Chart Note for Infant Review of Systems and Physical Exam

THE PEDIATRIC HISTORY AND PHYSICAL Test

By Lewis A. Barness

From: Principles and Do of Pediatrics, 2nd Edition. Affiliate 6. edited by Frank A. Oski et al. J. B. Lippincott Company, Philadelphia � 1994.

HISTORY

Obtaining a complete history on a pediatric patient not only is necessary, but likewise leads to the correct diagnosis in the vast majority of children. The history usually is learned from the parent, the older child, or the caretaker of a ill child. Afterwards learning the fundamentals of obtaining and recording historic information, the nuances associated with the giving of data must exist interpreted.

For the acutely sick child, a brusque, rapidly obtained study of the events of the immediate past may suffice temporarily, but as soon as the crisis is controlled, a more complete history is necessary. A convenient method of learning to obtain a meaningful history is to ask systematically and direct all of the questions outlined below. Subsequently conviction is gained with experience, questions can be trouble-directed and asked in an society designed to elicit more specific information almost a suspected affliction state or diagnosis. Some psychosocial implications volition be obvious. More subtle details often are obtained by asking open-ended questions. Those with organic disease unremarkably have brusque histories; those with psychosomatic disease take a longer list of symptoms and complaints.

During the interview, it is important to convey to the parent interest in the kid likewise as the illness. The parent is allowed to talk freely at first and to express concerns in his or her own words. The interviewer should look directly either at the parent or the child intermittently and not only at the writing instruments. A sympathetic listener who addresses the parent and child past name ofttimes obtains more accurate information than does a harried, distracted interviewer. Conscientious ascertainment during the interview frequently uncovers stresses and concerns that otherwise are not credible.

The written tape is non only helpful in determining a diagnosis and making decisions, but also is necessary for observing the growth and development of the kid. A well-organized record facilitates the retrieval of information and obviates problems if it is required for legal review.

The following guidelines point the information needed. If preferred, a number of printed forms are available, which contain similar material, or forms may be modified every bit long as consistency is maintained.

Full general Information

Identifying data include the engagement, proper name, age and birth engagement, sex, race, referral source if pertinent, human relationship of the child and informant, and some indication of the mental state or reliability of the informant. Information technology frequently is helpful to include the ethnic or racial groundwork, address, and phone numbers of the informants.

Chief Complaint

After the identifying information, the primary complaint should be recorded. Given in the informant'southward or patient's own words, the chief complaint is a brief statement of the reason why the patient was brought to exist seen. Information technology is not unusual that the stated complaint is not the truthful reason the child was brought for attending. Expanding the question of "Why did y'all bring him?" to "What concerns you?" allows the informant to focus on the complaint more than accurately. Advisedly phrased questions tin can elicit data without prying.

History of Nowadays Illness

Side by side, the details of the present disease are recorded in chronologic club. For the sick kid, information technology is helpful to begin: "The kid was well until "10" number of days before this visit." This is followed by a daily documentation of events leading upwards to the present fourth dimension, including signs, symptoms, and treatment, if any. Statements should be recorded in number of days before the visit or dates, just not in days of the week, because chronology volition be difficult to retrieve even a short time later if days of the week are used. If the child is taking medicine, the amount being taken, the name of the medicine, the frequency of administration, and how well and how long it has been or is being taken are needed.

For the well child, a simple argument such every bit "No complaints" or "No illness" suffices. A question about school omnipresence may be pertinent. If the past medical history is significant to the current illness, a brief summary is included. If information is obtained from old records, it should be noted hither or may exist recorded in the by medical history.

Past Medical History

Obtaining the past medical history serves not only to provide a tape of data that may exist significant either now or later to the well-beingness of the child, simply also to provide evidence of children who are at risk for health or psychosocial problems.

Prenatal History

If a prenatal interview has been held (run across below), this data already may be available. Questions to be answered include those regarding the health of the mother during this pregnancy, especially in regard to any infections, other illnesses, vaginal haemorrhage, toxemia, or care of animals, such as cats, which may induce toxoplasmosis or other brute-borne diseases, all of which tin can have permanent effects on the embryo and kid. The time and type of movements the fetus made in utero should be determined. The number of previous pregnancies and their results, radiographs or medications taken during the pregnancy, results of serology and blood typing of the female parent and babe, and results of other tests such every bit amniocentesis should be recorded. If the mother's weight gain has been excessive or insufficient, this also should be noted.

Birth History

The elapsing of pregnancy, the ease or difficulty of labor, and the duration of labor may be important, especially if there is a question of developmental delay. The blazon of delivery (spontaneous, forceps-assisted, or cesarean department), blazon of anesthesia or analgesia used during commitment, attendance past other family unit members at delivery, and presenting office (if known) are recorded. Note this child's birth society (if there have been multiple births) and nascency weight.

Neonatal History

Many informants are aware of Apgar scores at birth and at v minutes, any unusual advent of the child such equally cyanosis or respiratory distress, and whatever resuscitative efforts that took place and their duration. lf the mother was delayed in seeing the baby after birth, reasons should be sought. Jaundice, anemia, convulsions, dvsmorphic states, and congenital anomalies or infections in the mother or baby are some of the reasons that viewing or handling of the newborn by the mother may be delayed. The fourth dimension of onset of any of these abnormal states may exist significant.

Feeding History

Note whether the infant was breast- or canteen-fed and how well the baby took the first feeding. Poor sucking at the outset feeding may be the result of sleepiness of the infant, but likewise is a warning sign of neurologic aberration, which may not become manifest until much later in life. By the 2d or third feeding, even encephalon-damaged children usually nurse well.

