the procedures as you begin to perform them.

3. Principles of examination Rapport; Develop rapport with the child (care taker) and gain his or her confidence. Observation; You should have already gained a good deal of information by informal observation while taking the history. Undress the child; The child should be undressed to maximize your chances of finding physical signs. Examine in a room with adequate light, provide for privacy. Be systematic; follow a systematic structure to your examination. Leave unpleasant aspects such as the ears and throat to the end.

4. Principles of Physical Examination A systematic approach to the physical examination; In young children, the least distressing parts of the examination are completed first. In older cooperative children, the head-to-toe approach is generally used. Recording; of data facilitates exchange of information among different health professionals. Orderly sequence is usually altered; to accommodate the child’s development needs, although is recorded following the head to toe model.

5. Principles of physical examination Painful and disagreeable procedures should be reserved/performed last, deformed areas should be examined in routine fashion without overemphasis. For infants and toddlers, intrusive procedures should be done last to keep the child calm for as long as possible during the PE. Use play as much as possible to encourage cooperation.

6. Physical examination techniques Inspection ; Purposeful observation of the child’s physical features and behaviors. Physical Xtics include size, shape, color, movement, position, and location. Detection of odors is also a part of inspection Palpation ; Use of touch to identify characteristics of the skin, internal organs, and masses. Characteristics include texture, moistness, tenderness, temperature, position, shape, consistency, and mobility of masses and organs. The palmar surface of the fingers and finger pads helps determine position, size, consistency, and masses. The ulnar surface of the hand is best to detect vibrations

7. PE techniques cont…. Auscultation; Listening to sounds produced by the airway, lungs , stomach , heart, and blood vessels to identify their characteristics. Auscultation is usually performed with a stethoscope to enhance the sounds heard. Percussion; Striking the surface of the body, either directly or indirectly, to set up vibrations that reveal the density of underlying tissues and borders of internal organs.

8. General appearance Reveals cleanliness, nourishment, appropriate dressing, stature appropriate for age, posture, signs of pain ( frown/grimace). Behavior and personality, interactions with parents and nurse, temperament (calm or not). NB; If child is agitated , some assessments will need to be deferred until more cooperative and calm to minimize distress.

9. Physiological measurements Key elements in evaluating status of vital parameters include; temp, pulse, respiration and blood pressure ( and oxygen saturation). For best results count respirations first, take pulse next and measure temperature last. Respiration -observe abdominal mvts, count for a full minute. Pulse -radial in children over 2yrs, below this apical, for a full minute. Blood pressure ; accuracy based on appropriately sized cuff, this should be approximately 40% of arm circumference midway btn acromion and olecranion or 2/3 of arm. Not usually taken routinely. However should be taken in underlying pathological conditions.

10. Physical growth measurements Weight Height/length Head circumference- measure in children up to 36 months of age and in any child whose head size is questionable.

11. Skin Integrity Inspection Color : Pallor /cyanosis , flushing, Increased or decreased, pigmentation , mottling , bruises, erythema , cyanosis , or jaundice Birthmarks or other skin color deviations ( non-pathologic) Ecchymosis /abrasions, petechiae Lesions; describe location , size, type of lesion, pattern , and discharge, if present. Primary lesions (macules , papules, and vesicles ) are often the skin’s initial response to injury or infection. Secondary lesions (scars , ulcers, and fissures) are the result of irritation, infection , and delayed healing of primary lesions Vascular lesions

12. Skin integrity Palpation Lightly touch/stroke skin surface Texture ; dryness/moisture, temperature, resilience ( tugor ) Edema; pitting, non pitting Capillary refill; less than 2 seconds indicates circulatory inadequacy

13. Hair Note color, distribution, quality, texture , elasticity , and cleanliness- hair and scalp should be clean without lesions . Balding in an infant; need for more stimulation. Unusual hair growth patterns; low hairline on the neck or forehead may be associated with a congenital disorder such as hypothyroidism. Distribution of body hair on other skin surfaces, body hair in unexpected places should be noted. E.g , a tuft of hair at the base of the spine often indicates a spinal defect. Note the age at which pubic and axillary hair develops in the child to rule out precocious puberty Palpation; Hair should feel soft or silky with fine or thick shafts

14. Head and Neck Shape and symmetry; Inspect during several facial expressions such as resting, smiling, talking, and crying . Unusual facial features such as coarseness , tremors , tics, and twitching of facial muscles are often associated with seizures Palpate fontanels , should be closed by 18 months of age. Fontanels should neither be bulging nor sunken. Bossing of the forehead with cracked pot sound on percussion(macwen’s sign) and `sunset’ eyes indicates hydrocephalus.

15. Head and Neck cont… Down syndrome; small head, flattened nasal bridge, prominent epicanthal fold, low set ears. Note reports of headaches, swollen neck glands, neck stiffness, or decreased range of motion.

