Assessing Children:

Infancy
through Adolescence

Group A

Section- B
Group members
Saeed Abdullah Mazen
Badana Naveen
Kumar Duraiswamy Senthilnathan
Sundaram Arun Prashanth Chakravarthy Balasubramanyam
Balusupati Harika Venna Siva
Pushpa Bhavana Nandha Reddy
Ayudhala Chandana Nandyala Kavya susmitha
Ali Saif Vinti
Vijaykumar Chirag Avula Sai Keerthana
Kurni Sanskruthi Chavda Parth
Purohit Dilipkumar Bheraji Bhupatbhai
Allam Mary Bariya Miral Chunilal
Sathvika Nakum Amit S
Divya
OBJECTIVE
● General Principles of Child Development
● Assessing the Newborn
● Assessing the Infant
● Assessing Young and School-Aged Children
● Assessing Adolescents
Principle of child development

Child development Various physical, social,

proceeds along a and environmental factors,

01 predictable pathway 02 as well as diseases, can

affect child development
and health

The child’s
The range of normal developmental level

03 development is wide
04 affects how you conduct
the history and
physical examination
 New
born assessment
Infancy is divided into
Neonatal period (the first 28
days)
Postneonatal period (29 days
to 1 year).
Tips for examining Newborn
Examine the newborn in the presence of the parents.
● Swaddle and then undress the newborn as the examination proceeds.
● Dim the lights and rock the newborn to encourage the eyes to open.
● Observe feeding, if possible, particularly breast-feeding.
● Demonstrate calming maneuvers to parents (e.g., swaddling).
● Observe and teach parents about transitions as the newborn arouses.
● A typical sequence for the examination of the newborn:
● Careful observation before (and during) the examination
● Heart
● Lungs
● Head, neck, and clavicles
● Ears and mouth
● Hips
● Abdomen and genitourinary system
● Lower extremities, back
● Eyes, whenever they are spontaneously open or at end of
examination
● Skin, as you go along
● Neurologic system
 performed immediately after
delivery by obstetrical or
pediatric clinicians.

● Performed within 24 hours of

birth

● It is important for determining

general condition,
developmental status,
abnormalities in gestational
development, and any
congenital abnormalities.

● Reveal diseases of cardiac,

respiratory, or neurologic origin.
 APGAR SCORING
SYSTEM
Gestational age Birth weight
classification classification

Preterm - <34 Extremely low birth weight

weeks <1,000 g

Late preterm -34-36 Very low birth weight -

weeks <1,500 g

Term - 37-42 weeks Low birth weight <2,500 g

Postterm - > 42 Normal birth weight ≥2,500

weeks g
Ballard Score for Determining
Gestational Age in Weeks
Small for gestational age is a term used to
describe a baby who is smaller than the usual
amount for the number of weeks of pregnancy. SGA
babies usually have birthweights below the 10th
percentile for babies of the same gestational age

If the baby's gestational age findings after birth

match the calendar age, the baby is said to be
appropriate for gestational age (AGA). birth
weight is between the 10th and 90th percentiles for
the infant's gestational age and sex

Large for gestational age (LGA) refers to a fetus

or infant who is larger than expected for their age
and gender. It can also include infants with a birth
weight above the 90th percentile
Assessment of infants
● Physical development
● Cognitive and language development
● Social and emotional development
 Tips for infant
examination.

● The examination of infants is an art, demanding qualities

of understanding, sympathy and patience
● Approach the infant gradually, using toy or object for
distraction,mimic the infant sound to attract attention.
● Perform examination as possible with infant in parent lap
● Keep disturbing and painful procedures to the last.
● It is not necessary to be systemic in your examination,
but should be complete.
 Examination
Measurement should include

Vital signs
Temperature
Blood pressure
Heart rate
Respiratory rate

Growth parameters
Height
Weight
Head circumference
 Techniques of examination

Head
Length Weight
circumference
For children younger Weight infants Should always be
than age 2 years, directly with an infant measured during first 2
measure body length scale. Should be years of life.
by placing the child weighed naked or be It reflects the rate of
supine on a measuring clothed only in a growth of
board or in a diaper the cranium and the brain
measuring tray
 SKIN
INSPECTION
Inspect the skin for texture, color, appearance, rashes,any patch or birth mark,
blisters.

PALPATION
Palpate the skin to assess the degree of hydration’
It is important to determine the thickness , turgor, consistency of the skin.

Lanugo, fine downy hair, may be seen more prominent on the infant’s back, along the arms and the legs.
This is normal and the infant sheds this over time.

Vernix Caseosa, a cheesy-white substance covering the infant’s body that protects the skin inside the uterus,
may be seen more prominent along the skin folds.

Salmon patch–Also called the “stork bite,” or “angel kiss,” this splotchy pink
mark fades with age
Non pathologic condition

Acrocyanosis Jaundice
Acrocyanosis is Jaundice is a condition in which the skin,
blueness of the whites of the eyes and mucous
membranes turn yellow because of a
extremities (the hands high level of bilirubin
and feet) and the
center of your face like It occurs during days 2 to 5 of life.
the nose and ears
It progresses ftom head to toe as it
 Common benign rashes
Miliaria rubra -known as heat rash or prickly
heat, is a common skin condition caused by the
blockage of the sweat gland

Erythema toxicum - appears on 2-3 day of life.

Consist of erythematous macules with central
pinpoint vesicles scattered diffusely over the entire
body. They appear similar to
flea bites.

Pustular Melanosis- It is vesiculopustular and

made up of 1-3 mm fluid-filled lesions that rupture,
leaving behind a collarette of scale and a brown
macule.