If the babe has been bottle-fed, inquire about the type of formula used and the corporeality taken during a 24-hour period. At the aforementioned fourth dimension, ask near the mother'due south initial reaction to her baby, the nature of bonding and centre-to-eye contact, and the patterns of crying, sleeping, urinating, and defecating. Requirements for supplemental feeding, vomiting, regurgitation, colic, diarrhea, or other gastrointestinal or feeding bug should be noted.

Make up one's mind the ages at which solid foods were introduced and supplementation with vitamins or fluoride took place, likewise as the age at which weaning occurred and the method used to wean. In add-on, note the historic period at which infant foods, toddlers' foods, and table food were introduced, the response to these, and any show of nutrient intolerance or airsickness. If feeding difficulties are present, determine the onset of the problem, methods of feeding, reasons for changes, interval between feedings, amount taken at each feeding, airsickness, crying, and weight changes. With any feeding trouble, evaluate the result on the family past asking, "How did you manage the problem?"

For an older child, inquire the informant to supply some breakfast, lunch, and dinner (supper) menus, likes and dislikes, and response of the family to eating problems.

Developmental History

Interpretation of physical growth rate is of import. Attempt to ascertain the birth weight and the weights at 6 months, one yr, two years, 5 years, and 10 years. Lengths at like ages are desirable. These information are plotted on physical growth charts. Any sudden gain or loss in concrete growth should be noted particularly, considering its onset may correspond to the onset of organic or psychosocial illness. Information technology may exist helpful to compare the kid's growth with the rate of growth of siblings or parents.

Ages at which major developmental milestones were met aid in indicating deviations from normal. Some such milestones include post-obit a person with the optics, holding the head erect, grinning responsively, reaching for objects, transferring objects, sitting alone, walking with back up and alone, speaking the first words and sentences, and experiencing tooth eruption. Ages of dressing self, tying ain shoes, hopping, skipping, and riding a tricycle and bicycle should exist noted, as well as grade in school and school performance.

In improver, note should be fabricated of the historic period at which bowel and float control were accomplished. If problems exist, the ages at which toilet teaching began also may indicate reasons for problems.

Behavior History

Amount of sleep and sleep bug, and habits such every bit pica, smoking, and employ of alcohol or drugs should be questioned. The informant should state whether the child is happy or hard to manage, and should indicate the child'south response to new situations, strangers, and school. Temper tantrums, excessive or unprovoked crying, nail bitter, and nightmares and night terrors should be recorded. Question the child regarding masturbation, dating, dealing with the opposite sex, and parents' responses to menstruation and sexual evolution.

Immunization History

The types of immunizations received, with the number, dates, sites given, and reactions should be recorded equally part of the history. In improver, information technology is helpful to tape these immunizations on the forepart of the chart or in a conveniently obvious place with a lot number for future reference when completing schoolhouse physical examinations or when determining demand for booster immunizations or possible reactions.

History of Past Illnesses

A full general statement should be made about the kid'due south general wellness earlier the present encounter, such as weight change, fever, weakness, or mood alterations. Specific inquiry is helpful regarding the results of whatever screening tests and regarding any history of roseola, rubeola, rubella, pertussis, mumps, varicella, cherry fever, tuberculosis, anemia, recurrent tonsillitis, otitis media, pneumonia, meningitis, encephalitis or other nervous system disease, gastrointestinal tract disease, or any other affliction, as well as specific treatment, results, and residua. The history of each past illness should include dates of onset, course, and termination. If hospitalization or surgery was necessary, the diagnosis dates, and name of the hospital should he included. Questions concerning allergies include the occurrence and blazon of any drug reactions, nutrient allergies, hay fever, and asthma. Accidents, injuries, and poisonings should exist noted.

Review of Systems

The review of systems serves as a checklist for pertinent information that might have been omitted. If information has been obtained previously, simply state, "Run into history of present disease" or "Meet history of past illnesses." Questions apropos each system may be introduced with a question such as: "Are there any symptoms related to . . .?"

• Head (e.1000., injuries, headache)
• Optics (east.chiliad., visual changes, crossed or tendency to cross, belch, redness, puffiness, injuries, spectacles)
• Ears (e.yard., difficulty with hearing, pain, discharge, ear infections, myringotomy, ventilation tubes)
• Olfactory organ (east.g., belch, watery or purulent, difficulty in animate through olfactory organ, epistaxis)
• Rima oris and throat (eastward.yard., sore throat or tongue, difficulty in swallowing, dental defects)
• Neck (e.g., swollen glands, masses, stiffness, symmetry)
• Breasts (due east.g., lumps, pain, symmetry, nipple discharge, embarrassment)
• Lungs (east.thou., shortness of breath, ability to keep up with peers, cough with time of cough and grapheme, hoarseness, wheezing, hemoptysis, hurting in chest)
• Heart (east.thou., cyanosis, edema, eye murmurs or "center trouble," pain over center)
• Gastrointestinal (e.g., appetite, nausea, vomiting with relation to feeding, amount, color, blood- or bile-stained, or projectile, bowel movements with number and grapheme, abdominal hurting or distention, jaundice)
• Genitourinary (eastward.g., dysuria, hematuria, frequency, oliguria, character of urinary stream, enuresis, urethral or vaginal discharge, menstrual history, mental attitude toward menstruum and contrary sex activity, sores, pain, intercourse, crabs disease, abortions, nativity control method)
• Extremities (due east.g.. weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps)
• Neurologic (due east.grand., headaches, fainting, dizziness, incoordination, seizures, numbness, tremors)
• Peel (e.g., rashes, hives, itching, color modify, hair and boom growth, color and distribution, piece of cake bruising or bleeding)
• Psychiatric (eastward.thousand., usual mood, nervousness, tension, drug employ or corruption)

Family unit History

The family unit history provides evidence for considering familial diseases as well as infections or contagious illnesses.

