PCM - Approach to Pediatric Physical Examination (04/26/18)
What techniques are the same between adults and pediatric patients?
- Inspection - Percussion - Palpation - Auscultation
What do we look for in the pediatric rectal exam?
*Inspection* - Anomalies e.g. imperforate, with or without fistula - Anal tags, fissures, lacerations, warts ova of parasites e.g. pinworm *Digital* - Specific indications - Use 5th finger vs index finger
What is important for pediatric patients?
*OBSERVATION* - Interaction between child and caregiver - Interaction with you and environment
How do we conduct the pediatric neurological exam?
*Observation* is key - for deficits In general, similar to adult - Level of alertness or consciousness, CN exam, sensory, motor, DTRs - age appropriate assessment - Detailed adult-type neuro exam feasible with older, cooperative children who can follow instructions - Newborn primitive reflexes - Moro, palmar, grasp
How do we inspect the skin?
- *Color*: cyanosis, pallor - *Birthmarks*: hemangiomas, Mongolian spots - *Rashes*: detailed description e.g. macular, papular - *Hydration*: skin turgor
What do we look for in the pediatric throat examination?
- *Deformities*: cleft palate, deviated/bifid uvula - *Enlarged tonsils*: usually age related - Describe size of tonsils
What do we look for on nasal inspection?
- *Deformity*: saddle nose, flat nasal bridge, injury, nares - Deviation - Patent nares - Allergy features
What do we look for in the eyes of the pediatric patient?
- *Eye lids*: symmetry, swelling, lesions, discoloration, discharge, epicanthic folds - *Sclera*: color, inflammation - *Pupils*: light reflex - Red reflex - Visual fields, visual acuity
What is involved in the pediatric general examination?
- *General appearance*: well, sick, cooperative, crying, hydration - *Nutritional status*: using standardized growth curves - *Posture, gait, symmetry, age*: appropriate activity - *Characteristic dysmorphic features or facies* e.g. Down syndrome - *Color*: pallor, cyanosis
How do we conduct the pediatric MSK exam?
- *Inspection*: gait, posture, symmetry, deformities (varus, valgus, club feet), leg length discrepancy - *Spine*: kyphosis, scoliosis - screen at all ages - *Joint*: symmetry, swelling, range of motion - *Palpation*: muscle bulk, tone, strength/power - *Clavicles and hip exam*: newborn and infants
What comprises the pediatric cardiac exam?
- *Inspection*: symmetry, precordial activity, scars - *Palpation*: PMI, thrill, heave - *Auscultation*: same landmarks as adult; heart sounds, rate and rhythm, listen for added heart sounds (S3 or S4) and murmurs - *Heart rate vs. pulse rate*: easier to count HR in infants vs palpating for a pulse - *Peripheral pulses*: part of cardiovascular system exam - radio-femoral delay
What do we look for in the mouth examination?
- *Lips*: cleft, color - *Oral mucosa*: color, lesions, trauma - *Dental exam*: teeth, gums, periodontal area - *Tongue*: color, tongue tie, lesions - Salivary glands
How do we inspect external genetalia?
- *Male*: penis, scrotum, testicles, perineum - *Female*: vulva, vagina, clitoris, urethra *Inspection* - Tanner Staging - Circumcision, urethral meatus and testes position - Trauma, discharge, labial adhesions (F) *Palpation* - tenderness, masses
What do we look for on the internal nasal examination?
- *Mucosa*: color, bruising, bleeding - *Nasal septum*: deviation, perforation - *Swollen turbinates*: d/t allergy - Polyps - Foreign body - Tumors
Tell me about the pediatric respiratory exam.
- *Rate*: faster than adult, diminishes with age, count for 30-60 secs - *Inspection*: shape, symmetry, deformities, signs of respiratory distress e.g. retractions, accessory muscle use - *Palpation* (older children) - *Percussion* (older children) - *Auscultation*: same landmarks as adults, use bell of stethoscope if using adult stethoscope
What do we look for in the neck examination of pediatric patients?
