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CLASS 8
• Development
• Medical history
• Nutritional status
• Growth and vital sign measurements
• Physical assessment
• Guidelines for well child supervision
• Anticipatory guidance
• Immunizations
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Exam Settings
• Inpatient
• Moderate to severe illness
• Anxiety and stress
• School setting or health office
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
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Key Points to Assessment Procedure
Age Groups
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.
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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
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.
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
This is a 5-page summary, including one chart and additional summaries of pertinent growth and
development theories
General Assessment:
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Skin, Hair and Nails: Skin – Key Points
• Nevus flammeus (“port wine stains”), nevus vasculosis ---not likely to fade
Can be associated with Sturge-Weber Syndrome
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• Cavernous hemangioma: bluish red, more vascular than strawberry
Skin Pigmentations
• Jaundice: Observed in sclera, skin, fingernails, soles, palms & oral mucosa .
Does not blanche with pressure over chest or nose areas
Is associated with liver disease, hepatitis, red cell hemolysis, biliary
Obstruction & sever infection during infancy.
• Renal Disease: Yellowing of exposed skin areas (not sclera or mucous membranes)
May be associated with chronic renal disease
• Assess for dis tribution, 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
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HEENT: Head & Neck: Eyes: Ears: Nose, Face, Mouth & Throat
Head: Variations
• 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 of
ear. 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.
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Eyes: Key Points
Eyes: Variations
• Pupil & Iris: Brushfield’s spots (light speckling of iris) seen in Down s.
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Ears: Key Points
• Otoscope exam: Pull auricle down & back for infants, toddlers, preschoolers
Pull auricle up &back for school aged & adolescents
Cerumen removal may be necessary
Use pneumatic otoscopy
Ears: Variations
• Otitis externa: Pain with movement of auricle or tragus, discharge in canal, occurs
More often in summer (“swimmer’s ear”)
• 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
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Nose: Variations
• Structure variations: Observe flattened nose or nasolabial folds that may indicate
congenital anomolies.
• Palpate maxillary & frontal sinus areas for tenderness of sinusitis in older children
• Development of facial sinuses and location of sinus pain is listed below:
• Count teeth & inspect for caries, malocclusion and loose teeth.
20 deciduous teeth, begin eruption at 6 months & continue adding approximately 1/month
32 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 infants for rooting and sucking reflexes, Epstein pearls & thrush
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Mouth & Pharynx: Variations
• Vesicular eruptions: Can occur on lips, buccal mucosa & tongue, due to viral infections,
such as herpes simplex cold sores or aphthous stomatitis.
• White patches: White ulcerated sores on mucosa ae cankers, related to mild trauma,
viral infection, mild trauma or local irritants.
• Palate & uvula: With gag reflex, deviation of uvula to one side suggests either
Glossopharyngeal or vagus nerve involvement or infection of
peritonsillar or retropharyngeal abcess.
Green & black staining may indicate oral iron intake contacting teeth
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• Pharynx: Large tonsils, due to developmental lymph tissue hypertrophy
Are common in school aged children & adolescents
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 to
sternocleidomastoid 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
• 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.
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• Mumps: Parotitis produces swelling over angle of jaw, usually unilateral,
with redness & swelling of Stensen’s parotid duct in mouth & pain with
sour tastes.
• 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:
(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.
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Lungs & Respiratory Status: Key Points
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Heart
Stethoscope
Diaphragm: high pitch, S1
Bell: low pitch, S2
Functional Murmurs:
Change or disappear with position change (usually loudest supine)
Low grade, soft or musical
Intensity range from I-III/VI
Systolic (never diastolic)
Do not radiate
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• 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
• Contour
• Peristalsis
• Skin: color, veins
• Umbilicus
• Tenderness
• Ridigity
• Tympany
• Dullness
• Hernias: umbilical, inguinal, femoral
• Masses - size, shape, dullness, position, mobility
• Liver
• Spleen
• Kidneys
• Bladder
Breast: as previous
Female Genitalia
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Tanner Stages
I Prepubertal. No true pubic hair
II Sparse growth of slightly pigmented, downy hair, slightly curled, along labia
III Increas in hair, courser, curled, darker
IV Adult-type hair, but limited area. No spread to thighs
V 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
• Pubic hair
Tanner Stages
I Prepuberal, no true pubic hair, testes, scrotum, penis childhood size
II Sparse, slightly curled, downy hair (base of penis/along labia
Enlargement of testes & scrotum, scrotal skin reddens & coursens
III Hair courser, curled, darker. Enlargement of penis (length),
further growth scrotum/ testes
IV Adult type hair, no spread to medial thighs. Enlargement of penis
(width/length), enlargement of glans, scrotal skin darkens
V Adult hair distribution (triangle) & adult genital development
Problem Areas
• Asymmetries or weaknesses
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• Limp
• Legg-Calve` Perthes:
peak age 7 years: boys > girls
Hip or knee pain
May have history of trauma
+ Trendelenburg
• Slipped Capital Femoral Epiphysis
Adolescents: boys > girls
Obese
Hip or knee pain
• Joint infection
• Feet/legs: Variations may begin in feet, tibia or upper let & hip area
Feet turning in: varus
Feet turning out: valgus
• Legs:
Bowleg (genu varum -- knees 2 inches apart)
Knock-knee (genu valgum -- ankles 3 inches apart)
• Movement limitation:
crepitus with joint movement
meningeal signs, such as stiff neck, opisthotonous
• Muscular dystrophy
Progressive muscular weakness (Gower’s sign)
• Cerebral palsy or other muscular disease
Pes equinus (weight bearing on toes)
Short heel cords
• Cerebral Function:
• "Mental status" appearance, behavior, cooperation
• LOC, language, emotional status, social response, attention span
• Cerebellar Function
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• Sensory function
• Reflexes
• Cranial Nerves
C1 Smell
C2 Visual acuity, visual fields, fundus
C3, 4, 6 EOM, 6 fields of gaze
C5 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 & equilibrium
C9 "ah" equal movement of soft palate & uvula
C10 Gag, Taste, posterior 1/3 tongue
C11 Shoulder shrug & head turn with resistance
C12 Tongue movement
• Blink (dazzle)
st
Blinks to bright light, 1 year of life, absence indicates blindness
• Root
Turns direction cheek is stroked, disappears 3-4 months, may persist longer, absence
indicates neruologic disorder
• Suck
Sucks in response to stimuli, may persist during infancy, weak or absent reflex
indicates developmental/neurological disorder
• Extrusion
Tongue extends out when t ouched, disappears at 4 months, persistent extrusion may
indicate Down’s
• Moro & Startle
Arms & 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
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• Galant's (trunk incurvation)
Back moves toward paraspinal side stimulated, present for 4-8 weeks, absence
may indicate spinal cord lesions
• Dance or step
Feet withdraw or step up, when foot touched to surface, present 4-8 weeks,
persistence indicates neurological problem
• Palmar grasp
Finger’s curve around object placed in palm or palmar aspect of fingers, disappears 3-4
months, persistence indicates neurologic disorder
• Tonic neck
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 righting
When supine, shoulders, trunk pelvis turn to direction head is turned, absence or
persistence beyond 6 months indicates neurological disorder
• Crawling
Symmetrical 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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