A genetic type chart is easy to read and very helpful. Information technology should include parents, siblings, and grandparents, with their ages, health, or crusade of death. If problems with genetic implications exist, all known relatives should be inquired about. If a genetic blazon chart is used, pregnancies should exist listed in a series and should include the wellness of the siblings (Fig 6-one).

Figure vi-1. Genetic type chart.

(Circle, female, square, male.) i, maternal grandmother, 67 years old, living and well; paternal grandmother, 66 living and well. 2, Maternal grandfather, died at 62 of heart disease. 3, Paternal grandad, 71, living and well. four, Unmarried horizontal line, married. v, Double horizontal line, consanguineous wedlock. half-dozen, Mother, 39 years sometime, living, diabetic. 7, Father, 41 years old, living, hypertensive. eight, Stillbirth. 1968 (x, died). nine, Male sibling, fourteen years old, living, hay fever. 10, Patient, 12 years old (note light circle). 11, Brother, x years old, living and well. 12, Female, died at 2 days old of respiratory distress (twelvemonth can exist included).

Family diseases, such equally allergy; blood, middle, lung, venereal, or kidney illness; tuberculosis; diabetes; rheumatic fever; convulsions; pare, gastrointestinal, behavioral, or mental disorders; cancer; or other disease the informant mentions should be included. These diseases may have a heritable or contagious effect. Pertinent negatives should be included besides.

Social History

Details of the family unit include the number of people in the habitat and its size, the presence of grandparents, the marital condition of the parents, the meaning caretaker, the full family unit income and its source, and whether the mother and father work outside the dwelling. If information technology is pertinent to the current problems of the child, enquire about the family's attitude toward the child and toward each other, the type of bailiwick used, and the major disciplinarian. If the problem is psychosocial and only one parent is the informant, it may be necessary to interview the other parent and to outline a typical day in the life of the kid.

Prenatal History

It is desirable, if feasible, to interview the mother and father before the child is built-in. Not merely can some necessary data be obtained, simply as well the parents can become acquainted with the doctor who will be seeing them shortly after the arrival of their newborn. The wellness of the mother, whether she will nurse or bottle-feed the infant and whether the married man supports her choice, the grooming for the baby on inflow home, and whether help volition be available can exist ascertained. Because the male parent may feel bypassed past the pregnancy except for the initial effect, it is important to direct some questions to him, such as, "Practise you want your son circumcised?," and to become the family history of diseases start from him.

History From the Child

Even immature children should be asked nearly their symptoms and their understanding of their problem. This also provides an opportunity to determine the interaction of the kid with the parent. For most adolescents, it is important to accept role of the history from the boyish lone after request for his or her approving. Regardless of your own opinion, obtain the history objectively without whatsoever moral implications, starting with open-concluded questions related to the initial complaint then directing the questions.

PHYSICAL EXAMINATION

Test of the babe and young child begins with observing him or her and establishing rapport. The order of the examination should fit the child and the circumstances. It is wise to brand no sudden movements and to consummate first those parts of the examination that require the kid's cooperation. Painful or disagreeable procedures should be deferred to the end of the test, and these should exist explained to the kid before proceeding. For the older kid and boyish, exam can begin with the head and conclude with the extremities. The approach is gentle, just expeditious and complete. For the young, humble child, chatter, reassurance, or other communication oft permits an orderly test. Some children are best held by the parent during the examination. For others, part of the examination may require restraint past the parent or assistant.

When the complaint includes a report of pain in a certain area, this area should exist examined final. If the child has obvious deformities, that area should be examined in a routine fashion without undue emphasis, considering extra attention may increase embarrassment or guilt.

Because the entire child is to be examined, at some fourth dimension all of the habiliment must exist removed. This does not necessarily mean that it must be removed at the same time. Only the part that is existence examined needs to be uncovered so it can be re-clothed. Except during infancy, modesty should exist respected and the child should exist kept as comfortable equally possible.

With practice, the examination of the kid can be completed quickly even in about critical emergency states. Only in those with apnea, shock, absence of pulse, or, occasionally, seizures is the complete examination delayed. Although the method of procedure may vary, the record of examination should be in the aforementioned format for all children. This provides piece of cake admission to needed information later. The description that follows is the usual mode of recording the exam and not necessarily its required gild. When diseases are given with a sign, these are examples and non a complete differential for that sign. The significance of a previous examination cannot be overstressed. A murmur that was not heard a year ago but now is easily audible has far unlike significance than does a similar murmur heard many years before.

Completion of the history can be accomplished during the physical test. Talking to the parent frequently reassures the kid. Praising the young child, explaining the parts of the examination to the older child, and reassuring the adolescent of normal findings facilitates the examination. Normally, if the examiner enjoys the spontaneity and responsiveness of children, the examination volition exist easier and more thorough.

Measurements (Vital Signs)

Temperature is taken in the axilla or rectum in the immature child and by oral cavity after v or 6 years of age, when the child can empathise how to hold the thermometer. Electronic thermometer probes inserted as usual or in the ear canal requite rapid, accurate determinations. Elevated temperature occurs with infection, excitement, feet, exercise, hyperthyroidism, collagen-vascular disease, or tumor. Decreased temperature occurs with chilling, daze, hypothyroidism, or inactivity. Temperature may be decreased after taking sure drugs, with hypocortisolism, or with overwhelming infection.

