Examination in PaediatricExamination in Paediatric

Dr. Varsha Atul ShahDr. Varsha Atul Shah

Senior ConsultantSenior Consultant

Physical ExaminationPhysical Examination

Perform physical examination from head to toe on a Perform physical examination from head to toe on a pediatric patient. pediatric patient.

You may need to alter the order of the examination for You may need to alter the order of the examination for patient compliance for uncooperative or hyperactive patient compliance for uncooperative or hyperactive patients.patients.

Do not force a child to do something that may be Do not force a child to do something that may be frightening or uncomfortable to them.frightening or uncomfortable to them.

When examining an infant, toddler, or school-aged child When examining an infant, toddler, or school-aged child it is suggested to have a parent or guardian in the room it is suggested to have a parent or guardian in the room with you.with you.

Physical ExaminationPhysical Examination Examination of an infant or toddler may be Examination of an infant or toddler may be

preformed on the lap of the patient.preformed on the lap of the patient. With an adolescent, it may be more appropriate With an adolescent, it may be more appropriate

not to have the parent in the room with you, this not to have the parent in the room with you, this may allow the patient to feel that they can be may allow the patient to feel that they can be more candid.more candid.

To avoid possible legal issues, a male doctor To avoid possible legal issues, a male doctor may want a female staff member to be in the may want a female staff member to be in the examination room.examination room.

The doctor should verify confidentiality laws in The doctor should verify confidentiality laws in their particular state.their particular state.

Vital SignsVital Signs

Vital signs in pediatrics include temperature, heart rate, Vital signs in pediatrics include temperature, heart rate, blood pressure, respiratory rate, weight, length, and blood pressure, respiratory rate, weight, length, and head circumference.head circumference.

WeightWeight

Height, weight, and head circumference should be Height, weight, and head circumference should be plotted on a growth curve graph.plotted on a growth curve graph.

Decrease in weight percentile may be due to decreased Decrease in weight percentile may be due to decreased intake (malnutrition, central nervous system intake (malnutrition, central nervous system abnormality), malabsorption (cystic fibrosis, IBD, celiac abnormality), malabsorption (cystic fibrosis, IBD, celiac disease, parasitic infestation), or an increased metabolic disease, parasitic infestation), or an increased metabolic rate (hyperthyroidism, congestive heart failure).rate (hyperthyroidism, congestive heart failure).

Increase in weight is most commonly exogenous but Increase in weight is most commonly exogenous but may also be associated with certain genetic syndromes may also be associated with certain genetic syndromes (Prader- willi).(Prader- willi).

HeightHeight

A child’s length (lying flat on a table) is measured until 2 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 to 3 years of age; after that it is measured as height (standing). (standing).

Decrease height may be familial, or may be seen in Decrease height may be familial, or may be seen in conditions affecting weight or independent of weight conditions affecting weight or independent of weight (Turner syndrome).(Turner syndrome).

Increase height may be familiar or associated with Increase height may be familiar or associated with certain genetic and endocrine abnormalities (Cerebral certain genetic and endocrine abnormalities (Cerebral gigantism).gigantism).

Head CircumferenceHead Circumference

Head circumference is routinely measured until 2 to 3 Head circumference is routinely measured until 2 to 3 years of age.years of age.

Microcephaly may be part of a syndrome (Rett Microcephaly may be part of a syndrome (Rett syndrome), congenital infection (CMV), or the result of syndrome), congenital infection (CMV), or the result of abnormal brain growth (schizencephaly).abnormal brain growth (schizencephaly).

Macrocephaly may be familiar or may represent a Macrocephaly may be familiar or may represent a pathologic state (Hydrocephalus, Canavaan disease, AV pathologic state (Hydrocephalus, Canavaan disease, AV malformation).malformation).

Blood PressureBlood Pressure Blood pressure must be measured with a cuff wide Blood pressure must be measured with a cuff wide

enough to cover at least 1/2 to 2/3 of the extremity enough to cover at least 1/2 to 2/3 of the extremity and its bladder should encircle the entire extremity.and its bladder should encircle the entire extremity.

A narrow cuff elevates the pressure, while a wide cuff A narrow cuff elevates the pressure, while a wide cuff lowers it.lowers it.

Systolic hypertension is seen with anxiety, renal Systolic hypertension is seen with anxiety, renal disease, coarctation of the aorta, essential disease, coarctation of the aorta, essential hypertension, and certain endocrine abnormalities. hypertension, and certain endocrine abnormalities.

Diastolic hypertension occurs with endocrine Diastolic hypertension occurs with endocrine abnormalities and coarctation of the aorta.abnormalities and coarctation of the aorta.

Hypotension occurs in hypovolemia and other forms Hypotension occurs in hypovolemia and other forms of shock.of shock.

Blood PressureBlood Pressure

The level of systolic blood pressure increases gradually The level of systolic blood pressure increases gradually throughout infancy and childhood.throughout infancy and childhood.

