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Pediatric Physical Assessment

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PEDIATRIC ASSESSMENT: FOCUS ON PHYSICAL ASSESSMENT CLASS 8 Pediatric Assessment: The Major Focus Major differences between children and adults Specific approaches and techniques to physical exam Normal findings, variations and common pathological conditions Interpretation of exam results Major Concepts in Pediatric Physical Assessment Children are not little adults Understanding differences from adults is important Differences relate to both growth and development patterns Differences exist in motor skills and coordination, and in physiologic, psychosocial, behavioral, temperamental, language, and cognition areas Skills Utilized in Working with Children Knowledge of growth and development Communication skills with children and their parents Understanding of family dynamics and parent-child relationships Knowledge of health promotion and anticipatory guidance Major Concepts for Assessment and Health Promotion Development Medical history Nutritional status Growth and vital sign measurements Physical assessment Guidelines for well child supervision Anticipatory guidance Immunizations 1
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Page 1: Pediatric Physical Assessment

PEDIATRIC ASSESSMENT: FOCUS ON PHYSICAL ASSESSMENT

CLASS 8

Pediatric Assessment: The Major Focus

Major differences between children and adults Specific approaches and techniques to physical exam Normal findings, variations and common pathological conditions Interpretation of exam results

Major Concepts in Pediatric Physical Assessment

Children are not little adults Understanding differences from adults is important Differences relate to both growth and development patterns Differences exist in motor skills and coordination, and in physiologic, psychosocial, behavioral,

temperamental, language, and cognition areas

Skills Utilized in Working with Children

Knowledge of growth and development Communication skills with children and their parents Understanding of family dynamics and parent-child relationships Knowledge of health promotion and anticipatory guidance

Major Concepts for Assessment and Health Promotion

Development Medical history Nutritional status Growth and vital sign measurements Physical assessment Guidelines for well child supervision Anticipatory guidance Immunizations

Exam Settings

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Outpatient (office, clinic emergency room) Well child check Illness visit

Inpatient Moderate to severe illness Anxiety and stress

School setting or health office

Children usually healthy Illness visits primarily common acute problems and some chronic illness issues Health screenings

Environmental Setting

Safety is primary Pleasant, comfortable settings are helpful Accessible toys for young children are distracters and may reduce anxiety Age appropriate literature or items for teens and older children provide diversion in waiting areas

Standard Measurements

Weight Height Head Circumference Chest Circumference Vital Signs

Temperature Pulse, Heart Rate Respiration Blood Pressure

Gestational Age Assessment and Intrauterine Growth Charts

Sensory Issues

Smell: usually not tested; observe for unusual odors from child Taste: usually not tested; infants often prefer sweet tasting foods Touch: well developed in infant; if stimulated can invalidate other sensory tests Vision: right eye (OD), left eye (OS), both eyes (OU) Hearing: correlates with language development; localization requires both ears

Specific Evaluations

Development Vision Hearing Language

Key Points to Assessment Procedure

Head to foot exam is most orderly Vary sequence according to child’s response

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Examine young children in parent’s lap Do intrusive examinations last

Approach to Physical Exam

Consider age and developmental level; observe for “readiness” clues Take time to get “acquainted” Use play techniques for infants and young children Determine best exam place ( table, parent’s lap, examiner’s lap) Use systematic approach; but be flexible to accommodate child’s behavior Examine least intrusive areas first (i.e., hands, arms) Examine sensitive, painful or intrusive areas last (i.e. ears, nose, mouth) Determine what exam you want to complete before possible crying (i.e. heart, abdomen)

Age Groups

Neonate/Newborn Birth to 28 days Pre-term Gestational age <37 weeks Term Gestational age 37-42 weeks Post-term Gestational age > 42 weeks

Infant Birth to 1 year Young, Immobile Birth to 6 months Older, Mobile 6 to 12 months

Young Child 1-5 years Toddler 1-3 years Pre Schooler 3-6 years

School Age or Older Child 6-12 years Adolescent 13 to 18/21 years

Pre-Adolescent 10-12 years

Approach to Infants

Birth to 6 months: If baby is comfortable and stress free, exam can be conducted on table. Sensory methods, such as voice, noise makers, toys to see or touch, or skin touch attract babies. They like a smiling human face. Do quiet things first, then head to toe.

