Pediatric physical

examination
3rd stage / nursing college
Prepared by
Dr. Zaid W. Ahmed
Pediatrician
M.B.Ch.B F.I.B.M.S.
Examination: General tips

 Minimize discomfort: Use appropriate games and distraction to decrease fear

and enhance cooperation.
 Examine toddlers in parent’s lap if fearful of exam table.
 Offer gown as appropriate. Explain to parent/child as appropriate.
 Show them it doesn’t hurt by examining the parent. Let the child examine
YOU.
 Let the more invasive and fear-invoking maneuvers (i.e. ear and throat exam)
till last.
General Appearance:

 Observe any signs of acute or chronic distress as

evidenced by skin color, respiration, hydration, mental
status, cry and social interaction.

 Interpret the general appearance of the child including

size, dysmorphic features, development, behaviors and
interaction of the child with the parents and examiner.
Note:

1. Identify the anterior and posterior fontanels and assess

them for fullness.

2. Observation of the head size, shape, and symmetry.

3. Note facial features, ear size and hair type.

4. Check red reflex (corneal opacities and intraocular masses)

5. Assess dentition, oral mucosa and pharynx.

6. Assess hydration of the mucous membranes.

Assessment Techniques:

The order of techniques is as follows (Inspection – Palpation –

Percussion - Auscultation)
A. Inspection – critical observation *always first*

1. Take time to “observe” with all senses

2. Discover the area for examination.

3. Use good lighting

4. Look at color, shape, symmetry, position

5. Observe for odors from skin, breath, wound

6. Observe surroundings of the patient???

7. Ask the mother about previous admission.

B. Palpation – light and deep touch

1. A method of feeling the body part(size ,shape, firmness, consistency

& location) using the hands (palm and fingers).

2. Warming of hands .

3. Use Back of hand (dorsal aspect) to assess skin temperature.

4. Apply Fingers to assess texture, moisture, areas of tenderness

5. Assess size, shape, and consistency of lesions and organs (spleen,

liver, kidneys).
C. Percussion – sounds produced by touching body surface.

1. Tapping on surface to determine the underlying structure, done with

the middle finger of one hand tapping on the middle finger of the
other hand using a wrist action

2. Produces different notes depending on underlying mass (dull,

resonant, flat, and tympanic)

3. Used to determine size and shape of underlying structures by

establishing their borders and indicates if tissue is air-filled, fluid-
filled, or solid

4. Action is performed in the wrist.

D. Auscultation – listening to sounds produced by the body
1. Direct auscultation – sounds are audible without stethoscope
2. Indirect auscultation – uses stethoscope
3. Fine-tune your ears to pick up subtle changes.
4. Describe sound characteristics (frequency, degree intensity, duration,
quality) [practice skill]
5. Flat diaphragm picks up high-pitched respiratory sounds.
6. Bell picks up low pitched sounds such as heart murmurs.
Vital Signs:

 Measure heart rate, respiratory rate, BP

 Determine temperature and oxygen saturation as indicated

 Determine weight, height/length, head circumference (< 2

years), BMI (kg/m2).

 Apply on standard curves and determine percentiles.

Neck

1. Palpate for lymph nodes.

2. In Older children- note thyroid size and texture.

Chest:

1. Assess rate, pattern and effort of breathing, recognizing

normal variations.

2. Recognize grunting, nasal flaring, stridor, wheezing,

crackles/asymmetric breath sounds.

3. Distinguish between inspiratory and expiratory sounds.

4. Interpret less serious respiratory sounds such as

transmitted upper airway sounds.
Cardiovascular:

1. Identify the pulses in the upper and lower extremities through

palpation.

2. Assess cardiac rhythm, rate, quality of the heart sounds and

murmurs through auscultation.

3. Assess peripheral perfusion by capillary refill.

4. Assess for systemic signs of heart failure (enlarged liver, edema)

Abdomen:

1. Palpate for and percuss out liver and spleen.

2. Examine the umbilical cord in newborns for number of

vessels.

3. Identify granulation tissue and umbilical hernias.

4. Assess the abdomen for distention, local or rebound

tenderness, and masses through observation, auscultation
and palpation.
Genitalia

1. Recognize the appearance of normal male and female genitalia in

the newborn.

2. Palpate the testes.

3. Recognize male genital abnormalities including cryptorchidism,

hypospadias, hernias, hydrocele and testicular mass.

4. Recognize female genital abnormalities including signs of

imperforate hymen, labial adhesions and signs of injury (female
genitalia)
Extremities:

Examine the hips of a newborn for dysplasia using the Ortolani and
Barlow maneuvers.

Evaluate gait/limp.(walking)

Recognize pathology such as restricted or excessive joint mobility,

joint effusions, signs of trauma and inflammation.

Check for tibia bowing (rickets)

Back:

Assess for abnormalities/defects over spine.

Assess for scoliosis in the older child/adolescent.

Neurologic examination

Elicit primitive reflexes

Assess the quality and symmetry of tone, strength and reflexes using
age-appropriate techniques.
Skin:

Assess turgor, perfusion, color, pigmented lesions and rashes through

observation and palpation.

Identify jaundice, petechiae, purpura, vesicles and urticaria.

Head

1. Look for scars, lumps, rashes, hair loss, or other lesions.

2. Look for facial asymmetry, involuntary movements, or

edema.

3. Palpate to identify any areas of tenderness or deformity.

Fontanels in a newborn - toddler:

1. Posterior fontanel – triangle shaped; closes 2-3 months

2. Anterior fontanel – diamond shaped; closes at 9 months –

24 months
EAR.

For children pull the ear down and back.

d) Use the largest speculum that will fit comfortably.

e) Inspect the ear canal and middle ear structures noting any
redness, drainage, or deformity.

f) Insufflate the ear and watch for movement of the tympanic

membrane.

g) Repeat for the other ear.

4. Normal color of eardrum: shiny translucent, pearly gray.

5. Abnormal findings:

a) erythema –Otitis Media. purulent drainage.

b) Dull, non transparent gray – serous otitis media with

effusion

6. Conductive hearing loss is due to mechanical dysfunction

of inner or middle ear.

7. Sensory-neural hearing loss is due to pathological

problem of inner ear, CNS or cerebral cortex.
 Component
Score of 0 Score of 1 Score of 2
of acronym

blue at extremities no cyanosis

Skin color blue all over body pink body and Appearance
(acrocyanosis) extremities pink

Pulse rate absent <100 >100 Pulse

sneeze/cough/
no response to grimace/feeble cry
Reflex irritability pulls away when Grimace
stimulation when stimulated
stimulated

Muscle tone none some flexion active movement Activity

Breathing absent weak or irregular strong Respiration