The pulse rate can be obtained at any peripheral pulse (femoral, radial, or carotid) or by palpation over the heart. The normal rate varies from lxx to 170 beats per minute at birth to 120 to 140 shortly after birth, and ranges from 80 to 140 at ane to two years, from fourscore to 120 at 3 years, and from lxx to 115 later on 3 years. The sleeping pulse after the age of 2 years normally is about 20 beats per minute less than the awake pulse, but does non decrease with rheumatic fever or thyrotoxicosis. For each degree of temperature rising, the pulse charge per unit increases nearly 10 beats per infinitesimal. The pulse rate is elevated with excitement, exercise, or hypermetabolic states, and is decreased with hypometabolic states, hypertension, or increased intracranial pressure. Irregularity may be caused by sinus arrhythmia, just tin can indicate underlying heart disease. Absence of the femoral pulse is a cardinal sign of postductal coarctation of the aorta.

Respiratory Rate

The respiratory charge per unit should exist determined past observing the movement of the chest or abdomen or past auscultating the breast. The normal newborn rate is 30 to 80 breaths per minute; the charge per unit decreases to 20 to 40 in early infancy and childhood then to xv to 25 in late babyhood and boyhood. Exercise, anxiety, infection, and hypermetabolic states increment the rate; primal nervous system lesions, metabolic abnormalities, alkalosis, depressants, and other poisons decrease the rate.

Blood Force per unit area

The blood pressure should exist measured with a cuff, with the bladder completely encircling the extremity and the width covering one half to two thirds of the length of the upper arm or upper leg. The pressure should be recorded and compared with normal readings (Figs 6-2 through 6-7). High systolic pressure occurs with excitement, feet, and hypermetabolic states. High systolic and diastolic pressures occur with renal diseases, pheochromocytoma, adrenal disease, arteritis, or coarctation of the aorta.

Effigy 6-2. Age-specific percentiles of blood pressure level (BP) measurements in boys--birth to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP.

(American Academy of Pediatrics. Task Force on Blood Force per unit area. Pediatrics 1987;79:i.)

Figure 6-3. Age-specific percentiles of claret force per unit area (BP) measurements in boys--1 to thirteen years of historic period; Korotkoff phase IV (K4) used for diastolic BP

(American Academy of Pediatrics. Chore Force on Blood Pressure. Pediatrics 1987;79:1.)

Figure half dozen-4. Historic period-specific percentiles of blood force per unit area (BP) measurements in boys--13 to 18 years of age; Korotkoff phase V (K5) used for diastolic BP

(American Academy of Pediatrics. Chore Force on Blood Pressure. Pediatrics 1987;79:1.)

Effigy 6-5. Historic period-specific percentiles of blood force per unit area (BP) measurements in girls--nascency to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP

(American Academy of Pediatrics. Task Force on Claret Pressure. Pediatrics 1987;79:1.)

Figure six-half dozen. Historic period-specific percentiles of claret pressure (BP) measurements in girls--i to 13 years of historic period; Korotkoff phase Iv (K4) used for diastolic BP

(American Academy of Pediatrics. Job Force on Blood Pressure. Pediatrics 1987;79:1.)

Figure six-seven. Historic period-specific percentiles of blood pressure (BP) measurements in girls--13 to xviii years of age; Korotkoff phase V (K5) used for diastolic BP

(American Academy of Pediatrics. Task Forcefulness on Blood Pressure level. Pediatrics 1987;79:ane.)

Height, Weight, Head Circumference

To obtain pinnacle and weight recordings, measure the infant supine upwards to the age of ii years, and standing thereafter. Measure caput circumference in all infants less than 2 years of historic period and in those with misshapen heads. Record meridian, weight, and head circumference measurements with percentiles on a chart (Figs six-8 through 6-15).

Figures vi-8 through 6-fifteen are in PDF format and were downloaded from the National Center for Health Statistics (NCHS) Spider web site (http://www.cdc.gov/nchs/). Boosted figures, information, and statistics are freely available from this site.

• Effigy 6-8. NCHS percentiles of physical growth in girls--nativity to 36 months.

• Effigy 6-9. NCHS percentiles of physical growth in girls--ii to twenty years of age.

• Figure 6-ten. NCHS Girls Weight-for-Stature percentiles.

• Figure 6-11. NCHS percentiles of physical growth in boys--birth to 36 months.

• Effigy 6-12. NCHS percentiles of physical growth in boys--2 to xx years of age.

• Figure six-thirteen. NCHS Boys Weight-for-Stature percentiles.

• Figure 6-14. Caput circumference, boys.

• Effigy 6-xv. Head circumference, girls.

Shortness may be caused past malabsorption, chronic illness, or syndromes with dwarfism. Gigantism may exist the result of pituitary abnormalities. Compare sitting tiptop and total height in dwarfs to standard measurements to determine the type of syndrome nowadays.

Decreased weight tin be acquired by atmospheric condition similar to those that crusade decreased height. In states of malnutrition, weight percentile is less than height percentile; caput circumference remains normal unluess the condition is severe and persists. Overweight usually is exogenous and associated with increased peak until epiphyseal closure. Overweight resulting from endocrine disorders is associated with decreased linear growth.

Peel Fold Measurements

Skin fold measurements are useful in determining obesity and in identifying and following malnutrition. Pare fold calipers are applied over the mid-triceps.

General Appearance

A statement should be recorded about the alacrity, distress, full general development, and nutrition of the child. Mental status, activity, unusual positions, or anticipation or cooperativeness may direct one to consider an astute or chronic disease or no affliction at all. The child who lies quietly, staring into space, may exist gravely sick. The child who lies quietly but becomes irritable when held by his mother (paradoxic irritability) may accept meningitis or pain in movement. Notation any unusual odor, which may suggest the presence of a foreign body in one of the orifices or certain metabolic diseases or toxins.

Pare

In examining the pare, record its color and turgor, the type of any lesions, and the condition of body and scalp pilus and nails.

