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The Pediatric Physical
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Why do a physical?
• Despite technological advances, historyand physicals remain clinician’s mostimportant tool
• Only costs time
• Numerous anecdotal instances in whichPE reveals findings unrelated to
patient’s chief complaint
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HEENT Exam
• HEENT (head, eyes, ears, nose, throat)
• Initially exam head for shape andpresence/quality of hair, scalp defects,
lesions, lacerations, contusions – Are lumps/bumps soft or firm?
• Head circumference
– Should take until about 24 months
• Mucus Membranes (moist? dry?)
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HEENT
• Fontanelles – normal? Bulging/pulsating(increased ICP)? Depressed(dehydration, malnutrition)?
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HEENT
• Face – size of mouth, shape of lips, sizeand shape of nose, distance betweeneyes…
• “Does this baby look normal?”
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HEENT
• Eyes – check for reactivity to light,movement in all directions, discharge
• Ptosis Strabismus
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HEENT
• Red Reflex – good test to screen for retinoblastoma or congenital cataracts
– White pupil reflection = leukocoria
– Can be more difficult in patients with darkskin (may give more grey than red reflex)
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HEENT
• Conjunctivitis – bacterial vs viral
– Viral tends to be red, crusty, clear discharge
– Bacterial has white or pus-like discharge,also red and irritated, crusty
–
–
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HEENT
• Ear exam – Use otoscope to look attympanic membrane, assess light reflex,color, fluid levels, etc
• Look for redness around ear, pain uponpalpation
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HEENT
• Mouth/throat – inspect throat with light
– Look for redness/inflammation,cobblestoning, ulcers, cracked lips, dry
mouth, healthy teeth – Strep throat:
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HEENT
• Neck – inspect for distended veins (heartproblems, circulation problems), masses
– Palpate lymph nodes, thyroid – looking for
masses/sensitivity
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Chest
• Inspect first, looking for symmetry
– Is patient breathing comfortably? Does heneed to lean forward to breath? Do you
see retractions? Is the chest expandingwith each breath symmetrically?
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Chest
• Heart Sounds – Aortic, Pulmonic,Tricuspid, Mitral (“All Physicians TakeMoney”)
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Chest
• Heart Sounds
– Early systolic murmur
– Late systolic murmur
– Aortic insufficiency
– Extra heart sounds
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Chest
• Lungs – observe breathing, making suremovements are symmetrical
– Listen to at least 6 spots, 3 on each side
• Normal respiration• Wheeze
• Wheeze and crackles
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Abdomen
– First step… observe! (Big surprise).
• Symmetry, bulges, bruises/rashes, etc
– Ausculation – should have occasional
gurgling sounds, but inconsistent – Palpate light and deep in all 6 quadrants
– Hernias – common in children, should besoft and reducible
• If inflamed, painful, or unable to reduce,could be signs of more serious condition.
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Abdomen
• Appendicitis
– Often starts with pain around belly button,move to lower right quadrant
– Light palpation can elicit tenderness,guarding
– Patient often may have difficulty moving,and will try to move as little as possible
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Perineum
• Males
– Retract foreskin, never forcibly
– Check scrotum for descended testes
• Undescended over 1 yo further investigation
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Perineum
• Female
– Examine external anatomy, noting clitoris,urethral meatus , and vaginal introitus
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Back
• Once again… observation
– Asymmetry, skin lesions, soft tissuemasses
• Older kids, check for scoliosis – Mongolian spots – benign, clears
spontaneously
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Skin
• If see lesion, important to note: – Color
– Size
– Shape – Raised or flat
– Individual or coalesced
– Itchy (pruritic) or not itchy
– Moves with skin or fixed to lower structures• Almost all skin lesions in children are benign
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Skin
• Jaundice
– Generally appears first in eyes, under thetongue
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Skin
• Pigmentation (too little or too much)
– Spots without pigmentation (ex. vitiligo)
– Hyperpigmentation
• Café au lait spot (<4, all under 1 cm indiameter are considered normal findings)
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Skin
• Melanoma
– Rare in children, but does occur
– “ABCD’s of melanoma”
• And tendency to grow quickly
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Skin
• Vacscular Lesions (hemangiomas)
– 90% undergo spontaneous remission
– Generally benign, can be problematic if on
face or lower back (assoc w/other problems)
–
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Overview
• Always the first step???
• HEENT – fontanelles, eyes/red reflex,mouth/throat, neck
• Chest –palpate, auscultate• Lungs –auscultate
• Abdomen – listen, palpate
• GU exam
– Male: palpate testes, draw back foreskin
– Female: observe anatomy
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Overview
• Back – symmetry, scoliosis
• Skin (done by observation during rest of exam)
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Links
• Pediatric Physical
– http://www.peds.arizona.edu/medstudents/Phy
– http://66.99.255.20/cms/pediatrics/Pediatric%2
• Heart and Lung Sounds – http://www.med.ucla.edu/wilkes/intro.html
