State Establishment “Dnipropetrovs’k medical academy

MH of Ukraine”
Department: Propaedeutics of children’s diseases

Ratified on the department’s meeting

Head of the department
Professor Ilchenko S.I.

Methods of examination of the

child Date: 28.08.2015 Protocol № 1
(Guidelines for the students)

Discipline: Propaedeutics of Pediatrics

Faculty: I Іnternational

Course: 3 Semester: V Speciality: General medicine

Curator of the
theme: ass. professor Yaroshevs’ka T.V.

Contents

Collection of anamnesis 2
I. Passport part 2
II. Patient’s complaints 2
ІІI. History of the present disease 2
IV. Anamnesis of patient’s life 4
Objective examination of the patient 7
Estimation of physical development 7
Examination of the skin 12
Examination of subcutaneous fat 14
Examination of the peripheral lymph nodes 15
Examination of the muscular system 17
Examination of the skeletal system 18
Examination of the respiratory system 20
Examination of the cardiovascular system 27
Examination of the digestive system 34
Examination of the urinary system 41
Examination of the nervous system 43
Examination of the endocrine system 50
Literature 53

COLLECTION OF ANAMNESIS

I. PASSPORT PART
1. First name, last name of the child.
2. Age (date of birth).
3. Home address.
4. Does the child go to day kindergarten, school?
5. Profession, position and job of parents.

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 II. PATIENT’S COMPLAINTS (complaints of parents or child at
admission to hospital and in period of the examination by student).

III. HISTORY OF THE PRESENT DISEASE

When does the disease start (date)? Supposed reasons. Features of disease start
(acute, gradual) and further clinical course, including the symptoms dynamics in
clinic. General manifestations of disease: temperature, fever, changes of sleep,
appetite, behavior, dynamics under the influence of therapy. The main manifestations
of the disease from the side of organs and systems (respiratory organs, cardiovascular
system, organs of the digestive and urinary systems, muscular and skeletal, endocrine,
nervous systems).
The diagnosis of the directed establishment. The admitting diagnosis.
Conclusion about anamnesis of disease (supposition about the lesion of
separate organs and systems, features of the clinical course before your observation of
the child).

ІV. ANAMNESIS OF PATIENT’S LIFE

1. Age of parents, state of their health, harmful habits.
2. How many children are in family? What state of their health?
3. From what pregnancy and what number of child (if it is not a first
pregnancy, how finished the previous pregnancies)?
4. What pathology was during pregnancy and delivery?
5. Did the child cry right after birth?
6. Weight and length at birth.
7. When the breast was given to baby, how he took it?

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 8. When the umbilical cord fell away and how the umbilical wound
closed up?
9. Was there a physiologic jaundice? Time of its appearance, degree
of manifestation, duration.
10. Was there a physiological loss of weight and when the weight of
new-born was restored?
11. Development of child’s motor activity: from what age holds a
head, turns to side, on abdomen, from abdomen to side, sits, crawls, and
walks.
12. Neuropsychical development of the child: when began to smile,
babbling, recognize mother, articulate separate syllables, words, phrases?
13. Increase of weight and height on the first year of life and in the
following years.
14. Time and order of dentition, quantity of the teeth in one year.
15. Infant feeding: breast feeding, mixed feeding or artificial feeding.
Time and order of additional food introduction (weaning). Whether the
feeding schedule keeps? Feed after one year, favorite dishes.
16. Behavior of child in home and in collective.
17. Sleep, appetite.
18. Diseases: what, in what age, clinical course, severity,
complications, treatment in home or in hospital.
19. Prophylactic vaccination: what infections a child is vaccinated
against? Did the schedule of vaccination keep? Were there any reactions on
vaccination and haw they appeared?
20. Mantoux tuberculin skin tests results.

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ALLERGIC ANAMNESIS
1. Do parents, sisters, brothers, grandfathers, grandmothers, aunt,
uncle have: bronchial asthma, eczema, pollinosis, nettle-rash, vasomotor
rhinitis, Quincke's edema, diathesis?
2. Mather’s feeding during pregnancy.
3. State of skin in the first year of life.
4. Is there any reactions on medicines, food, plants, clothes, home
objects etc. in child?
5. Are there in house pets: cats, dogs, fishes, birds?
IMMUNOLOGIC ANAMNESIS
1. Reactions on prophylactic vaccinations.
2. Frequency and severity of course of the diseases.
EPIDEMIOLOGICAL ANAMNESIS
1. Connection of child’s disease with patients in home, school,
kindergarten.
2. Contacts with infectious patients.
3. Presence of tubercular, venereal patients in family.
GENEOLOGICAL ANAMNESIS
1. Presence of hereditary disease in family.
2. Family marriages.
3. Presence of abortions, stillborns.
4. Genealogy chart.
FINANCIAL AND HOME CONDITIONS
1. Housing conditions (separate flat, room, private house).
Characteristic of apartment (light, dark, warm, dry, humid). How often the
apartment is ventilated, what heating is there?
2. Does the child visit the children's institutions, from what age,
behavior in collective, progress at school?

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 3. Das the child have his own bed and enough linen?
4. Clothes according the season.
5. Bathing (regularly, not regularly, how often).
6. Walks (from what age, systematic, not systematic, duration).
7. Who nurse the child (state of health of the person, who nurses the
child).
8. Day regimen in detail (in hours), in the case of questioning of
schoolchildren – the load at school, additional loadings.

GENERAL CONCLUSION ABOUT ANAMNESIS

The lesion of what system can be supposed? Acute or chronic disease? What
negative factors from anamnesis of life could provide the development of the present
disease or burden its clinical course?

OBJECTIVE EXAMINATION OF THE PATIENT

General condition of patient (satisfactory, moderate, severe, very severe). How
does patient feel himself?
Position in a bed (active, passive, forced). Consciousness of patient (clear,
spoor, stupor, coma).

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 ESTIMATION OF PHYSICAL DEVELOPMENT
Estimation of physical development has the special value in child's age. For
estimation of physical development except measuring of length and mass of body, it is
necessary to determine the head and chest circumference, proportions of child’s body
and calculate the some indexes that allow giving the objective estimation of physical
development of this child.

Measuring of length of body of children in the first year of life

The length of body is measured by horizontal height-meter in a view of the
board with 80 cm long and 40 cm wide.
Measuring order: a child is measured in lying position. Child lay on back so that
head closely touch to the cross plank of height-meter. A head is fixed in position at
which the lower edge of eye-socket and upper edge of the external acoustic meatus
(tragus of ear) make one vertical line. Assistant or mother fixes a head closely to the
immobile plank. The child’s feet must be straightened by light pressing on the child’s
knees. It is necessary to bring to the heels of the child the mobile plank of height-
meter. The distance between the mobile and immobile planks of height-meter will
correspond to the growth of child.

Measuring of body length of elder children

Measuring of body length is executed in the standing position by vertical
height-meter. On a vertical plank there are two scales, one (on the right) - for height in
the standing position, other (on the left) – in the sitting position. A plank slides along
the vertical plank.
Measuring order: a child stays on the ground of height-meter, touching the
vertical plank with heels, buttocks, interscapular region and back of head, hands are
dropped along a body, heels together, socks separately, a head is fixed in position, at
which lower edge of eye-socket and upper edge of the external acoustic meatus

7
(tragus of ear) are in one horizontal line. A mobile plank is put to the head without
pressing on. The distance between the mobile and immobile planks of height-meter
shall correspond growth of child.