- *Short*: in infancy - *Range of motion*: torticollis - *Rash/lesions*: in between folds - *Nuchal rigidity*: meningitis - *Lymph nodes*: cervical nodes - size, consistency, tenderness, mobile - *Structures*: trachea, carotid vessels, external jugular, thyroid gland
How do we inspect the head?
- *Size*: macrocephaly, microcephaly - *Fontanelles*: infants - open, flat, soft, tense, bulging
When do we start checking blood pressure regularly?
- >3 years checked routinely - Use appropriate sized cuff that covers 2/3 of upper arm - Normal values are based on height, sex and age using a normogram
What is the main difference in physical exam between adults and pediatric patients?
- Approach - Order of exam
How are pediatric physical exams done?
- BY OPPORTUNITY - Go by region rather than system
What are Dr. O's helpful hints?
- Be friendly, put your patient at ease as soon as you enter room - Make allowance for child's developmental stage - Involve child as much as possible - Walk your patient through - tell him/her what you are doing - Save the worst (more invasive exam) for last - Never wake a sleeping child until you have to - Take what you're given first, make the most of unexpected opportunities - Be patient with your patient :)
What do we look for in the otoscopic exam for the pediatric patient?
- Cerumen - Discharge - otitis externa - Blood - trauma - Foreign body - Inflamed EAC - Carbuncle in EAC - Tumors (rare)
What lymph nodes are most commonly enlarged in pediatric patients?
- Cervical lymph nodes - Inguinal lymph nodes *URI and LE injury*
What is taken into account for the normal growth parameters?
- Height - Weight - BMI
How should we approach the pediatric patients?
- Introduce yourself: to parents and child - Wear name badge so family knows who you are and your role - Inform parents and child/adolescent what you'll be doing - Ensure you have verbal assent/consent before proceeding with any part of the physical exam - Be friendly, put your patient at ease as soon as you enter room - Understand and make allowance for child's developmental stage - Use the gift of distraction - Involve child as much as possible - Be patient
Where is the PMI in infants and toddlers?
- Left 4th intercostal space
Where is the PMI after age 7?
- Left 5th intercostal space
How do we inspect peripheral lymph nodes?
- Location - Visible enlargement - Color
What do we look for in pediatric breast exams?
- Mastitis in infants - Accessory nipples - Gynecomastia in infant and adolescent males - Sexual Maturity Rating (Tanner Staging)
Do we expect JVD in pediatric patients?
- No
How do we position the pediatric patient?
- Parent/caregiver arms/lap - Exam table if older
How do we conduct the pediatric ear exam?
- Position, deformities, creases, trauma, swelling - Tenderness on moving pinna or pressing tragus - Ear discharge - Mastoid process: erythema, tenderness
What is involved in the pediatric throat examination?
- Posterior pharynx - Soft and hard palates - Tonsils - Uvula - Epiglottis
How do we approach the pediatric HEENT exam?
- Prepare for resistance and how to handle it - Make the most of unexpected opportunities - Save the worst for last - most invasive/uncomfortable - Be honest - if its going to hurt say so in a calm manner - if you lie you lose credibility
How do we conduct the pediatric abdominal exam?
- Respect the privacy and dignity of your patient (decent exposure) - Warm hands, gentle palpation, palpate with edge of fingers (not tips) - Look at patient's face as you palpate, if you elicit tenderness - If abdomen tense, try flexing at hips - If child is crying, palpate during inspiration - Same landmarks and techniques as adults* - Spleen tip and liver edge often palpable in infancy - Examine hernia orifices
How do we palpate peripheral lymph nodes?
- Size - Warmth - Tenderness - Mobility - Overlying skin
What are the pediatric patient physical exam regions?
- Skin - Lymph nodes - HEENT - Musculoskeletal: spine, limbs - Chest: resp, CVS - Breast - Abdomen - Genitalia - Rectal - Neurologic
How do we palpate the skin?
- Specific skin lesions (nodules, pustules)
How should we position ourselves in the pediatric PE?
- Stay at child's level whenever possible - Avoid towering
