MANILA CENTRAL UNIVERSITY

COLLEGE OF MEDICINE

DEPARTMENT OF PEDIATRICS

GUIDE TO PHYSICAL EXAMINATION: GEN SURVEY, VITAL SIGNS,

ANTHROPHOMETRIC MEASUREMENTS, SKIN, HEENT

GENERAL SURVEY:

Nutrition and development, color, level of consciousness, activity, behaviour, evidence of

distress

VITAL SIGNS:

HEART RATE/ PULSE RATE

Palpate the femoral arteries in the inguinal area or the brachial arteries in the antecubital fossa, or
the radial artery at the wrist. Direct auscultation of the heart may be done also.

RESPIRATORY RATE

The respiratory pattern should be observed for at least 60 seconds. In infancy and early
childhood, diaphragmatic breathing is predominant; thoracic excursion is minimal.

TEMPERATURE

In children and adolescents, auditory canal temperature recordings are preferable because they
can be obtained quickly with essentially no discomfort.

For infants under 2 months of age, rectal temperatures are preferred because clinical guidelines
for evaluating serious bacterial infections use rectal temperature levels as a major criterion.

 
Technique for obtaining the rectal temperature: Place the infant or child in prone position. While
you separate the buttocks with the thumb and forefinger on one hand, with the other hand gently
insert a well-lubricated rectal thermometer, inclined approximately 20 from the table or lap,
through the anal sphincter to a depth of approximately 2 to 3 centimeters. Keep the thermometer
in place for at least 2 minutes.

BLOOD PRESSURE

Select the blood pressure cuff  wide enough to cover two thirds of the upper arm or leg. A
narrower cuff falsely elevates the blood pressure reading, while a wider cuff lowers it and may
interfere with proper placement of the stethoscope diaphragm over the artery.

ANTHROPHOMETRIC MEASUREMENTS:

WEIGHT (KG)

Weigh infants directly with an infant scale.  Infants should be clothed only in a diaper.

LENGTH OR HEIGHT (CM)

For children older than age 2 years, measure standing height, optimally using wall-mounted
stadiometers. Have the child stand with heels, back, and head against a wall or the back of the
stadiometer. If using a wall with a marked ruler, make sure to place a flat board or surface
against the top of the child’s head and at right angles to the ruler.

Rule of thumb on height: After age 2 years, children should grow at least 5 centimeters

per year.

For children under the age of 2 years, measure body length by placing the child supine on a
measuring board

COMPUTE FOR BMI (BODY MASS INDEX)

BMI = Weight (kg)

          Height (m2)

 

ALWAYS PLOT HEIGHT, WEIGHT, BMI ON THE Z-SCORE CHART

HEAD CIRCUMFERENCE

The head circumference of infants should be measured during the first 2 years of life, but
measurement can be useful at any age to assess growth of the head.

To measure head circumference, place the measuring tape over the occipital, parietal, and frontal
prominences to obtain the maximum circumference.

SKIN:

Inspect and palpate the skin.

COLOR - Look for increased pigmentation (brownness), loss of pigmentation, redness, pallor,
cyanosis, and yellowing of the skin.

MOISTURE - Examples are dryness, sweating, and oiliness.

TEMPERATURE - Use the backs of your fingers to make this assessment. In addition to
identifying generalized warmth or coolness of the skin, note the temperature of any red areas.

TEXTURE - Examples are roughness and smoothness.

MOBILITY & TURGOR - Lift a fold of skin and note the ease with which it lifts up (mobility)
and the speed with which it returns into place (turgor)   *test done in the abdominal area

LESIONS - Observe any lesions of the skin, noting their characteristics:

_ Their anatomic location and distribution over the body. Are they generalized or localized? Do
they involve the exposed surfaces, the intertriginous (skin fold) areas, or areas exposed to
specific allergens or irritants such as wrist bands, rings, or industrial chemicals?

_ Their arrangement:  linear, clustered, annular (in a ring), arciform (in an arc), or dermatomal

 _ The type(s) of skin lesions (e.g., macules, papules, vesicles, nevi).

HEAD
Observe the shape of the head, its symmetry, and the presence of abnormal facies. Examine the
hair, scalp, skull and face.

Measure the head circumference especially in children under 2 years.

 IN INFANCY

Examine the sutures and fontanelles.

On palpation, the sutures feel like ridges and the fontanelles like soft concavities.

The anterior fontanelle at birth measures 4 cm to 6 cm in diameter and usually closes between 4
and 26 months of age (90% between 7–19 mos).

The posterior fontanelle measures 1 cm to 2 cm at birth and usually closes by 2 months.