Weighing of children from birth to 2 years old

Weighing is executed on the tray-scales with the maximally possible loading up
to 20 kg with precision 10 gram. It is also possible to use the electronic scales with
precision of measuring up to 1 gram.
Weighing technique: at first a nappy is weighed. It is laid on the tray of scales
so that the edges of nappy are not let down from a tray. The naked child is laid on
wide part of tray with head and shoulder-girdle; the legs are on the narrow part of tray.
If a child can sit, he is seated on wide part of tray; the legs are on narrow part. Placing
a child on scales and taking off from it is possible only at the closed fixing of scales.
Reading of scales are on that side of weight, where are incisions. When the weight is
recorded, the weight put on a zero. For determination of child’s weight it is necessary
to subtract the weight of nappy from the reading of scales.

Weighing of children after 2 years

Weighing is executed on medical balance. The children are weighed in the
morning on an empty stomach, after urination and defecation. During weighing the
undressed child must stand motionless on the middle of the ground of scales.

Technique of measuring of circumferences

Measuring is made by a measure-tape.
At measuring of head circumference a tape is conducted behind on a place of
maximal protrusion of occipital tuber and in front - on a forehead, above the
eyebrows. Direction of the tape is back to front.

8
 The circumference of chest is measured in three states: maximal inspiration,
expiration and in state of rest (for little children only in state of rest). A measuring
tape is laid on the back - under the angles of shoulder and in front - on the lower edge
of mammary areolas.
The circumference of shoulder is measured in upper one-third of shoulder. A
tape is laid on the level of axillary skin-fold in the place of the most developed biceps
in a horizontal plane.
The circumference of thigh is measured by the tape laying it directly under the
gluteal fold in a horizontal plane.
The circumference of shin is measured by the tape laying it in area of most
developed of gastrocnemius muscle.
Circumferences of shoulder, thigh and shin are measured for the children of
first 3-4 years of life.

Indexes of physical development

The weight-height index is a ratio of weight at birth to height at birth. At
normotrophy the index must exceed 60, if it is below 60, it indicates the congenital
hypotrophy.
Degrees of congenital hypotrophy: 1 degree – 55-59
2 degree – 50-54
3 degree – below 50
The index of tropism is a ratio of the factual mass to the ideal mass, multiplied
on 100%. Norm: 100 ± 10%.
For the estimation of physical development of children the empiric formulas, tables
of body mass and height increase are used. This method of estimation of physical
development by the empiric formulas is an approximate. More exact estimation can
be executed with using of the tables of sigmal and percentile types or nomograms.

9
 Identification of somatotype
Somatotype is an integral estimation of physical development, characterizing
the rate of individual development of child as a whole. For determination of the
somatotipe it is necessary to calculate the sum of the percentile corridors numbers of
three indexes: mass, height and chest circumference of the child. If a sum is equal 10
and less, the microsomatotype is determined (delayed type of development). If the sum
is from 11 to 17 points – mesosomatotype (middle type of development). The sum
from 18 and more points – macrosomatotype (accelerated type of development).

Empiric formulas of physical development of child (under I.M. Vorontsov

and A.V. Mazurin):
1. Body mass of children of the first year of life: 8200 (8400) – the body
mass of child in the age of six months. For each missing month 800 g must be
deducted, and for each month more than 6 - 400 g must be added to 8200 (8400).
2. Body mass of children in the age of 2-12 years: Body mass in 5 years
old is 19 kg. For each subsequent year + 3 kg, for each missing year -2 kg.
3. Body mass of children in the age of 12-16 years: 5n-20 kg, where “n”
means the years of life.
4. Height of children of the first 6 months: height at birth is +3n, where
“n” is a number of months of life.
5. Height of children in the age of 7-12 months: 64 + n, where “n” is a
number of months of life.
6. Height of children in the age of 2-15 years: Height of children in the
age of 8 years is 130 cm. For each missing year 7 cm must be deducted, for each
subsequent year 5 cm must be added.
7. Calculation of circumference of head and chest:
At birth the child’s head circumference is 34-35 cm, to the year of life it is
about 46-47 cm. In 5 years it is 50 cm, in 12 years – 54 cm.

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 Increase of the head circumference for the children of the first year of life:
before 6 months – on 1,5 cm in each month; after 6 months - on 0,5 cm in each
month.
Increase of the head circumference after the first year:
before 5 years – on 1 cm in each year; after 5 years – on 0,6 cm in a year.
Circumference of chest of new-born is 32-34 cm, to the first year of life the
chest circumference is 48 cm. The chest circumference in 10 years is 63 cm. In 15
years old it is 75 cm.
Increase of the chest circumference for the children of the first year of life:
before 6 months the chest circumference increases on 2 cm every month; after 6
months – on 0,5 cm.
Increase of the chest circumference after the first year:
before 10 years the chest circumference increases on 1,5 cm in a year; after 10
years – on 3 cm in a year.

ESTIMATION OF THE PHYSICAL DEVELOPMENT OF CHILDREN BEFORE

3 YEARS BY THE DIAGRAMS OF PHYSICAL DEVELOPMENT
According the order of Ministry of Healthcare of Ukraine № 149 from
20.03.2008 the physical development of children of the first three years of life must
be estimated by the diagrams of physical development (see Appendix 2).

EXAMINATION OF THE SKIN

The objective methods of skin research are inspection, touching, research of
fragility of skin capillaries and determination of dermographics.
INSPECTION: Careful examination of child’s skin can be made only at
sufficient and desirably natural illumination. A child must be fully undressed. The

11
axillary creases, skin folds, area of anus, where pathological changes of skin more
often appear, must be examined with the special attention.
Pay attention to the color of skin and visible mucous membranes, on blood
filling, dilatation of veins and venous capillaries, presence of rash, hemorrhages, scars
and growth of hairs. The normal coloring of child’s skin is pinc. However, pallor or
reddening (hyperemia) of skin is possible, jaundice (icterus), cyanosis, sallow
complexion or earthily-grey tint are possible at pathology.
It is also necessary to pay attention to the other skin changes: dilatation of a
skin venous network in interscapular region (in upper part of the back), in upper part
of chest, on a head and abdomen.
It is necessary to examine the visible mucous membranes of the inferior eyelid
and oral cavity, mark the degree of their filling with blood, changing of color (pallor,
cyanosis, hyperemia), presence of rash.
PALPATION: Thickness and elasticity of skin is determined by palpation. For
this purpose it is necessary to take a skin (without a subcutaneous fat) in a small fold
by the first and index fingers of right hand. Then the fingers must be taken away.
Elasticity of skin is considered normal, if a fold falls out at once; if a fold falls out
gradually, such skin elasticity of skin is considered reduced. A skin in a fold is easier
to take in places, where the subcutaneous fat layer is little - on the backside of hand,
on a bend of elbow. Elasticity of skin can be defined also on an abdomen and chest.
Determination of skin elasticity has the special value for the early age children.
Humidity is determined by stroking of skin by fingers on the symmetric areas
of body: on a chest, trunk, axillary creases, inguinal region, on extremities, including
on hands and on soles, especially for the children of prepubescent period, on the back
of head - for sucking child. Normally moderate humidity of skin is determined by
palpation, there can be dryness of skin, raised humidity or increased hyperhidrosis can
be at pathology.

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 The temperature of skin is also determined by touching. The temperature of
skin can be low or high depending on the general temperature of body, but there can
be the local lowering or rise of temperature.
Research of fragility of skin capillaris: test of tourniquet (Konchalovsky-
Rumpel-Leede) - it is necessary to put a tourniquet on the middle third of shoulder of
child for 3-5 minutes. If the fragility of skin capillaries is heightened after tourniquet
removing of the tourniquet there will be the small hemorrhages on its place and also
on the bend of elbow or on forearm – more than 3-5 (more than one petechia for 1
cm2).
Test of a pinch: take a skin fold, better on the front or lateral surface of the
chest, squeeze the fold by the first fingers and index fingers of the right and left
hands. After this the parts of fold (across the length) are displaced in opposite
direction. Appearance of more than 3-5 hemorrhages (petechia) on the place of pinch
during 3-5 minutes considered as a positive symptom.
Hammer test: if petechia elements (3-5) are appeared at tapping by
neurological hammer of moderate force in area of breastbone, a symptom is
considered positive.
Research of demographics - to pass by index finger on the skin of the chest or
abdomen. After some time white strip (white demographics) or red strip (red
demographics) appears on the place of mechanical irritation of skin. It is necessary to
determine a type of demographics, speed of its appearance and disappearance, size
(wide or narrow). Appearance of white demographics indicates predominance of
sympathetic section of the vegetative nervous system, red – parasympathetic section.

