Pediatric Assessment: The Major Focus • • • • Major differences between children and adults Specific approaches and techniques to physical exam Normal findings, variations and common pathological conditions Interpretation of exam results

Major Concepts in Pediatric Physical Assessment • • • • Children are not little adults Understanding differences from adults is important Differences relate to both growth and development patterns Differences exist in motor skills and coordination, and in physiologic, psychosocial, behavioral, temperamental, language, and cognition areas

Skills Utilized in Working with Children • • • • Knowledge of growth and development Communication skills with children and their parents Understanding of family dynamics and parent-child relationships Knowledge of health promotion and anticipatory guidance

Major Concepts for Assessment and Health Promotion • • • • • • • • Development Medical history Nutritional status Growth and vital sign measurements Physical assessment Guidelines for well child supervision Anticipatory guidance Immunizations


Exam Settings • Outpatient (office, clinic emergency room) • Well child check • Illness visit Inpatient • Moderate to severe illness • Anxiety and stress School setting or health office • • • Children usually healthy Illness visits primarily common acute problems and some chronic illness issues Health screenings

• •

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


. Immobile • Older. They like a smiling human face. such as voice. heart. ears.e.Key Points to Assessment Procedure • • • • Head to foot exam is most orderly Vary sequence according to child’s response Examine young children in parent’s lap Do intrusive examinations last Approach to Physical Exam • • • • • • • • Consider age and developmental level. so provide comfort measures after unpleasant procedures. which continue with each age group. Increased mobility leads to additional safety measures and limit-setting concepts .e. parent’s lap. exam can be conducted on table. then head to toe. noise makers. mouth) Determine what exam you want to complete before possible crying (i. hands. nose. Sensory methods. Do quiet things first. or skin touch attract babies. arms) Examine sensitive. 3 . 6 to 12 months: Consider exam in parent’s lap due to separation or stranger anxiety (up to 4 years). observe for “readiness” clues Take time to get “acquainted” Use play techniques for infants and young children Determine best exam place ( table. painful or intrusive areas last (i. but be flexible to accommodate child’s behavior Examine least intrusive areas first (i. examiner’s lap) Use systematic approach. “Warm up” more slowly with play techniques. Mobile Young Child • Toddler • Pre Schooler School Age or Older Child Adolescent • Pre-Adolescent Birth to 28 days Gestational age <37 weeks Gestational age 37-42 weeks Gestational age > 42 weeks Birth to 1 year Birth to 6 months 6 to 12 months 1-5 years 1-3 years 3-6 years 6-12 years 13 to 18/21 years 10-12 years • • • • Approach to Infants Birth to 6 months : If baby is comfortable and stress free. Object permanence and ability to anticipate develops. toys to see or touch.e. abdomen) Age Groups • Neonate/Newborn • Pre-term • Term • Post-term Infant • Young.

attitude. non-frightening words and approaches. Explain in concrete terms. thought process. Play games. movement. time). exam and care plan. privacy. concentration. coordination. responsiveness/awareness. Use dolls. Address questions to patient. safe. breath. Magical thinking may cause fearfulness or thinking equipment is alive. pain. & lack of satisfaction. posture. Do least intrusive things first. Protect modesty. facial grimace. Offer to examine alone. (flexion/extension). Some will cooperate with exam on table. nutrition. LOC (person. Keep in mind. Save ears. cooperation. attention span. speech. protection of modesty are important. place. Use familiar. Guidelines for Adolescent Preventive Services can be useful An Additional Growth and Development Handout is Available to Download This is a 5-page summary. Offer simple acceptable choices.Approach to Pre-Schoolers Keep parent close. including one chart and additional summaries of pertinent growth and development theories General Assessment: Key Points • • • • Note general appearance State of wellness Degree of illness or distress Behavior General Assessment: • • Body: Symmetry. odor. Let them touch equipment. More common concerns among girls include body-image distortion.Approach to Toddlers Exam in parent’s lap. depression is more common in adolescents. without parent present. facial expression Development. respiration Behavior: • Distress: 4 . hygiene. due to need for parent security. Address questions more directly to child. affect. Answer questions honestly. Respect modesty. Elicit their active participation in history. animals or parents to “examine” first. Approach to Adolescents Confidentiality. Avoid “no” responses or choices they can not make. Let them play with equipment. social withdrawal & drop in school performance. throat for last. nose. Approach to School-Age Child Do a head to toe exam. Explain confidentiality parameters. build. loss of appetite & weight. Medical diagrams or teaching dolls are helpful. memory Posture. More common concerns among boys include irritability. especially girls. A health promotion system such as GAPS.

