general Examination in paediatric medicine

general examination pediatrics

1. GENERAL
EXAMINATION

2. VITAL SIGNS:
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.
•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.
•The level of systolic blood pressure increases gradually throughout infancy and
childhood.
•AGE SYSTOLIC DIASTOLIC
•New born 50-70 25-45
•Up to 6 months 60-80 30-50
•6months to 1 years 60-90 50-70
•1-6years 70-100 40-70
•7-12 years 90-110 50-70

3. Heart rate
•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.

4. 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

5. 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.
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

6. 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.
•Methods of taking Temperature:
•Rectal 96.8* to 98.6* F
•Axillary 2* F Lower
•Oral 1* F Lower
•Infrared same as rectal
•3 months of age and less always take temperature rectally.

7. Anthropometry:
The following measurements are very important & should
always be done.
•Weight(in kgs)
•Height or length(in cms)
•Chest Circumference(cms)-upto 3 years of age.
•Mid-arm circumference(cms)-between 1-5 years of age.
•Upper segment/lower segment ratio.

8. PALLOR
•Pallor is the paleness of the skin.
•Its presence depends on the thickness and quality of skin and the amount and quality of blood in the
capillaries.
•Pallor may be due to one of the following reasons:
1. Pallor due to thick skin
•Hypopituitarism
•Hypothyroidism
2. Pallor due to decreased blood flow
•Shock
•Left heart failure
3. Pallor with normal blood flow
•Severe anaemia
CYANOSIS
•Cyanosis refers to the bluish discolouration of skin and mucous membranes.
• It occurs due to the presence of more than 5g% of reduced haemoglobin in the blood.
•The sites at which cyanosis is likely to be evident are –Nail bed, Lips ,Tongue,Conjuctiva,Oral mucosa
•Depending on the mechanism and cause, cyanosis may be central, peripheral, mixed or differential.

9. •CLUBBING
•Clubbing is a bulbous enlargement of distal portion of terminal phalanx due to
proliferation of subungual connective tissue.
•Grades of clubbing
•Grade 1: Nail bed fluctuation
•Grade 2: Obliteration of Lovibond angle
•Grade 3: Parrot beaking
•Grade 4: Hypertrophic osteo-arthropathy(HOA)
•CAUSES
•thoracic & non-thoracic
•THORACIC causes: bronchitis, empyema, lung abscess, cystic fibrosis, Lung Ca, Esophageal
Ca, mesothelioma, Endocarditis.
•Interstitial lung disease: asbestosis, fibrosing
alveolitis.
•Vascular causes: AV malformations, Cyanotic
heart disease Non-
thoracic causes: Hepatic cirrhosis, Ulcerative colitis,
Crohn’s disease.

10. 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.
•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.

11. Head
•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.

12. Nose
•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.

13. 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

14. 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.

15. Trunk
•Note the symmetry of the chest, asymmetric expansion may be seen
with pneumothorax or diaphragmatic paralysis. Also note any
abnormal shapes.
•Barrel-shaped chest are sometimes seen in patients with chronic
obstructive pulmonary disease(chronic asthma or cystic fibrosis).
•Widely-spaced nipples may be a sign of Turner Syndrome.
•Note the pubertal development of the breast 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.

16. 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.
•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.
•Check for muscle tone and strength of the upper extremity.
•Evaluate all range of motion of each joint.

17. 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).
•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.

18. Bones, Joints & Spine
•Bones should be examined for any swelling, deformities, fractures,
tenderness at any site.
•Joints should be examined for color, temperature, swelling,
tenderness on palpation and movement.
•Spine should be examined for any swelling, tenderness or
deformities such as kyphosis, scoliosis, lordosis etc.
Genitalia
•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.
•Tanner Staging is the measurement for sexual maturation.

20. CASE
•A 22 month old boy presents to your clinic with a chief complaint of pallor. A visiting
relative who has not seen the child for 5 months told his mother that the boy appears pale.
The mother brings him in for a checkup even though she notices no change in his coloring
(he has always been fair skinned).
•What relevant history you will ask?
•On review of symptoms you find that he is an active toddler, with no recent fatigue,
exercise intolerance, or increase in sleeping. He has had no blood in his diapers and no
black or tarry stools. He is a picky eater, not taking any non vegetarian food. Takes some
rice and vegetables, but loves milk and drinks six to eight glasses of whole milk per day.
Micturation no cola or high colored urine
•Family history reveals a distant aunt who had anemia when she was pregnant but which
subsequently resolved. There is no history of splenectomy, gall stones at an early age, or
other anemia in the family.
•What you observe in the examination?
•Exam: VS: T 37.5, BP 90/52, P 145, RR 16, Height 85.5 cm (50th %ile), Weight 13.2 kg (75th
%ile). General appearance: He is a pale appearing, active toddler, holding a bottle, tearing
and eating paper from your exam table.
No scleral icterus. Pale conjunctiva. Mouth: Dental caries.
•Chest: Clear. Heart: Mild tachycardia, grade II/VI systolic ejection murmur heard best over
the upper left sternal border. Abdomen: No hepatosplenomegaly. Rectal: Dark brown, soft
stool, negative for occult blood.