6 to 12 months: Consider exam in parent’s lap due to separation or stranger anxiety (up to 4 years). “Warm up” more slowly with play techniques. Object permanence and ability to anticipate develops, so provide comfort measures after unpleasant procedures. Increased mobility leads to additional safety measures and limit-setting concepts, which continue with each age group.

Approach to Toddlers

Exam in parent’s lap, due to need for parent security. Play games. Do least intrusive things first. Save ears, nose, throat for last. Avoid “no” responses or choices they can not make. Offer simple acceptable choices. Let them touch equipment.Approach to Pre-Schoolers

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Keep parent close. Some will cooperate with exam on table. Protect modesty. Use dolls, animals or parents to “examine” first. Magical thinking may cause fearfulness or thinking equipment is alive. Let them play with equipment. Use familiar, safe, non-frightening words and approaches.

Approach to School-Age Child

Do a head to toe exam. Respect modesty. Address questions more directly to child. Explain in concrete terms. Medical diagrams or teaching dolls are helpful. Elicit their active participation in history, exam and care plan. Answer questions honestly.

Approach to Adolescents

Confidentiality, privacy, protection of modesty are important. Explain confidentiality parameters. Offer to examine alone, without parent present. Address questions to patient.Keep in mind, depression is more common in adolescents, especially girls. More common concerns among girls include body-image distortion, loss of appetite & weight, & lack of satisfaction. More common concerns among boys include irritability, social withdrawal & drop in school performance. A health promotion system such as GAPS, Guidelines for Adolescent Preventive Services can be useful

An Additional Growth and Development Handout is Available to Download

This is a 5-page summary, including one chart and additional summaries of pertinent growth and development theories

General Assessment: Key Points

Note general appearance State of wellness Degree of illness or distress Behavior

General Assessment:

Body: Symmetry, nutrition, build, hygiene, breath, odor, posture, movement, coordination, facial expression

Behavior: Development, attitude, affect, responsiveness/awareness,cooperation, speech, LOC (person, place, time), thought process, attention span, concentration, memory

Distress: Posture, (flexion/extension), pain, facial grimace, respiration

Skin, Hair and Nails: Skin – Key Points

Color: Jaundice, pallor, cyanosis, erythema, ecchymosis Texture & Turgor: Degree of hydration or dehydration Edema: Periorbital (crying, allergies, renal disease, juvenile hypothyroidism)

Dependent (renal or cardiac disease)

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Birth Marks Pigmentations: Hyperpigmentation (endocrine, growth disturbance); hypopigmentation Infectious lesions: Viral, bacterial, fungal (erythema, macule, papule, vesicule, pustule) Capillary bleeding: Petichiae and purpura usually indicate serious conditions Infestations: Pediculosis, scabies, insect bites Pruritis: Dry skin, allergy, eczema, contact dermatitis, hepatic, renal, lesions Trauma: Scars, ecchymosis, signs of abuse Hand: Dermatoglyphic variations associated with syndromes

Common Skin Variations in Newborns and Infants

Thin, transparent skin, especially premature Color Variations Vascular Markings Pigmentations Lanugo (downy hair) more prominent in premature Original hair may shed at 4-8 weeks, and be replaced

Skin Color Variations

Jaundice: Pathologic in first 24 hrs. physiologic after 24 hrs. Acrocyanosis Cyanotic, cool extremities; warm, pink trunk Cutis marmorata Bluish mottling due to chilling or stress Erythema toxicum Papules, vesicles on erythematous base @24-48 hrs.

Harlequin color change Lower side of body red, upper side pale – change reverses it Milia White papular epidermal cysts with sebaceous retention Miliaria (4 types) Obstruction of sweat ducts from head and humidity Neonatal acne, prickly head Miliaria – crystallina, rubra, pustulosa, profunda

Pallor Anemia or anoxia Plethora Erythematous flush, due to polycythemia

Skin Vascular Markings

Capillary hemangiomas (telangiectasia or telangiectataic nevus ornevus simplex --- “stork bites,” “angel kisses”) --- usually fade

Nevus flammeus (“port wine stains”), nevus vasculosis ---not likely to fadeCan be associated with Sturge-Weber Syndrome

Strawberry hemangioma: bright red, lobulated tumor

Cavernous hemangioma: bluish red, more vascular than strawberrySkin Pigmentations

Mongolian spots in darker pigmented infants Pigmented nevi, Café au Lait (<3cm and <6 in # are WNL – larger size or more spots associated with

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Neurofibromatosis , or Von Recklinghausen Disease) – an autosomal-dominant disorder, with tumors on peripheral or cranial nerves

Yellow Skin Color

Jaundice: Observed in sclera, skin, fingernails, soles, palms & oral mucosa .Does not blanche with pressure over chest or nose areasIs associated with liver disease, hepatitis, red cell hemolysis, biliary Obstruction & sever infection during infancy.