EXAMINATION OF SUBCUTANEOUS FAT

Some opinion about development and distribution of the subcutaneous fat layer
can be gotten at general inspection of child; however, the final conclusion about the

13
state of subcutaneous fat layer is made only after palpation. The more objective
method of research of subcutaneous fat layer is calipermetria.
For estimation of subcutaneous fat layer it is required more deep palpation, than
at research of skin. The first and index fingers of the right hand take not only a skin,
bur also subcutaneous fat. It is necessary to determine the thickness of subcutaneous
fat in different places (on a chest - between a nipple and breastbone, on a abdomen -
at the level of navel, on the back - under shoulder-blades, on extremities - on the
outside surface of thigh and shoulder, on face – on the cheeks), as in the pathological
cases the fat depositions in different places can be different. Depending on the
thickness of the subcutaneous fat layer it is talked about the normal, excessive and
insufficient deposition of fat. It is necessary to pay attention to the even (on all of
body) or uneven distribution of the subcutaneous fat layer.
At palpation attention should be taken on quality of subcutaneous fat layer, its
consistency. In some cases a subcutaneous fat layer becomes dense. The induration of
subcutaneous can be limited in the separate, small areas. An induration can take all or
almost all of subcutaneous fat. It is sclerema. Along with induration edema of
subcutaneous fat layer can be observed. It is scleredema.
Attention must be paid on the presence of edema and its distribution (localized:
on the face, eyelids, extremities; a general edema - anasarca). It is easy to see the
oedemata on face at inspection. To determine the presence of edema on the lower
extremities, it is necessary to press on anteriomedial surface of a shin by an index
finger. If at pressing a fossa formes and then it disappears gradually, it is talked about
the edema of subcutaneous fat. For a healthy child the fossa doesn’t form.
Determination of turgor of soft tissues is executed by squeezing all soft tissues
on the internal surface of thigh and shoulder by the first and index fingers of the hand.
You shall feel resistibility and flexibility named turgor. If child has the reduced turgor
of the soft tissues at squeezing you will feel flabbiness, that is a sign of dehydration,
hypotrophy.

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 EXAMINATION OF THE PERIPHERAL LYMPH NODES
Examination of the peripheral lymph nodes is executed by inspection and
palpation but the main method is palpation.
For clinical research the followings groups of lymph nodes can be accessible:
occipital; parotic; submandibular; anterior cervical and posterior cervical;
supraclavicular and subclavicular; axillary; thoracal; elbow or cubital; inguinal;
popliteal.
Palpation is executed symmetrically by II, III and IV fingers. For obtain all
necessary characteristics the nodes are pressed to the more dense tissues (muscular,
bone) by stroking motions of fingers (transversal, longitudinal, circle) trying to «roll»
the nodes under the fingers of researcher.
For each group of the palpable nodes following characteristics are determined:
- presence, symmetry, number: If in each group not more than 3 lymphatic
nodes are palpated, it is talk about the single lymph nodes, if there are more
than 3 – about multiple.
- size (in millimeters, centimeters): If the lymphatic node has the rounded form,
it is necessary to specify its diameter, if the form is oval are maximum and
minimum sizes must be indicated.
- consistency: There are determined the softly-elastic, dense-elastic, dense
lymph nodes.
- mobility: Specify attitude toward the nearby lymph nodes, surrounding tissues,
skin, subcutaneous fat layer. Lymph nodes can be movable, knitted with the
surrounding tissues and together. In last case it is talked about the «packages»
of lymph nodes.
- sensitivity: Perceptibility on palpation of the lymph nodes (painful, non
painful) is estimated on the subjective feelings of child.

15
 In norm practically always mandibular, axillary, inguinal lymph nodes are
available for palpation. They are single, no more than 1 cm in diameter, softly-
elastic, movable, painless.

16
 EXAMINATION OF THE MUSCULAR SYSTEM
At examination of the muscular system it is necessary to note the degree of
development and mass of muscles, muscular tonus, their force, and also volume
and character of motion.
Mass of muscles is determined by inspection and touching. Muscle strength for
elder children is determined by dynamometer. For the children of early age muscle
strength is determined only by subjective sensation of child’s resistance on one or
either motion.
Muscular tonus is determined by the passive flexing and straightening of the
upper and lower extremities. Degree of resistance, arising at passive motions, and
consistency of muscular tissue, determined by touching, allow to judge about the
muscular tonus. In a norm tonus and mass must be identical. The increase tonus can
be a symptom of hypertonia, the lowering of muscular tonus can be at hypotonia.
For children after 2-3 months of life the muscular tonus of the upper
extremities is checked up the traction test: a child lying on the back. A doctor takes
his wrists and carefully pull child on himself, trying to make him seating. At first a
child straightens arms, and then, in the second phase, bends arms and pulls himself
up. At hypertonia the first phase – straightening of arms is absent, at hypotonia
pulling is absent.
Return symptom is used for study of the muscles flexor tonus of upper and
lower extremities. The child lying on the back. A doctor carefully straightens his
extremities and press them in the straightened position to the table for 5 sec. When a
doctor removes his hands, the child’s extremities immediately return in starting
position. At hypotonia the extremities don’t return in starting position, and at
hypertonia doctor straightens the extremities with effort.
After disappearing of the physiological hypertonia the following procedure is
used: doctor embraces the child’s thorax by hands and carefully turns him in vertical
position by head down. If muscular tonus is normal, the head shall be in one vertical

17
plane with body, but not droop, the hands shall be flexed gently and the legs shall be
stretched. At hypotonia the head and legs droop and at the heavy muscular hypotonia
the hands droop too. At hypertonia the hands and legs are more flexed and head is
thrown back.

EXAMINATION OF THE SKELETAL SYSTEM

The objective examination of the skeletal system is carried out by inspection,
palpation, measurements and X-ray examination, if is required.
The skeletal system is researched in the following order: first of all the head
(the skull), then the body (the thorax and spinal column), upper and lower extremities.
At examination of head its size and form shall be determined. Attention is paid
to the increase (macrocephalia) or decrease (microcephalia) of the head sizes.
Attention shall be pay on the form of skull. The normal form of skull is round, but at
pathology it can be square, tetragonal, tower, egg-shaped etc.
Fontanels, seams and density of cranial bones are examined by palpation.
Palpation is carry out by both hands putting the first fingers on a forehead and palms
on the temporal regions: the long and index fingers study the parietal bones, occipital
bone, seams and fontanels, i.e. touch all surface of skull. Attention must be paid on
softening of the bones (osteomalacia), especially in occipital region (craniotabes),
parietal bones or skull defects.
Palpating the big fontanel it is necessary to define its size (distance between
two opposite sides of fontanel, not its diagonal). Touching the edges of fontanel
carefully, pay attention whether there are their softness, pliability, later or early
closing of fontanel (average term of closing of the big fontanel is 9-15 months),
protruding or falling back. Touch and estimate state of cranial seams, their softness,
and a divergence.
At examination of a thorax pay attention on its form. As child grows older, it
becomes little flatten and to school age the thorax gets the final form - slightly
18
truncated cone. At examination pay attention on presence of funnel or keeled chest,
Harrison’s fissure (retraction of the thorax on a place of the diaphragm attachment),
cardiac hump.
At palpation it is noted if there are any thickening of ribs on the border of osteal
and cartilage parts – “rachitic beading”.
At examination of the spinal column pay attention on the spinal curvature:
sideways – scoliosis, forward – lordosis, backwards – kyphosis. In the event of
scoliosis, at examination of child it can be note that one shoulder is above other and
one hand adjoins to body more close than other. In the case of anatomic scoliosis
asymmetry of costal arches is also defined when the child is in bending forward
position.
At examination of the upper extremities pay attention on presence of bone
deformation, the shortening of humeral bones, thickening in the zone of epiphysis of
radial bones (“bracelets”) and diaphyses of phalanxes (“the strings of pearls”). At
examination of lower extremities pay attention if there are any shortening of bones,
X- and O-shaped curvature of extremities, flat-foot (platypodia).
The joints must be is carefully inspected, palpated and measured. It is necessary
to define the form of joints, presence of deformation, to study volume of movements,
morbidity and painfullness in joints. By palpation doctor defines dermal temperature
in the field of joints. He defines the size of joints by centimeter tape: circles of both
symmetrical joints are measured at the same level.