Normal color of the skin is the effect of the presence of melanin; depigmented areas are vitiligo: absence of pigment occurs in albinism. Cyanosis is caused by unsaturation of or abnormal forms of hemoglobin; jaundice is caused by excessive bilirubin deposited in the adipose tissue. Notation the size and borders of nevi, which usually are darkly pigmented areas, and caf�-au-lait spots, which are brownish areas that may signal neurofibromatosis. White spots shaped like a leaf suggest tuberous sclerosis. Ecchymoses or petechiae and scars may indicate abuse.

Swelling may exist caused by edema. Lack of turgor occurs with aridity or recent weight loss. Describe any rashes, many of which are feature of viral or bacterial infection.

Head and Face

Record the shape, symmetry, and any defects of the head; the distribution of hair; and the size and tension of fontanelles. A big caput may be an early sign of hydrocephalus or an intracranial mass. A small caput may exist a result of early closure of sutures or lack of brain development. For any difference from normal head size, frequent measurements are necessary. The fontanelles normally are flat. The posterior fontanelle closes by 2 months of age, and the anterior fontanelle closes by 12 to xviii months of age. Unusual hair whorls are associated with severe intracranial abnormalities.

The face may appear distinctive for a number of syndromes. For case, unilateral facial paralysis may be associated with congenital heart disease. Fibroid facies occur with storage diseases. Epicanthal folds occur in a number of syndromes, including Down (5trisomy 21.)

Eyes

Test vision grossly in the young child with brightly colored objects. In the older child, test with Snellen's E chart. Evaluate for strabismus by noting the position of the reflection of low-cal on the cornea from a distant source. Evaluate the range of eye movements and the presence of nystagmus. Both eyelids should open up equally. Failure to open is ptosis and may be caused past neurologic or systemic diseases. Upward slanting of the palpebral fissures with covering of the inner canthus (epicanthal folds) is a sign of Down's syndrome. The conjunctivae should exist pink, merely not inflamed; the sclerae should exist white. Examine the cornea for haziness (a sign of glaucoma) or opacities. Record the size and shape of the pupils, the color of the iris, and the response of the iris to calorie-free and adaptation. In the fundoscopic examination, use a goose egg lens and note the presence of a cherry reflex, or hemorrhages or pigmented areas, and the size of the veins compared to the arteries. Any obstruction, such as corneal or lenticular cataract will obliterate part or all of the red reflex. The disc borders should be sharp. They are blurred with increased intracranial pressure. The macula may non exist clear, which is a sign of degenerative diseases. Obtain the corneal reflex by lightly touching the cornea with a slice of cotton. Failure to blink indicates trigeminal or facial nervus injury.

Ears

Note the position of the ears and abnormalities of the external ear, the pinna. Low-fix ears may advise the presence of renal agenesis. Tags and deformities frequently are associated with other small-scale or major anomalies. Grossly evaluate hearing, then proceed with examination of the inner ear. Pull the earlobe upwardly and anteriorly. Grasp an otoscope equipped with a bright light so that the holding hand rests on the child's caput and moves with any motion of the head, and utilize the largest speculum that will fit into the canal. The canal should be clear, and the drum should be pearly gray in color and concave. A cone of light, the malleus, and sometimes the incus will be identified. If the bones are non visualized, the pulsate is not gray in colour or is infected, or the pulsate is non concave, fluid may exist in the inner ear, which is diagnostic of otitis media.

Olfactory organ

Heighten the tip of the nose and wait upwardly the nose with a bright light. Deformities of the septum, bleeding, or discharges should exist recorded. The normal nasal mucosa is light pink in colour. Tap on the maxillary and frontal sinuses for tenderness. Feel for air egress from both nares.

Mouth and Throat

Examination of the mouth and throat usually is the most resistant role of the examination and should be performed nearly the end of the examination. The child should be sitting so that the natural language is less likely to obstruct the pharynx. Deformities or infections around the lips are recorded. Count the number and note the condition of the teeth. Similarly, note the condition and color of the natural language, buccal mucosa, palate. tonsils, and posterior throat. Normally, these are pinkish in colour. Exudate indicates infection past bacteria, viruses, or fungi, but etiology unremarkably cannot be adamant by physical test alone. Note also the presence of the gag reflex and the phonation or cry. If the child seems hoarse, question the parent apropos the normal voice. Laryngitis can lead to airway obstacle. After the age of 2 years, children should not drool. Chronic drooling may suggest mental deficiency, just astute onset of drooling is a grave sign of epiglottitis or poison ingestion.

Neck

Feel in the neck for lymph nodes, which unremarkably are nontender and up to ane cm in bore in both the anterior and posterior cervical triangles. Larger or tender nodes occur with local or systemic infection or malignancies. Experience the trachea in the midline. The thyroid may not exist palpable. Other masses may be nowadays and are always abnormal. Flex the neck. Resistance to flexion is a central sign of meningitis, except in infancy, but this also occurs with severe infections around the neck or dislocation of the cervical vertebrae.

Lymph Nodes

In addition to the lymph nodes in the cervix, palpate inguinal, epitrochlear, supraclavicular, axillary, and posterior occipital nodes. Normally, inguinal nodes may be upwards to 1 cm in diameter: the others are nonpalpable or less than 5 mm. Larger or tender nodes hold significance like to that described for abnormal cervical glands.

Chest

Detect the chest for shape and symmetry. The chest wall is most round in infancy and in children with obstructive lung disease. Respirations are predominantly intestinal until about half dozen years of age, when they become thoracic. Note suprasternal, intercostal, and subcostal retractions, which are signs of increased respiratory piece of work. Swelling at the costochondral junctions is an indication of rickets. Edema of the chest wall occurs in children with superior vena cava obstruction. Asymmetry of expansion occurs with diaphragmatic paralysis, pneumothorax, or other intrathoracic abnormalities.