16. Eyes and Vision Inspect internal and external eye structures, including the eyeballs, eyelids, and eye muscles. Hypertelorism , bulging, sunken, color, size, movement, condition of lashes, conjunctivae, ptosis, sunset sign, corneal light reflex, palpebral slant Internal structures of the eyes: white reflex, opacities within the red reflex Vision; 20/20 achieved a 6 years

17. Eyes & Vision Eyelids; color, size, position, mobility, and condition of the eyelashes. Conjunctivae; color Ptosis; injury to the oculomotor nerve, cranial nerve III Strabismus , or crossed eyes- corneal light reflex Extraocular movements; six cardinal gaze points; tests oculomotor, trochlear , and abducens nerves

18. Corneal light reflex Shine a light on the child’s nose, midway between the eyes. Identify the location where the light is reflected on each eye. The light reflection is normally symmetric, at the same spot on each cornea An asymmetric corneal light reflex indicates strabismus

19. Ear and hearing External ear; alignment, general hygiene, presence and amount of wax. Infant and children should respond to human voice. Pull pinna of the ear down and back for infants and up and back for children below 3 years of age to straighten the ear canal and visualize the inner ear structures. Low set ears Pit or hole in front of the auditory canal; presence of a sinus. Mastoiditis Discharge Auditory testing; age appropriate

20. Examination of I nner ear

21. Nostrils External nose; size , shape, symmetry, and midline placement on the face . unusual characteristics; a crease across the nose between the cartilage and bone is often caused by the allergic child’s wiping an itchy nose upward with a hand Patency; Flaring of the nostrils, which could indicate respiratory distress. Note any bleeding, swelling, discharge, dryness, or blockage that could indicate trauma, irritation, or infection such as a cold Smell; tested in school going children and adolescents Internal nose; color, discharge , swelling, lesions , or other abnormalities, turbinates , polyp , nasal septum should be straight without perforations , bleeding, or crusting . Sinuses; headache or pain/swelling around one or both eyes - sinusitis

22. M outh Lesions, drainage; indicating infection. Fissures, stomatitis, or glossitis may indicate fluid and nutritional deficits. White patches in infants or children may indicate candidiasis; herpes simplex or a syphilitic chancre may be noted with adolescents. Tonsil enlargement, redness, white patches, or drainage in throat could indicate tonsillitis or pharyngitis. Buccal mucosa ; redness, swelling, ulcerative lesions stensen duct, the parotid gland opening becomes red when the child is infected with mumps. Lips; color , shape, symmetry, moisture, and lesions Teeth; eruption, missing teeth, discoloration, hygiene malocclusion

23. Neck Palpate head and neck for lymph nodes and report swollen, tender, or warm nodes Throat; color , swelling, lesions, and the condition of the tonsils, symmetric rising movement of the uvula Tonsils are large in proportion to the size of the pharynx because lymphoid tissue grows fastest in early childhood Trachea; should be midline, without masses or pain Thyroid; not usually palpable in the child unless they are enlarged ROM; torticollis, persistent head tilting due to injury to the sternocleidomastoid muscle or from unilateral vision or hearing impairment; pain with flexion of the neck toward the chest ( Brudzinski’s sign) may indicate meningitis. Jugular distention could indicate congestive heart failure

24. Chest Note chest shape, symmetry, and movement. Report significant retraction of chest muscles, which could indicate respiratory distress. Heart with child in sitting and supine position; note heart murmurs and record the location and volume intensity. Rounded chest; AP diameter is approximately equal to the lateral diameter in a child over 2 years of age; chronic obstructive lung condition e.g. asthma or cystic fibrosis Abnormal chest shape pectus carinatum , pectus excavatum , scoliosis(lateral deviation) Primary respiratory muscle in children under 6 years; diaphragm, therefore respirations are more abdominal

25. Chest cont… Report if child reports experiencing chest pain, infant becomes fatigued or short of breath during feeding because these are signs of decreased circulation or cardiac function. Resting pulse rates according to the age of the child are as follows: • 0 - 3 months: pulse rate 100 to 160 beats/minute • 4 months to 2 years of age: 80 to 140 beats/minute • 2 years to 10 years: 70 to 110 beats/minute • 10 years to adulthood: 60 to 90 beats/minute

26. Cardiovascular Identify the pulses in the upper and lower extremities through palpation. Observe and palpate pre cordial activity. Assess cardiac rhythm, rate, quality of the heart sounds and murmurs through auscultation. Assess peripheral perfusion by capillary refill. Assess for systemic signs of heart failure (enlarged liver, edema, JVD)

27. Cardiovascular Apical pulse - varies with age Sinus arrhythmia, S 3 common Premature ventricular contractions common Functional murmur in 1/2 to 2/3 No cardiac symptoms Low intensity, do not radiate Usually mid systolic, never diastolic Change with position Still’s murmur louder supine Venous hum disappears supine