Assess the symmetry of the skull

A newborn’s scalp is often swollen from localized subcutaneous edema over the occipitoparietal
region, called caput succedaneum.

Asymmetry of the cranial vault (plagiocephaly) occurs when an infant lies mostly on one side,
resulting in a flattening of the parieto-occipital region on the dependent side and a prominence of
the frontal region on the opposite side.

Measure the head circumference.

Examine the skull. You can perform the following maneuvers with care:

_ On palpation of the infant’s skull, you may note that the cranial bones appear “soft” or pliable;
they will become firmer with increasing gestational age. An exception occurs in a condition
known as craniotabes, which is found in some normal infants but also in some with diseases. In
this condition, the cranial bones feel pliable and springy, much as a ping-pong ball springs back
upon pressure.

_ Percuss the parietal bone on each side of the skull using your index or middle finger. This will
produce a “cracked pot” sound (Macewen’s sign) in normal infants prior to closure of the cranial
sutures.

Examine the face for an overall impression of the facies;

EYES

IN INFANCY
Newborns keep their eyes closed except during brief awake periods. If you attempt to separate
their eyelids, they will tighten them even more. Bright light causes infants to blink, so use
subdued lighting. If you awaken the baby gently, turn down the lights, and support the baby in a
sitting position, you will often find that the eyes open. The eyes of many newborns are
edematous from the birth process.

You will not be able to measure the visual acuity of newborns or infants.

You can use visual reflexes to indirectly assess vision: direct and consensual pupillary
constriction in response to light, blinking in response to bright light (optic blink reflex), and
blinking in response to quick movement of an object toward the eyes. During the first year of
life, visual acuity sharpens as the ability to focus improves.

IN OLDER AGE GROUPS:Important Areas of Examination

VISUAL ACUITY

Snellen eye chart - Position the patient 20 feet from the chart. Ask the patient to cover one eye
with a card (to prevent peeking through the fingers) and to read the smallest line of print
possible. Determine the smallest line of print from which the patient can identify more than half
the letters. Record the visual acuity designated at the side of this line, along with use of glasses,
if any. Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the distance of
patient from chart, and the second, the distance at which a normal eye can read the line of letters.

VISUAL FIELDS BY CONFRONTATION

Screening starts in the temporal fields because most defects involve these areas. Imagine the
patient’s visual fields projected onto a glass bowl that encircles the front of the patient’s head.
Ask the patient to look with both eyes into your eyes. While you return the patient’s gaze, place
your hands about 2 feet apart, lateral to the patient’s ears. Instruct the patient to point to your
fingers as soon as they are seen. Then slowly move the wiggling fingers of both your hands
along the imaginary bowl and toward the line of gaze until the patient identifies them. Repeat
this pattern in the upper and lower temporal quadrants.

Normally, a person sees both sets of fingers at the same time. If so, fields are usually normal.

POSITION AND ALIGNMENT OF THE EYES - Stand in front of the patient and survey the
eyes for position and alignment with each other.

EYEBROWS - Inspect the eyebrows, noting their quantity and distribution and any scaliness of
the underlying skin.

EYELIDS - Note the position of the lids in relation to the eyeballs. Inspect for the following:

_ Width of the palpebral fissures

_ Edema of the lids

_ Color of the lids (e.g., redness)

_ Lesions

_ Condition and direction of the eyelashes

_ Adequacy with which the eyelids close. Look for this especially when the eyes are unusually
prominent, when there is facial paralysis, or when the patient is unconscious.

LACRIMAL APPARATUS - Briefly inspect the regions of the lacrimal gland and lacrimal sac
for swelling. Look for excessive tearing or dryness of the eyes.

CONJUNCTIVA & SCLERAE - Ask the patient to look up as you depress both lower lids with
your thumbs, exposing the sclera and conjunctiva.

Inspect the sclera and palpebral conjunctiva for color, and note the vascular pattern against the
white sclera background. Look for any nodules or swelling.

CORNEA  - With oblique lighting, inspect the cornea of each eye for opacities.

IRIS - At the same time, inspect each iris. The markings should be clearly defined. With your
light shining directly from the temporal side, look for a crescentic shadow on the medial side of
the iris. Since the iris is normally fairly flat and forms a relatively open angle with the cornea,
this lighting casts no shadow.

PUPILS - Inspect the size, shape, and symmetry of the pupils. If the pupils are large (>5 mm),
small (<3 mm), or unequal, measure them. A card with black circles of varying sizes facilitates
measurement.

