‫‪CLINICAL EXAMINATION‬‬

‫‪Pediatrics General‬‬
‫‪examination‬‬
‫‪By Dr ali bel kheir‬‬

‫اهداء‪:‬‬
‫لطلبة قروب ‪ – A‬دفعة المستحيل ‪2016 -2015‬‬
‫بالتوفيق والنجاح‬
‫تعلم فليس المرء يولد عالـمــا ‪ ...‬وليس أخو علم كمن هو جاهـل‬
‫وإن كبير القوم ال علم عـنـده ‪ ...‬صغير إذا التفت عليه الجحافل‬
‫وإن صغير القوم إن كان عالما ‪ ...‬كبير إذا ردت إليه المحـافـل‬
 General examination steps:
 Introduce yourself + permission+stand on right side of the bed
 Posture supine or sitting on bed
1. general look:
1. Well or not
2. Conscious level
3. Color
4. Built
5. Posture
6. Dysmorphic feature
7. RD S\S
8. Surrounding

2. vital signs:
 BP
 Temp
 RR

3. Anthropometric measurements:
 Weight
 height
 OFC

4. Head to toe

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 General look
1. Well or not
2. Conscious level
3. Color
4. Built
5. Posture
6. Dysmorphic feature
7. RD S\S
8. Surrounding
…………………………………………………………………………………………………………………………..
1. Well or notcalm-irritable-playing-crying-miserable
2. Conscious: 2 scale to assess:
 AVPU scale
 Alert: The patient is fully awake (although not necessarily oriented)
 Voice: The patient makes some kind of response when you talk to them
 Pain: The patient makes a response on any of the three component
measures
on the application of pain stimulus
 Unresponsive: Sometimes seen noted as 'Unconscious', this outcome is
recorded if the patient does not give any eye, voice or motor response to
voice or pain.
 Glasgow Coma Scale
 Include: motor response-eye opening-verbal response
 max=15 minimum=3
 Important number in scale is 8why?
3. Color:
 Pallor anemia-shock-HF
 Cyanosis respiratory or cardiac problems or Hemoglobinopathy
 Plethoric polycythemia / overheating/over oxygenation
 Yellowishjaundice.
 Yellowish brown or greenobstructive Jaundice

4. Built: underweight-overweightconfirmation by weight measurement

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6. Dysmorphic feature
Downs syndrome Edwards syndrome
Hypertelorism micrognathia
Upward slanting eyes cleft lip/cleft palate
Protruding Tongue hypertelorism
Fine silky hair upturned nose
low set ears narrow eyelid folds
small nose rocker bottom heel
depressed nasal closed fits with overlapping fingers

Turner syndrome Noonan syndrome (male turner)

Ugly short stature female Short stature
Low post hair line Triangle face
Webbing of the neck webbed neck
Wide spaced nipples wide-spaced nipples
Cubitus valgus flat nose bridge
(wide carrying angle) Hypertelorism
down slanting eyes
low-set ears
micropenis and cryptorchidism in males
Williams's syndrome Prader Willi syndrome
Microcephaly Prominent nasal bridge
Short upturned nose Excess fat, especially in the central
Flat nasal bridge portion of the body
Long philtrum High, narrow forehead
Prominent lower lip Thin upper lip
widely spaced teeth Downturned mouth
Wide mouth(ear to ear smile) Almond-shaped eyes
micrognathia
periorbital fullness Developmental delay
Lacy pattern of the irises can be
observed in children with blue eyes.

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5. Posture: on bed supine or 45 ˆ -in incubator-cot care
Any abnormal posture in details in CNS examination
Some examples:
 Opisthotonus  Tetanus / meningitis / cerebral palsy
 Carpopedal spasm tetany.
 Scissoring cerebral palsy.
 Frog like position generalized hypotonia.
 Waiter tip appearance Erb’s palsy.
…………………………………………………………………………………………………………………….
7.RD S\S:
1- Mild: Tachypnea & working alan nasi
2- Moderate: + Intercostal & subcostal retractions.
3- Severe: + Grunting.
4- Advanced: + Central cyanosis, disturbed consciousness
8.Surrounding:
 Monitor
 Pulse oximetry
 O2 mask
 Nasal prungs

…………………………………………………………………………………………………………………….
Vital signs
RR: rate-depth-special pattern-limitation of movment (Bilateral or uni)
 Rate:
 Obtain RR for 1 min due Periodic apneic Breathing
 Pts must be calm