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 EXAMINATION OF THE RESPIRATORY SYSTEM
The objective examination of the respiratory tract is carry out by inspection,
palpation, percussion and auscultation.

INSPECTION: General inspection begins from the face, and then doctor
examines the thorax. Pay attention on child’s breathing: whether the child breathes
through a mouth or a nose, whether there are discharges from a nose and their
character, whether there is an inflating of nose wings.
It is important to note the color of skin. At presence of cyanosis specify a
degree of its expressiveness, is it constant or periodical (appears at a suction, cry of
the child, at physical strain). Cyanotic discoloration often appears only in the zone of
nasolabial triangle (especially for little children) – perioral cyanosis.
At inspection of thorax pay attention to form of the thorax, symmetry of motion
of scapulas, intercostal bulging or retraction, retraction of one half of chest shall be
noted. Pay attention to participation of auxiliary muscles in the act of respiration.
It is important to describe the voice of child, his cry and cough. It is
recommended to ask elder children to make the forced inspiration and exhalation. Pay
attention on participation of the thorax in the act of breathing. Depending on primary
participation of a chest or an abdomen the type of respiration is determined (thoracal,
abdominal, diaphragmal respiration).
Define depth of respiration. A rhythm of respiration is determined on a
regularity of respiratory acts. It is necessary to count up the number of respiratory
movements in one minute and correlation of pulse and breathing. Calculation of
frequency of respiration make or approximately, or by hand putting on a chest or an
abdomen. At newborn and infants calculation of number of respiration can be made
by bringing the stethoscope to the child’s nose (better during sleep). Calculation of the
number of breathings is made during one minute.

20
 PALPATION: the state of skin in the field of thorax (local sweating,
hyperesthesia, edema) is determined by palpation. The palpation is made by both
hands by stroking: hands are put on symmetric researched sites of a chest. Define a
resistance (elasticity) of a chest by squeezing it by both hands in front to back and
from sides. Backlog of one half of thorax in the act of respiration may be defined,
putting fingers at angles of scapulas. The palpation allows finding out also a place and
a degree of painfulness of a chest.
Palpation is used also for determination of the vocal tremor (fremitus). It is
necessary to put hands on a chest symmetrically from both sides. Doctor asks the
child say words such as «one-two-three», «forty three», for a little child use weeping.
The vibrations of chest, stipulated by the voice vibration, are thus detected. In a norm
the vocal fremitus is symmetric; however it is more expressed in the top parts of
chest, especially in the right side.

PERCUSSION: At percussion of lungs the special attention should be paid on

the correct position of the child providing a symmetric position of a chest. The front
surface of a chest of the early age children is more convenient to percussion in a lying
position on the back; the back is percussed in a sitting position, thus a child needs to
be supported. Older children are percussed in a standing position.
At percussion of the front surface of chest a child stands quietly, dropping
hands. At percussion of back surface the child’s shoulders are few dropped, a head is a
little bent forward. At researching of an interscapular region the child moves scapulas
little outside to enlarge space accessible to examination. It is not necessary to cross
arms on a chest since it causes the strain of muscles. At percussion of the lateral
surfaces of chest the hands shall be take in sides, the best position is – hands are
behind head. Seriously sick can be percussed in sit and lying position, not forgetting
about symmetry of both halves of body location.

21
 In children younger than 5 years you can use immediate (direct) percussion, in
older children is applied mediate percussion.
There are distinguished topographical and comparative percussion.
TOPOGRAPHICAL PERCUSSION: the finger- plessimeter is put parallel to
the sought border, in the intercostal space. It is necessary to percuss down in
intercostal spaces. Definition of the lower borders of lungs begins with right lung on
medioclavicular, axillary and scapular lines. Then define the lower borders of left lung
on axillary and scapular lines. A mark of border make on the side of a finger -
plessimeter inverted to a clear sound.
Definition of height of standing of lung apexes begins in front. Doctor puts
finger - plessimeter above a clavicle, makes percussion, moving a finger - plessimeter
upwards till the sound becomes shorter (to dullness). Normally this site is on distance
of 2-4 cm from the middle of clavicle. The border is marked on the side of the finger-
plessimeter turned to the clear sound. From behind percussion of apexes is executed
from spina scapulae upwards up to dullness. Normally the height of lights tops
standing behind is defined on the level of acanthus of VII cervical vertebra. For
children of the preschool age (till 7 years) the upper border of lungs is not defined,
since the light apexes do not leave for a clavicle.
Mobility of the pulmonary border is defined for the elder children. Mobility of
the pulmonary border is the most expressed on scapular, middle or back axillary lines
because of big value of the pleural sinus in this place. Determination of the pulmonary
border is executed as follows. After determination of the lower border of lung on one
of the said line, the child is asked to take a deep inhalation and delay breathing.
Continuing percussion downwards, define the lower lung border on the maximum
inspiration. Then the doctor asks the child to take a deep expiratin and delay
breathing. Percuss upwards and define the lower lung border on the maximum
expiration. The distance between borders on the maximum inspiration and expiration

22
is the mobility of the lower pulmonary border. Among the elder children it is usually
equal 6-8 cm.
COMPARATIVE PERCUSSION: anatomically equal located regions of lungs
are compared with right and left sides: on medioclavicular, axillary, scapular and
paravertebral lines (percussion isn’t executed on the left side above the heart region).
The finger-plessimeter above the all regions of lungs is situated in parallel the ribs.
Only in the interscapular region it is parallel the spine.
At percussion of lungs it is possible to catch the following sounds:
1. clear vesicular resonance (clear pulmonary sound) - a sound of healthy lungs,
containing air;
2) blunted and dull resonance with various shades (depending on intensity of
dullness speak about shortening, dullness or absolute dullness), shortening of of
the percussion sound testifies about consolidation of the pulmonary tissues,
forming other airless tissue in pulmonary tissue or filling of the pleural cavity with
exudate;
3) tympanic resonance - high, long-lasting sound – is defined above cavities,
containing air (the cavities, cysts, pneumothorax).
4) bandbox resonance - high, short sound with tympanic tone - is defined at rising
elasticity of pulmonary tissues and increasing its airiness (the lungs emphysema).

At presence of an exudate in pleura the border of dullness is located on the line

of Ellis-Damoiseau-Sokolov. It is a parabolic line, which lasts from a backbone
upwards up to a back axillary line, then goes to forward. Simultaneously above
exudate the triangular space of clear percussion sound is detected. This space is
limited by spine, upper dullness border and direct horizontal line, connecting the
highest dullness point on a scapular line with spine, and called the Garland’s triangle.
This is an area of collapsing lung.