Milia-Pinhead-sized smooth white raised areas

without surrounding erythema on the nose, chin, and
 Birthmark
Café-au-lait Slate Blue
Spots Patches
 ● The areas where the major sutures intersect in the anterior and posterior portions of
Head
●
the skull are known as fontanelles.
Examine the sutures and fontanelles carefully.Pick up the infant and examine the skull
shape from behind

● Inspect the scalp veins carefully to assess for dilatation.

● On palpation, the sutures feel like ridges and the fontanelles like soft
concavities.Palpate along the suture lines. A raised, bony ridge at a suture line
suggests craniosynostosis. Auscultate for bruit.

● The anterior fontanelle at birth measures 4 to 6 cm in diameter and usually closes

between 2 and 26 months of age (90% between 7 and 19 months).
● Posterior fontanelle measures 1 to 2 cm at birth and usually closes by 2
months.enlarged posterior fontanelle may be present in congenital hypothyroidism.

Check the face of infants for symmetry. In utero positioning may result in transient facial
asymmetries.
-Micrognathia
-Percuss the cheek to check for Chvostek sign
EYE
➔
➔
Inspection of the eyes.
Bright light cause infants to blink, so use subdued lighting
➔ small colorful toys are useful as fixation devices in examining the eyes.
➔ Some newborns can follow your face and turn their heads 90° to each side. Examine
infants for eye movements.
➔ Hold the baby upright, supporting the head.
➔ Rotate yourself with the baby slowly in one direction. This usually causes the baby’s
eyes to open, allowing you to examine the sclerae, pupils, irises, and extraocular
movements.
➔ The baby’s eyes gaze in the direction you are turning.
➔ When the rotation stops, the eyes look in the opposite direction,after a few nystagmoid
movements
➔ Look for abnormalities or congenital problems in the sclera and pupils
➔ Examine the conjunctiva for swelling or redness
Inspection of eyes by Abnormalities
Doll eye reflex esotropia
Corneal light reflex testing Colobomas
Pupillary testing
Brushfield spots
Evaluation of red reflex
Fundus examination Congenital glaucoma
EAR
➔ Assess for asymmetry or irregular shape
➔ Examine the position, shape, and features of the ear and to detect
abnormalities.
➔ Note presence of auricular or preauricular pits, fleshy appendages,
lipomas
➔ Check for any discharge, deformity,discoloration,and displacement
Nose and sinuses

➔ Inspect the nose to ensure that the nasal septum is midline

➔ The size, shape and symmetry of nose should be noted.
➔ Look for deformities,obstruction of the airway, color of mucosa and
tenderness
➔ At birth, the maxillary and the ethmoid sinuses are present. Palpation
of the sinuses of newborns is not helpful.
➔ Test for patency of the nasal passages.
➔ Flaring of nasal hairs are always a sign of respiratory distress
Mouth and pharynx
➔ Use both inspection with a tongue depressor and flashlight and palpation to
inspect the mouth and pharynx Examine the external mouth for symmetry such
as drooping of the mouth.
➔ Look for tongue , palate, tonsils and pharynx
➔ Tongue should be examined for size, shape, color and coating.
➔ Examine the teeth for dental caries, color, number and for dental occlusion.
Neck
➔ Inspect the neck for symmetry, masses and enlargement of gland and lymph
node.
➔ Check the position of the thyroid cartilage and trachea

➔ Palpate the lymph nodes of the neck and assess for any additional masses such
as congenital cyst
➔ palpate the clavicles and look for evidence of a fracture
Thorax and lungs
INSPECTION
Carefully assess respirations and breathing patterns
Note general appearance, respiratory rate, color, nasal component of breathing, audible
breath sounds, and work of breathing

PALPATION
Assess tactile fremitus by palpation
PERCUSSION
The infant’s chest is hyperresonant throughout, and it is difficult to detect abnormalities on
percussion

Auscultate each side of the chest in a symmetrical pattern, comparing side to side:

● Pay attention to the inspiratory and expiratory sounds at each placement.

● Note the quality and volume of the breath sounds.
● Note any additional sounds (e.g. wheeze, coarse crackles)
Heart

INSPECTION
➔ Inspect for cyanosis
➔ Observe the infant for general signs of health. The infant’s nutritional status,Responsiveness,
irritability, and fatigue are all clues that may be useful in evaluating cardiac disease

PALPATE
➔ Palpation of the chest wall will allow you to assess volume changes within the heart
➔ Peripheral pulses, especially brachial
➔ PMI is not always palpable; 1 interspace higher than in adults
➔ Thrills
AUSCULTATE
➔ S1, S2 (split is normal but fuse together as single sound during deep expiration)
➔ S3 is frequently heard and is normal
➔ Murmurs - functional murmurs VS pathologic
 ABDOMEN
Inspect the abdomen with the infant lying supine (and, optimally,Asleep).

Examine umbilical cord to detect abnormalities.Inspect the area around the umbilicus for
redness or swelling

● Look for scars, discoloration, striae, sinuses, and fistulas

Auscultation of a quiet infant’s abdomen is easy.listen to the nine regions and four
quadrants of the abdomen.

Percussion -Percussion is useful for determining the size of organs and abdominal masses.