Movement:
 Baby↑ 7 yrs chest
 Baby ↓7yrs  abdominal

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 Tachypnea (↑R.R ):WHO Bradypnea (R.R ):
•↓2m  ↑60 c/m •RR below normal levels
•2m-1y ↑ 50 c/m
•1y ↑ 40 c/m
Causes: Causes:
1) Fever 1)Over dosage of narcotics
2) Anxiety 2)myxedema
3) Crying 3)Heart block
4) Disease : A. Pneumonia 4)excess digitalis
B. Asthma 5)↑ICP
C. HF
 Abnormal respiratory pattern:
Kussmaul breath Rapid deep breath 1. Metabolic acidosis
2. exercise
Rapid shallow Rapid shallow breath 1. Pneumonia
2. Pleuritic chest pain
Prolonged expiration Breath with prolonged 1. Obstructive problems
expiratory phase as asthma
Cheyne stokes breathing Gradual Deeping and  1) HF
RR followed by apnea 2) Narcotic over dose
3) Brain damage
Temperature:
Normal range: thermometer placed for 3 min
 Oral=36.6-37.2
 Rectal= (-0.5)
 Axillary or ear=(+0.5)
Fever:
 increase in the body's temperature the usual fevers = or 38c
Types:
Low grade fever Below or =38.5 c  As in viral infection
High grade fever Above 38.5 c  As in bacterial infection
hyperpyrexia = or above 41.6 c 1. intracranial hemorrhage
2. sepsis
3. Kawasaki syndrome
4. thyroid storm
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Continuous fever does not fluctuate more than 1. lobar pneumonia
1 °C in 24 hours 2. typhoid
3. Meningitis
4. urinary tract infection
5. brucellosis
6. typhus
Intermittent fever cycling back to normal 1. Malaria
2. kala-azar
3. pyaemia
4. septicemia
Remittent fever Temperature remains above 1. infective endocarditis
normal throughout the day
and fluctuates more than 1 °C
in 24 hours
Pel-Ebstein fever being high for one week and 1. Hodgkin's lymphoma
low for the next week

Hypothermia: = temperature = or below 35 c

Causes of fever hypothermia

1. infectionviral-bacterial-parasite-fungal 1. Hypoglycemia
Most common cause is viral infection 2. Preterm
(URTI) 3. poor clothing
2. Malignancyleukemia-lymphoma 4. hypothyroidism
3. Dehydration 5. sepsis
4. Heat stroke 6. cold environment
5. Brain injurytumor-hge
6. Atropine poisoning
7. Rheumatoid arthritis
8. Intravascular hemolysis
9.Mal development of brain

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Pulse :
 Apical=site of apex beat
 Bronchial=medial to biceps tendon in lower part of arm
 Radial=difficult to palpate below 2 years
 Femoral=one finger below midway between ASIS and symphysis pubis
 Popliteal=flexion of knees in 120 degree.fingers in popliteal area and
thumbs resting on patella
 Dorsalis pedis=over dorsum of foot by compressing over tarsal bones
Comment on:
Note:
1. Rate
Below 2 yearsbrachial p
2. Rhythm
Above 2 yearsradial p
3. Volume
4. Special character

Rate:

Tachycardia (↑rate) Bradycardia (↓rate)

 Physiological = exercise/crying. 1. myxedema
 pathological = 2. Heart block
1. fever (↑10-15 b/m/1Cᵒ.) 3. excess digitalis
2. HF 4. ↑ICP
3. Arrhythmia=supra ventricular tachycardia
4. hemorrhage/anemia
5. thyrotoxicosis
6. drugs =atropine/adrenaline/aminophylline
Volume: amount of elevation of palpating finger at each pulse wave
Normal High volume Low volume
• Just raising 1. anemia 1. shock
your finger 2. thyrotoxicosis 2. dehydration
3. fever 3. HF
4. aortic regurgitation
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Rhythm:
Normal Arrhythmia
- regular Irregular Regular
- sinus arrhythmia= irregularity irregularity
↑Rate(inspiration) Atrial fibrillation Extra systoles
↓Rate(expiration) (premature beats)
pulses bigeminus
ex: digoxin toxicity
Special character:
Bounding pulse = (collapsing pulse):
• Caused by wide variation in pulse pressure
• Its detected by holding child's wrist and feel radial pulseleft hand upward
quicklyslow initially followed with increase intensity
• Found in: PDA-AR-peripheral arterio venous fistula
Pulse deficit:
• Apical pulse is more than radial pulse=(difference ↑ or = 10 beats/min).
• found in : atrial fibrillation.
Pulses paradoxes : PP
• Normally systolic BP ↓ 10 mmHg during inspirationIf ↑ 10 mmHg =PP
• Found in :
1. Sever bronchial asthma
2. Cardiac temponade
Slow rising pulse:
• Slow rising- moderate to severe aortic stenosis