macule. pustule) Petichiae and purpura usually indicate serious conditions Pediculosis. allergy. upper side pale – change reverses it White papular epidermal cysts with sebaceous retention Obstruction of sweat ducts from head and humidity Miliaria – crystallina. pallor. hypopigmentation Viral. rubra. growth dis turbance). ecchymosis Degree of hydration or dehydration Periorbital (crying. erythema. and be replaced Skin Color Variations • • • • • • • • • • Jaundice: Acrocyanosis Cutis marmorata Erythema toxicum Harlequin color change Milia Miliaria (4 types) Neonatal acne. renal disease. pustulosa. bacterial. renal. signs of abuse Dermatoglyphic variations associated with syndromes Common Skin Variations in Newborns and Infants • • • • • • Thin. lobulated tumor 5 . insect bites Dry skin. allergies.Skin. physiologic after 24 hrs. juvenile hypothyroidism) Dependent (renal or cardiac disease) Hyperpigmentation (endocrine. vesicles on erythematous base @24-48 hrs. pink trunk Bluish mottling due to chilling or stress Papules. cool extremities. prickly head Pallor Plethora Pathologic in first 24 hrs. profunda Anemia or anoxia Erythematous flush. eczema. fungal (erythema. vesicule. papule. due to polycythemia Skin Vascular Markings • • • Capillary hemangiomas (telangiectasia or telangiectataic nevus or nevus simplex --. scabies. Hair and Nails: Skin – Key Points • • • • • • • • • • • Color: Texture & Turgor: Edema: Birth Marks Pigmentations: Infectious lesions: Capillary bleeding: Infestations: Pruritis: Trauma: Hand: Jaundice. hepatic. lesions Scars.“stork bites.usually fade Nevus flammeus (“port wine stains”). ecchymosis. warm. cyanosis. Cyanotic. Lower side of body red. nevus vasculosis ---not likely to fade Can be associated with Sturge-Weber Syndrome Strawberry hemangioma: bright red. especially premature Color Variations Vascular Markings Pigmentations Lanugo (downy hair) more prominent in premature Original hair may shed at 4-8 weeks.” “angel kisses”) --. transparent skin. contact dermatitis.

with tumors on peripheral or cranial nerves Yellow Skin Color • Jaundice: Observed in sclera. May remain jaundiced for 3 to 12 weeks Physiologic: Breast Feeding: Hair: Key Points • • • • • Assess for dis tribution. amount. face. dry. brittle or depigmented hair may indicate nutrition deficiency or thyroid disorder Alopecia may be related to tinea capitus. soles. color. skin. Does not blanche with pressure over chest or nose areas Is associated with liver disease. condition. fingernails. Peak at 3 to 5 days Onset at 5-7 days. with eating yellow vegetables Yellowing of exposed skin areas (not sclera or mucous membranes) May be associated with chronic renal disease • Carotenemia: • Renal Disease: Hemolytic Jaundice of Newborn: Biirubin above 5ml/dl • • • Pathologic: Occurs first 24 hrs of life. skin (not in sclera or mucous membranes) Blanches easily to pressure over chest or nose Occurs in older infants. soles. palms & oral mucosa . Declines at 4 to 7 days Early onset: Late onset: Onset at 2 to 4 days. hair pulling or persistent positioning White eggs (nits) attached to hair shafts indicate pediculosis Hair tufts on spine or buttocks may indicate spina bifida Nails: Key Points • • • • • Inspect for color. or Von Recklinghausen Disease) – an autosomal-dominant disorder. Café au Lait (<3cm and <6 in # are WNL – larger size or more spots associated with Neurofibromatosis . Peak at 10 to 15 days. quality and for infestations Course.• Cavernous hemangioma: bluish red. texture. hepatitis. Bilirubin increases faster than 5ml/dl/day Onset after 24 hrs. with peak from 72-90 hrs. more vascular than strawberry Skin Pigmentations • • • Mongolian spots in darker pigmented infants Pigmented nevi. shape. red cell hemolysis. nail biting and infection Clubbing may indicate chronic hypoxia (respiratory or cardiac dis ease) “Spoon” nails may indicate iron deficiency anemia Pitted nails may indicate psoriasis Splinter hemorrhages under nails may indicate trauma or endocarditis 6 . Observed in palms. biliary Obstruction & sever infection during infancy.

