Professional Documents
Culture Documents
CLASS 8
• Development
• Medical history
• Nutritional status
• Growth and vital sign measurements
• Physical assessment
• Guidelines for well child supervision
• Anticipatory guidance
• Immunizations
Exam Settings
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• Illness visit
• Inpatient
• Moderate to severe illness
• Anxiety and stress
• School setting or health office
Environmental Setting
• Safety is primary
• Pleasant, comfortable settings are helpful
• Accessible toys for young children are distracters and may reduce anxiety
• Age appropriate literature or items for teens and older children provide diversion in waiting areas
Standard Measurements
• Weight
• Height
• Head Circumference
• Chest Circumference
• Vital Signs
• Temperature
• Pulse, Heart Rate
• Respiration
• Blood Pressure
• Gestational Age Assessment and Intrauterine Growth Charts
Sensory Issues
• Smell: usually not tested; observe for unusual odors from child
• Taste: usually not tested; infants often prefer sweet tasting foods
• Touch: well developed in infant; if stimulated can invalidate other sensory tests
• Vision: right eye (OD), left eye (OS), both eyes (OU)
• Hearing: correlates with language development; localization requires both ears
Specific Evaluations
• Development
• Vision
• Hearing
• Language
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Approach to Physical Exam
Age Groups
Approach to Infants
Birth to 6 months: If baby is comfortable and stress free, exam can be conducted on table. Sensory
methods, such as voice, noise makers, toys to see or touch, or skin touch attract babies. They like a
smiling human face. Do quiet things first, then head to toe.
6 to 12 months: Consider exam in parent’s lap due to separation or stranger anxiety (up to 4 years).
“Warm up” more slowly with play techniques. Object permanence and ability to anticipate develops,
so provide comfort measures after unpleasant procedures. Increased mobility leads to additional safety
measures and limit-setting concepts, which continue with each age group.
Approach to Toddlers
Exam in parent’s lap, due to need for parent security. Play games. Do least intrusive things first.
Save ears, nose, throat for last. Avoid “no” responses or choices they can not make. Offer simple
acceptable choices. Let them touch equipment.Approach to Pre-Schoolers
Keep parent close. Some will cooperate with exam on table. Protect modesty. Use dolls, animals
or parents to “examine” first. Magical thinking may cause fearfulness or thinking equipment is
alive. Let them play with equipment. Use familiar, safe, non-frightening words and approaches.
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Approach to School-Age Child
Do a head to toe exam. Respect modesty. Address questions more directly to child. Explain in
concrete terms. Medical diagrams or teaching dolls are helpful. Elicit their active participation in
history, exam and care plan. Answer questions honestly.
Approach to Adolescents
This is a 5-page summary, including one chart and additional summaries of pertinent growth and
development theories
General Assessment:
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• Hand: Dermatoglyphic variations associated with syndromes
• Harlequin color change Lower side of body red, upper side pale – change reverses it
• Milia White papular epidermal cysts with sebaceous retention
• Miliaria (4 types) Obstruction of sweat ducts from head and humidity
• Neonatal acne, prickly head Miliaria – crystallina, rubra, pustulosa, profunda
• Nevus flammeus (“port wine stains”), nevus vasculosis ---not likely to fade
Can be associated with Sturge-Weber Syndrome
• Jaundice: Observed in sclera, skin, fingernails, soles, palms & oral mucosa .
Does not blanche with pressure over chest or nose areas
Is associated with liver disease, hepatitis, red cell hemolysis, biliary
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Obstruction & sever infection during infancy.
• Renal Disease: Yellowing of exposed skin areas (not sclera or mucous membranes)
May be associated with chronic renal disease
• Assess for distribution, color, texture, amount, quality and for infestations
• Course, dry, brittle or depigmented hair may indicate nutrition deficiency or thyroid disorder
• Alopecia may be related to tinea capitus, hair pulling or persistent positioning
• White eggs (nits) attached to hair shafts indicate pediculosis
• Hair tufts on spine or buttocks may indicate spina bifida
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Head: Variations
• Macewen’s sign: “Cracked pot” sound with tapping over parietal bone.
May be WNL in infants, or associated with ICP & suture separation
(i.e. lead encephalopathy, tumor)
• Chevostek’s sign: Spasm of facial muscle with percussion over zygomatic bone in front
of
ear. May be associated with hypocalcemic tetany and tetanus.
• Flattened head areas: Especially occipital flattening with hair loss, may indicate persistent
placement of baby in same position.
Eyes: Key Points
Eyes: Variations
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Dacryocystitis (blocked tear duct) may cause rednnes,
swelling and discharge
“Allergic shinner” (dark circles) may indicate allergy
Perorbital edema may indicate renal problems
Sunken eyes may indicate dehydration
• Pupil & Iris: Brushfield’s spots (light speckling of iris) seen in Down s.