Carotenemia: Observed in palms, soles, face, skin (not in sclera or mucous membranes)Blanches easily to pressure over chest or noseOccurs in older infants, with eating yellow vegetables

Renal Disease: Yellowing of exposed skin areas (not sclera or mucous membranes)May be associated with chronic renal disease

Hemolytic Jaundice of Newborn: Biirubin above 5ml/dl

Pathologic: Occurs first 24 hrs of life.Bilirubin increases faster than 5ml/dl/day

Physiologic: Onset after 24 hrs, with peak from 72-90 hrs.Declines at 4 to 7 days

Breast Feeding: Early onset: Onset at 2 to 4 days. Peak at 3 to 5 daysLate onset: Onset at 5-7 days. Peak at 10 to 15 days.

May remain jaundiced for 3 to 12 weeks

Hair: Key Points

Assess for distribution, color, texture, amount, quality and for infestations Course, dry, brittle or depigmented hair may indicate nutrition deficiency or thyroid disorder Alopecia may be related to tinea capitus, hair pulling or persistent positioning White eggs (nits) attached to hair shafts indicate pediculosis Hair tufts on spine or buttocks may indicate spina bifida

Nails: Key Points

Inspect for color, shape, condition, nail biting and infection Clubbing may indicate chronic hypoxia (respiratory or cardiac disease) “Spoon” nails may indicate iron deficiency anemia Pitted nails may indicate psoriasis Splinter hemorrhages under nails may indicate trauma or endocarditis

HEENT: Head & Neck: Eyes: Ears: Nose, Face, Mouth & Throat

Head: Symmetry of skull and face Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes Eyes: Vision, placement, external and internal fundoscopic exam Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane Nose: Exam of nose and sinuses

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Mouth: Structures of mouth, teeth and pharynx

Head: Key Points

Head Circumference (HC): Frontal Occipital Circumference (FOC) Fontannels/sutures: Anterior closes at 10-18 months, posterior by 2 months Symmetry & shape: Face & skull Bruits: Temporal bruits may be significant after 5 yrs Hair: Patterns, loss, hygiene, pediculosis in school aged child Sinuses: Palpate for tenderness in older children Facial expression: Saddness, signs of abuse, allergy, fatigue Abnormal facies: “Diagnostic facies” of common syndromes or illnesses

Head: Variations

Neonates: Molding (suture overlap) resolve 2 days Capput succedaneum (scalp swelling) resolve 2 days Cephalohematoma (subperiosteal hemorrhage) resolve wks/months

Fontannels: Tense and bulging with increased intracranial pressure (ICP)Depressed with dehydration

Large HC/ICP: Increased HC due to increased ICP (before suture closure), tense & bulging fontannels, dilated head veins, “sunset sign.”Head may tranilluminate.May indicate hydrocephalus, intraventricular hemorrhage, trauma, meningitis or tumors. In older child, after cranial sutures close, ICP increases are more like adult signs ( headache, vomiting, BP increases, change in LOC)

Small HC: May indicate microcephaly or craniosynostosis

Craniosynostosis: Asymmetric head shape due to premature closure of sutures.Surgical separation corrects defect.

Craniotabes: “Ping-pong” effect with pressure over temporo-parietal-occipital areas. May be WNL, or result of hydrocephaly, rickets or infection

Macewen’s sign: “Cracked pot” sound with tapping over parietal bone.May be WNL in infants, or associated with ICP & suture separation(i.e. lead encephalopathy, tumor)

Chevostek’s sign: Spasm of facial muscle with percussion over zygomatic bone in front ofear. May be associated with hypocalcemic tetany and tetanus.

Flattened head areas: Especially occipital flattening with hair loss, may indicate persistent placement of baby in same position.