Palpate the abdomen to assess for organomegaly:

● Liver: should be palpable no more than 2cm below the costal margin (if palpable lower
in the abdomen consider hepatomegaly).
● Spleen: may be palpable at the left costal margin in healthy infants (if easily palpable,
consider splenomegaly).
● Kidneys: normally only palpable using deep bimanual palpation (if easily palpable
consider polycystic kidney disease).
● Bladder: should not be palpable in healthy infants (if easily palpable, considering
urinary tract obstruction)
Male Genitalia
Inspection
Inspect the male genitalia with the infant supine
➔ Penis : Inspect the shaft of the penis, noting any abnormalities on the ventral
surface. Make sure the penis appears straight.
➔ Scrotum : Inspect the scrotum noting rugae which should be present by 40 weeks
gestation. Scrotal edema may be present for several days following birth because of
the effect of maternal estrogen.

Palpation
● Palpate the testes in the scrotal sacs, proceeding downward from the external
inguinal ring to the scrotum. If you feel a testis up in the inguinal canal, gently milk it
downward into the scrotum.
● The newborn’s testes should be about 10 mm in width and 15 mm in length and
should lie in the scrotal sacs most of the time.
Examine the testes
● For swelling within the scrotal sac and over the
inguinal ring.
● If you detect swelling in the scrotal sac try to
differentiate it from the testis.
● Note whether the size changes when the
infant increases abdominal pressure by crying.
● See if your fingers can get above the mass,
trapping it in the scrotal sac.
● Apply gentle pressure to try to reduce the size
of the mass and note any tenderness and also
whether it transilluminates.
 Female Genitalia
➢ In the newborn female, the genitalia will be prominent due to
the effects of maternal estrogen.
➢ The labia majora and minora have a dull pink color in light
skinned infants and may be hyperpigmented in dark-skinned
infants.
➢ During the first few weeks of life there is often a milky white
vaginal discharge that may be blood tinged and is not a cause
for concern. This estrogenized appearance of the genitalia
decreases during the first year of life .
 Female genital examination

● Examine the female genitalia with the infant supine.

● Examine the different structures systematically, including the size of
the clitoris, the color and size of the labia majora, and any rashes,
bruises, or external lesions.
● Next, separate the labia majora at their midpoint with the thumb of
each hand,
● Inspect the urethral orifice and the labia minora. Assess the hymen,
which in newborns and infants is a thickened, avascular structure with
a central orifice, covering the vaginal opening.
● You should note a vaginal opening, although the hymen will be
thickened and redundant. Note any discharge.
 Rectal Examination
The rectal examination generally is not performed for infants or
children unless there is question of patency of the anus or an
abdominal mass.

In such cases, flex the infant’s hips and fold the legs to the
head. Use your lubricated and gloved pinky to perform the
examination.
The Musculoskeletal System
The examination of the infant focuses on detection of congenital
abnormalities, particularly in the hands, spine, hips, legs, and feet.

Hands
➔ Inspect The newborn’s hands are clenched. Because of the palmar grasp
reflex. Inspect the fingers carefully, noting any defects.
➔ Palpate along the clavicle noting any lumps, tenderness, or crepitus; these
may indicate a fracture

Spine
➔ Inspect the spine carefully. Although major defects of the spine such as
meningomyelocele are obvious and often detected by ultrasound before birth,
➔ Palpate the spine in the lumbosacral region, to find any deformities of the
vertebrae.
Hips

➔ Examine the newborn and infant’s hips carefully at each examination for signs of
dislocation

There are two major techniques

● Ortolani test to test for the presence of a posteriorly dislocated hip

● Barlow test to test for the ability to sublux or dislocate an intact but unstable
hip
Ortolani test
Barlow test
Place the baby supine with the legs
place your hands in the same
pointing toward you. Flex the legs to
position as for the Ortolani test. Pull the
form right angles at the hips and knees,
leg forward and adduct with posterior
placing your index fingers over the
force (that is press in the opposite
greater trochanter of each femur and
direction with your thumbs moving down
your thumbs over the lesser
toward the table and outward). Feel for
trochanters. Abduct both hips
any movement of the head of the femur
simultaneously until the lateral aspect
laterally. Normally, there is no
of each knee touches the examining
movement and the hip feels “stable.
table.
Legs and feet
➔ Newborn or infant’s legs and feet examine is to
detect developmental abnormalities.
➔ It is common for normal infants to have asymmetric
thigh skin folds, but if you do detect asymmetry,
make sure you perform the instability tests because
dislocated hips are commonly associated with this
finding.
➔ Some normal infants exhibit twisting or torsion of the
tibia inwardly or outwardly on its longitudinal axis.
➔ At birth, the feet may appear deformed from
retaining their intrauterine positioning, often turned
inward.
➔ The newborn’s foot appears flat because of a plantar
fat pad.
➔ Babies with adduction of the forefoot without
inversion called metatarsus adductus.
➔ most toddlers have some pronation during early
stages of weight-bearing with eversion of the foot. In
all of these normal variants the abnormal position
can be easily overcorrected past midline. They all
 The Nervous System
Unlike many neurologic abnormalities in adults that produce asymmetric
localized findings, neurologic abnormalities in infants often present as
developmental abnormalities such as failure to do age appropriate tasks.

Neurologic examination

● The neurologic screening examination of all newborns should include

assessment of mental status, gross and fine motor function, tone, cry, deep
tendon reflexes, and primitive reflexes.
● It can reveal extensive disease but will not pinpoint specific functional deficits or
minute lesions.

Mental Status

➔ Assess the mental status of newborns by observing the newborn activities

Motor Function and Tone.
➔ Assess the motor tone of newborns and infants,
➔ first by carefully observing their position at rest and
testing their resistance to passive movement.
➔ Further, assess tone as you move each major joint
through its range of motion, noting any spasticity or
flaccidity.
➔ Hold the baby in your hands to determine whether
the tone is normal, increased, or decreased. Either
increased or decreased tone may indicate
intracranial disease although such disease is
usually accompanied by a number of other signs.

