PAEDIATRIC

PHYSICAL EXAMINATION

Submitted to, Submitted by,

Mrs. Bindhu K Shankar Aswathy. R. C
Assistant professor 1 st yr MSc Nursing
Govt. College of Nursing Govt. College of Nursing
Thrissur Thrissur
Physical examination of a child involves a complete head-to-foot examination, including all
the systems with special emphasis on the area most probably affected, as per the history taken.
Younger children are best examined in the mother's lap. Older children can be examined on an
examination couch or in standing position. An adolescent female should always be examined
in the presence of her mother or female attendant if examined by a male doctor.
SEQUENCE OF EXAMINATION
1. General appearance: Consciousness and mental state, stature, nutritional status,
posture/attitude, other typical findings (body odour, cry, facies)
2. Vital signs (pulse rate, respiratory rate, temperature, blood pressure)
3. Anthropometry
4. Developmental assessment
5. Head-to-toe examination (skull, facies, eyes, nose, ears, mouth, throat, neck, chest, genitalia,
rectal examination, extremities, oedema, skin, nails, hair, spine). Oedema, pallor, cyanosis,
jaundice, clubbing should not be missed
6. Significant lymphadenopathy
7. Body surface area 8. Systemic examination
1.GENERAL APPEARANCE
The general appearance gives valuable information regarding the condition of the child. The
examiner should note if the child looks healthy, unwell or ill. It is also important to observe if
the child appears comfortable or irritable.
CONSCIOUSNESS AND MENTAL STATE
Consciousness is a person's awareness of self and surroundings. The examiner should note the
level of the child's consciousness and grade it accordingly.

 Delirium
 Lethargy
 Stupor
 Coma
Glasgow Coma Scale
This neurological tool is used to record the conscious state of a person for initial as well as
subsequent assessments.
Values of the eye, motor and verbal responses are added to get a final score. These values are
also considered separately. The lowest possible Glasgow Coma Scale score is 3 (deep coma or
death), while the highest is 15.
Mental and Emotional State
Types of mental and emotional states are as given below:

 Happy, playful, alert and interested in the surroundings (normal healthy child)
 Anxious (anxiety neurosis) Elation: A feeling of well-being or excitement (in bipolar
mania)
 Euphoria: An exaggerated feeling of well-being often not justified by circumstances
 Depression (depressive psychiatric disorders)
 Restless (hyperactive child and child with pain)
 Dull, not interested in surroundings, apathetic or irritable (in kwashiorkor)
STATURE
a.Normal Stature
The height or length is between 3rd and 97th percentile for age, sex, region and race.
b.Short Stature
The height or length is below 3rd percentile or less than two standard deviations of mean for
the age, sex, region and race. The causes of short stature are as follows:
 Familial
 Chromosomal disorders such as Down syndrome
 and Turner syndrome Endocrine disorders such as hypopituitarism and
 hypothyroidism
 Undernutrition
 Skeletal dysplasias such as achondroplasia Children born small for gestational age
c.Tall Stature
The length or height is above 97th percentile or two standard deviations above the mean for
normal population of same age, sex, region and race. The causes for tall stature are as follows:

 Constitutional (or familial)

 Cerebral gigantism
 Marfan syndrome

VITAL SIGNS
1.TEMPERATURE
Sites to Record Body Temperature
 Oral cavity
 Axilla
 Rectum
 Groin (between the abdomen and the flexed thigh)
 Ear canal (tympanic membrane)
 Skin over the forehead
The clinician should remember that the rectal temperature is 1°F more than the oral temperature
and the oral temperature is 1°F more than the axillary temperature.
Temperature Ranges
Temperature Degree celsius Degree fahrenheit

Normal 36.6- 37.2 98-99

Subnormal <36.6 <98

Febrile >37.2 >99

Hyperpyrexia >41.6 >107

Hypothermia <35 <95

2.PULSE
Pulse should be palpated in all the peripheral arteries.
Age Pulsations/min
<6 months 120-160
6-12 months 110-120
1-5 years 95-110
6-12 years 80-110
>12 years 60-100