Eyes: Key Points

Vision: Red reflex & blink in neonateVisual following at 5-6 wks 180 degree tracking at 4 monthsE chart & strabismus check for preschool childSnellen charts for older children

Irritations & infections PERRLA

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Amblyopia (lazy eye): Corneal light reflex, binocular vision, cover-uncover test EOMs: tracking 6 fields of vision Fundoscopic exam of internal eye & retina

Eyes: Variations

Placement & symmetry: Wide set: hypertelorism – Down syndromeClose set: hypotelorismEpicanthal folds or upward slants – ethnicity, Down s.Character of eyebrows

Eyelids: Ptosis, lid lag, blepharitis (stye), swellingDacryocystitis (blocked tear duct) may cause rednnes, swelling and discharge“Allergic shinner” (dark circles) may indicate allergyPerorbital edema may indicate renal problemsSunken eyes may indicate dehydration

Conjunctive: Inflammation, pallor (anemia), Cobblestone appearance may indicate allergy

Sclera: Jaundice (liver disease), injection (conjunctivitis),Hemorrhage, blue color (osteogenesis imperfecta)

Cornea: Smooth, moist,clear (not injected with conjunctivitis red eye)

Pupil & Iris: Brushfield’s spots (light speckling of iris) seen in Down s.

Coloboma (notch at outer edge or iris) may indicate visual field defect.

Othalmoscope: Partial or dark red reflex indicates pathology, various retinal anomalies or opacities of cornea, anterior chamber or lens(i.e. cataract)

White retinal reflex indicates pathology (i.e., retinoblastoma,Retinal detachment chorioretinitis)

Retinal hemorrhage is pathological, associated with a variety of causes: Is a specific diagnostic criteria in “shaken baby” syndrome.

Papilledema of increased ICP more likely in olde child, with closed cranial sutures

Ears: Key Points

Exam last In younger children

Restrain Young children in lap, head braced against parent’s chest

Hearing: Especially if language delay or frequent otitis media

Otoscope exam: Pull auricle down & back for infants, toddlers, preschoolersPull auricle up &back for school aged & adolescents

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Cerumen removal may be necessaryUse pneumatic otoscopy

Tuning fork: Weber & Rinne tests to differentiate conductive vs sensorineural hearing loss are not effective with younger children

Ears: Variations

External: Malformed auricle/pinna, or low-set or obliquely-set ears may be Associated with many syndromes, or genitourinary & chromosomal abnormalities.

Otitis externa: Pain with movement of auricle or tragus, discharge in canal, occurs More often in summer (“swimmer’s ear”)

Otitis media: Proper position & holding of otoscope facilitates comfortableAs middle ear pressure or fluid increases, the tympanic membrane (TM) becomes less mobile with pneumatic otoscopy. Exam of TM:

TM: Dull, gray, retracted, loss of light reflex, landmarks may be more difficult to see, with possible superior injection near short process of malleus is associated with blocked or obstructed eustachian tubes.

TM: Dull, bulging, gray or with some injection is associated with pressure, fluid or pus accumulating in the middle ear.

TM: Red, dull/thick/bulging, with landmarks not visible is associated with acute otitis media.

TM: Orange-amber color, with/without bubbles/fluid lines is associated with serous otitis media with effusion, often associated with viral URIs, or pressure changes, such as diving or flying. TM may be retracted, with landmarks easier to see.

Nose: Key Points

Exam nose & mouth after ears (after crying from ear exam) Observe shape & structural deviations Nares: ( check patency, mucous membranes, discharge, inferior turbinates, bleeding) Septum: (check for deviation) Infants are obligate nose breathers Nasal flaring is associated with respiratory distress

Nose: Variations

Allergy: Pale, boggy mucous membranes & interior turbinates, watery discharge, mouth breathing & “allergic salute” line across nose.

Infection: Erythematous, edematous mucous membranes, with purulent yellow or green nasal discharge

Foreign body: Foul odor or unilateral discharge

Excoriation: Irritating discharge, frequent wiping or nose picking

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Structure variations: Observe flattened nose or nasolabial folds that may indicate congenital anomolies.

Asymmetry of nasolabial folds may indicate facial nerve impairment or Bell’s palsy.