Sensory Function
➔ Test for pain sensation by flicking the infant’s palm
or sole with your finger.
➔ Observe for withdrawal, arousal, and change in
facial expression.
Deep Tendon Reflexes
➔ The deep tendon reflexes are present in
newborns but may be difficult to elicit and
may vary in their intensity because the
corticospinal pathways are immature.
➔ The triceps, brachioradialis, and abdominal
reflexes are difficult to elicit before 6 months
of age.
➔ The anal reflex is present at birth and
important to elicit if a spinal cord lesion is
suspected In newborns.
➔ In order to best elicit the ankle reflex of an
infant, grasp the infant’s malleolus with one
hand and abruptly dorsiflex the ankle. You
may note rapid rhythmic plantar flexion of
the newborn’s foot (ankle clonus) in
response to this maneuver Up to 10 beats
THE HEALTH
HISTORY
Assessing Younger Children
 Assessing Older Children
When interviewing a child, you need to consider the needs and perspectives
of both the child and the caregivers.

Establishing Rapport
● Begin the interview by greeting and establishing rapport with each person
present.
● Refer to the child by name rather than by “him” or “her.”
● Clarify the role or relationship of all of the adults and children.
like.,“Now, are you Jimmy’s grandmother?”

Working with Families

● While eventually you need to get information from both the child and the
parent, it is useful to start with the child.
● Asking simple open-ended questions like “Are you sick? . . . Tell me about it,”
Multiple Agendas
● Each individual in the room, including the clinician, may have a different
idea about the nature of the problem and what needs to be done about it.
● Discover as many of these perspectives and agendas as possible.
● Your goals need to include uncovering the concerns of each person and
helping the family to be realistic about the range of “normal.”

The Family as a Resource

● A good strategy is to view the parents as experts in the care of their child
and yourself as their consultant

Hidden Agendas
● Create a trusting atmosphere that allows parents to be open about all their
concerns by asking facilitating questions such as:
Do you have any other concerns about Randy?
Was there anything else that you wanted to tell/ask me
today?
HEALTH PROMOTION
AND COUNSELING
Children 5 to 10 Years

➢ As for earlier ages, these visits present opportunities to

assess the child’s physical, mental, and developmental
health and the parent– child relationship and the child’s
relationships with peers and school performance.
➢ Health promotion should be incorporated into all
interactions with children and families.
➢ Focus on healthy habits such as good nutrition, exercise,
reading, stimulating activities, health sleep hygiene,
screen time, and safety.
➢ About 12% to 20% of children have some type of chronic
physical, developmental or mental condition. These
children should be seen more frequently for monitoring,
disease management, and preventive care .
TECHNIQUES OF
EXAMINATION
General Survey and Vital Signs
SOMATIC GROWTH
Height
● For children older than 2 years measure standing height, 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.
● After age 2 years children should grow at least 5 cm per year.

Weight
● Children who can stand should be weighed in a gown (or in clothing without
shoes) on a stand-up scale.

Head circumference
● Measured until the child reaches 24 months. Afterward, head circumference
Body Mass Index for Age
● BMI in children is associated with body fat, related to subsequent health
risks for obesity.
● BMI measurements are helpful for early detection of obesity in children
older than 2 years.
● Obesity is now a major childhood epidemic and it often begins before age 6
to 8 years.
● Consequences of childhood obesity include hypertension, diabetes,
metabolic syndrome, and poor self-esteem.
● Childhood obesity often leads to adult obesity and shortened lifespan.
VITAL SIGNS
Blood Pressure

● Children have elevated blood pressure during exercise, crying, and anxiety.
● If the blood pressure is initially elevated you can perform blood pressure
readings again at the end of the examination.
● Elevated readings must always be confirmed by subsequent measurements.
● A proper cuff size is essential for accurate determinations of blood pressure in
children.
● Among chubby young children, the Korotkoff sounds are not easily heard. In
such instances, you can use palpation to determine the systolic blood pressure,
remembering that the systolic pressure obtained is approximately 10 mm Hg
lower by palpation than by auscultation.
● If unable to obtain the blood pressure by auscultation/palpation, watch for the
needle to bounce by about 10 mm Hg. The systolic blood pressure obtained by
“inspection” is about 1 mm Hg higher than that obtained by auscultation.
Pulse

Measure the heart rate over a 60-second interval.

Respiratory Rate

● The rate of respirations per minute ranges from 20 to 40 during early

childhood and 15 to 25 during late childhood, reaching adult levels at
around 15 years of age.
● For young children, observe the movements of the chest wall for two 30-
second intervals or over 1 minute, preferably before stimulating them.
● The commonly accepted standard for tachypnea in children older than age
1 year is a respiratory rate >40 breaths per minute.

Temperature

● In children, auditory canal temperature recordings are preferable because

they can be obtained quickly with essentially no discomfort.
Head
➢ carefully observe the shape of the head, its symmetry, and the presence of
abnormal facies.
➢ Abnormal facies may not be apparent until later in childhood; therefore,
carefully examine the face as well as the head of all children.