28. Chest cont… Blood pressure also varies according to age (systolic: age + 90; diastolic: 1 to 5 years, 56, and 6 to 18 years, age + 52). Average blood pressure • <2 years: 95/58 mm Hg • 2 to 5 years: 101/57 mm Hg • 6 to 10 years: 112/75 mm Hg • 11 to 18 years: 120/80 mm Hg

29. Chest cont… Breath sounds should be clear; decreased or absent breath sounds could indicate lung congestion or consolidation, Abnormal breath sounds should be described. Respiratory rates vary with age: • <1 year: 30 to 35 breaths/minute • 2 to 3 years: 25 breaths/minute • 4 to 6 years: 21 to 23 breaths/minute • 8 to adulthood: 19 to 22 breaths/minute

30. Abdomen Always auscultate before palpation or percussion of the abdomen to avoid altering current bowel sound pattern with artificial stimulation of bowel activity. Examine all four quadrants of the abdomen. Report visible peristaltic waves, which may indicate pathologic state. Note absence or asymmetric abdominal reflex in infants and children >1 year of age.

31. Abdomen cont… Have child cough to increase intraabdominal pressure while inspecting for hernia. Report hyper peristalsis or absence of bowel sounds, both of which may indicate a gastrointestinal disorder. Lack of tympany on percussion could indicate full stomach, or presence of fluid or solid tumor; avoid assessment of stomach immediately after meals. Note guarding and tenderness, particularly rebound tenderness, or pain that could indicate inflammation or infection.

32. Genitourinary Exam can be anxiety provoking for older child and adolescents, thus secure privacy (ask preference for parental presence), preserve modesty, and when possible offer same-sex examiner. If complaint of burning, frequency or difficulty voiding, obtain urine specimen for possible culture. Note urinary and genital structures, size, and appearance; explain anatomy for older child and caution that you will touch an area prior to doing so to prepare the child.

33. Genitourinary cont… Report undescended testes ( cryptorchidism ), urinary meatus that is not central at the tip of the shaft of the penis, large scrotal sac (possible hernia), or enlarged clitoris.

34. Back and spine Lumbar lordosis in toddlers is normal. Screen at all ages for scoliosis, especially just before onset puberty at which time may dramatically increase. Look for shoulder/scapular height, spine, arm/torso triangle, pelvis tilt, height of posterior ribs (spine flexed)

35. Extremities Symmetry, ROM, muscle strength Congenital hip dysplasia/dislocation Clunk with Ortolani , Barlow’s maneuvers Limited hip abduction Asymmetrical creases Leg length discrepancy Asymmetrical knee height with Galeazzi maneuver

36. Neurologic AVPU scale to determine level of consciousness. Elicit primitive reflexes- most should have disappeared by 6 months. Assess the quality and symmetry of tone, strength and reflexes using age-appropriate techniques. Assess developmental milestones.

37. Sucking reflex: A feeding reflex that occurs when the infant’s lips are touched. The reflex persists throughout infancy. • Rooting reflex: A feeding reflex elicited by touching the baby’s cheek, causing the baby’s head to turn to the side that was touched. The reflex usually disappears after 4 months. • Moro reflex: Often assessed to estimate the maturity of the central nervous system. A loud noise, a sudden change in position , or an abrupt jarring of the crib elicits this reflex. The infant reacts by extending both arms and legs outward with the fingers spread, then suddenly retracting the limbs. Often the infant cries at the same time. This reflex disappears after 4 months . • Palmar grasp reflex : Occurs when a small object is placed against the palm of the hand, causing the fingers to curl around it. This reflex disappears after 3 to 6 months. • Plantar reflex: Similar to the palmar grasp reflex; an object placed just beneath the toes causes them to curl around it. This reflex disappears after 8 to 10 months. • Tonic neck reflex (TNR) or fencing reflex: A postural reflex. When a baby who is lying on its back turns its head to, for example, the right side, the left side of the body shows a flexing of the left arm and the left leg. This reflex disappears after 4 to 6 months . • Stepping reflex (walking or dancing reflex): Can be elicited by holding the baby upright so that the feet touch a flat surface. The legs then move up and down as if the baby were walking. This reflex usually disappears at about 2 months . • Babinski reflex: When the sole of the foot is stroked, the big toe rises and the other toes fan out. A newborn baby has a positive Babinski. After age 1, the infant exhibits a negative Babinski; that is, the toes curl downward. A positive Babinski after age 1 can indicate possible upper motor neuron damage

38. Developmental Should be performed at all health maintenance visits Majority done by observation and maternal history. Use of a tool (e.g. Denver II) allows better quantitation . Express in developmental age or developmental quotient

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