allergy. or associated with ICP & suture separation (i. lead encephalopathy. ICP increases are more like adult signs ( headache. after cranial sutures close. external and internal fundoscopic exam Hearing. 7 . vomiting. meningitis or tumors. • • Fontannels: Large HC/ICP: • • • • Small HC: Craniosynostosis: Craniotabes: Macewen’s sign: • • Chevostek’s sign: Flattened head areas: Especially occipital flattening with hair loss. signs of abuse. tense & bulging fontannels. loss. fatigue “Diagnostic facies” of common syndromes or illnesses Head: Variations • Neonates: Molding (suture overlap) resolve 2 days Capput succedaneum (scalp swelling) resolve 2 days Cephalohematoma (subperiosteal hemorrhage) resolve wks/months Tense and bulging with increased intracranial pressure (ICP) Depressed with dehydration Increased HC due to increased ICP (before suture closure). “sunset sign. thyroid. “Ping-pong” effect with pressure over temporo-parietal-occipital areas. external. Face.e.HEENT: Head & Neck: Eyes: Ears: Nose. tumor) Spasm of facial muscle with percussion over zygomatic bone in front of ear. May indicate hydrocephalus. May be associated with hypocalcemic tetany and tetanus. May be WNL in infants. teeth and pharynx Head: Key Points • • • • • • • • Head Circumference (HC): Fontannels/sutures: Symmetry & shape: Bruits: Hair: Sinuses: Facial expression: Abnormal facies: Frontal Occipital Circumference (FOC) Anterior closes at 10-18 months. In older child. hygiene.” Head may tranilluminate. rickets or infection “Cracked pot” sound with tapping over parietal bone. trauma. ear canal and otoscopic exam of tympanic membrane Exam of nose and sinuses Structures of mouth. Mouth & Throat • • • • • • Head: Neck: Eyes: Ears: Nose: Mouth: Symmetry of skull and face Structure. or result of hydrocephaly. vessels and lymph nodes Vision. movement. may indicate persistent placement of baby in same position. pediculosis in school aged child Palpate for tenderness in older children Saddness. dilated head veins. Surgical separation corrects defect. BP increases. change in LOC) May indicate microcephaly or craniosynostosis Asymmetric head shape due to premature closure of sutures. placement. posterior by 2 months Face & skull Temporal bruits may be significant after 5 yrs Patterns. May be WNL. intraventricular hemorrhage. trachea.