Eyes
The two most important components of the eye examination for young children
are to determine whether the gaze is conjugate or symmetric and to test visual
acuity in each eye.
★ Conjugate Gaze. for adults to assess conjugate gaze, or the position and
alignment of the eyes, and the function of the extraocular muscles.
Visual Acuity

➔ It may not be possible to measure the visual acuity of children younger than 3
years who cannot identify pictures on an eye chart.
➔ In all tests of visual acuity it is important that both eyes show the same result
because of the risk for amblyopia.
➔ Visual acuity in children 4 years and older can usually be formally tested using
an eye chart with one of a variety of optotypes (characters or symbols).
➔ A child who does not know letters or numbers reliably can be tested using
pictures, symbols, or the “E” chart.
 Ears
➢ There are two common positions: the child lying down and
restrained, and the child sitting in the parent’s lap
➢ If the child is held supine, have the parent hold the arms
either extended or close to the sides to limit motion. Hold
the head and pull the pinna (auricle) upwards with one hand
while you hold the otoscope with your other hand.
➢ If the child is on the parent’s lap, the child’s legs should be
between the parent’s legs. The parent could help by placing
one arm around the child’s body and using the second arm
to steady the head (with the parent’s hand on the child’s
forehead).
➢ Carefully inspect the area behind the pinna, over the
mastoid bone.
➢ use a tympanometer, which measures the compliance of
the tympanic membrane and helps to diagnose a middle
Tympanic Membrane

There are two ways to hold the otoscope

➔ The first method is generally used in adults, with the

otoscope handle pointing upward or laterally while you
pull up on the auricle.

Hold the lateral aspect of your hand that has the

otoscope against the child’s head to provide a buffer
against sudden movements by the patient.

➔ The second position, with the handle of the otoscope

pointing down toward the child’s feet,

While holding the otoscope with the handle pointing

down, pull up on the auricle. Steady your hand against
the child’s head and pull up on the auricle with that
hand, while you hold the otoscope with the other hand.
Hearing Testing

● Formal hearing testing is necessary for accurate detection of hearing

deficits in young children.
● You can grossly test for hearing in very young children by using the
whispered voice test. Stand behind the child (so that the child cannot read
your lips). cover one of the child’s ear canals, and rub the tragus, using a
circular motion then Whisper.
● The AAP recommends that all children older than 4 years have a full-scale
acoustic screening test using standardized equipment.
● If you do use an acoustic screening test, be sure to test the entire acoustic
range, including the speaking range (500 to 6,000 Hz).
The Nose and Sinuses
➢ Inspect the anterior portion of the nose by using a large speculum on your
otoscope.
➢ Inspect the nasal mucous membranes, noting their color and condition.
➢ Look for nasal septal deviation and the presence of polyps.

● Maxillary sinuses are noted on x-rays by age 4 years,

● sphenoid sinuses by age 6 years, and
● frontal sinuses by age 6 to 7 years.
 The Mouth and Pharynx

➢ Ask the child to say “ahhhh” to make child mouth to

open more wider.
➢ The child who can say “ahhh” will usually offer a
sufficient (albeit brief) view of the posterior pharynx so
that a tongue depressor is unnecessary.

Teeth
● Examine the teeth for the timing and sequence of
eruption, number, character, condition, and position.
● Abnormalities of the enamel may reflect local or general
disease.
● Visualize the inside of the upper teeth by having the child
look up at the ceiling with the mouth wide open.
● Look for abnormalities of the position of the teeth. These
include malocclusion, maxillary protrusion (overbite), and
Tongue

● Carefully inspect the tongue, including the underside.

● Some young children have a tight frenulum. Have the child touch the
tongue to the roof of the mouth to diagnose this condition which often
does not require treatment unless it interferes with eating or speech.

Tonsils

● Note the size, position, symmetry, and appearance of the tonsils.

● The peak growth of tonsillar tissue is between 8 and 16 years.
● The size of the tonsils varies considerably in children and is often
categorized on a scale of 1+ to 4+.
● 1+ being easy visibility of the gap between the tonsils, and 4+
being tonsils that touch in the midline with the mouth wide
open.
● Tonsils in children usually have deep crypts on their surfaces,
which often have white concretions or food particles protruding
Voice

● Note the quality of the child’s voice.

● Certain abnormalities can change the pitch and quality of the voice.
The Neck
➢ Beyond infancy, the techniques for examining the neck
are the same as for adults.
➢ Lymphadenopathy is unusual during infancy but very
common during childhood.
➢ The child’s lymphatic system reaches its zenith of
growth at 12 years, and cervical or tonsillar lymph
nodes reach their peak size between 8 and 16 years.
➢ Check for neck mobility. It is important to ensure that
the neck of all children is supple and easily mobile in
all directions.
➢ In children, the presence of nuchal rigidity is a more
reliable indicator of meningeal irritation than Brudzinski
sign or Kernig sign.
The Thorax and Lungs

➢ Auscultation is usually easiest when a child barely notices

(as when in a parent’s lap).
➢ Assess the relative proportion of time spent on inspiration
versus expiration. The normal ratio is about 1:1.
➢ Prolonged inspirations or expirations are a clue to disease
location.
➢ Degree of prolongation and effort or “work of breathing”
are related to disease severity.
➢ Demonstrate to older children how to take nice, quiet, and
deep breaths.
➢ Children in respiratory distress may assume a “tripod
position” in which they lean forward to optimize airway
patency. This same position can also be caused by
pharyngeal obstruction.
The Heart
➢ General abnormalities may suggest increased likelihood of congenital
cardiac disease as exemplified by Down syndrome or Turner
syndrome.