Note :
Compare femoral, radial pulse if :
Coarctation of aorta
There is delay (radio-femoral delay)
Or absence of femoral pulse

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 Press for 5 sec on: Delayed if more
•
Capillary refilling • Sternum=neonate than 2 sec (max of
• Dorsum of normal 3)
hand=toddler found in:
• Child= nail • Dehydration
• Shock
• Peripheral vascular
disease (PVD)
• Hypothermia
…………………………………………………………………………………………………………………………
BP : measured by sphengomanometery or automated devices (dinamap)
• Proper cuff size ,Calm not crying • ⅔ of arm (proper).
• Crying, anxiety =↑BP • large cuff low reading.
• ↑Muscular activity =↑BP • small cuff high
• Systolic BP in legs is 10-30 mmHg, higher than that in arms.
reading
• (Diastolic pressure is equal in both).

Normal blood pressure: Hypertension Hypotension

• Neonate70/40 Renal : common 1. HF
• Infant80/50 1. Glomerulonephritis. 2. shock
• Child90/60 2. Renal artery stenosis. 3. aortic
• mean diastolic= 3. Renal tumor. stenosis
55 + age in years 4. Reflux nephropathy.
• mean systolic = Endocrinal :
90 + age in years. 1. Cushing’ syndrome.
• The upper limits of 2. pheochromocytoma.
normal are 3. Hyperthyroidism.
(mean + 20) mmHg for Vascular :
diastolic and 1. COA
(mean+ 18) mmHg for 2. PDA
systolic. 3. A.V.fistula.
Measure 3 timesput mean Neurologic :
on centile BP chart 1. Neurofibromatosis.
2. Guillain-Barre syndrome.
Drugs :
Corticosteroid.

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 Anthropometric measurements
In details in growth and development chapter
Weight:Normal at birth 2.5 – 4.5kg
↓2.5kg ↑4.5kg
↓2.5 = LBW Macrosomia
↓1.5 = VLBW
↓1 = ELBW
Weight gain:
 Neonates generally lose 5–8% (maximum being 10%) weight during
first 2–3 days of life???, which is regained by the 10th day.
 Average daily weight gain during:
• First 3 months: 30 g
• 3–6 months: 20 g (birth weight x2 by 5–6 months of age)
• 6–9 months: 15 g
• 9–12 months: 12 g (birth weight x3 by first birthday)
•1–3 years: 8 g (around 3 kg/year). birth weight x4 by 2 years of age.
•4–6 years: 6 g (around 2 kg/year);

97th centile

Weight kg Normal

3rd centile

Age(months-years)

• Fiftieth percentile is the average (median) line for the given population.
• It describes the percent of children expected to be on or below that line,

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• e.g. 50th centile means that 49% of the observations are below and 50%
above that observation
• Boy with height in 40th percentile and weight in the 85th percentile
• (he is taller than 40% of the kids of his age, but weighs more than 85% of
kids his age)
‫ من االطفال الطبيعين الي عندهم نفس وزنه يقعو في هده النقطة وماتحتها‬%... ‫في هده الحظة‬
‫ من االطفال الي عندهم نفس وزنه او اكبر يقعو في هده النقطة ومافوقها‬%....‫و‬
After measurement of wtcentile chart acoording to age /sex/race
Under weight-FTT Over weight
Below 3th centile above 97th centile
Or weight deceleration that crosses Or weight acceleration that crosses
two major percentile lines on a growth two major percentile lines on a growth
chart chart
1. Dehydration. 1. Over feeding.
2. Acute infection. 2. Endocrinal disorders :
3. Feeding disorders. • Hypothyroidism.
4. Mal absorption. • Hyperadrenalism.
5. Chronic disease. 3. Intra cranial disorders
6. Emotional problems. 4. edema
Note:
Obesity =Defined as a BMI >98th centile of the UK
BMI= Weight in kg ÷ (height in meter)²
………………………………………………………………………………………………………………………..
Length / height:
• If baby supine length / if standing height.
• Normal at birth = 50 cm.
• In first 3m => + 3cm/m.
• Second 3m => +2cm/m.
• 6m12m => +1.5cm/m.
• At one year 75 cm
• After one year height=age in years x5+80