2years 96/60 112/782years 96/60 112/78 6years 98/64 116/806years 98/64 116/80 9years 106/68 126/849years 106/68 126/84 12years 114/74 136/8812years 114/74 136/88

PulsePulse

An elevated heart rate is seen in infections, An elevated heart rate is seen in infections, hypovolemia, hyperthyroidism, and anxiety.hypovolemia, hyperthyroidism, and anxiety.

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

Bradycardia is seen in hypertension, increased Bradycardia is seen in hypertension, increased intracranial pressure, certain intoxications, or other intracranial pressure, certain intoxications, or other hypometabloic states.hypometabloic states.

It is best to examine an infant’s heart first during the It is best to examine an infant’s heart first during the exam.exam.

Heart RateHeart Rate

Birth 140Birth 140 1 - 6 months 1301 - 6 months 130 6 - 12 months 1156 - 12 months 115 1 - 2 years 1101 - 2 years 110 2 - 6 years 1032 - 6 years 103 6 - 10 years 956 - 10 years 95 10 - 14 years 8510 - 14 years 85 14 - 18 years 8214 - 18 years 82

RespirationRespiration

Tachypnea is seen with increased activity, Tachypnea is seen with increased activity, hypermetabolic states, fever, or respiratory distress. hypermetabolic states, fever, or respiratory distress.

A decreased respiratory rate is seen with conditions A decreased respiratory rate is seen with conditions affecting the central nervous system, including affecting the central nervous system, including medications/toxins, congenital malformations, and medications/toxins, congenital malformations, and other lesions. other lesions.

A variable respiratory rate, known as periodic A variable respiratory rate, known as periodic breathing, is commonly seen in neonates but more breathing, is commonly seen in neonates but more than a 20 second pause is always abnormal.than a 20 second pause is always abnormal.

Cheyne-Stokes breathing is seen with brainstem Cheyne-Stokes breathing is seen with brainstem abnormalities.abnormalities.

Respiratory RateRespiratory Rate

Newborn 30 - 75Newborn 30 - 75 6 - 12 months 22 - 316 - 12 months 22 - 31 1 - 2 years 17 - 231 - 2 years 17 - 23 2 - 4 years 16 - 252 - 4 years 16 - 25 4 - 10 years 13 - 234 - 10 years 13 - 23 10 - 14 years 13 - 1910 - 14 years 13 - 19 15 + same as adult15 + same as adult

TemperatureTemperature

Temperature may be elevated with infections, tumors, Temperature may be elevated with infections, tumors, hyperthyroidism, autoimmune disease, environmental hyperthyroidism, autoimmune disease, environmental exposures, certain medications, or increased activity.exposures, certain medications, or increased activity.

Temperature may be decreased with infections Temperature may be decreased with infections (especially in neonates), hypothyroidism, certain (especially in neonates), hypothyroidism, certain medications, environmental exposures, shock, or CNS medications, environmental exposures, shock, or CNS disease affecting the hypothalamus.disease affecting the hypothalamus.

Control of heat production and heat loss is maintained by Control of heat production and heat loss is maintained by the thermoregulatory center in the hypothalamus.the thermoregulatory center in the hypothalamus.

Methods of Taking TemperatureMethods of Taking Temperature

Rectal 96.8* to 98.6* FRectal 96.8* to 98.6* F Axillary 2* F LowerAxillary 2* F Lower OralOral 1* F Lower 1* F Lower Infrared same as rectalInfrared same as rectal

For the appropriately clothed child a fever is considered For the appropriately clothed child a fever is considered 100.4* F rectal.100.4* F rectal.

3 months of age and less always take temperature 3 months of age and less always take temperature rectally.rectally.

General InspectionGeneral Inspection

A comment should be made about the patients general A comment should be made about the patients general appearance.appearance.

Activity level and whether the patient is ill, is interacting Activity level and whether the patient is ill, is interacting with the surroundings, and level of distress, if any.with the surroundings, and level of distress, if any.

Comment about unusual odors.Comment about unusual odors.

HeadHead In an infant the size and topography of the anterior In an infant the size and topography of the anterior

fontanel should be noted.fontanel should be noted. Ant. Fontanel is the largest 4 to 6 cm and closes between 4 and Ant. Fontanel is the largest 4 to 6 cm and closes between 4 and

26 months.26 months. Post. Fontanel is 1 to 2 cm and closes by 2 months.Post. Fontanel is 1 to 2 cm and closes by 2 months.

Bulging of the fontanel may indicate increased Bulging of the fontanel may indicate increased intracranial pressure found in infections, neoplastic intracranial pressure found in infections, neoplastic diseases of the central nervous system, or obstruction of diseases of the central nervous system, or obstruction of the ventricular circulation.the ventricular circulation.