Breasts

Breasts commonly are hypertrophied at birth; they regress within 6 months and develop with the onset of puberty. Development during boyhood is staged. Breast development in both boys and girls usually begins asymmetrically. Palpate for nodules, which may be cysts or tumors. Redness, heat, and tenderness ordinarily indicate infection.

Lungs

Examination of the lungs includes observation, palpation, percussion, auscultation, and, if indicated, transillumination.

Observation

Note the blazon and rate of the kid's breathing. The rate of respiration varies, equally described previously. Rapid rates, known equally tachypnea, are associated with infection, fever, excitement, exercise, heart failure, or intoxicants. Slower rates are feature of intracranial lesions, depression caused by sedative drugs, heart block, or alkalosis. Cheyne-Stokes animate, which is characterized past periods of deep, rapid respirations followed by slow, shallow respirations, is common in premature and newborn infants, and in those with intracranial or metabolic abnormalities. Dyspnea, or distress during animate, is associated with flaring of the intercostal spaces and nares. Inspiratory dyspnea is more common with obstruction high in the respiratory system and expiratory dyspnea is more common with lower respiratory diseases.

Palpation

Feel the unabridged chest with the palms and fingertips. Annotation masses or areas of tenderness. Tactile fremitus, a vibratory awareness during crying or speaking, normally is felt over the entire chest. Fremitus is absent-minded if the airway is obstructed.

Percussion

Either direct percussion (tapping the chest wall directly with either the index or center fingers) or indirect percussion (placing a finger of 1 hand firmly on the chest wall and borer that finger with the index or middle finger of the opposite hand) may exist used in children. The entire chest wall is percussed anteriorly, posteriorly, and forth the midaxillary line. A resonant sound volition be obtained over most of the chest except over the scapulae, diaphragm, liver, and heart, where dullness is elicited. Dullness detects consolidation in the lungs, as well as the size and position of the liver and centre. Scratch percussion, which involves tapping the chest wall with a finger while listening with a bell stethoscope over the heart and liver, is especially useful in determining heart and liver size. Increased resonance is establish with increased trapped air, emphysema, or air in the pleural space (pneumothorax).

Auscultation

To auscultate the lungs in children, listen with a small-scale bell in small children and with the diaphragm in older children. Normal breath sounds are bronchovesicular and inspiration is twice as long as expiration in young children; breath sounds are vesicular and inspiration is three times as long as expiration in older children. Breath sounds are decreased with consolidation or pleural fluid in the immature kid and increased with pneumonia in the older child. Fine crackles either in inspiration or expiration (rales) indicate foreign substances, usually fluid, in the alveoli or smaller bronchi, equally occurs in bronchitis, pneumonia, or eye failure. Fibroid inapplicable sounds (rhonchi) are the result of foreign substances in the larger airways, equally in crying or upper respiratory infection. Musical extraneous sounds (wheezes) are caused by airflow through compromised larger airways, equally in asthma.

Transillumination

If pneumothorax is present, the breast volition transilluminate. This is particularly useful in the newborn.

Heart

In add-on to the heart'south rate (pulse) and rhythm, and the claret pressure, note the size, shape, sound quality, and presence of murmurs when examining the middle.

Precordial jutting is a sign of right-sided enlargement. A cardiac impulse may non be noted in a young child, simply in a thin, active child, information technology may suggest the size and position of the heart. An apex beat exterior the midclavicular line in the 5th interspace indicates cardiomegaly, which is a meaning sign of heart affliction or heart failure. Palpation and percussion are described above. Auscultate both in the sitting and the supine position. Determine the centre rate and rhythm if this was not done previously. Auscultate initially over the noon (mitral area), and then over the lower right sternal edge (tricuspid area), the second left intercostal space at the sternal edge (pulmonary area), and the 2nd right intercostal space at the sternal edge (aortic area). Next, keep to the remainder of the precordium, the axillae, back, and cervix. Note heart sounds and any arrhythmia. A loud showtime audio at the noon occurs with mitral stenosis, a loud second sound at the pulmonary area occurs with pulmonary hypertension, and a fixed split-2d sound in the pulmonary area occurs with an atrial septal defect. Innocent murmurs are systolic, musical, or vibratory and of low intensity, and ordinarily are heard at the 2d left Interspace, only inside the apex, or below either clavicle. The latter is a venous hum that may be continuous and that disappears when the patient is supine. Diastolic murmurs are almost e'er significant. Significant systolic murmurs may exist stenotic and are loudest in mid-systole over the aortic or pulmonary areas. Regurgitant murmurs begin immediately afterward the starting time sound. Over the mitral or tricuspid area, they indicate valvular insufficiency. A continuous or uneven systolic murmur along the upper left sternal border indicates patent ductus arteriosus.

Abdomen

Find the shape of the abdomen. A flat abdomen may indicate diaphragmatic hernia; a distended belly may indicate intestinal obstruction or ascites. Auscultate before percussing or palpating. Normally, peristaltic sounds are heard every 10 to 30 seconds. High-pitched frequent sounds occur with obstruction or peritonitis; absent sounds indicate ileus. Adjacent, palpate gently, showtime in the left lower quadrant and proceeding to the left upper, right upper, correct lower, and midline areas. So palpate more deeply in the same areas and follow with palpation in the same areas with the unused hand, pushing toward the front hand from the child's back. Feel particularly for the liver in the correct upper quadrant and the spleen in the left upper quadrant, and guess their size. Any other masses are abnormal. Determine tenderness and effort to locate the maximum indicate of whatever tenderness, which may betoken intra-abdominal infection such as peritonitis, cystitis, or appendicitis, or rapid enlargement of organs, as occurs with enlargement of the liver in heart failure. Percuss to verify findings. Feel in the costovertebral angles to determine kidney size. Tenderness usually indicates pyelonephritis.