                                                                                               

Test the pupillary reactions to light. Ask the patient to look into the distance, and shine a bright
light obliquely into each pupil in turn. (Both the distant gaze and the oblique lighting help to
prevent a near reaction.) Look for:

_ The direct reaction (pupillary constriction in the same eye)

_ The consensual reaction (pupillary constriction in the opposite eye)

Always darken the room and use a bright light before deciding that a light reaction is absent.

EXTRAOCULAR MUSCLES - From about 2 feet directly in front of the patient, shine a light
onto the patient’s eyes and ask the patient to look at it. Inspect the reflections in the corneas.
They should be visible slightly nasal to the center of the pupils.
Finally, test for convergence. Ask the patient to follow your finger or pencil as you move it in
toward the bridge of the nose. The converging eyes normally follow the object to within 5 cm to
8 cm of the nose.

EARS

The major goals are to determine if the position, shape, and features of the ear are normal and
to detect abnormalities. Note the position of the ears in relation to the eyes. An imaginary line
drawn across the inner and outer canthi of the eyes should cross the pinna or auricle; if the pinna
is below this line then the infant has low-set ears.

AURICLE - Inspect for deformities, lumps, or skin lesions. If ear pain, discharge, or
inflammation is present, move the auricle up and down, press the tragus, and press firmly just
behind the ear.

EAR CANAL & DRUM - Inspect the ear canal, noting any discharge, foreign bodies, redness of
the skin, or swelling.  Inspect the eardrum, noting its color and contour. The cone of light—
usually easy to see—helps to orient you.

AIR & BONE CONDUCTION - If hearing is diminished, try to distinguish between

conductive and sensorineural hearing loss. You need a quiet room and a tuning fork, preferably
of 512 Hz

or possibly 1024 Hz. These frequencies fall within the range of human speech (300 Hz to 3000
Hz)—functionally the most important range. Forks with lower pitches may lead to
overestimating bone conduction and can also be felt as vibration.

Set the fork into light vibration by briskly stroking it between thumb and index finger or by
tapping it on your knuckles.

_ Test for lateralization (Weber test).

Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head or on the

midforehead. Ask where the patient hears it: on one or both sides. Normally the sound is heard in
the midline or equally in both ears. If nothing is heard, try again, pressing the fork more firmly
on the head.

Compare air conduction (AC) and bone conduction (BC) (Rinne test).

Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level
with the canal. When the patient can no longer hear the sound, quickly place the fork close to the
ear canal and ascertain whether the sound can be heard again. Here the “U” of the fork should
face forward, thus maximizing its sound for the patient. Normally the sound is heard longer
through air than through bone (AC > BC).
NOSE & THROAT

Note any asymmetry or deformity of the nose.

Observe:

_ The nasal mucosa that covers the septum and turbinates. Note its color and any swelling,
bleeding, or exudate. If exudate is present, note its character: clear, mucopurulent, or purulent.
The nasal mucosa is normally somewhat redder than the oral mucosa.

_ The nasal septum. Note any deviation, inflammation, or perforation of the septum. The lower
anterior portion of the septum (where the patient’s finger can reach) is a common source of
epistaxis (nosebleed).

_ Any abnormalities such as ulcers or polyps.

MOUTH & PHARYNX

LIPS - Observe their color and moisture, and note any lumps, ulcers, cracking, or scaliness.

ORAL MUCOSA - Look into the patient’s mouth and, with a good light and the help of a tongue
blade, inspect the oral mucosa for color, ulcers, white patches, and nodules.

GUMS & TEETH - Note the color of the gums, normally pink. Inspect the gum margins and the
interdental papillae for swelling or ulceration. Inspect the teeth. /

ROOF OF THE MOUTH - Inspect the color and architecture of the hard palate.

TONGUE & FLOOR OF THE MOUTH - Ask the patient to put out his or her tongue. Inspect it
for symmetry—a test of the hypoglossal nerve (Cranial Nerve XII). Note the color and texture of
the dorsum of the tongue.

THROAT - If you need to use the tongue blade to visualize the throat, the best technique is to
push down and pull slightly forward toward yourself while the child says “ahhh,” being careful

not to place the blade too far posteriorly, eliciting a gag reflex.

NECK

Palpate the lymph nodes of the neck - size, shape, delimitation (discrete or matted together),
mobility, consistency, and any tenderness. Small, mobile, discrete, nontender nodes, sometimes
termed “shotty,” are frequently found in normal persons.

Assess the presence of any additional masses such as congenital cysts. Because the necks of
infants are short, it is best to palpate the neck while infants are lying supine, whereas older
children are best examined while sitting. Check the position of the thyroid cartilage and trachea.
Check for neck mobility.