Depression of the fontanel is found in decreased Depression of the fontanel is found in decreased intracranial pressure and may be a sign of dehydration.intracranial pressure and may be a sign of dehydration.

HeadHead

Symmetry should be examined from various Symmetry should be examined from various perspectives:perspectives: Plagiocephaly: is characterized by flattening of the occipital Plagiocephaly: is characterized by flattening of the occipital

skull.skull. Scaphocephaly: describes an elongated head with flattening of Scaphocephaly: describes an elongated head with flattening of

the bones in the temporoparietal regions.the bones in the temporoparietal regions. Cephalhematoma: term applied when there is bleeding over Cephalhematoma: term applied when there is bleeding over

the outer surface of a skull bone elevating the periosteum.the outer surface of a skull bone elevating the periosteum. Caput succedaneum a localized pitting edema in the scalp that Caput succedaneum a localized pitting edema in the scalp that

may overlie sutures of the skull, usually formed during labor as may overlie sutures of the skull, usually formed during labor as a result of circular pressure of the cervix on the fetal occiput.a result of circular pressure of the cervix on the fetal occiput.

Craniosynostosis refers to premature fusion of one or more of Craniosynostosis refers to premature fusion of one or more of the sutures of the cranial bones, and should be considered in the sutures of the cranial bones, and should be considered in any neonate with an asymmetric cranium.any neonate with an asymmetric cranium.

HeadHead Craniotabes is a term for softening of the skull Craniotabes is a term for softening of the skull

bones, with pressure the skull may be bones, with pressure the skull may be momentarily indented before springing out momentarily indented before springing out again. The major clinical significance is with again. The major clinical significance is with congenital rickets. Rarely, osteogenesis congenital rickets. Rarely, osteogenesis imperfecta or congenital hypophosphatasia may imperfecta or congenital hypophosphatasia may be causes. Pressure to skull makes a sound be causes. Pressure to skull makes a sound “Crack” like a ping pong ball.“Crack” like a ping pong ball.

Macewen’s Sign: is characterized by a “Cracked Macewen’s Sign: is characterized by a “Cracked pot” sound when the cranium is percussed with pot” sound when the cranium is percussed with the examining finger. A positive Macewen’s sign the examining finger. A positive Macewen’s sign may be evident until fontanel closure.may be evident until fontanel closure.

HeadHead The shape of the head can reveal much about the The shape of the head can reveal much about the

baby’s trip through the birth canal.baby’s trip through the birth canal. Palpate suture lines for abnormalities.Palpate suture lines for abnormalities. Palpate for any bumps or points of tenderness.Palpate for any bumps or points of tenderness. Examine the hair and eyebrows for texture, quantity, Examine the hair and eyebrows for texture, quantity,

and pattern.and pattern. Abnormalities in hair may be associated with systemic Abnormalities in hair may be associated with systemic

disease or abnormality. Dry, course and brittle hair disease or abnormality. Dry, course and brittle hair may be associated with congenital hypothyroidism.may be associated with congenital hypothyroidism.

Alopecia Areata: well circumscribed areas of complete Alopecia Areata: well circumscribed areas of complete or almost complete hair loss, the scalp is smooth w/o or almost complete hair loss, the scalp is smooth w/o signs of inflammation. Hair loss usually begins signs of inflammation. Hair loss usually begins suddenly, and total loss of scalp and body hair may suddenly, and total loss of scalp and body hair may develop.develop.

HeadHead

Tinea Capitis is a fungal infection of the scalp Tinea Capitis is a fungal infection of the scalp characterized by a patch of short broken off hairs and characterized by a patch of short broken off hairs and the patches of hair loss may be scaly or they may be the patches of hair loss may be scaly or they may be marked with inflammation, bogginess, and pustules marked with inflammation, bogginess, and pustules called “kerion.”called “kerion.”

EyesEyes

The shape and position of the eyes should be noted.The shape and position of the eyes should be noted. Any abnormal eye movement and the ability to focus on Any abnormal eye movement and the ability to focus on

the examiner are important to note.the examiner are important to note. Hard to examine because of the bright lights.Hard to examine because of the bright lights.

NoseNose Look for deformities, obstruction of the airway, color of Look for deformities, obstruction of the airway, color of

the mucosa, discharge, and tenderness.the mucosa, discharge, and tenderness. Check the nose for foreign bodies (beans, carrots, Check the nose for foreign bodies (beans, carrots,

crayons) younger children often putting foreign objects crayons) younger children often putting foreign objects into the various orifices of the body and they often get into the various orifices of the body and they often get stuck their.stuck their.

A green, foul smelling, purulent discharge from only A green, foul smelling, purulent discharge from only one side of the nose is common with a foreign object one side of the nose is common with a foreign object being left in the nose.being left in the nose.

Purulent discharge bilaterally indicates infection.Purulent discharge bilaterally indicates infection. Delivery can give nasal obstruction due to Delivery can give nasal obstruction due to

displacement of the septal cartilage.displacement of the septal cartilage.