Blood Pressure
● Measure the blood pressure in both arms and one leg at one time
around age 3 to 4 years to check for possible coarctation of the aorta.
● Thereafter, only the right arm blood pressure needs to be measured.
Benign Murmurs
● Preschool and school-aged children often have benign murmurs.
● Carotid artery compression will usually cause the precordial murmur to
disappear.
● In preschool or school-aged children, you may detect a venous hum. This
is a soft, hollow, continuous sound, louder in diastole, heard just below the
right clavicle.
● The murmur heard in the carotid area or just above the clavicles is known
as a carotid bruit.
The Abdomen
➢ Toddlers and young children commonly have
protuberant abdomens, most apparent when they
are upright.
➢ Try flexing the knees and hips to relax the child’s
abdominal wall.
➢ Palpate lightly in all areas, then deeply.
➢ .The spleen, like the liver, is felt easily in most
children. It is too soft with a sharp edge, and it
projects downward like a tongue from under the left
costal margin.
➢ The spleen is moveable and rarely extends more
than 1 to 2 cm below the costal margin.
Male Genitalia

Inspection
● The size in prepubertal children has little significance unless it is
abnormally large.
● In precocious puberty, the penis and testes are enlarged with signs
of pubertal changes.
● Examine the child when he is relaxed because anxiety stimulates
the cremasteric reflex.

Palpation
● With warm hands, palpate the lower abdomen, working your way
downward toward the scrotum along the inguinal canal. This will
minimize retraction of the testes into the canal.
● A useful technique is to have the boy sit cross legged on the
examining table.
● Examine the inguinal canal as you would for adults noting any
swelling that may reflect an inguinal hernia.
 FEMALE GENITALIA
❏ The genital examination can be anxiety provoking for the older child and
adolescent (especially if you are of the opposite sex) and for parents.

❏ Depending on the child’s developmental stage, explain what parts of the

body you will check and that this is part of the routine examination.

❏ After infancy, the labia majora and minora flatten out and the hymenal
membrane becomes thin, translucent, and vascular, with the edges easily
identified
 ● The Female genital examination is the same for all ages of children. from late infancy until
adolescence.
● gentle approach including a developmentally appropriate explanation as you do the
examination.
● Most children can be examined in the supine, frog-leg position.
● If the child seems reluctant, it may be helpful to have the parent sit on the examination with the
child.
● the examination may be performed while the child sits in the parent’s lap
● Do not use stirrups as these may frighten the child……in the figure 18.82 u can demonstrates a
5-year-old girl sitting on her parent’s lap with the parent holding her knees outstretched
● Examine the genitalia in an efficient and systematic manner.
Inspection: The external genitalia for pubic hair
The size of the clitoris
The color and size of the labia majora,
The presence of rashes, bruises, or other lesions
❖ Next, visualize the structures by separating the Techniques of
labia with your fingers, as shown in Figure 18-83.
Examination
❖ You can also apply gentle traction by grasping
the labia between your thumb and index finger of
each hand

❖ Now, separating the labia majora laterally and

posteriorly to examine

❖ The inner structures as shown in Figure 18-

84…..Labial adhesions, or fusion of the labia
minora

❖ may be be noted in prepubertal children and can

obscure the vaginal and urethral orifices.

❖ They may be a normal variant.

❖ Vaginal bleeding is always cause for concern.
❖ Note the condition of the labia minora, urethra,
hymen, and proximal vagina.

❖ If you are unable to visualize the edges of the

hymen, ask the child to take a deep breath to relax
the abdominal muscles.

❖ Another useful technique to be performed by an

experienced pediatric examiner is to position her in
the knee– chest position, as shown in Figures 18-
85 and 18-86.

❖ These maneuvers will often open the hymen.

❖ Experience examiners can also use saline drops to

make the edges of the hymen less sticky.
❖ Avoid touching the hymenal edges because the hymen is
exquisitely tender without the protective effects of hormone

❖ Examine for discharge:

a. labial adhesion
b. lesions
c. estrogenization (indicating onset of puberty)
d. hymenal variations ( such as imperforate or
septate hymen)
e. hygiene
The Rectal Examination
❖ The rectal examination is not routine but should be done whenever
intraabdominal, pelvic, or perirectal disease is suspect

❖ The rectal examination of the young child can be performed with the child in
either the side-lying or lithotomy position.

❖ For many young children, the lithotomy position is less threatening and
easier to perform.

❖ Provide frequent reassurance during the examination, and ask the child to
breathe in and out through the mouth to relax.

❖ Palpate the abdomen with your other hand, both to distract the child and to
note the abdominal structures between your hands.

❖ The prostate gland is not paplate in younger boy.

EXAMPLES OF ABNORMALITIES(RECTAL)
●
Anal skin tags are present in inflammatory bowel diseases but out
are more often an incidental finding when located in midline.

● Tenderness noted on rectal examination of a child usually indicates

an infectious or inflammatory cause, such as an abscess or
appendicitis
The Musculoskeletal
System
❖ Abnormalities of the upper extremities are rare in the absence of injury (older
children)
❖ The normal young child has increased lumbar concavity and decreased thoracic
convexity compared with the adult…
❖ often has a protuberant abdomen
❖ Observe the child standing and walking barefoot
❖ Ask the child to touch the toes
❖ rise from sitting, run a short distance, and pick up objects.
❖ You will detect most abnormalities by watching carefully from both front and
behind.
❖ note the soles of the shoes to see whether one side of the soles is worn down.
TECHNIQUES OF EXAMINATION
❖ During early infancy, there is a ❖ The knock-knee pattern (Fig. 18-
common and normal progression 88) is usually maximal by age 3
from bowleggedness (Fig. 18-87)
to 4 years and gradually corrects
that begins to disappear at about 18
months of age, often followed by by age 9 or 10 years
transition toward knock-knees…
❖ The presence of tibial torsion can be assessed in
several ways 55; one method is shown in Figure
18-89.
❖ Have the toddler lie prone on the examination
table, with the knees flexed to 90°. Note the
thigh–foot axis
❖ Usually there is ±10° of internal or external
rotation noted by a foot pointing off in a direction.
❖ Check the position of the malleoli—they should
be symmetric
❖ Children may toe in when they begin to walk.
❖ This may increase up to 4 years of age and then
gradually disappear by about 10 years of age.
Inspect: any child who can stand for
scoliosis using techniques described under
“Adolescents.”