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 short stature tall stature
Height below 3th centile Height above 97th centile
standing height more than 2 standard standing height more than 2 standard
deviations (SDs) below the mean deviations (SDs) above the mean
Causes: 1. Constitutional tall stature
A.familial 2. Exogenous obesity
B.Constitutional 3. Precocious puberty
C.Pathological which can be : 4. Hyperthyroidism
proportional or disproportional 5. Growth hormone excess—
Proportional: Gigantism
1. Malnutrition 6. Sotos syndrome
2. Chromosomal anomaly: 7. Marfan syndrome
• Down syndrome 8. Homocystinuria
• Prader willi 9. Beckwith–Wiedemann syndrome
• Noonan 10. Klinefelter syndrome
• Russell silver 11. Fragile X-syndrome
3.Chronic systemic illness:
• Malabsorption: celiac
• Chronic hemolytic anemia
:thalassemia
• Renal:CRF
4.Others: CF-asthma-CHD
5.Endocrinal:
• Hypothyroidism
• Hypopituitarism
• Cushing syndrome
• Precocious puberty
• DM
Disproportional
short limb:
• Achondroplasia
• Rickets
Osteogenesis imperfect
Short trunk
• Skeletal dysplasia
• Fanconi anemia

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Upper and lower segments
• Lower Segment
Measure from the symphysis pubis to the floor.
• Upper Segment
Subtract the LS from the height.
Measuring the arm span
• the arm span is shorter than height before puberty and greater than height
after midpuberty
• Scoliosis and related conditions can lead to shortened vertebral growth and
an arm span disproportionate to height.

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O.F.C
Measure it 3 times and take the largest reading.
From 2 prominent bone frontal, occipital.
Normal :
• At birth 35cm.
• 1st 2m  + 4cm.
• 2nd 2m + 3cm.
• 3rd 2m  + 2cm.
• 4th 2m  + 1cm.
• 5th 2m  + 1cm.
• At end of first year  47cm.
• Use growth chart as usual.
• Measured if concern about size of head or baby below 2 years
Causes of large head Causes of small head
OFC above 97 centile according to age and OFC below 3th centile according
sex or 2 standards Deviation above mean to age and sex or 2 standards
Deviation below mean

Cranial causes: • Craniosynostosis

1. Constitutional • True microcephaly:
2. Achondroplasia A. Genetic:
3. Familial 1.Familial : AR
4. Anaemia (chronic haemolytic) 2.Chromosomal trisomy:21,18,13
5. Rickets B. Non genetic:
Intracranial causes:  Prenatal:
1. Hydrocephalus
1. TORCH infection.
2. Space occupying lesion EX. tumor
2. Fetal irradiation.
3. Subdural haematoma or effusion
3. Maternal diabetes or PKU
4. Hydrancephaly
4.Maternal drugs Ex: phenytoin,
5. Megalencephaly which may be due to:
alcohol.
A. Cretinism
B. Storage Diseases
 Natal: HIE
(E.X:mucopolysacharidosis)
C. Familial Post natal: Early meningitis&
Encephalitis

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 4. Head to toe:
Head :
1. Shape, symmetry,suture,skull:
Sutures if
• Molding  infant ↓4m
• Craniosynstosis=premature closer of sutures
• Wideex :hydrocephaly
Shape of skull
• Flattened occiput child in supine position for long period
• BossingRickets
 Chronic hemolytic anemia (ex. Thalassemia major)

Abnormal skull shapes:

name shape definition Suture fused
scaphocephaly Elongated naroow Saggital suture
skull

brachycephaly Short Both coronal

Broad skull sutures

plagiocephaly Unilateral Single coronal or

forehead lambdoid
flattening

oxycephaly High pointed head Coronal

Sagittal
lambdoid

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2. Fontanels= (7)
Anterior fontanel:
• Placed at the junction of the sagittal suture, coronal suture, and frontal
suture
• It is lozenge-shaped
• allows the skull to deform during birth to Ease its passage through the birth
canal and for expansion of the brain after birth.
• Measure Ant. Fontanel: ‫الطول‬+‫العرض‬ If ↑5cm = wide.
= 5cm
2
• closed normally from 9 up to 18 mts

