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PHYSICAL ASSESSMENT I. INTEGUMENTARY Inspect -skin integrity for color variations, lesions, etc.

-scalp -hair (color, quantity, distribution) -nails -note smell/odors -edema (if appropriate)

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III. NECK Inspect -Neck structure and symmetry -Skin color and integrity -Appearance of lesions, masses, swelling -Tested range of motion (rom) flexion, extension, hyperextension, lateral flexion, rotation -Carotid pulse -Jugular venous pattern and pulsations -position of trachea -thyroid gland (visible enlargement or mass) Palpate -neck (sternocleidomastoid &trapezius muscles) -trachea (alignment & deviation) -thyroid gland for size, irregularity, masses - lymph nodes (pre-auricular, posterior auricular, submental, submaxillary, submandibular, tonsilar, superficial cervical nodes, anterior deep cervical chain, supraclavicular, occipital, posterior cervical) CN Testing -XI (spinal accessory) IV. EYES Inspect -position and alignment -eyelashes, bony orbits and brows -lacrimal apparatus -lids -sclera -conjunctiva (bulbar/ palpebral) -iris -cornea and lens - pupil Palpate -bony orbit -eyelids / eyeballs -lacrimal apparatus

Special Tests
-visual acuityRosenbaum, Snellens, Jaeger, E chart (CN II) - visual fields ( confrontation test) -cover and position test -extraocular movements--- H -convergence test (test for accommodation) -corneal light reflex blink / corneal reflex (CN V) -direct and consensual light reflex

Palpate -temperature -texture and moisture -mobility and turgor -edema (if appropriate) II. HEAD AND FACE Inspect -head/skull size, shape, configuration -face for symmetry, facial features, expressions & condition -consistency, distribution & color of hair Palpate -head for size, shape & configuration -temporal arteries for elasticity and tenderness -temporomandibular joints (TMJ) when client opens & closes mouth Auscultate -bilateral temporal artery CN Testing -V (Trigeminal- sharp and dull sensation) -VII (Facial expressions- smile, frown, show teeth, blow out cheeks, raise eyebrows, tightly close eyes)

Visual Function Test -light perception -hand movements -counting fingers CN Testing -VII (Facial expressions- strength of eyebrows &eyelids) V. EARS Inspect -position of ears in relation to eye -auricles, tragus, lobule of shape, position, lesions, discolorations & discharges -maneuver for appropriate for amembranege Using Penlight -auditory canal (color, consistency, discharge) -checked auditory canal for color & cerumen -tympanic membrane (ear drum) for color, shape, consistency and landmarks Palpated -auricles for texture, elasticity, areas of tenderness -mastoid process for tenderness CN Testing -voice- whisper test -watch tick test Tuning fork test -Webers test for diminished hearing in one ear -Rinnes test to compare cone & air conduction (tuning on mastoid; then in front of the ears)

VI. NOSE AND SINUSES Inspect - external nose for color, shape, size & consistency Using Penlight -septum alignment or deviation -mucosa for swelling, discharge, bleeding, foreign bodies Transillumination test -frontal sinuses -maxillary sinuses Palpate -checked patency of nares -external nose for masses, tenderness, smoothness, consistency -frontal sinuses -maxillary sinuses Percuss -frontal sinuses -maxillary sinuses CN Testing -I (olfactorysmell test) VII. MOUTH AND THROAT Inspect -lips for color, symmetry, consistency, contour, lesions -mucosa and gums for color, integrity, adherence, lesions -salivary glands --- Whartons / Stensens duct
-teeth for number, condition (oral hygiene), dental works

Palpate -lips and gums -salivary glands -tongue -hard(ant)/ soft(post) palates CN Testing -V (Trigeminal- ability to chew aneal- ngd masticate) -VII and XII (Facial & Glossophary and taste) -IX & X ( Glosspharyngeal & Vagus speech, swallow, gag reflex) -XII (Hypoglossal tongue strength) VIII. LUNGS AND THORAX *ANTERIOR CHEST Inspect -color of chest -level of clavicles, sternum and costal angle -shape of chest -respiratory quality & pattern of respirationsn (rate, rhythm, depth) -intercostal spaces for bulging & retractions -use of accessory muscles for respirations Palpate -tactile fremitus -tenderness, sensation, crepitus, masses, lesions -determined anterior chest expansion/ excursion Percuss -tone at apices above clavicles then at intercostals spaces (comparing bilaterally) -tone at anterior intercostals spaces Auscultate -anterior breath sounds and adventitious breath sounds -anterior voice sounds bronchophony (99), egophony (eee) , whispered pectoriloquy (1,2,3) -noted & describe cough & sputum, if present