NoseNose Flaring of the nostril almost always shows respiratory Flaring of the nostril almost always shows respiratory

distress.distress. Mucosal Assessment:Mucosal Assessment:

Red: Acute infectionRed: Acute infection Blue and Boggy: AllergyBlue and Boggy: Allergy Gray and Swollen: RhinitisGray and Swollen: Rhinitis

Maxillary and Ethmoid are developed in infancy.Maxillary and Ethmoid are developed in infancy. Frontal sinus developed by 5 years of age.Frontal sinus developed by 5 years of age. The size, shape and symmetry of the nose should be The size, shape and symmetry of the nose should be

noted.noted. A horizontal crease may be seen in the skin on the A horizontal crease may be seen in the skin on the

surface of the nose, this signifies repetitive wiping of surface of the nose, this signifies repetitive wiping of the nose commonly seen in allergic rhinitis.the nose commonly seen in allergic rhinitis.

EarsEars

The size and any aberration in shape of the external The size and any aberration in shape of the external ear (Pinna) should be noted.ear (Pinna) should be noted.

A low position (below the level of the eyes) or small A low position (below the level of the eyes) or small deformed auricles may be an indication of a brain deformed auricles may be an indication of a brain defect or congenital kidney abnormality, especially defect or congenital kidney abnormality, especially renal agenesis.renal agenesis.

Inspection of the auricle and pariauricular tissues can Inspection of the auricle and pariauricular tissues can be done by checking the 4 D’s:be done by checking the 4 D’s: DischargeDischarge DiscolorationDiscoloration DeformityDeformity DisplacementDisplacement

EarsEars Discharge: from the ear canal can be a result of otitis Discharge: from the ear canal can be a result of otitis

external or chronic untreated otitis media.external or chronic untreated otitis media. Discharge may be thick and white, it may accompany a Discharge may be thick and white, it may accompany a

bright pink or red canal.bright pink or red canal. To differentiate between otitis externa and otitis media, To differentiate between otitis externa and otitis media,

pull on the pinna, if this elicits pain, it is most likely pull on the pinna, if this elicits pain, it is most likely otitis externa.otitis externa.

Prolonged moisture in the ear canal promotes bacteria Prolonged moisture in the ear canal promotes bacteria and fungal growth which predisposes the child to otitis and fungal growth which predisposes the child to otitis externa (swimmers ear).externa (swimmers ear).

Equal mixture of alcohol and vinegar used as a rinse Equal mixture of alcohol and vinegar used as a rinse will keep the ears dry and keep bacteria from growing.will keep the ears dry and keep bacteria from growing.

EarsEars

If the discharge is accompanied with perforation of the If the discharge is accompanied with perforation of the tympanic membrane, otitis media is suspected.tympanic membrane, otitis media is suspected.

The presence of a foreign bodies in the ear is common 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 and if left in the ear for a period of time may cause an inflammatory response which may produce a foul-inflammatory response which may produce a foul-smelling purulent discharge.smelling purulent discharge.

DiscolorationDiscoloration in the form of eccymosis over the mastoid in the form of eccymosis over the mastoid area is called “Battle Sign”, and is associated with area is called “Battle Sign”, and is associated with trauma and should be considered an emergency.trauma and should be considered an emergency.

EarsEars Deformity of the ears may develop from intrauterine positioning or Deformity of the ears may develop from intrauterine positioning or

could be the results of hereditary factors.could be the results of hereditary factors. These deformities are of minor concern unless gross deformities are These deformities are of minor concern unless gross deformities are

present.present. Gross deformities of the external ear are often associated with Gross deformities of the external ear are often associated with

anomalies of the middle and inner ear structures.anomalies of the middle and inner ear structures. Displacement of the auricle away from the skull is a distressing sign Displacement of the auricle away from the skull is a distressing sign

associated with mastoiditis, other signs of mastoiditis are erythema associated with mastoiditis, other signs of mastoiditis are erythema and tenderness over the mastoid and pinna, fever, and purulent and tenderness over the mastoid and pinna, fever, and purulent discharge.discharge.

Other conditions associated with displacement of the auricle are Other conditions associated with displacement of the auricle are parotitis, primary cellulitis, contact dermatitis, and edema.parotitis, primary cellulitis, contact dermatitis, and edema.

ThroatThroat Examine the external mouth for symmetry, such as Examine the external mouth for symmetry, such as

drooping of the corner of the mouth.drooping of the corner of the mouth. The lips and mucous membrane should be examined for The lips and mucous membrane should be examined for

evidence of cyanosis.evidence of cyanosis. The tongue should be palpated for movement and strength The tongue should be palpated for movement and strength

of suck, this evaluates the function of the of suck, this evaluates the function of the glossopharyngeal, vagus, and hypoglossal nervesglossopharyngeal, vagus, and hypoglossal nerves

The soft palate should be examined for presence of the The soft palate should be examined for presence of the gag reflex, evaluates the vagus nerve.gag reflex, evaluates the vagus nerve.

