Pediatric Physical Examination

PediatricsCHSC 6304

Patient Vital Signs

• Temperature– Normal: Oral 98.6°F, 37°C…Rectal 99.6°F, 37.5°C– Fever: Oral 99.5°F, 37.5°C…Rectal 100.4°F, 38°C– Child must be old enough to cooperate to take

oral temperature– Rectal temperature is most accurate– Axillary temperature is least accurate in early

stages of fever– Auricular temperature C/I in Otitis Media and in

first 10d post partum d/t presence of vernix

Patient Vital Signs

• Temperature is raised in the following situations:– Highly active child– Stress or crying– Amount of clothing infant is wearing – Environment

– Diurnal variation: temperature is 1 degree higher after 5pm

Patient Vital Signs

• Temperature to touch:– Dry/warm or hot– Moist/warm or hot– Cold/clammy– Hot/sticky

Patient Vital Signs

• Height– Record in inches and centimeters– Average NB is 19-21” or 48.5-53.5cm– Measure patient supine until ~2yoa– Measure by marking heels and vertex– Have parent help by holding head or heels

– Record on growth chart in file

Patient Vital Signs

• Weight– Measure in lbs and grams– Average NB is 7lbs, 8oz or 3402 grams– Best to use baby scale– Can weight infant with mom and then mom and

do the math

– Record on growth chart in the file

Patient Vital Signs

• Pulse rate– NB: 120-140 bpm– Take at femoral or brachial artery

• Note rhythm and amplitude

• Blood pressure– ~100 SBP using the Flush Method for NB

Patient Vital Signs• Flush Method

– Average of SBP and DBP– Use a pediatric sphygmomanometer/stethoscope/ace bandage– Cuff: cover no less than ½ and no more than 2/3 or the arm or thigh– Encircle arm/thigh without overlapping the bladder– Find palpatory systolic– Place cuff– Elevate limb– Wrap bandage from distal to proximal– Inflate cuff to suspected SBP– Remove bandage– Lower the extremity – Deflate cuff until color returns (flushes the limb)– Take/record reading

Patient Vital Signs• Conditions that influence pulse rate:

– Crying ~190bpm– Sleeping ~90bpm– Fever can elevate pulse mildly or moderately

• Auscultate PMI or full minute• <7yoa use the 4th intercostal space right of mid clavicular

line• >7yoa use the 5th intercostal space right of mid clavicular• Palpate the anterior fontanelle pulsations• Palpate carotid and femoral arteries

Patient Vital Signs

• Respiration Rate– 0-1yoa: 30-60 bpm– 1-3yoa: 24-40 bpm– 3-6yoa: 22-34 bpm– 6-12yoa: 18-30 bpm– 12-18: 12-16 bpm

– Note the rise and fall of the abdomen for 1-2 minutes for accuracy

Patient Vital Signs

• Signs of respiratory distress:– Grunting– Excessive drooling in absence of teething– Chest retraction– Raising of clavicles and episternal notch d/t

recruitment of accessory breathing muscles– Nostril flaring– Cyanosis around the lips

Patient Vital Signs

• Head Circumference– NB: 13.5”; 35cm– @1yoa: 18.5”; 47cm– 60% of lifetime growth occurs in first year of life– Do not use a cloth measuring tape d/t stretch– Place tape around EOP to glabella measuring the

widest part of the head– Measure hemicranium for sutural overlap from

EOP to glabella on each side

Patient Vital Signs

• Head Circumference– Side of larger measurement (1/4” is significant)

with a lower medial canthus of the eye is the side of overlap

• Head Circumference enlarged:– Hydrocephalous– Increased ICP

Patient Vital Signs

• Head Circumference:– Small:• Craniostenosis • Microcephaly• Anencephaly

– Anterior Fontanelle Closes: 7-19moa; avg ~12moa– Posterior Fontanelle Closes: ~3moa– All sutures (except anterior) are PALPABLY closed

by 6moa

Visceral Reflexes

• Direct light NAD/abn• Consensual NAD/abn• Accommodation NAD/abn

• Record findings in space provided

Nose/Throat

• Rhinoscopic NAD/abn– Note the following:• Integrity• Colour• Consistency of nasal mucosa• Position of septum• Patency of nares (place stethescope under nostril)

Nose/Throat• Allergic rhinitis:– Pale, boggy nasal mucosa– Clear mucus– Line on nose from allergic salute– Allergy shiner

• Infection:– Red nasal mucosa– Yellow or green mucus

Nose/throat

Nose/throat

• Epistaxis/Excoriation– Indicative of nose picking– Number one reason for nose bleeds in children– Excessive nose bleeds could be a sign of:• high blood pressure• Increased intracranial pressure• Cranial tumor• leukemia

Nose/throat

• Polyps:– Greyish, soft grape like out-growth

Nose/throat

• Tongue NAD/abn– Observe movement– Older children to touch tongue to roof of mouth– Infant look for tongue to come past lips

• Glossoptosis– Downward displacement and/or retraction of the

tongue m.c. seen in Down’s syndrome

Nose/throat

• Tongue– Koplik spots:

• Near 2nd molar on buccal mucosa, small greyish center, red rim, indicative on onset of measles

– Halitosis• Poor hygiene, constipation, dehydration, local irritants,

sinusitis, infection, allergies, food trapped in tonsilar crypts, decay

– Thrush• Candida albicans, white covering that is hard to remove and

can cause ulcers when you do so• Long term anitbiotic use

Oral thrush

Nose/throat

• Tongue– Red/inflamed• Scarlet fever “strawberry tongue

Nose/throat

• Tonsils NAD/abn– Should be same colour as buccal mucosa– Infection: red/covered with exudates– Diptheria: thick, grey exudates– Adenoids: visualization suggests enlargement– Voice quality:• is nasal when adenoids enlarged and child may snore• Croup/tetany/cretinism = hoarse cry• Increased ICP = shrill, high pitch cry

Nose/throat

• Teeth eruption– Refer to charts– Note how many and which teeth are present– Look for any discolouration/decay– “Baby bottle syndrome”

Ears

• External Ears NAD/abn– Position of auricle• Line from inner canthus to occiput = top of ear should

cross this line• Low set ears seen in cases of mental

retardation/Down’s Syndrome, Trisomy 13• Ears that stick out are considered normal but DC should

check for rotation of temporal bones

Ears

• Otosopic Exam NAD/abn– Pull auricle down and out– Small speculum (2/3) for infants; (3/4) children– Change between sides– Note colour of tympanic membrane, fluid,

buldging or retraction• Consistent crying • Teething

– Whisper, weber, rinne, acoustic blink

eyes

• External eyes

Tonsils