❏ Determine any leg shortening that may

accompany hip disease by comparing.

❏ the distance from the anterior superior

spine of the ilium to the medial
malleolus on each side.

❏ Straighten the child by pulling gently on

the legs, and then compare the levels of
the medial malleoli with each other
➢ Test for severe hip disease with its
associated weakness of the gluteus
medius muscle.

➢ Observe from behind as the child shifts

weight from one leg to the other (Figs.
18-90 and 18-91).

➢ A pelvis that remains level when weight

is shifted from one foot to the other is a
negative Trendelenburg sign,With an
abnormal positive sign in severe hip
disease.

➢ the pelvis tilts toward the unaffected hip

during weight bearing on the affected
side positive Trendelenburg sign.
The Nervous
System
➢ Beyond infancy, the neurologic examination includes the components
evaluated in adults.
➢ Combine the neurologic and developmental assessment
➢ turn this into a game with the child to assess optimal development and
neurologic performance
➢ Use a validated developmental screen for preschool children
➢ Children usually enjoy this component, and you can too.
➢ Many neurologic conditions in children are accompanied by
developmental abnormalities
 TECHNIQUES OF
EXAMINATION
1. Sensation :
2. Deep Tendon
Reflexes.
❏ The sensory examination
❏ Deep tendon reflexes can be tested as in adults.
can be performed by using a
First, demonstrate the use of the reflex hammer on
cotton ball or tickling the
the child’s hand, assuring the child that it will not
child.
hurt. Children love to feel their legs bounce when
❏ This is best performed with
you test their patellar reflexes.
the child’s eyes closed. Do ❏ Have the child keep the eyes closed during some
not use pin pricks
of this examination because tensing will disrupt the
results
3. Cognitive
❏ Development
You can ask children older than 3 years to draw a picture or copy objects and then discuss
their pictures to test simultaneously for fine motor coordination, cognition, and language.

❏ Among school-aged children, the best test for development is their school performance. You
can obtain school records or psychological testing result.
 4 Gait, Strength, and
Coordination. 5. Cerebellar
❏ Observe the child’s gait while the child is
walking and, optimally, running. Note any Function
The cerebellar examination can be tested using
asymmetries, weakness, undue tripping, or finger-tonose and rapid alternating movements of
clumsiness. Follow developmental the hands or fingers (Figs. 18-93 and 18-94).
milestones to test for appropriate maneuvers
Children older than 5 years should be able to tell
such as heel-to-toe walking (Fig. 18-92),
hopping, and jumping. right from left so you can assign them right–left
❏ Use a toy to test for coordination and strength discrimination tasks as is done in the adult patient
of the upper extremities.
6. Cranial
Nerves
ASSESSING
ADOLESCENTS
 Development: 11 to
20 Years
➔ Adolescence can be divided into three stages: early, middle, and
late. Interview and examination techniques vary widely depending
on the adolescent’s physical, cognitive, and social–emotional levels
of developmen
 Cognitive
Development.
❏ Although less obvious, cognitive changes
during adolescence are as dramatic as
changes in physique. Most adolescents
progress from concrete to formal operational
thinking, acquiring an ability to reason logically
and abstractly and to consider future
implications of current actions (Fig. 18-95)
Social and Emotional
Development
❏ Adolescence is a tumultuous time, marked
by the transition from family-dominated
influences to increasing autonomy and peer
influence (Fig. 18-96). The struggle for
identity, independence, and eventually
intimacy leads to stress, health-related
problems, and often, high-risk behaviors
 The Health History
❖ The key to successfully examining adolescents is a
comfortable, confidential environment. This makes
examination more relaxed and informative. when
deciding issues of privacy, parental involvement, and
confidentiality (Fig. 18-97)
❖ Adolescents are more likely to open up when the
interview focuses on them rather than on their
problems.

❖ As in middle childhood, modesty is important.

❖ The patient should remain dressed until the
examination begins (Fig. 18-98). Leave the room
while the patient puts on a gown
❖ Not all adolescents are willing to don a gown, so
partially uncovering as the examination proceeds to
preserve the patient’s modesty is import.
❖ Most adolescents older than 13 years prefer to be
 Techniques of Examination
➢ General Survey and Vital Sign
Somatic
Growth.
➔ Adolescents should wear gowns to
be weighed or have them remove
their shoes and heavy clothing.
➔ This is particularly important for
adolescent girls being evaluated for
underweight problems.
➔ Ideally, serial weights (and heights)
should use the same scale
Vital Signs
➔ Ongoing evaluations of blood pressure are
important for adolescents
➔ The average heart rate from age 10 to 14
years is 85 beats per minute
➔ A range of 55 to 115 beats per minute
considered normaL
➔ .Average heart rate for those 15 years and
older is 60 to 100 beats per minute
 The
➔ Skin
Examine the adolescent’s skin carefully. Many adolescents will have
concerns
about various skin lesions….

➔ such as acne, dimples, blemishes, warts, and moles.

.
➔ Many adolescents spend considerable time in the sun and at tanning
salons.

➔ You may detect this during a comprehensive health history or by

noticing signs of tanning during the physical examination.