Early closure Delay or delay Bulging Depressed

closerclosure
1. Microcephaly 1. Rickets 1. Crying 1. Dehydration
2. Craniosynostosis 2. Achondroplasia 2. ↑ICP ex: 2. Malnurition
3. Congenital 3. Down syndrome • Meningitis 3. shock
hyperthyroidism 4. Increase ICP • Encephalitis
5. Osteogenesis • Space
imperfect occupying
6. Hypothyroidism lesion
7. Hydrocephaly 3. Pseudo
tumour
cerebri
Post fontanel:
• closed normally from birth up to 2 mts
• is triangle-shaped. It lies at the junction between the sagittal suture and
lambdoid suture
• Delay closer post fontanelle Congenital hypothyroidism

3th fontanel:
 closed before or at birth
 Delay closer 3th fontanelle Down syndrome, prematurity
 along the sagittal suture about 2 cm anterior to the posterior fontanelle

2 anerolateral fontanelle closed before or at birth

2posterolateral fontanelle closed before or at birth
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 Face:
 Dismorphic features :

1. Cretinism
2. Syndrome as before
3. Thalassemic face

Thalassemic face
 Protrusion of maxilla.
 Depression of nasal.
Bridge
 Protrusion of upperteeth
 Bossing forehead

 Malar rash on checks  MS- SLE

Sclera :
 Blue glucoma.
 Yellow jaundice.
Eye lid :
 Normally located between iris and pupil. (upper eye lid)
 If upper sclera present sunset eyes hydrocephaly.
 Ptosis occulomotor nerve palsy.  Up slanting=trisomy 21/18/13
 Oedema nephrotic syndrome.  Down slanting=Noonan syndrome
Conjunctiva :
 Pale anemia-shock-HF
 Red conjunctivitis.
Look :
 Sunken eyes dehydration/marasmus
 sunset eyes hydrocephaly
 Squint can be normal up to 6mᵒ. up down
 Epicanthus fold / hyperthelorism

Other details will found in neonatal examination

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Note:
 Hypertelorism= abnormally large distance between pupils (‫)مكان عين تالتة‬
 Hypertelorismdistance Between two medial epicanthus X100
distance Between two lateral epicanthus
 normal=38(+-)6
 if below 32= Hypotelorism
 if above 44= Hypertelorism

Nose:
 Depression in 
1. Black race.
2. Cretinism (hypothyroidism).
3. Down’s syndrome.
 Acting alae nasi RD.
 Nasal discharge 
 Watery --> allergic.
 Purulent --> infection.
 Blood --> bilateral bleeding disorder- congestion
Uni F.B
Ears: position –shape-any accessory auricle
 Imaginary line started from medial epicanthus of eyepass to occipit
 Normally=upper 1\3 above line and 2\3 below
 In low set ear=less than 1\3 above line
 Low set ear found in:
1. Down’s syndrome-Edward and other syndromes
2. 1ry Microcephaly.
Shape:
 Normal or enlarged as fragile x syndrome
 bat ear edward syndrome
 any accessory ear (rag) or ear pitsmust do renal u|S 20% associated
with renal anomaly
 Ear dischargeotitis media or bloody in F.B

Palpate mastoid bone pain and tenderness occur in mastoiditis

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Mouth :
tongue
 Dry dehydration.
 Enlarged cretinism.
 Fissured=scrotaldowns syndrome
 Smooth megaloblastic anaemia.
 Strawberryscarlet fever/Kawasaki disease
Lips
 Paleanaemia.
 Blue central cyanosis.
 Fissure=angular stomatitisvit B2
Teething
 1ry=milk teeth=20 teeth
First at 6-7m/complete at 2year.
 2ry=permanent=32 teeth Delayed teething:
First at 6-7 y/complete at 22 y 1. Normal variant
Tonsils 2. Rickets
Normally same colour. 3. PEM
Congestion tonsillitis. 4. Down syndrome
Gum 5. cretinism
 Hypertrophiedleukemia/phenytoin
 Bleedingmalnutrition/bleeding disorder
Note:
 kopliks spots pathognomonic of measles
 Mouth ulcerherpetic gingivostomatitis/hand foot mouth disease/chicken
pox
…………………………………………………………………………………………………………………………..
Neck : Look for :
1. VeinsJVP
2. ArteriespulsationAR(Corrigan)/suprasternalhyperdynamic circulation
3. L.Ncervical
4. Parotid gland-->enlarged in mumps-parotitis-infectious mononucleocis-
leukemia
5.thyroid glandgoiter
6. Neck motionmeningismusmeningitis-CP-tetanus-rheumatoid arthritis