*POSTERIOR AND LATERAL CHEST Inspect -color of chest -configuration & shape of scapulae & chest wall -use of accessory muscles when breathing Palpate -tactile fremitus -tenderness, sensation, crepitus, masses, lesions -determined diaphragmatic excursions Percuss -tone at posterior intercostals spaces (bilaterally) Auscultate -posterior breath sounds and adventitious breath sounds -posterior voice sounds bronchophony ( 99), egophony (eee) , whispered pectoriloquy (1,2,3) -noted & describe cough & sputum, if present IX. BREAST AND AXILLAE Inspect -retractions or dimpling of nipples, through specific functioning or maneuvers instructed to client -color of breast -size, symmetry, texture & superficial venous pattern of breasts -color of areola & nipples -position of areola & nipples -montgromery tubercles, discharges, nipple inversion (if any) Palpate -breast according to recommend method (concentric, vertical, radial/pie) -tail of Spence -areola & nipples for discharge

-tongue for color, moisture, size, texture, coating, vessels -labial and lingual frenulums -hard(ant)/ soft(post) palates for color, integrity -breath and breath sounds -uvula and tonsils (color, continuity, integrity, lesions, inflammation, size) -posterior pharyngeal wall

Axillae -noted position for axilla palpation -noted axilla condition -palpates axillae for rashes, infection & anterior, central & posterior lymph nodes -taught breast self examination (BSE) X. HEART Inspect -precordium movement @MCL, 5 th ICS -jugular veins -heart landmarks (pulmonic, aortic, tricuspid, mitral)

XI. ABDOMEN -empty bladder Inspect -overall abdominal skin color -vascularity; striae, lesions, rashes -hair distributions -symmetry & contour of abdomen -surface movements (peristaltic waves or any pulsation) -location, contour & color of umbilicus -measured abdominal girth Auscultate -bowel sounds over four quadrants Percuss -tone over 4 quadrants -liver location, size &span -spleen location & size -kidneys -bladder -perform shifting dullness (test for ascites), if needed of indicated Light Palpate -4 quadrants resistance to identify tenderness & muscular



Palpate -carotid pulse one at a time -precodium -apex, left sterna border, & base of the heart for any abnormalities Auscultate
-carotid artery -utilized correct positioning for the auscultation (left sidelying, leaning forward) -traditional heart landmarks (pulmonic, aortic, Erbs point, tricuspid, mitral) -note heart rate & rhythm --- S1 & S2 sound --- identify irregular/ abnormal heart sounds (murmur, atrial/ventricular gallops.)

XII. NUTRITION --24 hour diet recall - Identified current order diet -assessed appetite basing on the meal percentage charting -identify body built (ectomorph, endomorpg, mesomorph) --wrist size -- wrist circumference ( height to wrist ration[HWHR]) -checked height -checked weight -Determined ideal body weight -calculate body mass index (BMI) -measure weight circumference -calculate waist-to-hip ratio (WHR) Hydration status -intake and output -skin moisture -skin turgor -identified s/sx of fluid volume deficit (dehydration) and fluid volume excess (fluid overload/ overhydration) XIII. MUSCULOSKELETAL Inspect - Posture -Spine alignment -gait -Tested Range of Motion (ROM) of joints to upper and lower extremities - Performed "nudge test' for the elderly or handicap - Muscle size, shape, symmetry Graded Muscle strength - Left upper extremity - Right upper extremity
- Left lower extremity - Right lower extremity - Enumerated at least 5 Activities of Daily Living (ADLs) affected(with limitations) basing on client's condition --bed mobility, eating, toy, transfer, walk in room, walk in corridor, locomotion on/off unit, dressing, toilet use, personal hygiene, bathing