➔ This is a good opportunity to counsel adolescents about the dangers

of excessive ultraviolet exposure, the need for sunscreen, and the
risks of tanning salon

➔ This is a good opportunity to counsel adolescents about the dangers

of excessive ultraviolet exposure, the need for sunscreen, and the
risks of tanning salon
 Head, Ears, Eyes, Throat,
and Neck
➔ The examination of these body parts is generally the same as for adults.

➔ The methods used to examine the eye, including testing for visual acuity, are the
same adults.

➔ Refractive errors become common, and it is important to test visual acuity

monocularly at regular intervals, such as during the annual health supervision visit.

➔ The ease and techniques of examining the ears and testing the hearing approach the
methods used for adults.

➔ There are no ear, mouth, throat, or neck abnormalities or variations of normal unique
to this age group
●
The Heart
The technique and sequence of examination are the same as those for adults.

● Murmurs are a continued cardiovascular issue for evaluation

● The benign pulmonary flow murmur is a grade I–II/VI sof

● nonharsh murmur with the timing characteristics of an ejection murmur, beginning after the first
sound and ending before the second sound, but without the marked crescendo–decrescendo
quality of an organic ejection murmur.

● If you hear this murmur, evaluate whether…

● the pulmonary closure sound is of normal intensity and whether splitting of the second heart
sound is eliminated during expiration
● An adolescent with a benign pulmonary ejection murmur will have normal intensity and normally
split second heart sounds
 The Breasts
● Physical changes in a girl’s breasts are one of the first signs of puberty.
● As in most developmental changes, there is a systematic progression.
● Generally, over a 4-year period.
● the breasts progress through five stages, called Tanner stages or Tanner sex maturity rating
stages, as shown in the box on the next page. Breast buds in the preadolescent stage enlarge,
changing the contour of the breasts and areola.
● The areola also darkens in color.
● These stages are accompanied by the development of pubic hair and other secondary sexual
Menarche usually occurs when a girl is in breast stage 3 or 4.
● By then, she has passed her peak growth spurt
 TECHNIQUES OF EXAMINATION
★ Guidelines for the usefulness of clinical breast
examinations by a clinician are changing.
★ the American Cancer Society no longer
recommends clinical breast examinations for
women of any age to screen for breast cancer.
★ However, professional organizations consistently
recommend providing female patients with
instructions for self-examination (see p. 442)
★ In the event of a clinical breast examination, a
chaperone (parent or nurse) should assist male
clinicians
★ Breasts in boys consist of a small nipple and
areola. During puberty, about 1/3boys develop a
breast bud 2 cm or more in diameter,usually in
one breast.
★ Obese boys may develop substantial breast
tissue
The Abdomen (TECHNIQUES OF
EXAMINATION)
❖ Techniques of abdominal examination are the same as for adults
❖ The size of the liver approaches the adult size as the teen progresses
through puberty, and is related to the adolescent’s overall height
❖ it is likely that evidence from adult studies apply, particularly for older
adolescents
❖ Palpate the liver. If it is nonpalpable, hepatomegaly is highly
unlikely. If you can palpate the lower edge, use light
percussion to assess liver span
 Male Genitalia(TECHNIQUES OF
EXAMINATION)
➔ The genital examination of the adolescent boy
proceeds like the examination of the adult male.
➔ Be aware of the many boys experience during this
aspect of the examination.
➔ Important anatomical changes in the male genitalia
accompany puberty and help to define its progress.
➔ The first reliable sign of puberty (Fig. 18-100),
starting between ages 9 and 13.5 years is an
increase in the size of the testes.
➔ Important anatomical changes in the male genitalia
accompany puberty and help to define its progress.
➔ The first reliable sign of puberty (Fig. 18-100),
starting between ages 9 and 13.5 years is an
increase in the size of the testes.
Female Genitalia (TECHNIQUES
➔ The external examination of adolescent female
OF
EXAMINATION)
genitalia proceeds in the same manner as for
school-aged children
➔ If clinically necessary to perform a pelvic
examination, the technique is the same as for an
adult female.
➔ Of note, indications for performing pelvic
examinations in adolescents have become much
more stringent.
➔ When performing a pelvic examination, a full
explanation of the steps of the examination,
demonstration of the instruments, and a gentle,
reassuring approach are necessary because the
adolescent is usually quite anxious.
➔ A chaperone (parent or nurse) must be present. An
adolescent’s first pelvic examination should be
performed by an experienced health care provider.
➔ The first easily detectable sign of puberty is usually
the appearance of breast buds although pubic hair
The Musculoskeletal
➔ First, examine the patient standing assessing
System(EXAMINATION)
symmetry of shoulders, scapula, and hips.

➔ then have the child bend forward with the knees

straight and head hanging straight down between
extended arms (Adams forward bend test).

➔ Next, evaluate any asymmetry in positioning.

➔ Scoliosis in a young child is unusual and abnormal

scoliosis in an older child is not uncommon.

➔ scoliosis appears as an asymmetrical rise in the

thoracic region (as shown in Fig. 18-102) or lumbar
region, or both.

➔ the scoliometer over the spine at a point of maximum

prominence making sure that the spine is parallel to
the floor at that point, as shown in Figure 18-102.
➔ You can also use a plumb line, a
string with a weight attached, to
assess symmetry of the back (Fig.
18-103). Place the top of the plumb
line at C7 and have the child stand
straight. The plumb line should
extend to the gluteal crease.

➔ Scoliosis is more common among

children and adolescents with
neurologic or musculoskeletal
abnormalities

➔ The remainder of the

musculoskeletal examination is
similar to that for adults, except for
Screening Musculoskeletal
Examination for Sports
 The
Nervous
System
● The neurologic examination of the
adolescent and the adult is the same.
Assess the adolescent’s developmental
achievement according to age-specific
milestones