Cobblestone appearance may indicate allergy Jaundice (liver disease). lid lag.clear (not injected with conjunctivitis red eye) Brushfield’s spots (light speckling of iris) seen in Down s. • Othalmoscope: Partial or dark red reflex indicates pathology.. swelling Dacryocystitis (blocked tear duct) may cause rednnes. cataract) White retinal reflex indicates pathology (i.Eyes: Key Points • Vision: Red reflex & blink in neonate Visual following at 5-6 wks 180 degree tracking at 4 months E chart & strabismus check for preschool child Snellen charts for older children Irritations & infections PERRLA Amblyopia (lazy eye): Corneal light reflex. Retinal detachment chorioretinitis) Retinal hemorrhage is pathological.e. mo ist. retinoblastoma. blepharitis (stye). Coloboma (notch at outer edge or iris) may indicate visual field defect. Papilledema of increased ICP more likely in olde child. associated with a variety of causes: Is a specific diagnostic criteria in “shaken baby” syndrome. blue color (osteogenesis imperfecta) Smooth. with closed cranial sutures • Eyelids: • • • • Conjunctive: Sclera: Cornea: Pupil & Iris: 8 . pallor (anemia). binocular vision. various retinal anomalies or opacities of cornea. anterior chamber or lens (i.e. Character of eyebrows Ptosis. Down s. injection (conjunctivitis). cover-uncover test EOMs: tracking 6 fields of vision Fundoscopic exam of internal eye & retina • • • • • Eyes: Variations • Placement & symmetry: Wide set: hypertelorism – Down syndrome Close set: hypotelorism Epicanthal folds or upward slants – ethnicity. Hemorrhage. swelling and discharge “Allergic shinner” (dark circles) may indicate allergy Perorbital edema may indicate renal problems Sunken eyes may indicate dehydration Inflammation.

with landmarks not visible is associated with acute otitis media. with possible superior injection near short process of malleus is associated with blocked or obstructed eustachian tubes. retracted. • • Otitis externa: Otitis media: TM: TM: TM: Nose: Key Points • • • • • • Exam nose & mouth after ears (after crying from ear exam) Observe shape & structural deviations Nares: ( check patency. or low-set or obliquely-set ears may be Associated with many syndromes. gray. dull/thick/bulging. often associated with viral URIs. fluid or pus accumulating in the middle ear. Orange-amber color. discharge. the tympanic membrane (TM) becomes less mobile with pneumatic otoscopy. TM may be retracted.Ears: Key Points • • • • Exam last Restrain Hearing: Otoscope exam: In younger children Young children in lap. mucous membranes. Dull. inferior turbinates. Pain with movement of auricle or tragus. loss of light reflex. preschoolers Pull auricle up &back for school aged & adolescents Cerumen removal may be necessary Use pneumatic otoscopy Weber & Rinne tests to differentiate conductive vs sensorineural hearing loss are not effective with younger children • Tuning fork: Ears: Variations • External: Malformed auricle/pinna. bleeding) Septum: (check for deviation) Infants are obligate nose breathers Nasal flaring is associated with respiratory distress 9 . bulging. or pressure changes. Red. with landmarks easier to see. discharge in canal. with/without bubbles/fluid lines is associated with serous otitis media with effusion. Exam of TM: TM: Dull. or genitourinary & chromosomal abnormalities. occurs More often in summer (“swimmer’s ear”) Proper position & holding of otoscope facilitates comfortable As middle ear pressure or fluid increases. head braced against parent’s chest Especially if language delay or frequent otitis media Pull auricle down & back for infants. landmarks may be more difficult to see. gray or with some injection is associated with pressure. toddlers. such as diving or flying.

size & texture Count teeth & inspect for caries. tongue & palate for moisture. sores. Asymmetry of nasolabial folds may indicate facial nerve impairment or Bell’s palsy. Erythematous. with purulent yellow or green nasal discharge Foul odor or unilateral discharge Irritating discharge. gingivae. color. watery discharge. malocclusion and loose 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 for quality of voice Observe infants for rooting and sucking reflexes. edematous mucous membranes. moisture. symmetry. bleeding. 20 deciduous teeth. frequent wiping or nose picking Infection: Foreign body: Excoriation: Structure variations: Observe flattened nose or nasolabial folds that may indicate congenital anomolies. Sinuses: Key Points • • Palpate maxillary & frontal sinus areas for tenderness of sinusitis in older children Development of facial sinuses and location of sinus pain is listed below: Sinus • • • • Pain Location cheek & upper teeth medial & deep to eye forehead & above eyebrow deep behnd eye in occiput Age of Development present @ birth present @ birth approximately 7 years adolescence Maxillary Ethmoid Frontal Sphenoid Mouth & Pharynx: Key Points • . lesions. Epstein pearls & thrush Observe breath for halitosis • • • • 10 . mouth breathing & “allergic salute” line across nose. Inspect tongue & frenulum for movement. intactness. fissures Inspect buccal mucosa. swelling. • • • Inspect lips for color. begin eruption at 6 months & continue adding approximately 1/month 32 permanent teeth. boggy mucous membranes & interior turbinates.Nose: Variations • • • • • Allergy: Pale.