Sinuses: Key Points

Palpate maxillary & frontal sinus areas for tenderness of sinusitis in older children Development of facial sinuses and location of sinus pain is listed below:

Sinus Pain Location Age of Development Maxillary cheek & upper teeth present @ birth Ethmoid medial & deep to eye present @ birth Frontal forehead & above eyebrow approximately 7 years Sphenoid deep behnd eye in occiput adolescence

Mouth & Pharynx: Key Points

Inspect lips for color, symmetry, moisture, swelling, sores, fissures. Inspect buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding,

lesions.

Inspect tongue & frenulum for movement, size & texture

Count teeth & inspect for caries, malocclusion and loose teeth.20 deciduous teeth, begin eruption at 6 months & continue adding approximately 1/month32 permanent teeth, erupt from 6 to 25 years, with molar eruption from 1to 25 years

Inspect uvula for symmetrical movement or bifid uvula (indicating cleft palate or WNL

Observe for quality of voice

Observe infants for rooting and sucking reflexes, Epstein pearls & thrush

Observe breath for halitosis

Mouth & Pharynx: Variations

Newborn cysts: White retention epitheleal cysts occur in the newborn:Epstein’s pearls occur along midline of palate.Bohn’s nodules occur along gum line, resembling teeth.

Vesicular eruptions: Can occur on lips, buccal mucosa & tongue, due to viral infections,such as herpes simplex cold sores or aphthous stomatitis.

Fissure/cracked lips: May be due to harsh climate or vitamin deficiencies.

Color variations: Central cyanosis can be observed in lips & mucosa..Pallor may indicate anemia.

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Cherry red coloration may be seen in acidosis.

White patches: White ulcerated sores on mucosa ae cankers, related to mild trauma, viral infection, mild trauma or local irritants.

Koplik’s spots, small white, red rimmed eruptions on buccal mucosa next to first & second molars, appear and disappear before the onset of Measles (rubeola) rash.

White curdy patches that cannot be scraped away, may be oral candidiasis (thrush), and is common in infants, especially following antibiotic therapy.

Tongue variations: A smooth, red tongue may be related to vitamin deficiencies.

“Strawberry” and “Raspberry” tongue are seem in scarlet fever.

A short frenulum with inability to touch tongue to upper gum ridge(“tongue tie” or ankyloglossia) may lead to later speech problems.

Palate & uvula: With gag reflex, deviation of uvula to one side suggests eitherGlossopharyngeal or vagus nerve involvement or infection of peritonsillar or retropharyngeal abcess.

An absent or bifid (notched) uvula may indicate submucosal or soft palate cleft.

Tooth markings: Brown & black spots may indicate caries.

“Baby bottle” caries appear on teeth at gum line and aredue to babies taking a bottle to bed, and milk pools around the teeth.

Brown-white mottling may indicte excessive fluoride intake.

Green & black staining may indicate oral iron intake contacting teeth

An increase in tooth decay or evidence or eroded enamel may indicate frequent, self-induced vomiting, especially in adolescent girls. Callous marks on fingers/knuckles might also be observed

Pharynx: Large tonsils, due to developmental lymph tissue hypertrophyAre common in school aged children & adolescents

Large red tonsils covered with white exudate are suggestive of streptococcal tonsillitis, especially if palatal petichiae & red uvula are present.

Thick, gray exudate may indicate diptheric tonsititis

A gray, necrotic discoloration of tonsillar tissue may suggest infeftious mononucleosis.

A unilateral, red, enlarged tonsil suggests peritonsillar abcess.

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Voice quality: Nasal voice may indicate enlarged adenoids

Hoarse cry may indicate croup, cretinism or tetany.

Shrill, high-pitched cry may indicate increased ICP, such as head injury or meningitis.

Neck: Key Points

Check for position, lymph nodes, masses, cysts or fistulas/clefts Suppleness & Range of Motion (ROM) Check clavicle in newborn Head control in infant Trachea & thyroid in midline Carotid arteries (bruits) Torticollis Webbing Meningeal irritation

Neck: Variations

Head lag: Significant lag after 6 months may indicate cerebral palsy

Torticollis: “Stiff neck” with resistance to lateral head turn as result of injury tosternocleidomastoid muscle, more often seen in newborn

Clavicle: Check for fracture in newborn, associated with shortening, break in contour, Crepitus at fracture site, and decreased motion of arm

Webbing: Feature of “Turner’s syndrome” or other congenital abnormalities

Meningeal: Irritation indicated by nuchal rigidiy, opisthotonos, tripod position with sitting, Positive Brudzinski’s sign (with patient supine, neck flexion produces pain and flexion of hips and knees).Positive Kernig’s sign (with patient supine, hip & knee flexed, extension of knee Produces pain & resistance

Nodes: Lymphadenopathy common with infection in older children, upper neck areas, and below angle of jaw, usually bilateral. Should not be deep cervical or clavicular.