Special Test -Hepatojugular reflex -Pulse deficit *PERIPHRAL CIRCULATION IDENTIFY,PAgLPATE & GRADE - temporal, carotid, radial, brachial,ulnar, femoral, popliteal, dorsalis pedis(pedal) posterior tibial. special test -allen, burger, trendelenburg, manual compression test, capillary refill, homans & edema (grade if present)

Deep Palpate -4 quadrants for masses -umbilicus -liver -spleen -kidneys -bladder Special Tests -blumbergs tets (rebound tenderness) -iliopsoas -obturator -hypersensitivity -inspiratory arrest (murphys)
-ballotement (w/ variations, either single-hand/ bimanual method)

- Enumerated at least 3 Instrumental Activities of Daily Living(IADLs) affected (with limitations) basing on client's condition---housekeeping, use of telephone, managing money, preparing meals, driving/traveling, shopping, taking medication, laundry, taking out garbage Palpate - Joints for mobility, smoothness, symmetry. Noted
edema, heat, tenderness, pain, nodules, or crepitus.

-Epididymis -Spermatic cord -Inguinal and femoral areas -while client shifted weight to each corresponding side, palpated for inguinal hernia -taught testicular self-examination (TSE) *ANUS & RECTUM Inspect - Perianal area for lumps, ulcer, lesions, hemorrhoids, rashes, redness, fissures, or thickening of epithelium - Sacrococcygeal area for swelling, redness, dimpling, or hair - Instructed client to bear down or perform Valsalva maneuver, and inspected for bulges or lesions Palpate - External sphincter for tenderness, nodules, and hardness - Rectum for tenderness, irregularities, nodules, and hardness - Prostate for size, shape, tenderness, and consistency - Inspected and described characteristics of stool, if any - Collected and/or tested feces for occult blood, if noted, or needed XV. FEMALE GENITOUNRINARY Inspect - Pubic hair distribution, density, growth - Mons pubis, labia majora, and perineum for vascularity,
moisture, symmetry, lesions, swelling, excoriations, and discharge - Labia minora, clitoris, urethral meatus, and vaginal opening for lesions, swelling or discharge - Identified sexual maturity according to Tanner's Sexual Maturity Rating

Palpate - labia (masses, tenderness) -Bartholin's glands, urethra, and Skene's glands - Size of vagina, and vaginal musculature - Femoral and inguinal hernia Bimanual Palpate - Cervix for contour, consistency, mobility, and tenderness - Uterus for size, position, shape, and consistency - Ovaries for size and shape *ANUS & RECTUM Inspect - Perianal area for lumps, ulcer, lesions, hemorrhoids, rashes, redness, fissures, or thickening of epithelium - Sacrococcygeal area for swelling, redness, dimpling, or hair - Instructed client to bear down or perform Valsalva maneuver, and inspected for bulges or lesions Palpate - External sphincter for tenderness, nodules, and hardness - Rectum for tenderness, irregularities, nodules, and hardness - Inspected and described characteristics of stool, if any - Collected and/or tested feces for occult blood, if noted, or needed

Special test -Straight Leg Raising (LaSegue's Test) -Length Discrepancy - Ballottement -Bulge sign/ milking - Balloon Sign XIV. MALE GENITOUNRINARY Inspect - Pubic hair distribution (amount, texture/ cleanliness/
foreign, body)

-Penis (circumcised/uncircumcised)base of penis -Skin and shaft of penis for rashes, lesions, lumps, hardened or tender areas - Glans for size, shape, lesions, or redness and location of urinary meatus, and discharge -Scrotal skin for color, integrity and lesions - Scrotum for size, shape, and position - Transilluminated scrotal contents for red glow, swelling, or masses, if a mass is found during inspection and palpation. - Identified sexual maturity according to Tanner's Sexual Maturity Rating Scale - With client standing, instructed to bears down, inspected for bulges in inguinal and femoral areas Palpate - Shaft of penis -Urethral discharge by gently squeezing the glans -scrotom - Bilateral testes

With speculum> - Vagina for color, consistency, and discharge

- Cervix for lesions and discharge - Collects specimen as indicated or appropriate