The hard palate should be evaluated for structure, The hard palate should be evaluated for structure, absence of clefts, and alignment of the arch. A high arched absence of clefts, and alignment of the arch. A high arched palate may possibly indicates future dental problems palate may possibly indicates future dental problems associated with insufficient space for teeth ( high arched associated with insufficient space for teeth ( high arched palate may indicate syndromes like Marfan syndromepalate may indicate syndromes like Marfan syndrome).).

MumpsMumps

ThroatThroat The color of the oropharynx should be noted, the The color of the oropharynx should be noted, the

size of the tonsils and tonsillar pillars and any size of the tonsils and tonsillar pillars and any discharge should be noted.discharge should be noted.

Cobblestoning of the posterior pharyngeal wall is a Cobblestoning of the posterior pharyngeal wall is a sign of chronic allergic disease.sign of chronic allergic disease.

The quality of the patient’s voice should also be The quality of the patient’s voice should also be noted.noted.

The tongue should be examined for size, shape, The tongue should be examined for size, shape, color, and coating.color, and coating. A coated tongue is nonspecificA coated tongue is nonspecific A smooth tongue is found in avitaminosisA smooth tongue is found in avitaminosis A strawberry or raspberry tongue is seen in specific A strawberry or raspberry tongue is seen in specific

stages of Scarlet Fever.stages of Scarlet Fever. A geographic tongue is a common finding.A geographic tongue is a common finding.

ThrushThrush

Thrush on the TongueThrush on the Tongue

Oral ThrushOral Thrush

Acute TonsillitisAcute Tonsillitis

Diphtheria Bull NeckDiphtheria Bull Neck

Diphtheria PsudomembraneDiphtheria Psudomembrane

StomatitisStomatitis

Stomatitis of the TongueStomatitis of the Tongue

MastoiditisMastoiditis

MastoiditisMastoiditis

MumpsMumps

ThroatThroat Examine the oral mucosa may have creamy Examine the oral mucosa may have creamy

white reticular plaques commonly seen with white reticular plaques commonly seen with thrush caused by Candida Albicans.thrush caused by Candida Albicans.

A gray/white, sand grain sized dots on the A gray/white, sand grain sized dots on the buccal mucosa opposite the lower molars, buccal mucosa opposite the lower molars, called Koplik Spots are seen with Rubeola.called Koplik Spots are seen with Rubeola.

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

Examine the neck for masses, enlarged glands, Examine the neck for masses, enlarged glands, tracheal tugging, carotid bruits, mobility, and tracheal tugging, carotid bruits, mobility, and webbed neck.webbed neck.

Kippel FeilKippel Feil

Congenital Muscular TorticollisCongenital Muscular Torticollis

Thorax and HeartThorax and Heart Note the symmetry of the chest, asymmetric expansion may be Note the symmetry of the chest, asymmetric expansion may be

seen with pneumothorax or diaphragmatic paralysis. Also note seen with pneumothorax or diaphragmatic paralysis. Also note any abnormal shapes (Pectus Excavatum or Pectus carinatum. any abnormal shapes (Pectus Excavatum or Pectus carinatum.

Barrel-shaped chest are sometimes seen in patients with Barrel-shaped chest are sometimes seen in patients with chronic obstructive pulmonary disease(chronic asthma or cystic chronic obstructive pulmonary disease(chronic asthma or cystic fibrosis).fibrosis).

A rechitic rosary may be seen or palpated in rickets.A rechitic rosary may be seen or palpated in rickets. Widely-spaced nipples may be a sign of Turner Syndrome.Widely-spaced nipples may be a sign of Turner Syndrome. Note the pubertal development of the breast (Tanner staging) in Note the pubertal development of the breast (Tanner staging) in

females.females. Note any masses, tenderness, or discharge of the breast and Note any masses, tenderness, or discharge of the breast and

describe in detail.describe in detail. Breast buds are commonly seen in neonates.Breast buds are commonly seen in neonates. The integrity of the clavicles should be noted in newbornsThe integrity of the clavicles should be noted in newborns Males sometimes develop unilateral or bilateral breast Males sometimes develop unilateral or bilateral breast

hypertrophy during puberty, called gynecomastia, with milk hypertrophy during puberty, called gynecomastia, with milk production may or may not be present.Approximately 40% of all production may or may not be present.Approximately 40% of all males between the ages of 10 and 16.males between the ages of 10 and 16.