self-induced vomiting. Bohn’s nodules occur along gum line. due to viral infections. deviation of uvula to one side suggests either Glossopharyngeal or vagus nerve involvement or infection of peritonsillar or retropharyngeal abcess. red rimmed eruptions on buccal mucosa next to first & second molars. viral infection. An absent or bifid (notched) uvula may indicate submucosal or soft palate cleft. Callous marks on fingers/knuckles might also be observed 11 . appear and disappear before the onset of Measles (rubeola) rash. buccal mucosa & tongue. mild trauma or local irritants. especially following antibiotic therapy.. Green & black staining may indicate oral iron intake contacting teeth An increase in tooth decay or evidence or eroded enamel may indicate frequent. and is common in infants. especially in adolescent girls. resembling teeth. related to mild trauma. • Palate & uvula: With gag reflex. such as herpes simplex cold sores or aphthous stomatitis. Pallor may indicate anemia. • White patches: • . Fissure/cracked lips: May be due to harsh climate or vitamin deficiencies. A short frenulum with inability to touch tongue to upper gum ridge (“tongue tie” or ankyloglossia) may lead to later speech problems. Tongue variations: A smooth. small white. red tongue may be related to vitamin deficiencies “Strawberry” and “Raspberry” tongue are seem in scarlet fever. and milk pools around the teeth.Mouth & Pharynx: Variations • Newborn cysts: White retention epitheleal cysts occur in the newborn: Epstein’s pearls occur along midline of palate. “Baby bottle” caries appear on teeth at gum line and are due to babies taking a bottle to bed. Koplik’s spots. may be oral candidiasis (thrush). White curdy patches that cannot be scraped away. Brown-white mottling may indicte excessive fluoride intake. Color variations: Central cyanosis can be observed in lips & mucosa. White ulcerated sores on mucosa ae cankers. • • • Vesicular eruptions: Can occur on lips. • Tooth markings: Brown & black spots may indicate caries. Cherry red coloration may be seen in acidosis.

gray exudate may indicate diptheric tonsititis A gray. cysts or fistulas/clefts Suppleness & Range of Motion (ROM) Check clavicle in newborn Head control in infant Trachea & thyroid in midline Carotid arteries (bruits) Torticollis Webbing Meningeal irritation Neck: Variations • • • • • Head lag: Torticollis: Significant lag after 6 months may indicate cerebral palsy “Stiff neck” with resistance to lateral head turn as result of injury to sternocleidomastoid muscle. neck flexion produces pain and flexion of hips and knees). 12 . cretinism or tetany. Crepitus at fracture site. such as head injury or meningitis. more often seen in newborn Check for fracture in newborn. tripod position with sitting. break in contour. Positive Kernig’s sign (with patient supine. high-pitched cry may indicate increased ICP. Shrill. hip & knee flexed. and below angle of jaw. Should not be deep cervical or clavicular. Positive Brudzinski’s sign (with patient supine. especially if palatal petichiae & red uvula are present. enlarged tonsil suggests peritonsillar abcess. • Voice quality: Nasal voice may indicate enlarged adenoids Hoarse cry may indicate croup. usually bilateral. opisthotonos. Neck: Key Points • • • • • • • • • Check for position. necrotic discoloration of tonsillar tissue may suggest infeftious mononucleosis .• Pharynx: Large tonsils. associated with shortening. A unilateral. upper neck areas. red. extension of knee Produces pain & resistance Nodes: Lymphadenopathy common with infection in older children. and decreased motion of arm Feature of “Turner’s syndrome” or other congenital abnormalities Clavicle: Webbing: • Meningeal: Irritation indicated by nuchal rigidiy. due to developmental lymph tissue hypertrophy Are common in school aged children & adolescents Large red tonsils covered with white exudate are suggestive of streptococcal tonsillitis. masses. Thick. lymph nodes.