- Checked and determined LOC

-Performed GCS - Checked and determined pupillary reaction and size - Checked and graded bilateral hand grasp strength -Romberg's test, as indicated or appropriate - Performed at least 3 cerebellar testing relevant to client s condition -gait -heel to toe (tandem walking) - walk on tip toes - walk on heels - hop on one foot (then with the other) - Performed at least 3 test tor coordination relevant to client's condition - Finger to nose - Finger to nose and to the nurses finger - Finger to fingers - Rapid afternating hand movements (RAHM) -heel to shin -draw a circle or figure of 8 with each foot on the ground or air - rapidly flex and extend each foot - touch the finger of the nurse with the large toe of each foot - Checked at least 3 sensory testing relevant to client's condition -pain (sharp/dull) -temperature -light touch -vibration -position, joint mobility(kinesthesia) -tactile discrimination (streogenesis) -number identification (graphethesia) -2 point discrimination -extinction -point location

- Checked at least 3 superficial reflexes relevant to client's condition -abdominal -cremasteric (male clx) -bulbocavernosus (male clx) -plantar/ babinski -anal -Checked and graded at least 3 deep tendon reflexes relevant to client's condition -biceps -triceps -brachioraadialis -patellar -ankle jerk (achilles) Others: -brudzinski -kernigs sign - Performed other neurologic tests relevant to client's condition; XVII. MENTAL STATUS Assessed for the following: 1. Mood and emotional state (affect) 2. Facial expressions 3. Speech and language abilities 4. Orientation to person, time, place 5. Concentration, ability to focus and follow directions 6. Recall of unrelated information in 5 or 10 minute period 7. Recent memory of happenings today 8. Remote memory 9. Calculation (Digit Span) 10. Thought content and process 11. Visual perception and constructional ability 12, Judgment and abstract reasoning

Differences of a Pediatric History Compared to an Adult History: I. Content Differences A. Prenatal and birth history B. Developmental history C. Social history of family - environmental risks D. Immunization history II. Parent as Historian A. Parents interpretation of signs, symptoms 1. Children above the age of 4 may be able to provide some of their own history 2. Reliability of parents observations varies 3. Adjust wording of questions - When did you first notice Johnny was limping? instead of When did Johnnys hip pain start? B. Observation of parent-child interactions 1. Distractions to parents may interfere with history taking 2. Quality of relationship C. Parental behaviors/emotions are important 1. Parental guilt - nonjudgmental/reassurance 2. The irate parent: causes Outline of the Pediatric History: I. Chief Complaint - Brief statement of primary problem (including duration) that caused family to seek medical attention II. History of Present Illness - Initial statement identifying the historian, that persons relationship to patient and their reliability Age sex race other important identifying information about patient Concise chronological account of the illness, including any previous treatment with full description of symptoms (pertinent positives) and pertinent negatives. It belongs here if it is relates to the differential diagnosis for the chief complaint.

III. Past Medical History Major medical illnesses Major surgical illnesses-list operations and dates Trauma-fractures, lacerations Previous hospital admissions with dates and diagnoses Current medications Known allergies (not just drugs) Immunization status - be specific, not just up to date IV. Pregnancy and Birth History Maternal health during pregnancy: bleeding, trauma, hypertension, fevers, infectious illnesses, medications, drugs, alcohol, smoking, rupture of membranes Gestational age at delivery Labor and delivery - length of labor, fetal distress, type of delivery (vaginal, cesarean section), use of forceps, anesthesia, breech delivery Neonatal period - Apgar scores, breathing problems, use of oxygen, need for intensive care, hyperbilirubinemia, birth injuries, feeding problems, length of stay, birth weight V. Developmental History Ages at which milestones were achieved and current developmental abilities - smiling, rolling, sitting alone, crawling, walking, running, 1st word, toilet training, riding tricycle, etc (see developmental charts) School-present grade, specific problems, interaction with peers Behavior - enuresis, temper tantrums, thumb sucking, pica, nightmares etc. VI. Feeding History -Breast or bottle fed, types of formula, frequency and amount, reasons for any changes in formula Solids - when introduced, problems created by specific types Fluoride use VII. Review of Systems: (usually very abbreviated for infants and younger children) o Weight - recent changes, weight at birth o Skin and Lymph - rashes, adenopathy, lumps, bruising and bleeding, pigmentation changes