Mumps: Parotitis produces swelling over angle of jaw, usually unilateral, with redness & swelling of Stensen’s parotid duct in mouth & pain withsour tastes.

Thyroid Ascends with swallowing (not normally palpable in young child).Check bruits, nodules or goiter (& accelerated growth, staring eyes)

Lymph Nodes: Key Points

Inspect & palpate lymph nodes for size, color, location, temperature, consistency, tenderness, firmness & mobility.

Nodes are proportionately large in older children & adolescents, and smaller in the elderly. Lymphadenopathy in the head & upper neck area are common with various infections:

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(Occiptal, pre & post auricular, superficial anterior cervical, posterior cervical, tonsillar, submandibular, submaxillary, submental, sublingual)

Inguinal lymphadenopathy may be observed in some diapered children, but not usually otherwise.

Deep cervical, supraclavicular, infraclavicular, axillary & epitrochlear lymphadenopathy may indicate pathology.

Thorax & Lungs: Key Points

Structure: Observe for shape, symmetry & posture Chest deformities: can be WNL, but significance varies with severity etiology

AP diameter: round chest or 1:1 ratior during infancy, with transverse diameterincreasing, with AP:lateral ration 1:2 during school age years.

Pectus carinatum or pigeon breast: concavity of sternum Pectus excavatum or funnel chest protrusive sternum Harrison;s Groove: horizontal ression groove of lower ribs with lower rib flarring,

may indicate vitamin D deficiency (richets) Beading or richitic rosary: protrusive deformities along costochondral junctions,

may indicate vitamin D defenciency (richets)

Breast: Key Points

Inspection: size, color, symmeetry, color, nipples/accessory nipples, dimpling Palpation: masses, consistency, elasticity, nipple discharge Male gynecomastia Self Exam

Tanner Stages for Female:

I Prepubertal, elevation of papilla onlyII Breast bud, elevation of breast & papilla as small mount, enlargement of areolaIII Further enlargement of breast & areola, no separation of contoursIV Areola projected as secondary moundV Mature, recession of areolar mound to breast contour, projection of

papilla only

Lungs & Respiratory Status: Key Points

Symmetry of expansion, decreased expansion (pneumonia, pneumothorax, FB)

Prolonged expiratory phase Resp rate (>40 at rest, after neonate period = respiratory distress) Color: cyanosis or mottling Clubbing Nasal flaring Grunting (expiratory) Stridor (inspiratory): croup Snoring (expiratory): upper airway obstruction, allergy, enlarged lymph

tissue

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Retractions Respiratory movement: males abdominal, females thoracic-costal,

elderly shallow, infants abdominal Dyspnea Orthopnea Fremitus: Increase: pneumonia, atelectasis, mass

Decrease: asthma, pneumothorax or FB Dullness to percussion: fluid or mass Quality: vesicular (bronchioles, alveoli)

bronchovesicular (bronchi)bronchial (trachea)

Adventitious (adventiginous) sounds Crackles (rales) Rhonchi (course breath sounds) Wheeze Pleural friction rub

Cardiovascular: Key Points

Vital signs:compare with normal/age values Peripheral pulses: apical, carotid, radial/brachial, femoral, pedal Rate, rhythm: compare cardiac rhythm with pulse Peripheral vascular: color, temperature, edema, skin texture/changes Capillary refill: immediate Peripheral pulses: femoral pulses absent or diminished in aortic stenosis Deep vein thrombosis: Homan's sign Skin: pallor, cyanosis (lips, nail beds, ear lobes) Clubbing Pulsating neck vessels (JVD)

Bulging chest Elevated BP Thrills Bruits

Heart

Rate, rhythm, heart sounds Size, PMI Auscultation: sitting, lying, left recumbent & bending forward PMI: Lt. ventricular contraction during systole location & size of heart: midclavicular 5th intercostal space (4th/infant)

StethoscopeDiaphragm: high pitch, S1Bell: low pitch, S2

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S1: Mitral & Tricuspid AV valves close (ventricles are full,prior to ventricular contraction--systole begins,best at apex