23
 On the healthy side the dullness (because of mediastinum displacement) as
paravertebral triangle Rauchfus-Grocco is found out. Its top corresponds to the upper
border of exudate. The line of the spine forms the other side of this triangle. The base
of triangle is a lower border of healthy lung.
Accumulation of liquid in left pleural cavity also gives blunting in the region of
Traube's semilunar space, limited from the top by heart dullness, from below – by a
costal margin, from sides – by a liver and spleen. In this region a healthy child usually
has tympanitic resonance. For determination of the line of Ellis-Damoiseau-Sokolov,
Garland’s triangle and triangle of Grocco percussion is carry out on the back surface
on vertical lines, beginning from the back axillary lines to spine. In connection with
significant difference of percussion sound, percussion above the scapulaes is possible.

By percussion it is possible to define a condition of intrathoracic lymph nodes.

Symptom of Koranii–De la Kamp: direct percussion is executed on acanthuses
from below upwards, beginning from 7-8th thoracic. In norm the dullness of
percussion sound is on the 2-nd thoracic vertebra for small children and on 3-4th
thoracic for elder children. In this case the symptom of Koranii is considered
negative. In case of presence of dullness below the specified vertebrae the symptom is
considered positive.
"Symptom of bowl" by Phylosofov: the loud percussion is executed in the first
and second intercostal spaces on both sides in direction to the breastbone (the finger-
plessimeter is parallel breast-bone). In norm dullness is detected on breast-bone - the
symptom is considered negative. In case of presence of dullness on both sides from a
breast bone, the sign is considered positive.

AUSCULTATION: To make auscultation the child, as well as to make

percussion, is possible in any position - standing, sitting, lying. It is better to
auscultate seriously ill patients in lying position. Symmetric regions are auscultated:

24
apexes, anterior surface of lungs, axillary regions, behind - above scapulas,
paravertebral regions, under scapulas. First of all, at auscultation it is necessary to
define character of the basic respiratory noise and then to estimate supplementary
noises.
In children till 3-6 months the weakened vesicular respiration is listened, from
6 months till 5-7 years the puerile respiration, which essentially is the strengthened
vesicular respiration, is listened. It is louder and longer noise in both phases of
respiration. Appearance of the puerile respiration for children is explained by the
features of the structure of respiratory organs.
For children elder then 7 years respiration gradually assumes the vesicular
character: reminds the soft sound «f», the exhalation makes one third of inspiration.
For healthy children above a larynx, trachea, large bronchus, in the interscapular
region at the level of the III–IV pectoral vertebra the bronchial (tracheal) respiration
is auscultated. It also called tracheal or laryngeal respiration and reminds the sound
«h». Expiration is louder and longer than inspiration.
Pathological changes of respiration:
1. rough respiration is the rough vesicular respiration with a prolonged
expiration (an expiration is longer than one third of inspiration) – testifies to a lesion
of small bronchi, observes at bronchitis and pneumonias;
2. bronchial respiration (if it is auscultated in not typical regions) – indicates
on consolidation of pulmonary tissue, observes at segmental and lobar pneumonias,
abscess of lung;
3. weakened of vesicular respiration – observes at weakening of respiratory
act with reduction of air inflow into the lung alveolus, considerable bronchiospasm,
obstructive syndrome, compression of the pulmonary tissue by anything, loss of
elasticity of pulmonary tissue; insufficiency of respiratory movements;

25
 4. strengthening of vesicular respiration – at narrowing of small bronchi
(strengthening takes place due to expiration), at compensatory strengthening on
healthy side in a case of pathological processes on other.
At auscultation it is possible to hear the rales. There are distinguished the dry
(whistling, buzzing etc.), moist (coarse, medium and fine). Large bubbling rales are
observed only for elder children. It is necessary to distinguish the rales, appearing in
pulmonary tissue and conducted from upper air passages. For differentiation it is
necessary to use the followings properties of the conducting rales: they are well
audible above a nose and mouth, well conducted above the scapulas and transverse
processes of thoracic vertebra, disappear or decrease after coughing. At auscultation
of the rales it is necessary to define their localization, quantity and character, a phase
of an auscultation (on an inspiration or expiration).
At auscultation it is also possible to define of crepitation and pleural friction
rub.
Crepitation - a supplementary noise, appearing at sonorous unstick of alveolus
at inspiration. Crepitation reminds the crack of cellophane or rustling sound, arising
up at grinding of bunch of hairs by fingers near the ear. In contrast to rales, crepitation
is the stable sound phenomenon (does not change after expectoration).
Pleural friction rub is a supplementary noise, arising up at the dry pleurisy. It
is auscultated in both phases of breathing, can be quiet, tender, or, vice versa, rough,
loud, as scraping. It is often auscultated locally in the places of maximal respiratory
excursions (inferior lateral parts of the chest). Pleural friction rub is auscultated as a
sound, arising at the surface of chest, increasing at pressing by stethoscope. Pleural
friction rub does not change after a cough, continues to be heard at minimum
breathing. For determination of the pleural friction rub doctor asks a child to take a
deep breath, close a mouth and nose by hand, after that to make motion of diaphragm
and ribs, as at breathing. Thus rales and crepitation disappear and pleural friction rub
remains.

26
 Bronchophony – vocal resonance (increased conducting of sound, connected
with the consolidation of lung tissue) also can be determined by auscultation.
Symptom of d'Espin: auscultation is carry out above the spinous process of
vertebra, beginning from 7-8th thoracic vertebra from top to down during the child’s
whisper (words «kiss-kiss», «ninety-nine»). Normally there is the strengthening of the
sound conducting in the region of the second spinous process of vertebra for little
children, for elders children - on the level of 3-4th spinous process of vertebra
(symptom is negative). In the case of the lymph nodes increasing in the region of
tracheal bifurcation the voice conducting is improved below the specified vertebrae
(symptom is positive).

EXAMINATION OF THE CARDIOVASCULAR SYSTEM

Objective examination of cardiovascular system includes inspection, palpation,
percussion and auscultation. Definition of arterial pressure and functional tests of
cardiovascular system concerns to additional methods also.

INSPECTION: usually begin from the face and neck of patient, pay attention
on the color of skin - presence of cyanosis, pallor. At inspection of neck pay attention
to pulsation of carotid arteries (carotid dancing) in standing position, pulsation and
swelling of bulbar vein. For elder children swelling of bulbar vein may be in
horizontal position without any cardiovascular pathology, but in this case swelling
disappears in vertical position of child.
Then it is necessary to examine a chest: pay attention to presence of the
asymmetric bulging of a chest in the heart region (cardiac hump), note absence or
presence of intercostal retraction in the heart region.
Examine an apex beat - the periodic rhythmical pulsation of a thorax in the
field of heart apex in the moment of the heart systole. Often, especially in obese

27
children, an apex beat can be not visible. It is well seen in children - astenics with
badly advanced subcutaneous fat layer. In healthy children depending on age the apex
beat may be posed in 4-th (in breast children) or in 5-th intercostals, 1-2 cm lateral to
the medioclavicular line (till the age of 7 years), or on it (7-12 years), or little middle
from the left mediclavicular line (after 12 years). The area of an apex beat should not
exceed 1-2 cm ². A negative apex beat, which is characterized by retraction of
intercostal space during a systole in the field of an apex beat, can be observed in
pathology.
The cardiac thrust - concussion of a thorax, which is observed in the field of
the heart and spreaded on a breastbone and epigastria. It is caused by pulsation of
hypertrophic heart and, mainly, adjoining to the thorax right ventricle. In healthy
children the cardiac thrust is not observed.