• Otoscope exam: Pull auricle down & back for infants, toddlers, preschoolers
Pull auricle up &back for school aged & adolescents
Cerumen removal may be necessary
Use pneumatic otoscopy
Ears: Variations
• Otitis externa: Pain with movement of auricle or tragus, discharge in canal, occurs
More often in summer (“swimmer’s ear”)
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• Otitis media: Proper position & holding of otoscope facilitates comfortable
As middle ear pressure or fluid increases, the tympanic membrane
(TM) becomes less mobile with pneumatic otoscopy.
Exam of TM:
• Exam nose & mouth after ears (after crying from ear exam)
• Observe shape & structural deviations
• Nares: ( check patency, mucous membranes, discharge, inferior turbinates, bleeding)
• Septum: (check for deviation)
• Infants are obligate nose breathers
• Nasal flaring is associated with respiratory distress
Nose: Variations
• Structure variations: Observe flattened nose or nasolabial folds that may indicate
congenital anomolies.
• Palpate maxillary & frontal sinus areas for tenderness of sinusitis in older children
• Development of facial sinuses and location of sinus pain is listed below:
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• Sphenoid deep behnd eye in occiput adolescence
• Count teeth & inspect for caries, malocclusion and loose teeth.
20 deciduous teeth, begin eruption at 6 months & continue adding approximately 1/month
32 permanent teeth, erupt from 6 to 25 years, with molar eruption from 1to 25 years
• Inspect uvula for symmetrical movement or bifid uvula (indicating cleft palate or WNL
• Observe infants for rooting and sucking reflexes, Epstein pearls & thrush
• Vesicular eruptions: Can occur on lips, buccal mucosa & tongue, due to viral infections,
such as herpes simplex cold sores or aphthous stomatitis.
• White patches: White ulcerated sores on mucosa ae cankers, related to mild trauma,
viral infection, mild trauma or local irritants.
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• Palate & uvula: With gag reflex, deviation of uvula to one side suggests either
Glossopharyngeal or vagus nerve involvement or infection of
peritonsillar or retropharyngeal abcess.
Green & black staining may indicate oral iron intake contacting teeth
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Neck: Variations
• Head lag: Significant lag after 6 months may indicate cerebral palsy
• Torticollis: “Stiff neck” with resistance to lateral head turn as result of injury to
sternocleidomastoid muscle, more often seen in newborn
• Clavicle: Check for fracture in newborn, associated with shortening, break in contour,
Crepitus at fracture site, and decreased motion of arm
• Meningeal: Irritation indicated by nuchal rigidiy, opisthotonos, tripod position with sitting,
Positive Brudzinski’s sign (with patient supine, neck flexion produces pain and
flexion of hips and knees).
Positive Kernig’s sign (with patient supine, hip & knee flexed, extension of knee
Produces pain & resistance
• Nodes: Lymphadenopathy common with infection in older children, upper neck areas,
and below angle of jaw, usually bilateral. Should not be deep cervical or
clavicular.
• Mumps: Parotitis produces swelling over angle of jaw, usually unilateral,
with redness & swelling of Stensen’s parotid duct in mouth & pain with
sour tastes.
• Inspect & palpate lymph nodes for size, color, location, temperature, consistency, tenderness,
firmness & mobility.
• Nodes are proportionately large in older children & adolescents, and smaller in the elderly.
• Lymphadenopathy in the head & upper neck area are common with various infections:
(Occiptal, pre & post auricular, superficial anterior cervical, posterior cervical, tonsillar,
submandibular, submaxillary, submental, sublingual)
• Inguinal lymphadenopathy may be observed in some diapered children, but not usually
otherwise.
• Deep cervical, supraclavicular, infraclavicular, axillary & epitrochlear lymphadenopathy may
indicate pathology.