HEENT - headaches, concussions, unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, mouth breathing, snoring, apnea, oral thrush, epistaxis, caries Cardiac - cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, palpitations Respiratory - pneumonia, bronchiolitis, wheezing, chronic cough, sputum, hemoptysis, TB GI - stool color and character, diarrhea, constipation, vomiting, hematemesis, jaundice, abdominal pain, colic, appetite GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary stream, polyuria, previous infections, facial edema Musculoskeletal - joint pains or swelling, fevers, scoliosis, myalgia or weakness, injuries, gait changes Pubertal - secondary sexual characteristics, menses and menstrual problems, pregnancies, sexual activity Allergy - urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions VIII. Family History - Illnesses - cardiac disease, hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy and asthma, epilepsy - Mental retardation, congenital anomalies, chromosomal problems, growth problems, consanguinity, ethnic background IX. Social - Living situation and conditions - daycare, safety issues - Composition of family - Occupation of parents

Differences in Performing A Pediatric Physical Examination Compared to an Adult: I. General Approach Gather as much data as possible by observation first Position of child: parents lap vs. exam table Stay at the childs level as much as possible. Do not tower!! Order of exam: least distressing to most distressing Rapport with child 1. Include child - explain to the childs level 2. Distraction is a valuable tool Examine painful area last-get general impression of overall attitude Be honest. If something is going to hurt, tell them that in a calm fashion. Dont lie or you lose credibility! Understand developmental stages impact on childs response. For example, stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult. II. Vital signs A. Normals differ from adults, and vary according to age 1. See code card for charts of age-adjusted normals B. Temperature 1. Tympanic vs. oral vs. axillary vs. rectal C. Heart rate 1. Auscultate or palpate apical pulse or palpate femoral pulse in infant 2. Palpate antecubital or radial pulse in older child D. Respiratory rate -Observe for a minute. Infants normally have periodic breathing so that observing for only 15 seconds will result in a skewed number. E. Blood pressure 1. Appropriate size cuff - 2/3 width of upper arm 2. Site F. Growth parameters - must plot on appropriate growth curve 1. Weight 2. Height/length 3. OFC: Across frontal-occipital prominence so greatest diameter (Occipital Frontal Circumference)

III. Unique findings in pediatric patients (See outline below Outline of a Pediatric Physical Examination I. Vitals - see above II. General Statement about striking and/or important features. Nutritional status, level of consciousness, toxic or distressed, cyanosis, cooperation, hydration, dysmorphology, mental state Obtain accurate weight, height and OFC III. Skin and Lymphatics Birthmarks - nevi, hemangiomas, mongolian spots etc Rashes, petechiae, desquamation, pigmentation, jaundice, texture, turgor Lymph node enlargement, location, mobility, consistency Scars or injuries, especially in patterns suggestive of abuse IV. Head Size and shape Fontanelle(s) 1. Size 2. Tension - calm and in the sitting up position Sutures - overriding Scalp and hair V. Eyes General 1. Strabismus 2. Slant of palpebral fissures 3. Hypertelorism or telecanthus EOM Pupils Conjunctiva, sclera, cornea Plugging of nasolacrimal ducts Red reflex Visual fields - gross exam

VI. Ears Position of ears - Observe from front and draw line from inner canthi to occiput Tympanic membranes Hearing - Gross assessment only usually V. Nose Nasal septum Mucosa (color, polyps) Sinus tenderness Discharge VI. Mouth and Throat Lips (colors, fissures) Buccal mucosa (color, vesicles, moist or dry) Tongue (color, papillae, position, tremors) Teeth and gums (number, condition) Palate (intact, arch) Tonsils (size, color, exudates) Posterior pharyngeal wall (color, lymph hyperplasia, bulging) Gag reflex VII. Neck Thyroid Trachea position Masses (cysts, nodes) Presence or absence of nuchal rigidity VIII. Lungs/Thorax A. Inspection 1. Pattern of breathing a. Abdominal breathing is normal in infants b. Period breathing is normal in infants (pause < 15 seconds) 2. Respiratory rate 3. Use of accessory muscles: retraction location, degree/flaring 4. Chest wall configuration