PALPATION: pulse can be researched in children in several places: for little

children - on carotid, temporal, femoral carotids; for elder children - on radial arteries.
Pulse on radial arteries should be felt simultaneously on both arms. At absence of a
difference of pulse (pulse is synchronous) the further research is carried out on one
arm. The child’s arm is placed at the level of his heart in the relaxed state. Doctor
takes the hand of child by the right hand in the field of a radiocarpal joint, from the
backside, the 1st finger is on the ulnar side of the child’s arm, the 2-nd and 3-rd
fingers palpate an artery.
Distinguish the following characteristics of pulse: rate, rhythm, tension, filling,
size and the form.
Pulse rate (PR) is determined by palpating not less than during one minute,
simultaneously heart rate (HR) is established by palpating apex beat or by
auscultation of heart. The phenomenon, at which there is a difference between HR and
PR, has the name deficiency of pulse.

28
 Rrhythm of pulse is estimated on uniformity of intervals between the beat of
the pulse. There are distinguished a rhythmic (regular) and arrhythmic (irregular)
pulse. Sometimes arrhythmia of pulse can be connected with respiration (PR increases
on inspiration and decreases on expiration). The phenomenon is physiological for
children from 2 to 10 years, named a respiratory arrhythmia. The breath holding
excludes this kind of an arrhythmia.
Tension of pulse is determined by force, which is necessary for squeezing a
pulse till its disappearance. There are distinguished the normal tension pulse, hard
pulse and soft pulse.
Research of pulse filling is executed by two fingers: after squeezing an artery
the distal located finger is got the feeling of filling of an artery by a blood. On filling
there are distinguished the pulse of the satisfactory filling, full pulse (filling more than
ordinary) and empty (filling less than ordinary).
Size of pulse – conclusion about this parameter is made by the doctor on the
basis of tension and filling of pulse. There are distinguished: pulse of a normal size, a
large pulse (pulsus magnus) and small pulse (pulsus parvus).
The form of pulse is determined by spreed of rise and descent of pulse wave
(by moderate squeezing an artery by both fingers). Pulse may be the usual form, swift
(fast rise and recession of pulse wave) and slack (slow rise and recession of pulse
wave).
The properties of an apex beat are specified by palpation. For this purpose the
doctor put a palm of right hand to the left edge of a breastbone that fingers covered
area of an apex beat. Then doctor continues palpation by slightly bent 4 fingers of
right hand. Properties of an apex beat: localization, the area (extension), height
(magnitude), force (resistance). In healthy child the area of an apex beat is 1-2cm ².
The height is characterized by amplitude of vibrations in the field of apex beat. There
are distinguished a high and low apex beat. The force of apex beat is measured by

29
pressure, which it renders on fingers. There are distinguished the moderate, strong and
weak force.
The symptom of «cat’s purring» (systolic or diastolic tremor) is determined by
palpation. For this purpose it is necessary to put a palm on all region of heart. In the
same way sometimes it is possible to palpate of the pericardial friction rub.

PERCUSSION: is carried out in the vertical or horizontal position of the

patient. There are distinguished immediate and mediate percussion of heart. At
mediate percussion the finger-plessimeter is closely put to the chest, parallel to the
determined border, on direction from a clear sound to dull one, percussion can be
mean force and the most silent. An important point is drawing percussion strictly in a
direction in front to back (concerning a body of the child). Marking of the heart
border is carried out on the external border of the finger-plessimeter, turned to the
clear pulmonary sound. Order of percussion: right, upper, left borders of heart. In
absence of pathology it is difficult to determine the borders of absolute dullness of
heart for children, therefore they practically are not percussed.
Determination of the right border of relative heart dullness: the finger-
plessimeter puts in the second intercostals on the right medioclavicular lines. Moving
the plessimeter-finger from top to bottom on ribs and intercostals, by silent percussion
one defines the lower border of lung. Then a doctor transfers the finger-plessimeter on
one intercostal space above, terns it on 90 degrees, placing it parallel to right border
of cardiac dullness. While making of the percussion impact of average force, one
moves the finger-plessimeter on intercostals in the direction of heart before
occurrence of dullness. At estimation of the right border the distance from the right
border of breastbone must be specified.
Determination of upper border of relative heart dullness: the finger-
plessimeter is put in the left parasternal line, starting from the first intercostal space.
The doctor moves a finger consistently on ribs and intercostal spaces downward, a

30
percussion step is equal to the width of finger. A mark of the top border make on the
top edge of a finger.
Determination of the left border of relative heart dullness: find an apex beat
and percuss on according intercostal, starting from a media-axillary line, the
plessimeter-finger it is necessary to place parallel to determined border, and impact
should make strictly in front to back direction, i.e. in sagittal planes.

AUSCULTATION: Common rules of auscultation:

a) The auscultation of the child should be carried out in a horizontal and
vertical position, and also in a position on left to a side and after physical loading.
b) The auscultation of older children should be carried out during a breath
holding (after a deep inspiration and the following exhalation) for removing of the
respiratory noises, interfering at auscultation of the sound phenomena of heart.
c) The auscultation is carried out in the standard points (places of the best
auscultation of the sound phenomena) in the certain sequence.
d) Sometimes auscultation is carried out not only in classical points, but
also above all area of heart, vessels of a neck, axillaries, subclavicular areas,
epigastria, and area of a back may by useful).

Points and order of auscultation:

1. Area of an apex beat (an auscultation of the sound phenomena from the
mitral valve).
2. The second intercostal space on the right edge of a breastbone (auscultation
of the sound phenomena from the aortal valve).
3. The second intercostal space on the left edge of a breastbone (an auscultation
of the sound phenomena from valves of a pulmonary artery).
4. The lower third of breastbone in a place of attachment of xiphoid process, a
little right from middle line (a projection of the tricuspid valve).

31
 5. Botkin-Erb’s point – at the level of 3-4-th intercostals space at the left edge
of a breastbone (an additional point of an auscultation of the sound phenomena of
aortal valves).
Whole heart region should be auscultated for children, as well as the vessels of
necks, axillary, subclavicular, epigastric regions and the back.

Some rules of auscultation:

First of all it is necessary to estimate the tones, their loudness, rhythmicity,
correlation in different points (the first tone corresponds to pulse impact on the carotid
artery or apex beat; besides, usually the pause between the first and the second tone is
shorter, than between the second and the first).
Only after this pay attention on presence or absence of the cardiac murmurs.
At auscultation of murmur it is necessary to note its features: timbre, force, in what
phase of heart activity it is heard (systolic or diastolic murmur), what part of the
systole or diastole it is occupied, its connection with the heart tone, dependence on the
position of a child or a physical loading.

DETERMINATION OF BLOOD PRESSURE

Blood pressure for children is determined by Korotkov’s method by
sphygmomanometer. For measurement accuracy the size of cuff should correspond to
the age of child (the width of cuff should make half of circle of a brachium of the
child). The arm of the child should lay in the weakened condition palm up. The child
should not talk. A cuff is put on 2 cm above the ulna fold, not tight – you shall be able
to enter one finger under a cuff. Air must be removed from cuff. The bell of the
stethoscope is placed on brachial artery, Pump air up to the value on 30-40 mm of the
mercury column exceeding than pressure, under which stopping of artery pulsation
has been noted. Begin to slowly reduce the pressure in a cuff. Appearance of the heart
tone at auscultation on the brachial artery corresponds to the maximum arterial

32
pressure, its disappearance - minimum. It is recommended to measure the arterial
pressure three times with two-three-minute interval. The sought-for is the minimum
value of pressure.
The estimation of the received results of systolic and diastolic pressure is made
with the nomograms and percentile tables.
The average systolic arterial pressure in children elder than year is defined by
Molchanov’s formula: 90+2n, where n - number of years of life of the child.
The diastolic pressure forms from 1/2 - 1/3 of systolic pressure and may be
calculated by the formula: 60 + n.
In children of the first year of life systolic arterial pressure is equal 76 + n,
where n – number of months.