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• Inspection: size, color, symmeetry, color, nipples/accessory nipples, dimpling
• Palpation: masses, consistency, elasticity, nipple discharge
• Male gynecomastia
• Self Exam
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• Peripheral pulses: femoral pulses absent or diminished in aortic stenosis
• Deep vein thrombosis: Homan's sign
• Skin: pallor, cyanosis (lips, nail beds, ear lobes)
• Clubbing
• Pulsating neck vessels (JVD)
• Bulging chest
• Elevated BP
• Thrills
• Bruits
Heart
Stethoscope
Diaphragm: high pitch, S1
Bell: low pitch, S2
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Functional Murmurs:
Change or disappear with position change (usually loudest supine)
Low grade, soft or musical
Intensity range from I-III/VI
Systolic (never diastolic)
Do not radiate
• Contour
• Peristalsis
• Skin: color, veins
• Umbilicus
• Tenderness
• Ridigity
• Tympany
• Dullness
• Hernias: umbilical, inguinal, femoral
• Masses - size, shape, dullness, position, mobility
• Liver
• Spleen
• Kidneys
• Bladder
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Genitourinary and Reproductive: Key Points
Breast: as previous
Female Genitalia
Tanner Stages
I Prepubertal. No true pubic hair
II Sparse growth of slightly pigmented, downy hair, slightly curled, along
labia
III Increas in hair, courser, curled, darker
IV Adult-type hair, but limited area. No spread to thighs
V Adult distsribution & quantity with spread to thighs
Male Genitalia
• Penis: Size, color, skin integrity, circumcision
• Urethral meatus: Shape, placement, discharge, ulceration, discharge
meatal stenosis, hypospadias, epispadias
• Scrotum: Color, size, symmetry, edema, masses, lesions, tenderness,
• testes descended bilaterally
• Pubic hair
Tanner Stages
I Prepuberal, no true pubic hair, testes, scrotum, penis childhood size
II Sparse, slightly curled, downy hair (base of penis/along labia
Enlargement of testes & scrotum, scrotal skin reddens & coursens
III Hair courser, curled, darker. Enlargement of penis (length),
further growth scrotum/ testes
IV Adult type hair, no spread to medial thighs. Enlargement of penis
(width/length), enlargement of glans, scrotal skin darkens
V Adult hair distribution (triangle) & adult genital development
Problem Areas
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• Spinal changes: scoliosis, kyphosis, lordosis
• Scoliosis: pre-adolescent growth
Lateral curvature
contralateral hip hump
Prominent scapula
Asymmetry: shoulder, arms, hips
• Congenital hip dislocation or dysplasia: check hip abduction & symmetry
• Asymmetries or weaknesses
• Limp
• Legg-Calve` Perthes:
peak age 7 years: boys > girls
Hip or knee pain
May have history of trauma
+ Trendelenburg
• Slipped Capital Femoral Epiphysis
Adolescents: boys > girls
Obese
Hip or knee pain
• Joint infection
• Feet/legs: Variations may begin in feet, tibia or upper let & hip area
Feet turning in: varus
Feet turning out: valgus
• Legs:
Bowleg (genu varum -- knees 2 inches apart)
Knock-knee (genu valgum -- ankles 3 inches apart)
• Movement limitation:
crepitus with joint movement
meningeal signs, such as stiff neck, opisthotonous
• Muscular dystrophy
Progressive muscular weakness (Gower’s sign)
• Cerebral palsy or other muscular disease
Pes equinus (weight bearing on toes)
Short heel cords
• Cerebral Function:
• "Mental status" appearance, behavior, cooperation
• LOC, language, emotional status, social response, attention span
• Cerebellar Function
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• Balance, gait & leg coordination, ataxia, posture, tremors
• Finger to nose (fingers to thumb) 3-4 yrs
• Finger to examiner's finger 4-6 yrs
• Ability to stand with eyes closed (Romberg) 3-4 yrs
• Rapid alternations of hands (prone, supine) school age
• Tandum walk 4-6 yrs
• Walk on toes, heels school age
• Stand on one foot 3-6 yrs
• Sensory function
• Reflexes
• Cranial Nerves
C1 Smell
C2 Visual acuity, visual fields, fundus
C3, 4, 6 EOM, 6 fields of gaze
C5 Sensory to face: Motor--clench teeth,
Corneal reflex---is C5 & C7
C7 Raise eyebrows, frown, close eyes
tight, show teeth, smile, puff cheeks,
Taste--anterior 2/3 tongue
C8 Hearing & equilibrium
C9 "ah" equal movement of soft palate & uvula
C10 Gag, Taste, posterior 1/3 tongue
C11 Shoulder shrug & head turn with resistance
C12 Tongue movement
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• Blink (dazzle)
Blinks to bright light, 1st year of life, absence indicates blindness
• Root
Turns direction cheek is stroked, disappears 3-4 months, may persist longer,
absence indicates neruologic disorder
• Suck
Sucks in response to stimuli, may persist during infancy, weak or absent
reflex indicates developmental/neurological disorder
• Extrusion
Tongue extends out when t ouched, disappears at 4 months, persistent
extrusion may indicate Down’s
• Moro & Startle
Arms & legs extend symmetrically & arms return to midline, when
stimulated by position change or sudden noise, disappears by 4-6 months,
absence or asymmetry of responses indicate injury, neurological disorder or
hearing loss
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