Pectus Excavatum Pectus Excavatum

Pectus ExcavatumPectus Excavatum

Pigeon BreastPigeon Breast

GynecomastiaGynecomastia

GynecomastiaGynecomastia

Thorax and HeartThorax and Heart Female breast usually develop Female breast usually develop

asymmetrically.asymmetrically. Inspect the thorax for color, respiration, Inspect the thorax for color, respiration,

type of breathing.type of breathing. Auscultate breath sounds (rate, ease, Auscultate breath sounds (rate, ease,

depth, rhythm).depth, rhythm). Palpate thorax (tenderness, respiratory Palpate thorax (tenderness, respiratory

excursion, vocal or tactile fremitus, and excursion, vocal or tactile fremitus, and areas of abnormality)areas of abnormality)

Measure chest circumference at nipple Measure chest circumference at nipple line.line.

Auscultate the heart (murmurs, rubs, Auscultate the heart (murmurs, rubs, clicks, or gallops) should be noted.clicks, or gallops) should be noted.

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

Thorax and HeartThorax and Heart

A history of excessive perspiration and difficulties in A history of excessive perspiration and difficulties in feeding are two of the most common complaints of early feeding are two of the most common complaints of early congestive heart failure.congestive heart failure.

Important questions to ask the parent:Important questions to ask the parent: How has the infant been feeding?How has the infant been feeding? Does he or she get out of breath or appear exhausted?Does he or she get out of breath or appear exhausted? Has the child’s growth pattern changed recently?Has the child’s growth pattern changed recently? Does the child tire easily, with eating or with playing?Does the child tire easily, with eating or with playing? Does the child perspire excessively, especially with efforts such Does the child perspire excessively, especially with efforts such

as feeding?as feeding? Does the infant breathe rapidly, even at rest.Does the infant breathe rapidly, even at rest.

Upper ExtremityUpper Extremity Examination of the upper extremities should Examination of the upper extremities should

include inspection for normal anatomy and limb include inspection for normal anatomy and limb position, palpation for structural integrity, and position, palpation for structural integrity, and joint range of motion.joint range of motion.

The extremities should be examined for clubbing, The extremities should be examined for clubbing, cyanosis, and edema.cyanosis, and edema.

Acrocyanosis is a common finding in neonates, Acrocyanosis is a common finding in neonates, characterized by cyanotic discoloration, characterized by cyanotic discoloration, coldness, and sweating of the extremities, coldness, and sweating of the extremities, especially the hands.especially the hands.

Any deformities or extra digits should be noted. Any deformities or extra digits should be noted. Range of motion, swelling, erythema, and Range of motion, swelling, erythema, and

warmth should be noted of any joint. warmth should be noted of any joint. Check for signs of contusions, abrasions, and Check for signs of contusions, abrasions, and

edema which are common signs of trauma.edema which are common signs of trauma.

PolydactylyPolydactyly

PolydactylyPolydactyly

Upper ExtremityUpper Extremity

Check for muscle tone and strength of the upper Check for muscle tone and strength of the upper extremity.extremity.

Evaluate all range of motion of each joint.Evaluate all range of motion of each joint.

AbdomenAbdomen Inspection is the most important first step.Inspection is the most important first step. The order of examination has been changed slightly The order of examination has been changed slightly

in that palpation is done last.in that palpation is done last. It is a good idea, before performing abdominal It is a good idea, before performing abdominal

examination, to ask the child if they need to use the examination, to ask the child if they need to use the restroom.restroom.

For the examination of the infant or toddler the knees For the examination of the infant or toddler the knees may be bent in order to relax the abdomen and the may be bent in order to relax the abdomen and the child’s arms down at their sides. child’s arms down at their sides.

Inspect for rashes, scars, lesions, or discoloration. Inspect for rashes, scars, lesions, or discoloration. Observe overall contour and symmetry.Observe overall contour and symmetry. Inspect the umbilicus for shape, signs of inflammation Inspect the umbilicus for shape, signs of inflammation

or herniaor hernia

AbdomenAbdomen

Auscultation of the abdomen should be done before Auscultation of the abdomen should be done before palpation or percussion since the latter may alter the palpation or percussion since the latter may alter the frequency and quality of bowel sounds.frequency and quality of bowel sounds.

Listen to the 4 quadrants noting the frequency and Listen to the 4 quadrants noting the frequency and quality of the bowel sounds.quality of the bowel sounds.

Abnormal sounds:Abnormal sounds: gurglesgurgles clicksclicks growlsgrowls

Frequency of sounds is from 5 to 34 times per minute.Frequency of sounds is from 5 to 34 times per minute.

AbdomenAbdomen An increase in frequency or pitch of bowel sounds An increase in frequency or pitch of bowel sounds

may be associated with intestinal obstruction or may be associated with intestinal obstruction or diarrhea.diarrhea.

Decreased or absent sounds may be associated with Decreased or absent sounds may be associated with paralytic ileus or peritonitis.paralytic ileus or peritonitis.

To be certain that bowel sounds are absent listen for To be certain that bowel sounds are absent listen for 2 minutes in the area just inferior and to the right of 2 minutes in the area just inferior and to the right of the umbilicus.the umbilicus.