FUNCTIONAL TESTS
1. With breath-holding (test of Shtange, Shtange-Gench).
Test of Shtange-Gench – breath-holding on inspiration. It consists in
determination of time of the maximum breath-holding after three deep breaths . The
test is executed without load at rest and after load. For healthy children breath-holding
duration is from 15-25 sec at rest (in 5-7 years old), 26-40 sec (schoolchildren), after
load it is from 22 to 25 sec.
2. Test with changing of body position (orthostatic test of Valdfogel).
The quiet lying child is calculated the pulse and measured the arterial pressure.
Hereon child is offered to stand up quietly and measurements repeat again. Hereon
child lies again. Normally at turning from horizontal position in vertical pulse
becomes more frequent not more than on 5-10 beats in minute and arterial pressure
remains on the same level or rises on 5-8 mm of mercury column. After 3 mines of
quiet lying the indexes return to source values.
3. Load tests (test of Gorinevsky, test with the dosed load according N.A.
Shalkov).

33
 Test of Gorinevsky: 60 jumps during 30 sec. After load pulse becomes more
frequent on 25-30% and then goes back to an initial level after 2-3 min.
Test according N.A. Shalkov: child in quiescent state is measured pulse and
breathing rate, arterial pressure. Minute volume of blood is calculated under the
formula (pulse pressure - difference between maximal and minimum pressure,
multiplied on the pulse rate). Then, depending on the state of child, character of
disease and regimen the followings loads are offered:
- load No1: child is offered to change lying position for sitting and back three times;
- load No2: the same again, but 5 times;
- load No3: the same again, but 10 times;
- load No4: child stands on the floor, he is offered to squat 5 times during 10 sec.;
- load No5: the same again, but 20 squats during 20 sec.;
- load No6: the same again, but 20 squats during 30 sec.

Loads N 1, 2, 3 are prescribed to sick children, being on bed regimen, loads N

4, 5, 6 are prescribed at the semi-bed regimen. Each subsequent load is prescribed
only after adequate answer on the previous load.
Right after load and after 2-5 min. measuring of the pulse and breathing rate,
arterial pressure and minute volume of blood are executed. The results are estimated.

EXAMINATION OF THE DIGESTIVE SYSTEM

Examination of digestive system consists of inspection, palpation, percussion.
Auscultation is used rarely and does not have significant importance.

INSPECTION: begins from abdomen and finish (in little children) by

inspection of oral cavity. Inspection of abdomen is executed in horizontal and vertical
positions. Pay attention on the form of the abdomen, its size, symmetry, presence of

34
visible gastric and intestinal peristalsis, participating in breathing. Condition of skin
on abdomen, tension of skin, its luster, vasculature, state of umbilicus (inverted,
smoothed, protruding) are important. Inspection of anus is obligatory for
identification presence of fissures, prolapsed rectum and incompletely closed anus.
At inspection of oral cavity pay attention on the state of mucous tissue of
mouth, gums, palatine, tongue, state of teeth and tonsils. Obligatory condition of
inspection is good illumination of the oral cavity. For careful inspection of the oral
cavity in a small child assistant or mother of child takes him on knees, back to herself,
and fixes the child’s feet between her legs. A doctor must be from the right side from
child and don’t cover light by head. Inspection of the oral cavity is necessary to
execute by a spatula or spoon. Never examine a mouth without the spatula. First of all
it is necessary to examine the mucous tissue of lips, cheeks, gums, soft and hard
palate, tongue, pharynx. Pay attention on color of mucous tissue its humidity,
presence of hyperemia, ulcerations, aphta, loose gums and hemorrhages. Pay attention
on the state of tongue (glossitis, ulcers, spot, lingual papillae, geographic tongue etc.)
and teeth (number, permanent or milk, presence of caries and dental deposit).
Inspection of the oral cavity is finished by inspection of the pharynx. For this
inspection it is necessary to enter a spatula to the root of tongue and press it down
moderately forcing child to gape. The tongue must be in the oral cavity. If child will
clench his teeth, push a spatula between cheek and gums and through a slot behind the
molars press the root of tongue. Child should open a mouth, and even epiglottis will
be well seen. Pay attention on tonsils - are they expanded (normally they do not leave
the palatine arches), are there any film or loose, purulent plugs, are there any changes
of mucous tissue under the tonsils? In presents of any films pay attention on its color.
Does it remove easily or hardly? Does the tonsil surface bleed after film removing?

PALPATION: for correct palpation doctor sits on the right from patient. Child
must lay on the back with the legs slightly bended in hip and knee joints, hands must

35
be extended along the body, head must be on the same level with body. It is desirable
to divert child's attention.
Superficial or approximate palpation is executed by light stroking and gently
pressing on the abdominal wall. For this purpose put one or both hands palm down on
the abdominal wall, pressing is executed by 2-3-4-5-th fingers of the palpating hand.
The whole abdomen region can be examined: from below upwards, palpating
symmetrical regions on the left and on the right sides or moving counterclockwise. By
this method of palpation pain localization, zones of skin hyperesthesia and muscles
tonus can be detected. After approximate palpation begin the deep palpation. Deep
palpation begins from the large intestine: sigmoid colon, caecum, ascending and
descending parts of the colon, transverse colon. Then the stomach is palpated. The
deep palpation is finished by liver, spleen, pancreas and mesenterial lymph nodes.
Palpation of the large intestine:
Palpation of the sigmoid colon: the doctor’s right hand is put palm down with
slightly bend fingers on the left iliac region, perpendicular to the length of the sigmoid
colon. By the surface motion of fingers skin is moved medially, on expiration the
fingers gradually penetrate into abdomen. Then execute the gliding hand motion in
toward perpendicular to the longitudinal axis of colon.
Palpation of the caecum: palpation technique is the same, as for palpation of the
sigmoid colon, but it is executed in the right iliac region. Direction of the caecum is
from top to down and from right to left. Simultaneously with the blind gun appendix
is palpated.
Palpation of the transverse colon: executed by one or by both hands
(bimanual). Fingers are put parallel to the colon’s direction on 2-3 cm higher than
umbilicus. The skin is moved and fingers move deep into the abdominal cavity on
expiration. Then sliding top-down motion of hands is made.

36
 At palpation of any part of large intestine it is necessary to mark the following
properties of palpating region: localization, form, diameter, consistency, surface,
mobility, presence of rumbling and palpatory tenderness.
Palpation of liver:
There are distinguished two basic methods of liver palpation: superficial sliding
palpation by Strazhesko and deep palpation by Obraztsov.
Method of the superficial sliding palpation of liver: patient’s position is on the
back with legs slightly bended in knee joints, hands are along of a body or lie on a
chest. The fingers of palpating hand are on one line, parallel the low border of liver,
and make light sliding motion from top to down. It is necessary to touch by sliding
motions of all surface of liver accessible for palpation. More often the sliding method
of liver palpation is used for the breast children.
Bimanual palpation of liver by Obraztsov: right palpating hand lies on the right
half of the abdominal wall palm down; left hand covers the right half of chest in a
lower region. Leaving a right hand, deeply entered in the abdominal region at
expiration, ask child to take a deep breath. At inhalation the palpating hand is taken
out from the abdominal region in direction forward and upwards. Thus the lower
border of liver, sliding downward, seeks to go round the palpating fingers, and at this
moment the form and outlines of the lower border of liver, its consistency and
painfulness are determined.
Kerr’s point or point of the gall-bladder projection is located on crossing of the
outward border of rectus muscle of abdomen with the right costal margin. At liver
and cholecyst affection is a positive Kerr’s symptom: tenderness at deep palpation in
the region of gall-bladder.
Murphy symptom - child sits, slightly bending forward, doctor immerses the
fingers below the border of costal margin in the region of the cholecyst projection, in
the moment of deep inhalation a patient feels severe, sharp pain. This symptom is
possible to examine in lying position. Thus the first finger is deeply plunged in the