S2: Aortic & Pulmonary semilunar valves close -- ventricles eject--after ventricular contraction--diastole begins, atrial filling begins

S2: may be split--widens during inspiration (increase venous return--increase filling time--delayed pulmonic closing)

S3: can be functional sound in childhoodS4: not normally audible, associated with cardiac abnormalities

Murmurs:may be systolic, diastolic or continuous (timing, location, quality (course, harsh, blowing, high pitched)

GRADE: I - faint, may not be heard sittingII - readily heard with stethoscopeIII - loud, no thrillIV - loud with stethoscope, thrillV - loud with stethoscope barely to chest, thrillVI - loud with stethoscope not touching chest, thrill

Functional Murmurs:Change or disappear with position change (usually loudest supine)Low grade, soft or musicalIntensity range from I-III/VISystolic (never diastolic)Do not radiate

COMMON FUNCTIONAL MURMURS: Cardiac murmurs occurring in absence of significant heart disease or structural abnormality

Still’s Murmur: 2 years – adolescence; midway between apex & LLSB, Grade I-II/VI, mid-systolic, soft, low pitched, louder in supine position; may beLouder with fever or tachycardia

Basal systolic ejection murmur: high pitched, blowing, systolic, best heard in pulmonic area, in supine position

Physiologic peripheral pulmonic stenosis, or pulmonary outflow murmur: disappears during infancy as pulmonary arteries enlarage; short systolic, grade I-II/VI, heard best in axillae

Venous hum: usually after 3 yrs, UR&LSB & lower neck, continuous musical hum Grade I-III/VI; heard best in infra & supraclavicular areas; loudest in sitting position & decreases in supine position or with turning child’s head or occluding jugular vessels

Organic Murmurs & sounds: Diastolic murmurs: always organic Systolic murmurs:may be functional or organic Friction rubs Before 3 yrs, usually congenital

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After 3 yrs often acquired Rheumatic fever Kawasaki disease

Abdomen: Key Points

Contour Peristalsis Skin: color, veins Umbilicus Tenderness Ridigity Tympany Dullness Hernias: umbilical, inguinal, femoral Masses - size, shape, dullness, position, mobility Liver Spleen Kidneys Bladder

Genitourinary and Reproductive: Key Points

Breast: as previous

Female Genitalia

External genitalia: Pelvic 16-18 years or when sexually active Mons pubic, prepuce (clitoral hood), clitoris, labia minora/majora,

vagina, Skene's & Bartholin's ducts, anus Size, color, skin integrity, masses Redness, swelling, labial adhesions/fusion, lesions, discharge (foul-smelling)

Tanner StagesI Prepubertal. No true pubic hairII Sparse growth of slightly pigmented, downy hair, slightly curled, along

labiaIII Increas in hair, courser, curled, darkerIV Adult-type hair, but limited area. No spread to thighsV Adult distsribution & quantity with spread to thighs

Male Genitalia Penis: Size, color, skin integrity, circumcision Urethral meatus: Shape, placement, discharge, ulceration, discharge

meatal stenosis, hypospadias, epispadias Scrotum: Color, size, symmetry, edema, masses, lesions, tenderness, testes descended bilaterally

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Pubic hair

Tanner StagesI Prepuberal, no true pubic hair, testes, scrotum, penis childhood sizeII Sparse, slightly curled, downy hair (base of penis/along labia

Enlargement of testes & scrotum, scrotal skin reddens & coursensIII Hair courser, curled, darker. Enlargement of penis (length),

further growth scrotum/ testesIV Adult type hair, no spread to medial thighs. Enlargement of penis

(width/length), enlargement of glans, scrotal skin darkensV Adult hair distribution (triangle) & adult genital development

Musculoskeletal: Key Points

Alignment, contour, strength, weakness & symmetry Limb, joint mobility: ROM, stiffness, contractures -

Neck, shoulder, elbow, wrist, hip, knee, ankle, foot Digits Dermatoglyphics

Problem Areas

Spinal changes: scoliosis, kyphosis, lordosis Scoliosis: pre-adolescent growth

Lateral curvaturecontralateral hip humpProminent scapulaAsymmetry: shoulder, arms, hips

Congenital hip dislocation or dysplasia: check hip abduction & symmetry

asymmetrical hip abduction asymmetrical thigh & gluteal folds Ortolani's click Barlow's test Trendelenburg gait Allis' sign Trendelenburg sign & gait: indicates hip disease in ambulatory child