sublingual) Inguinal lymphadenopathy may be observed in some diapered children. Nodes are proportionately large in older children & adolescents. with redness & swelling of Stensen’s parotid duct in mouth & pain with sour tastes. pre & post auricular. elasticity. • Pectus carinatum or pigeon breast: concavity of sternum • Pectus excavatum or funnel chest protrusive sternum • Harrison. infraclavicular. color. submental. usually unilateral. submandibular. superficial anterior cervical. nipples/accessory nipples.• Mumps: Parotitis produces swelling over angle of jaw.s Groove: horizontal ression groove of lower ribs with lower rib flarring. dimpling Palpation: masses. Ascends with swallowing (not normally palpable in young child). but not usually otherwise. no separation of contours Areola projected as secondary mound Mature. temperature. with transverse diameter increasing. elevation of breast & papilla as small mount. Deep cervical. nipple discharge Male gynecomastia Self Exam Tanner Stages for Female: I II III IV V Prepubertal. Thorax & Lungs: Key Points • • Structure: Observe for shape. elevation of papilla only Breast bud. color. enlargement of areola Further enlargement of breast & areola. posterior cervical. location. symmeetry. and smaller in the elderly. submaxillary. nodules or goiter (& accelerated growth. consistency. but significance varies with severity etiology • AP diameter: round chest or 1:1 ratior during infancy. may indicate vitamin D deficiency (richets) • Beading or richitic rosary: protrusive deformities along costochondral junctions. symmetry & posture Chest deformities: can be WNL. staring eyes) • Thyroid Lymph Nodes: Key Points • • • • • Inspect & palpate lymph nodes for size. Check bruits. axillary & epitrochlear lymphadenopathy may indicate pathology. Lymphadenopathy in the head & upper neck area are common with various infections: (Occiptal. tonsillar. color. firmness & mobility. tenderness. with AP:lateral ration 1:2 during school age years. projection of papilla only 13 . may indicate vitamin D defenciency (richets) Breast: Key Points • • • • Inspection: size. supraclavicular. recession of areolar mound to breast contour. consistency.

rhythm: compare cardiac rhythm with pulse • Peripheral vascular: color. females thoracic-costal. pneumothorax or FB Dullness to percussion: fluid or mass Quality: vesicular (bronchioles. infants abdominal Dyspnea Orthopnea Fremitus: Increase: pneumonia. cyanosis (lips. pedal • Rate. decreased expansion (pneumonia. FB) Prolonged expiratory phase Resp rate (>40 at rest. alveoli) bronchovesicular (bronchi) bronchial (trachea) Adventitious (adventiginous) sounds • Crackles (rales) • Rhonchi (course breath sounds) • Wheeze • Pleural friction rub Cardiovascular: Key Points • Vital signs: compare with normal/age values • Peripheral pulses: apical. femoral. radial/brachial. atelectasis. carotid. after neonate period = respiratory distress) Color: cyanosis or mottling Clubbing Nasal flaring Grunting (expiratory) Stridor (inspiratory): croup Snoring (expiratory): upper airway obstruction. enlarged lymph tissue Retractions Respiratory movement: males abdominal.Lungs & Respiratory Status: Key Points • • • • • • • • • • • • • • • • • Symmetry of expansion. nail beds. mass Decrease: asthma. elderly shallow. allergy. temperature. pneumothorax. ear lobes) • Clubbing • Pulsating neck vessels (JVD) Bulging chest Elevated BP Thrills Bruits • • • • 14 . edema. skin texture/changes • Capillary refill: immediate • Peripheral pulses: femoral pulses absent or diminished in aortic stenosis • Deep vein thrombosis: Homan's sign • Skin: pallor.