3.RESPIRATORY RATE
The respiratory rate should be counted exactly by watching the chest or abdomen movements
for 1 minute. The movements should be observed for at least 10 seconds.
Age Normal respiratory Tachypnoea
rate
Up to 2 months 30-50 >60
2-12 months 20-40 >50
12 months to 5 yr 20-30 >40
5-10 yr 15-20 >30
>10 yrs 15-18 >30
Tachypnoea
Respiratory rate is increased in the following conditions:

 Anxiety, exertion, fever, hypoxia and acidosis

 Respiratory causes such as pneumonia
Bradypnoea
Respiratory rate is decreased in the following conditions:
 Alkalosis
 Hypothyroidism
 Increased intracranial tension

Hyperpnoea
Increased depth of breathing is seen in the following conditions:
 Acidosis
 Hysterical
 Brainstem lesions
4.BLOOD PRESSURE
Blood pressure should ideally be recorded in all four limbs.
Separate cuffs should be used for children of different ages. A cuff of the appropriate size
covers two-thirds of the length of the arm on which it is tied, with the inflatable bladder
covering the entire circumference of the arm with no overlapping
The normal blood pressure in a child depends upon the age of the child. The blood pressure is
low in newborn and infants. In older children, the blood pressure is more.
Age Systolic Diastolic
Newborn 50-70 25-45
Up to 6 months 60-80 30-50
6 months – 1 year 60-90 50-70
1-6 years 70-100 40-70
7-12 years 90-110 50-70

ANTHROPOMETRY
Anthropometry is the measurement of the body. It includes measurement of the following
parameters:

 Weight
 Length, if the child is <2 years old or bed ridden
 Height, if the child >2 years old
  Crown-rump length
 Head circumference
 Chest circumference
 Midarm circumference

HEAD-TO-TOE EXAMINATION
SKULL
 Size of the Head: Macrocephaly, Microcephaly
 Shape of Head: Dolichocephaly, Brachycephaly
 Fontanel: Anterior fontanel, Posterior fontanel
FACE
 Facial palsy
EYES
 Spacing- Distance between both eyes. It is measured by canthal index.
 Eyebrows, Eyelids, Eyelashes- Ptosis, lid lag, lid retraction
 Strabismus – presence of squint
 Sclera- Yellowish discolouration
 Lens- The examiner should look for discolouration of lens and cataract
 Conjunctiva- check for pallor or anaemia, Bitot’s spot
EARS
 Presence of pinna
 Preauricular skin tag
 Low set ears
 Able to hear normal voice tone
NOSE
 Nasal bridge: Flat nasal bridge,saddle nose
 Nostrils: presence of any nasal polyps
MOUTH & THROAT
 Lips: cyanosis, cheilosis
 Buccal mucosa: Oral thrush, Ulcers,
 Teeth: Absent teeth, Natal teeth, dental caries
 Gums: Gum hypertrophy, gum bleeding
 Tongue: Microglossia, Macroglossia, colour, Tongue tie
 Check Tonsils, pharynx and larynx.
NECK
 Torticollis
 Excessive skinfolds
 Position of trachea
CHEST
 Chest deformities: Pectus excavatum, Pectus carinatum, Barrel chest
 Retraction of intercostal muscles
 Symmetrical chest expansion
 Noisy respiration
LUNGS
 Abdominal respiration
 Air entry
HEART
 Apex
ABDOMEN
 Presence of visible peristalsis
 Distension
 Vomiting, Diarrhea
GENITALIA
Female
 Discharge or bleeding
 Signs of infection
Male
 Hypospadiasis, Epispadiasis
 Hydrocele
 Signs of infection
Back and rectum if indicated

EXTREMITIES
 Electromelia
 Phocomelia
 General examination of arms and hands
 Examination of axilla
 Test for reflexes
 Examination of joints for movements,tenderness and inflammation.
 Check for clubbing and capillary refill