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Examination of neck :
Inspection:
 Scars.
 Visible veins.
 Swelling comment on :
 Site.
 Size.
 Moved with swallowthyroid swellingbecause it sheathed by pretracheal
fascia.
 Not moved Moved with protruding of tongue thyroglossal cyst.
Palpation:
 Behind pt. • Site of swelling.
 Palpate for :
• Size.
 Hotness.
• Surface.
 Thrill. • Tenderness.
 Swelling
• Consistency.
Fix one hand and palpate by the other • Edges.
Hand and comment on • Fixed or not
 Palpate cervical L.N.
Percussion: over suprasternal notch, if swelling extend.
Auscultation: bruit (over swelling)Finally examine the eyes for exophthalmos.
…………………………………………………………………………………………………………………………..
L.N. Examination : Comment on:
1) Sub mental  Site L.N.
2) Pre auricular  Size
3) Post auricular  Tenderness
4) Sub mandibular  Fixed or mobile
5) Occipital  Consistency
6) Cervical (Ant.+Post.) Rubber lymphoma
7) Supra clavicular  Attached to skin or
8) Axillary (apical,Ant,Post,medial, lateral group). not
9) Inguinal=midway between ASIS and symphysis pubic.  Usually :
10) Popliteal = supine + flex knee
 Painful infection.
 Painless tumours.

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Causes of generalized lympho-adenopathy:
 Virus EBV-HiV
 Bacterial T.B-Brocillosis
 Fungal laptosporduse
 Parasite toxoplasma
 Cancer 
1ry: lymphoma, leukaemia
2ry: due to metastasis
 Drugs Phenytoin
 Other sarcoidosis-SLE
…………………………………………………………………………………………………………………………..
Extremities:
1. Ricketsepiphyseal enlargement (wrist –ankles)
Marfans sign
Bowing deformity
2. Peripheral cyanosis.
3. Palmer Erythema hyper dynamic circulation
4. Ossler nodule it’s painful nodule on tip of fingers, found in infective
endocarditis.
5. Creases pale anaemia.
6.Skin scar or changeskwashiorkor
7. Nail 
Koilonychia spooning of nail iron deficiency anaemia.
Leukonychia  nail white in colour hypoalbumenemia.
Pitting nail (oil spots) psoriasis.
Onycholysis separation of nail plate from bed *trauma,
*psoriasis.
Splinter haemorrhage red lines under nail 
 Infective endocarditis.
 Liver cirrhosis.
 Trauma.
 ↓Vit. C.
Clubbing: it’s swelling of terminal phalanges due to interstitial oedema and
dilatation of capillary it will lead to loss of normal angle between nail/bed.

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Grades of clubbing:
G₁ = swelling subcutaneous over base of nail.
G₂ = swelling involve nail bed.
G₃ = swelling of pulp of fingers. (drum stick).
 Fluctuation test  
 Window test loss of angle, no space between two nails.
D/D of finger clubbing:

1.Pulmonary causes : Also during palpation of hand

1) Bronchiectasis. comment on :
2) Pulmonary abscess. 1) Temperature.
3) Empyema. 2) Tenderness.
4) Interstitial fibrosis. 3) Swelling.
5) Malignancy. 4) Sweating :
2.Cardiac causes : 5) Hyperthyroidism.
1) Cyanotic heart disease. 6) Anxiety.
2) Sub acute infective endocarditis.
3) Chronic congestive HF.
3.Hepatic causes :
1) Biliary cirrhosis.
2) Biliary atresia.
4.GIT:
1) IBD.
2) Small bowel syndrome.
3) Celiac disease.
5.Endocrine causes :
1) Thyrotoxicosis.
2) Thyroid deficiency.
3) Idiopathic.
4) Familial.
L.L:
Put pt in supine position, exposure above knee.
Inspect for visible veins/ scars/ oedema/ ecchymosis/ deformities/ tenderness.
sandals sign /peripheral cyanosis