Auscultation 1. Equality of breath sounds 2. Rales, wheezes, rhochi 3. Upper airway noise Percussion and palpation often not possible and rarely helpful IX. Cardiovascular Auscultation 1. Rhythm 2. Murmurs 3. Quality of heart sounds Pulses 1. Quality in upper and lower extremities X. Abdomen Inspection 1. Shape a. Infants usually have protuberant abdomens b. Becomes more scaphoid as child matures 2. Umbilicus (infection, hernias) 3. Muscular integrity (diasthasis recti) Auscultation Palpation 1. Tenderness - avoid tender area until end of exam 2. Liver, spleen, kidneys a. May be palpable in normal newborn 3. Rebound, guarding a. Have child blow up belly to touch your hand XI. Musculoskeletal Back 1. Sacral dimple 2. Kyphosis, lordosis or scoliosis Joints (motion, stability, swelling, tenderness) Muscles Extremities 1. Deformity 2. Symmetry 3. Edema 4. Clubbing

Gait 1. In-toeing, out-toeing 2. Bow legs, knock knee a. Physiologic bowing is frequently seen under 2 years of age and will spontaneously resolve 3. Limp Hips 1. Ortolanis and Barlows signs XII. Neurologic - most accomplished through observation alone A. Cranial nerves B. Sensation C. Cerebellum D. Muscle tone and strength E. Reflexes 1. DTR 2. Superficial (abdominal and cremasteric) 3. Neonatal primitive XII. GU A. External genitalia B. Hernias and Hydrocoeles 1. Almost all hernias are indirect 2. Can gently palpate; do not poke finger into the inguinal canal C. Cryptorchidism 1. Distinguish from hyper-retractile testis 2. Most will spontaneously descend by several months of life D. Tanner staging in adolescents - See Tanner Staging handouts E. Rectal and pelvic exam not done routinely - special indications may exist

Introductory information Introduce, establish rapport. Name, age, gender. Person giving the history (parent, etc). Origin. Presenting complaint Description of the presenting complaint, in chronological order. Including whether came in through casualty or admitted by GP. History of presenting complaint SOCRATES: Time course: seasonal or diurnal fluctuation. Exacerbating factors: foods. Referral by GP vs. came in through casualty. Relevant negatives. If using slang, ask for clarification. Past medical, surgical history, Birth history Length of gestation. Age and parity of mother at delivery. Any maternal insults [alcohol, smoking] or illnesses during gestation. Where born: city, hospital. Birth weight, mode of delivery, difficulties in delivery. Resuscitation, intensive care requirement at birth. Cyanosis, pallor, jaundice, convulsions, birthmarks, malformations, feeding or respiratory difficulties. Apgar score at birth if known. How baby was fed in first few days. Whether child went home with mother. Nutritional history Breast-fed vs. bottle-fed o When breast started, stopped. o If formula: type, amount, pre-mixed vs concentrate [and dilution used]. Vitamin supplements. Age when beikost started. Appetite and growth. Current diet.

Immunization history See Immunization Schedule Reference. Get dates of each.

3 days BCG 2 months DTP Live polio Hib 3 months DTP Live polio Hib 4 months DTP Live polio Hib

12-18 months MMR 3-5 years MMR Live polio booster Diphtheria booster Tetanus booster 10-14 years Rubella [girls] BCG [sometimes] 15-18 years Live polio booster Diphtheria booster Tetanus booster

Illnesses and operations Past illnesses, operations. Childhood illness, obs/gyn. o Tests and treatment prescribed for these. o Problems with the anesthetic insurgery. Developmental history Gross motor. Fine motor. Vision, speech, hearing. Social. See Developmental Milestones Reference. Education history Start of school attendance. Where attend school. Special needs requirements. Impact of symptoms: absent school days. Family history The current complaint in parents/ siblings: health, cause of death, age of onset, age of death. Parents/siblings: age, health, where living. Height and weight of parents. Hereditary dz suspected: do a family tree.