Percussion in the pediatric patient is the same as the Percussion in the pediatric patient is the same as the adult patient.adult patient.

Because children tend to swallow a lot of air when Because children tend to swallow a lot of air when eating or crying the stomach and intestines has a eating or crying the stomach and intestines has a great amount of air in them.great amount of air in them.

AbdomenAbdomen A distended abdomen may signify an obstruction, A distended abdomen may signify an obstruction,

infection, celiac disease, ascites, or an abdominal mass. infection, celiac disease, ascites, or an abdominal mass. Palpation will reveal masses (note size and location) Palpation will reveal masses (note size and location)

hepatosplenomegaly, and any sources of pain.hepatosplenomegaly, and any sources of pain. If the liver is felt below the costal margin (it commonly is If the liver is felt below the costal margin (it commonly is

1 cm below the margin) its span in the midclavicular line 1 cm below the margin) its span in the midclavicular line should be percussed.should be percussed.

Danforth’s sign is right shoulder pain with RUQ Danforth’s sign is right shoulder pain with RUQ palpation (represents an irritated diaphragm) is strongly palpation (represents an irritated diaphragm) is strongly suggestive of liver injury.suggestive of liver injury.

Kehr’s sign is left shoulder pain with LUQ palpation Kehr’s sign is left shoulder pain with LUQ palpation (represents an irritated diaphragm) is strongly (represents an irritated diaphragm) is strongly suggestive of splenic injury.suggestive of splenic injury.

AbdomenAbdomen

Rovsing’s sign is RLQ pain with LLQ palpation is Rovsing’s sign is RLQ pain with LLQ palpation is suggestive of appendicitis.suggestive of appendicitis.

McBurney’s point is 2/3 of the way from the umbilicus to McBurney’s point is 2/3 of the way from the umbilicus to the anterior superior iliac crest in the RLQ and the anterior superior iliac crest in the RLQ and tenderness there is also suggestive of acute tenderness there is also suggestive of acute appendicitis.appendicitis.

RectumRectum A chaperone may be necessary.A chaperone may be necessary. The anus should be inspected for position (an The anus should be inspected for position (an

imperforated anus is associated with a host of other imperforated anus is associated with a host of other anomalies; an abnormally places anus can also be anomalies; an abnormally places anus can also be associated with constipation or encopresis, depending associated with constipation or encopresis, depending on the position of the orifice with respect to the on the position of the orifice with respect to the sphincter).sphincter).

Any fissures, trauma, or parasites should be noted.Any fissures, trauma, or parasites should be noted. A rectal prolapse may be seen with many conditions A rectal prolapse may be seen with many conditions

including malnutrition, constipation, and cystic fibrosis.including malnutrition, constipation, and cystic fibrosis. The rectal exam is mandatory for any child complaining The rectal exam is mandatory for any child complaining

of abdominal pain, encopresis, constipation, of abdominal pain, encopresis, constipation, hematochezia, or melena.hematochezia, or melena.

RectumRectum

A lubricated small finger is used to palpate A lubricated small finger is used to palpate for any masses, tone of the sphincter, and for any masses, tone of the sphincter, and any focal pain, as may be seen with any focal pain, as may be seen with appendicitis.appendicitis.

The stool should be tested for occult The stool should be tested for occult blood.blood.

Rectal examination on infants and young Rectal examination on infants and young children should be performed in the supine children should be performed in the supine position.position.

GenitaliaGenitalia

Patient’s should always be examined is the presence of Patient’s should always be examined is the presence of a parent or a caretaker or in the case of a pre-teen or a parent or a caretaker or in the case of a pre-teen or teenager with a staff member present.teenager with a staff member present.

It is not common for Doctors of Chiropractic to do female It is not common for Doctors of Chiropractic to do female genitalia or pelvic exam.genitalia or pelvic exam.

It is common for the D.C. to give a hernia examination It is common for the D.C. to give a hernia examination and Tanner Staging for school or sports physicals.and Tanner Staging for school or sports physicals.

Tanner Staging is the measurement for sexual Tanner Staging is the measurement for sexual maturation.maturation.

Lower ExtremityLower Extremity Visually inspect the lower extremity for abrasions, Visually inspect the lower extremity for abrasions,

contusions, rashes, edema, cyanosis, clubbing, and contusions, rashes, edema, cyanosis, clubbing, and discoloration.discoloration.

Visually inspect for any abnormalities or deformities (any Visually inspect for any abnormalities or deformities (any extra digits should be noted).extra digits should be noted).

Measure the extremity as to circumfrencial Measure the extremity as to circumfrencial measurements, actual leg length (ASIS to Medial measurements, actual leg length (ASIS to Medial malleolus) and apparent leg length (Umbilicus to Medial malleolus) and apparent leg length (Umbilicus to Medial Malleoolus).Malleoolus).