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 Genitalia
male female
 Ambiguous genitalia  Ambiguous genitalia
 Napkin rash  Napkin rash
 For penis sizelarge in PP  Labia majora cover labia minora or
 Circumcised or not not
 urethral meatus central or not  Discharge
Hypospadias  PP changes
 Palpate tests (if both presented or
not) The Undescended Testicle
 If hydrocele do fluctuation and
transillumination test
PR-anal region
 Examine for: specially in pts with chronic constipation
1. Rectal prolapse
2. Anal fissure
3. Excoriation marks
4. Anal tone anal mass
5. Blood and anal fistula

General related to:

General examination related to respiratory
1. General look and postureposture-color-surround
2. Anthropometric measurementwt-OFC-length
3. Vital signsBP-pulse-HR-temp
4. from head to toes

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  Central and  working alan nasi
peripheral cyanosis

 Noisy breath
Ex:
 Stridor-grunting
 wheeze

 Pushed liver
 BCG scar

 Peripheral cyanosis  subcostal-intercostal-

 Clubbing sternal –suprasternal
recession

General related to abdominal system:

5. General look and posture
 Well or unwell- including conscious level (hepatic coma)
 Biult- Nutritional status over or under wtconfermed by measurment
 Colour: paleGIT bleeding-malabsorption
Yelowishjaundice
 Skin rashes : dermatitis herpetiformis
 Pigmentation  cafe-au-lait patches as a result of NF1(Gl) stromal
tumours
 Dysmorphic featuresmucopolysaccharidoses
 Souroundednasogastric tube – IVF
2.Anthropometric measurement: very important to confirm if child thriving or
not thriving
3. Vital signsBP-pulse-HR-tempdetails in general examination
4. from head to toes
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  Sclera Jaundice  Dry lipsdehydration
 Skin yellow or green/brownobstructive  smooth tongue and angular
jaundice stomatitis ex: Iron deficiency
 Plethorachronic liver disease  Mouth ulcer Crohn's
 Cyanosis hepatopulmonary syndrome disease, ulcerative colitis,
coeliac, behcets disease
 Gum hypertrophy myeloid
 Level of conscious
leukaemia
Hepatic coma
 drugs: ciclosporin, phenytoin
Severe dehydration
Reye's syndrome  Macroglossia- in
hypothyroidism
 Dysmorphic feature
mucopolysaccharidoses
 Down syndrome
 Hairnutritional problems
1.Finger clubbing ex: Acrodermatitis enteropathica
 Cystic fibrosis  Neck for L.N
 Crohn's disease  Gynecomastia
 Coeliac disease (rar)  Edema in face –L.L-dorsum of
 Liver disease hand and foot
2. Pale palmar Which caused by PLE and
Creases=anemia ex: Liver disease
 Malabsorbtion  Skin changesPEM
 Chronic GIT bleeding Acrodermatitis enteropathica
3. Koilonychia ex:
 Iron deficiency
4. Leuconychia ex:
 Cirrhosis
5.palmar erythema ex:
 Chronic liver disease
6. Xanthoma ex:
 Hypercholesterolaemia

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 General examination related to CVS
6. General look and posture
 Posturesquatting positionTOF
 Colorcyanosis (central-peripheral)=cyanotic CHD
Pale=HF
 Surround pulse oximetry -infusion pump-IVF-mask
7. Anthropometric measurementwt-OFC-lengthFTT in chronic disease
8. Vital signsBP-pulse-HR-tempdetails in general examination
Don’t forget to check pulse in most of sites

9. from head to toes  Dimorphic feature

ex: down syndrome
turner syndrome
 Central and peripheral
cyanosis  Check next paper

 Teeth= caries high

 Difficult in pediatrics due
risk for infective
short neck
endocarditis
 Capillary refilling
 S-S of RD
 Tender HepatomegalyHF  Base of lungfine
crepitation=HF
 Hand:
 Oslers nodule=IE
 Splinter he=IE  Splenomegalyinfective
 Clubbing endocarditis
 Cyanosis
 Differential clubbing=COA
 Edema

‫علي بالخير‬.‫ د‬- ‫ بالتوفيق للجميع‬-‫التنسونا من صالح الدعاء‬

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