low pitched. harsh. thrill loud with stethoscope not touching chest. rhythm. S2 S1: S2: S2: S3: S4: Mitral & Tricuspid AV valves close (ventricles are full. S1 low pitch. best heard in pulmonic area. PMI Auscultation: sitting. high pitched) GRADE: I II III IV V VI faint. in supine position 15 . midway between apex & LLSB. soft or musical Intensity range from I-III/VI Systolic (never diastolic) Do not radiate COMMON FUNCTIONAL MURMURS: Cardiac murmurs occurring in absence of significant heart disease or structural abnormality • • Still’s Murmur: 2 years – adolescence. best at apex Aortic & Pulmonary semilunar valves close -. blowing. Grade I-II/VI. louder in supine position.Heart • • • • • Rate. thrill Functional Murmurs: Change or disappear with position change (usually loudest supine) Low grade. thrill loud with stethoscope barely to chest. no thrill loud with stethoscope. lying. diastolic or continuous (timing.ventricles eject-after ventricular contraction--diastole begins. quality (course. may be Louder with fever or tachycardia Basal systolic ejection murmur: high pitched. may not be heard sitting readily heard with stethoscope loud. blowing. ventricular contraction during systole location & size of heart: midclavicular 5th intercostal space (4th/infant) Stethoscope Diaphragm: Bell: high pitch. systolic. location. soft. atrial filling begins may be split--widens during inspiration (increase venous return-increase filling time--delayed pulmonic closing) can be functional sound in childhood not normally audible. associated with cardiac abnormalities Murmurs:may be systolic. prior to ventricular contraction--systole begins. left recumbent & bending forward PMI: Lt. heart sounds Size. mid-systolic.

loudest in sitting position & decreases in supine position or with turning child’s head or occluding jugular vessels Organic Murmurs & sounds: • Diastolic murmurs: always organic • Systolic murmurs: may be functional or organic • Friction rubs • Before 3 yrs. labia minora/majora. continuous musical hum Grade I-III/VI. discharge (foul-smelling) 16 . position. mobility Liver Spleen Kidneys Bladder Genitourinary and Reproductive: Key Points Breast: as previous Female Genitalia • • • • External genitalia: Pelvic 16-18 years or when sexually active Mons pubic. skin integrity. usually congenital • After 3 yrs often acquired • Rheumatic fever • Kawasaki disease Abdomen: Key Points • • • • • • • • • • • • • • Contour Peristalsis Skin: color. prepuce (clitoral hood). femoral Masses . lesions. inguinal. Skene's & Bartholin's ducts. or pulmonary outflow murmur: disappears during infancy as pulmonary arteries enlarage.• • Physiologic peripheral pulmonic stenosis. anus Size. labial adhesions/fusion. swelling. veins Umbilicus Tenderness Ridigity Tympany Dullness Hernias: umbilical. UR&LSB & lower neck.size. heard best in axillae Venous hum: usually after 3 yrs. heard best in infra & supraclavicular areas. masses Redness. short systolic. vagina. grade I-II/VI. clitoris. color. shape. dullness.

arms. skin integrity. symmetry. No spread to thighs V Adult distsribution & quantity with spread to thighs Male Genitalia • Penis: Size. slightly curled. along labia III Increas in hair. further growth scrotum/ testes IV Adult type hair. darker. slightly curled. shoulder. hip. contractures Neck. scrotum. epispadias • Scrotum: Color. masses. foot Digits Dermatoglyphics Problem Areas • • Spinal changes: scoliosis. penis childhood size II Sparse. downy hair (base of penis/along labia Enlargement of testes & scrotum. strength. ulceration. downy hair. enlargement of glans. scrotal skin reddens & coursens III Hair courser. wrist. No true pubic hair II Sparse growth of slightly pigmented. hips Congenital hip dislocation or dysplasia: check hip abduction & symmetry • • • • • • • • asymmetrical hip abduction asymmetrical thigh & gluteal folds Ortolani's click Barlow's test Trendelenburg gait Allis' sign Trendelenburg sign & gait: indicates hip disease in ambulatory child • Asymmetries or weaknesses 17 . curled. size. elbow. lesions. scrotal skin darkens V Adult hair distribution (triangle) & adult genital development Musculoskeletal: Key Points • • • • Alignment. curled. no spread to medial thighs. kyphosis.Tanner Stages I Prepubertal. joint mobility: ROM. tenderness. darker IV Adult-type hair. placement. color. lordosis Scoliosis: pre-adolescent growth lateral curvature contralateral hip hump prominent scapula asymmetry: shoulder. stiffness. • testes descended bilaterally • Pubic hair Tanner Stages I Prepuberal. but limited area. courser. discharge meatal stenosis. no true pubic hair. circumcision • Urethral meatus: Shape. knee. weakness & symmetry Limb. testes. hypospadias. Enlargement of penis (width/length). Enlargement of penis (length). discharge. ankle. contour. edema.