Genitalia

Boilerplate boyish development in girls proceeds as follows:

1. breast development at  10.5 years of historic period,
2. pubic hair at 11 years of age,
3. increase in height velocity at 12 years of age,
4. menarche at 12.5 years of historic period
5. axillary pilus at thirteen years of age.

Average development in boys gain as follows:

1. testicular enlargement at 11.v years of age,
2. pubic pilus at 12.5 years of historic period,
3. increase in height velocity at 14 years of age,
4. facial and axillary hair at 14.5 years of age.

Variations in gild of development suggest hormonal abnormalities. Modesty of the child should be respected during the examination, peculiarly of the genitalia.

Inspect the genitalia for urethral discharges, which are always pathologic and indicate infection anywhere in the genitourinary systems.

In a girl, vaginal haemorrhage after the newborn menses and before puberty may be the result of injury or foreign torso. Fused labia minora usually part with hygiene. Imperforate hymen causes hydrocolpos before puberty and hematocolpos later menarche. Vaginal discharge may be the result of injury or foreign body in a immature girl, usually is normal at the start of puberty, and suggests infection in an older girl. Adolescents with vaginal discharge, dysuria, lower abdominal pain, irregular bleeding, or sexual activity require a complete vaginal examination. The uterus in a younger kid is palpated for size, shape, and tenderness with 1 hand over the lower belly and a finger of the other paw in the rectum. For an older child, the cervix is visualized with a vaginoscope or small speculum, and cultures are obtained.

In boys, testes should be in the scrotum later birth, although agile cremasteric reflexes may empty the scrotum temporarily. The meatal opening should be slit-similar and the urinary stream should exist strong. Hydroceles, which do non reduce and do transilluminate, and hernias, which reduce only do not transilluminate, enlarge the scrotum. Testicular tenderness suggests torsion of the testis or epididymitis.

Rectal

Audit the anus for fissures, inflammation, or lack of tone. The latter may indicate child abuse. The rectum is not examined routinely, but is examined in all children with abdominal or gastrointestinal complaints, including diarrhea, constipation, or haemorrhage from the rectum.

Extremities and Back

Asymmetry, anomalies, unusual size, hurting, tenderness, heat, and swelling deformities of the extremities and back must exist distinguished from congenital malformations, osteomyelitis, cellulitis, myositis, or, rarely, rickets and scurvy. Joint heat, tenderness, swelling, effusion, redness, and limitation or hurting on move may signal arthritis, arthralgia, synovitis or injury, or septic arthritis (which is a medical emergency). Detect as the child walks for the presence of a limp. Clubbing of the fingers is a sign of chronic hypoxemia, as in congenital center or chronic pulmonary diseases.

The spine should be straight with mild lumbar lordosis. Kyphosis, scoliosis, masses, tenderness, limitation of motion, spina bifida, pilonidal dimples, or cysts may exist caused by injury, malformation, infections, or tumors.

Weakness, tenderness, or paresis of the muscles suggests inflammatory musculus disease, congenital or metabolic neuromuscular diseases, or central nervous system abnormalities.

Neurologic Examination

Mental status and orientation help determine the acuteness of a child's illness, depending on the ecology conditions. Position at remainder and abnormal movements such as tremors, twitchings, choreiform movements, and athetosis are feature of hyperirritability of the key nervous system. Incoordination of gait usually indicates cerebellar dysfunction. Kernig's sign (inability to extend the leg with the hip flexed) and Brudzinski'south sign (flexing the cervix with resultant flexion of the hip or genu) are indications of meningeal irritation.

Cranial nerves can be tested. Dysfunction of olfactory nerve 1 results in anosmia. Nerves 2, III, IV, and VI are described briefly under "Eyes" in Chapter 34, and nervus 8 is discussed under "Ears" in Capacity 36.6 and 36.7. Dysfunction of the trigeminal nerve V results in lack of sensation of the face and tongue. With peripheral facial nerve Vii paralysis, neither the brow nor the confront moves. With nuclear Seven paralysis, the brow moves. Difficulty in swallowing and loss of pharyngeal reflexes are caused by dysfunction of the glossopharyngeal nervus Nine or the vagus nervus X. Patients cannot contract the sternocleidomastoid or trapezius muscles with interest of the spinal accessory nervus XI. The tongue protrudes to the involved side with hypoglossal nervus XII lesions.

Exam of tendon reflexes (biceps, triceps, patellar, and Achilles) is less of import than is ascertainment of general activity. Hyperactive reflexes indicate an upper motor neuron lesion or hypocalcemia. Decreased reflexes are seen in lower motor neuron lesions or the muscular dystrophies.

NEWBORN Examination

In the delivery room, a minimal examination is needed. The general appearance is noted and, at 1 and 5 minutes of age, an Apgar score is assigned (Tabular array 6-1). A score of 7 or less indicates that an infant is at risk.

The infant is placed in a warmer. A small catheter is passed through both nares. Secretions are aspirated, and the tube is continued into the stomach and the stomach contents are aspirated. Easy passage of the catheter indicates patency of both nares. Passage into the stomach obviates blind pouch types of tracheoesophageal fistula. The infant may urinate or defecate, indicating patency of these orifices. The oral cavity is inspected for cleft palate. Gestational age is assessed based on neurodevelopmental signs. Newborn care then is given and further test is deferred to the nursery.