Asymmetries or weaknesses Limp

Legg-Calve` Perthes:peak age 7 years: boys > girlsHip or knee painMay have history of trauma+ Trendelenburg

Slipped Capital Femoral EpiphysisAdolescents: boys > girlsObeseHip or knee pain

Joint infection

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Feet/legs: Variations may begin in feet, tibia or upper let & hip areaFeet turning in: varusFeet turning out: valgus

Legs:Bowleg (genu varum -- knees 2 inches apart)Knock-knee (genu valgum -- ankles 3 inches apart)

Movement limitation: crepitus with joint movementmeningeal signs, such as stiff neck, opisthotonous

Muscular dystrophyProgressive muscular weakness (Gower’s sign)

Cerebral palsy or other muscular diseasePes equinus (weight bearing on toes)Short heel cords

Neurological Evaluation: Key Points

Cerebral Function: "Mental status" appearance, behavior, cooperation LOC, language, emotional status, social response, attention span

Cerebellar Function

Balance, gait & leg coordination, ataxia, posture, tremors Finger to nose (fingers to thumb) 3-4 yrs Finger to examiner's finger 4-6 yrs Ability to stand with eyes closed (Romberg) 3-4 yrs Rapid alternations of hands (prone, supine) school age Tandum walk 4-6 yrs Walk on toes, heels school age Stand on one foot 3-6 yrs

Motor Function: Gross motor & fine motor movements

Muscle size, symmetry, strength, tone, movement Involuntary movements, posture Developmental maturation

Sensory function

Tested in cranial nerves Sharp-dull 2 point discrimination Stereognosis Graphesthesia Infants: responsive to touch, vision, hearing, smell

Present only one sensory stimulation at a time, if testing

Reflexes

Deep tendon: Biceps C5, C6Triceps C6, C7, C8

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Brachioradialis C5, C6Patellar L2, L3, L4Achilles S1, S2

Superficial: Cremasteric T12, L1, L2Abdominal T7, T8, T9, T10, T11

Infant Automatisms: Primitive Reflexes

Cranial Nerves

C1 SmellC2 Visual acuity, visual fields, fundusC3, 4, 6 EOM, 6 fields of gazeC5 Sensory to face: Motor--clench teeth,

Corneal reflex---is C5 & C7 C7 Raise eyebrows, frown, close eyes

tight, show teeth, smile, puff cheeks,Taste--anterior 2/3 tongue

C8 Hearing & equilibriumC9 "ah" equal movement of soft palate & uvulaC10 Gag, Taste, posterior 1/3 tongueC11 Shoulder shrug & head turn with resistanceC12 Tongue movement

Infant Reflexes: Most disappear between 4-6 months of age

Blink (dazzle)Blinks to bright light, 1st year of life, absence indicates blindness

RootTurns direction cheek is stroked, disappears 3-4 months, may persist longer, absence indicates neruologic disorder

SuckSucks in response to stimuli, may persist during infancy, weak or absent reflex indicates developmental/neurological disorder

ExtrusionTongue extends out when t ouched, disappears at 4 months, persistent extrusion may indicate Down’s

Moro & StartleArms & legs extend symmetrically & arms return to midline, when stimulated by position change or sudden noise, disappears by 4-6 months, absence or asymmetry of responses indicate injury, neurological disorder or hearing loss

Galant's (trunk incurvation)Back moves toward paraspinal side stimulated, present for 4-8 weeks,

absencemay indicate spinal cord lesions

Dance or stepFeet withdraw or step up, when foot touched to surface, present 4-8 weeks, persistence indicates neurological problem

Palmar graspFinger’s curve around object placed in palm or palmar aspect of fingers, disappears 3-4 months, persistence indicates neurologic disorder

Tonic neck

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Fencing position: head turn-arm extend, leg extend to same side & all reverse with change to opposite side, appears strongest at 2 months & disappears by 6 months, persistence indicates neurological problem

Neck rightingWhen supine, shoulders, trunk pelvis turn to direction head is turned, absence or persistence beyond 6 months indicates neurological disorder

CrawlingSymmetrical crawling movements when prone, asymmetries indicate neurological disorder

Babinski+ for toe fanning, present until child walks well, or at 2 years of age

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