heels school age Stand on one foot 3-6 yrs • Motor Function: Gross motor & fine motor movements • • • Muscle size. tone. posture Developmental maturation 18 . posture.• 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. movement Involuntary movements. emotional status. behavior.knees 2 inches apart) Knock-knee (genu valgum -. symmetry. attention span • Cerebellar Function • • • • • • • • Balance. 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 Neurological Evaluation: Key Points • Cerebral Function: • "Mental status" appearance. cooperation • LOC. supine) school age Tandum walk 4-6 yrs Walk on toes. language.ankles 3 inches apart) Movement limitation: crepitus with joint movement meningeal signs. ataxia. tibia or upper let & hip area Feet turning in: varus Feet turning out: valgus Legs: Bowleg (genu varum -. social response. 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. gait & leg coordination. strength.

when stimulated by position change or sudden noise. S2 Superficial: Cremasteric T12. absence indicates blindness Root Turns direction cheek is stroked. C8 Brachioradialis C5. hearing. 6 EOM. smile. T11 Infant Automatisms: Primitive Reflexes • Cranial Nerves C1 Smell C2 Visual acuity. Corneal reflex---is C5 & C7 C7 Raise eyebrows. persistent extrusion may indicate Down’s Moro & Startle Arms & legs extend symmetrically & arms return to midline. fundus C3. visual fields. puff cheeks. 4. smell Present only one sensory stimulation at a time. C6 Patellar L2. Taste. L4 Achilles S1. L1. C7. may persist longer. disappears 3-4 months. T9. weak or absent reflex indicates developmental/neurological disorder Extrusion Tongue extends out when t ouched. may persist during infancy. L2 Abdominal T7. posterior 1/3 tongue C11 Shoulder shrug & head turn with resistance C12 Tongue movement • Infant Reflexes: Most disappear between 4-6 months of age • • • • • Blink (dazzle) st Blinks to bright light. close eyes tight.• Sensory function • • • • • • Tested in cranial nerves Sharp-dull 2 point discrimination Stereognosis Graphesthesia Infants: responsive to touch. absence or asymmetry of responses indicate injury. disappears by 4-6 months. neurological disorder or hearing loss 19 . disappears at 4 months. show teeth. Taste--anterior 2/3 tongue C8 Hearing & equilibrium C9 "ah" equal movement of soft palate & uvula C10 Gag. if testing • Reflexes Deep tendon: Biceps C5. frown. absence indicates neruologic disorder Suck Sucks in response to stimuli. 6 fields of gaze C5 Sensory to face: Motor--clench teeth. T10. vision. C6 Triceps C6. 1 year of life. L3. T8.

persistence indicates neurologic disorder Tonic neck Fencing position: head turn-arm extend. asymmetries indicate neurological disorder Babinski + for toe fanning. persistence indicates neurological problem Neck righting When supine. disappears 3-4 months. absence may indicate spinal cord lesions Dance or step Feet withdraw or step up. present until child walks well.• • • • • • • Galant's (trunk incurvation) Back moves toward paraspinal side stimulated. appears strongest at 2 months & disappears by 6 months. when foot touched to surface. leg extend to same side & all reverse w ith change to opposite side. present for 4-8 weeks. persistence indicates neurological problem Palmar grasp Finger’s curve around object placed in palm or palmar aspect of fingers. trunk pelvis turn to direction head is turned. or at 2 years of age 20 . present 4-8 weeks. absence or persistence beyond 6 months indicates neurological disorder Crawling Symmetrical crawling movements when prone. shoulders.

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