Table 6-i. Apgar Score

Rating	0	1	ii
Appearance	Pale or blue	Torso pink, extremities blueish	Pink all over
Pulse	Absent	100	100
Grimace	None	Weak	Strong
Activity (tone)	Limp	Some flexion	Spontaneous movement
Respiratory try	Absent	Hypoventilation, gasping	Coordinated, vigorous weep

Preferably within the first few hours of nascence, an access newborn exam is performed in the presence of the parents. The examiner should develop a routine for the newborn examination so that disquisitional areas are never omitted. In the first few hours of life, the newborn ordinarily is awake, simply later four hours, he or she may be sleepy. The pressing question to be answered in the showtime examination is: "Is my child normal?" Although the guild of the examination may vary, as with the history, a stereotyped order of recording should be initiated for like shooting fish in a barrel retrieval of information if it is needed later.

Vital Signs

Vital signs include temperature, eye rate, respiratory rate, blood pressure (using an appliance for newborns) in an upper and a lower extremity, weight, length, and head, chest, and abdominal circumferences. In add-on to recording these, it is essential that they also be plotted on a nautical chart (meet Figs half-dozen-viii, six-11).

Full general Appearance

Inside a few moments, observe the motion of the iv extremities, the advent of the head and neck, trunk symmetry, and any gross abnormalities.

Skin

The pare may exist covered by a white, greasy, easily removable material called vernix caseosa. Note skin color, consistency, and hydration. Cyanosis, jaundice, eruptions, edema, bruises, petechiae, and pallor are significant abnormalities. Note too hemangiomas and nevi, their size and location. Mongolian (brown) spots over the dorsum are not suggestive of disease, just caf�-au-lait spots, if they are numerous, may be a cardinal sign of neurofibromatosis. Papules and pustules must be identified as either normal eruptions or infections.

Head and Neck

The fontanelle size and head circumference are variable on the first twenty-four hour period because of molding. Scalp edema (caput succedaneum) crosses the midline and may be nowadays; this is distinguished from cephalhematoma, which does not cross the midline and is caused past subperiosteal haemorrhage.

Unusual facies suggests dysmorphic syndromes. Peripheral facial nerve palsies are common. Edema of the eyelids is a result of birth processes or reaction to argent nitrate prophylaxis. Sub-conjunctival and retinal hemorrhages are found frequently. Cherry-red reflex from the fundus, if non visible, indicates some obstruction in the preretinal chambers. Malformation of the pinnae of the ears often is accompanied by severe built malformations. If the nose was not establish to be patent in the first test, it should be examined at this time by passing a catheter through both nares. The mouth should be reexamined for cleft palate. The cervix should be examined for shortening (as in Klippel-Feil syndrome), redundant skin folds (as in gonadal dysgenesis), vertebral anomalies, cysts, sinuses, and limitation of motion (torticollis).

Chest

The chest normally is barrel-shaped and smooth at nativity, and expands symmetrically with no retractions. Unequal expansion or asymmetry suggests intrathoracic pathology such equally cardiac enlargement, pneumothorax, or diaphragmatic hernia. The respiratory rate commonly is less than lx breaths per minute. Occasional irregularities with apnea up to 10 seconds can exist normal. Auscultation may reveal adventitious sounds for the starting time 4 to 6 hours. Percussion is resonant throughout. Maximal cardiac impulse is felt in the 4th interspace close to the sternum. Thrills, if they are nowadays, ordinarily point cardiac abnormalities. Murmurs are nowadays in threescore% of normal newborns, only the lack of a murmur does non eliminate a diagnosis of congenital heart affliction. Brachial and femoral pulses, if they are not of equal intensity, advise vascular anomalies such as coarctation of the aorta. If chest expansion is unequal, transilluminate the breast. Transillumination occurs with pneumothorax and occasionally with diaphragmatic hernia.

Belly

Distention of the abdomen occurs with sepsis, intestinal or urinary organization obstruction, ascites, tumors, or pneumoperitoneum. Scaphoid abdomen suggests a diaphragmatic hernia. Palpate gently. The liver'due south edge usually is felt 1 to 2 cm beneath the costal margin and the spleen tip is barely palpable. The bladder, if it is palpable, should exist reexamined after voiding. Palpation of the costovertebral angle with ballottement helps to decide the size of the kidneys. The umbilical cord contains 2 arteries, which are small and thick-walled, and one vein, which is larger and thin-walled. A single umbilical artery is associated with an increased incidence of congenital anomalies. Erythema at the base of the cord suggests omphalitis. Note the patency of the urethral meatus past observing voiding and the patency of the anus either past observing the passage of meconium or past inserting a pocket-size rubber catheter.

Extremities

Disproportionate posturing requires careful palpation of the clavicles, shoulders, and extremities for fractures or brachial plexus injuries. Anomalies of the easily and feet such as webbing, polydactyly, and clubfoot are noted. Abduct both legs to determine any limitation of movement or instability of the hips, which is characteristic of dislocated hips. Read Barlow and Ortolani tests.

Ballocks

Testes normally are in the scrotum of term infants. Determine the position and size of the urethral meatus. The newborn's penis is greater than 2cm in length. An enlarged clitoris tin can be dislocated with a pocket-sized penis and requires evaluation for chromosomal sex activity and other abnormalities of the genitourinary system. The vaginal opening is inspected, and mucosal tags, imperforate hymen, and ambiguous genitalia are sought.

Neurologic Examination

Assess muscle tone and strength. Extremities usually recoil spontaneously when they are extended from a flexed position and thrash almost when irritated. Moro's reflex, which is obtained by loud noise or sudden move, involves abduction of the upper arms and legs, and extension at the elbows and knees, followed by flexion. Absenteeism of this reflex indicates central nervous system depression. Disproportion suggests extremity fracture or peripheral nerve injury.

Selected Reading

Bamess LA: Manual of Pediatric Physical Diagnosis, 6^th ed. St Louis: Mosbv- Year Volume. 1991.

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