A way to determine true leg length is to take a A way to determine true leg length is to take a Scanogram (this is a x-ray procedure where three views Scanogram (this is a x-ray procedure where three views are taken of the extremities the first is through the head are taken of the extremities the first is through the head of the femurs, the second is through the knees, and the of the femurs, the second is through the knees, and the third is through the ankles) using a Bell Thompson Ruler.third is through the ankles) using a Bell Thompson Ruler.

Lower ExtremityLower Extremity

Range of motion should be preformed and any joint Range of motion should be preformed and any joint swelling, erythemia, and warmth should be noted.swelling, erythemia, and warmth should be noted.

Hips are routinely examined in infants (see orthopedic Hips are routinely examined in infants (see orthopedic sect.)sect.)

Foot abnormalities are common in infancy but not in later Foot abnormalities are common in infancy but not in later life.life.

The peripheral pulses, especially the femoral pulses.The peripheral pulses, especially the femoral pulses.

Orthopedic TestingOrthopedic Testing

Infant orthopedic testing should include all rang of Infant orthopedic testing should include all rang of motion testing, static and motion palpation.motion testing, static and motion palpation.

Ortolani’s Test is a common test performed on the infant.Ortolani’s Test is a common test performed on the infant. It is a reduction test.It is a reduction test. With the baby relaxed in the supine position, the hips With the baby relaxed in the supine position, the hips

and knees are flexed to 90*, the examiner grasp the and knees are flexed to 90*, the examiner grasp the baby’s thigh with middle finger over the greater baby’s thigh with middle finger over the greater trochanter and lifts the thigh an simultaneously gently trochanter and lifts the thigh an simultaneously gently abducting the thigh, thus reducing the dislocation and abducting the thigh, thus reducing the dislocation and a “clunk” will be observeda “clunk” will be observed

Orthopedic TestingOrthopedic Testing

Barlow’s Test is a provocative test (dislocation) also Barlow’s Test is a provocative test (dislocation) also called Reverse Ortolani’s test.called Reverse Ortolani’s test.

Barlow’s Test is performed to discover any hip instability.Barlow’s Test is performed to discover any hip instability. The baby’s thigh is grasped with the middle finger along The baby’s thigh is grasped with the middle finger along

the baby’s thigh adducted and with a gentle downward the baby’s thigh adducted and with a gentle downward pressure. pressure.

Dislocation is palpable as the femoral head slips out of Dislocation is palpable as the femoral head slips out of the acetabulum.the acetabulum.

Orthopedic TestingOrthopedic Testing Allis’ or Galeazzi’s Sign is another orthopedic test used Allis’ or Galeazzi’s Sign is another orthopedic test used

to test for a dislocatable hip and is preformed by flexing to test for a dislocatable hip and is preformed by flexing the child’s knees and hips placing feet on the table the the child’s knees and hips placing feet on the table the lower one the femoral head lies posterior to the lower one the femoral head lies posterior to the acetabulum.acetabulum.

Another test for a dislocated hip, shortening of the thigh Another test for a dislocated hip, shortening of the thigh will bunch up the soft tissue and will accentuation of the will bunch up the soft tissue and will accentuation of the skin folds.skin folds.

Telescoping of the thigh is elicited because the femoral Telescoping of the thigh is elicited because the femoral head is not contained within the acetabulum.head is not contained within the acetabulum.

Trendelenburg’s Test with the child standing with weight Trendelenburg’s Test with the child standing with weight on the affected side the normal hip drops down, on the affected side the normal hip drops down, indicating weakness of the abductor muscles of the indicating weakness of the abductor muscles of the affected side.affected side.

Neurological TestingNeurological Testing Much of the neurologic exam comes from observation Much of the neurologic exam comes from observation

of the child.of the child. Any limitation in the use of the hands, legs, or pupillary Any limitation in the use of the hands, legs, or pupillary

light response.light response. Babinski Reflex the baby’s foot is stroked from heel Babinski Reflex the baby’s foot is stroked from heel

toward the toes. The big toe should lift up, while the toward the toes. The big toe should lift up, while the other toes fan out: absence of the reflex may suggest other toes fan out: absence of the reflex may suggest immaturity of the CNS, defective spinal cord, or other immaturity of the CNS, defective spinal cord, or other problems. This reflex may be seen up to age 12 to 24 problems. This reflex may be seen up to age 12 to 24 months. Then it will reverse with toes curling months. Then it will reverse with toes curling downward.downward.

Doll’s Eye while manually turning baby’s head, his eyes Doll’s Eye while manually turning baby’s head, his eyes will stay fixed, instead of moving with the head. While will stay fixed, instead of moving with the head. While normally vanishing around one month of age, if it normally vanishing around one month of age, if it reappears later, there may be damage to the CNS.reappears later, there may be damage to the CNS.