37
region of the point of Kerr, and other fingers fix a costal margin; at inspiration patient
feels pain.
Ortner symptom - tenderness at percussion by a palm rib on the right costal
margin.
Mussy symptom (phrenicus-symptom) - tenderness at pressing between the
pedicles of the right sternocleidomastoid muscle, arising in region of pressing, in a
right hypochondrium and spreading in a right shoulder.
Palpation of spleen: It can be executed by two methods: sliding and bimanual
palpation. Technique of palpation is the same, as for liver, but at bimanual palpation
of spleen a child lies on a right side with slightly bended legs and bended head (a chin
must touch to a chest).
It is possible to execute palpation in the position on a back. Thus doctor fixes
the left hypochondrium by left hand, and executes palpation by right hand, beginning
from below and gradually displacing fingers from a below to top towards the Х rib,
trying to define its lower pole. The distinctive feature of spleen is an incisure of the
lower border.
Palpation of the pancreas by the Grott’s method: is executed bimanual in the
position on a back (the legs are bended in knees). Left hand, clenched into a fist, is
under a patient’s loin, fingers of the right palpating hand are entered into the
abdominal cavity on externally border of the left rectus muscle of abdomen in the
upper left quadrant. The finger’s direction is to the spinal column. Palpation is
executed at expiration. The palpating fingers, achieving a spine on the level of
umbilicus, palpate the pancreas like a cylinder with diameter about 1 cm, overlaying
aslant of a spinal column.
The pain point and zones on the front abdominal wall, which pressing bring on
pain, have diagnostic importance. The Desjardin’s point (pain point of the pancreas
head) is situated on a line, connecting umbilicus and the top of right axillary excision,
on the distance of 4-6 cm from umbilicus (depending on age). The Mayo-Robson’s

38
point (pain point of the pancreas tail) is situated on the bisector of the left upper
quadrant, on one third not getting to the costal margin. Chauffard’s zone (zone of a
pancreas body projection) is situated in the upper right quadrant between its bisector
and midline of abdomen, about 3-5 cm above umbilicus.
Palpation of the mesenterial lymph nodes: is executed in Sternberg’s zones
(left upper and right lower quadrants of abdomen). The right hand fingers are entered
in the abdominal cavity on external border of the rectus muscle of abdomen in the
regions of the left upper and right lower quadrants. The finger’s direction is to the
spinal column, motion – sliding along the spinal column from top to down. In the
event of palpation of the mesenterial lymph nodes it is need to estimate their number,
size, tenderness and mobility.
Method of undulation (fluctuation) gives possibility to determine presence of
free liquid in the abdominal cavity by palpation. For this purpose put the left hand
flatways on the lateral surface of the abdominal wall, and make the short blow on the
abdominal wall by the other hand. This blow causes fluctuations of liquids, which are
sent on the other side, and perceived by the left hand.

PERCUSSION. Percussion of abdomen is executed in horizontal position

toward from umbilicus to the right and to the left (finger-plessimeter is located
parallel the white line of abdomen) and in vertical position toward from the top to
down in the region of rectus muscle of abdomen or on its external border (finger-
plessimeter is located parallel the lower line of abdomen). There are following tones
of percussion sound: moderate tympanitis (normal), dullness (ascites, pseudoascites,
tumor) and high tympanitis (meteorism).
Presence of free liquid in the abdominal cavity can be determined by
percussion. In this case percussion is executed in horizontal position of patient, one
notes the border of dullness and ask patient to turn on the side which is examined. If
an ascites presents the border of dullness should displace to the midline of abdomen.

39
 Determination of the liver sizes by Kurlov. Percussion of the liver borders is
executed from top to down on three lines, the finger-plessimeter is located parallel the
liver border:
a) on the middle clavicle line;
b) on the midline;
c) on the left oblique line - a distance from upper border of the liver on the
midline to the point of tympanitis at the percussion of left costal margin. This distance
reflects the length of the left half of liver.
Measurement is executed from up to down border by the measuring tape. For
healthy children after 7 years old the sizes of liver are 9 8  7 cm.
Percussion of the spleen borders is executed by the method of quiet
percussion. The lateral size of spleen is determined on the middle axillary line: upper
border – percussion is executed from top to down till turning the clear pulmonary
sound on dull one; lower border - percussion is executed on the same line toward from
below upwards till the tympanic sound becomes dull. At normal size of spleen its
upper border is situated on the IX rib, lower border is on the level of XI rib, width of
the splenetic dullness is about 4 cm in average. Determination of the front and back
border of spleen is executed by the means of percussion on the X rib. The finger-
plessimeter is disposed near the border of costal margin perpendicular this rib and
percussion is executed till the tympanic sound shall change on dull (front border). The
back border is defined on a back. The finger-plessimeter is disposed perpendicular the
X rib between the left back axillary and scapular lines. Percuss along this rib till the
dull sound appears. The distance between these points is a length of the spleen (in
average 6 cm).

AUSCULTATION OF ABDOMEN: at auscultation of abdomen in healthy

child you can hear the intestinal peristalsis; intensity of these sound phenomena is
moderate. At pathology the sound phenomena can increase, become weaken or

40
disappear. By combined method of study (auscultation and percussion) it is possible
to identify the borders of stomach. Put the stethoscope on the region of stomach and
make percussion by one finger from top to down on the Sergeant’s white line from the
xiphoid process to the umbilicus. Above the stomach the percussion sound sharply
increases.

EXAMINATION OF THE URINARY SYSTEM

Examination of the urinary system consists from inspection, palpation and
percussion.
INSPECTION: Pay attention on the color of skin, pallor, edema (especially on
eyelids), face puffiness, form and size of abdomen (particularly in lumbar region). It
is necessary to examine also a scrotum and externals. For detecting of the invisible
edema patient is systematically weighed. Edema dui to tissue hydrophilicity is also
detected the by the method of the "blister test" by McClure- Aldrich. For this purpose
0.2 ml of isotonic solution of sodium chloride is intracutaneously injected in the
forearm whereupon a blister appears on skin. For healthy children of the first year of
life the blister dissolves during 15-20 min., for children from 1 to 5 years - during 20-
25 min., for elder children - after 40 min.

PALPATION OF KIDNEYS is executed by bimanual deep palpation by

Obraztsov in horizontal and vertical (mainly for elder children) position. Child lies on
the back with mildly bent legs. The doctor’s left hand with put together fingers is
under the patient’s lumbar region on the level of XII rib. The right hand is acted from
the rectus muscle of abdomen on the level of costal margin. The gradual approaching
of the hands is executed till the front and back abdominal walls will touch. At
achievement of touch child is asked to make a deep inspiration – the lower pole of the
kidney is palpated. Herewith define its relief, surface and tenderness. Palpation in

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standing position (Botkin’s method) is executed at forward bending of body, arms are
descent. The doctor’s left hand is on the child’s lumbar region, right hand is acted
from the rectus muscle of abdomen on the level of costal margin. Procedure of
palpation is the same, like in lying position. For breast children other procedure of
palpation of kidneys can be used, when palm of hand is situated thereby that the
doctor’s first finger lies frontal, in the region of hypochondrium, and 4 other fingers
are behind, on the lumbar region. Approaching fingers and moving hand from below
upwards, it is possible to palpate a kidney.
The kidneys can be palpated only for early age children (before 2 years old) and
with malnutrition. For healthy elder children the normal size kidneys are not palpated.
Therefore palpating of kidneys indicates their increase or displacement
(hydronephrosis, tumor of kidney, nephroptosis and floating kidney).
For children under 5-7 years it is possible to palpate the urinary bladder in the
filled state, as it goes out from the small pelvis cavity.

PERCUSSION: by percussion the symptom of Pasternatsky, presence of free

liquid in abdominal cavity and upper border of urinary bladder are determined.
Symptom of Pasternatsky – in yang children percussion executed by bended
fingers in the symmetric regions of the lumbar area both sides from a spine. For elder
children – percussion by edge of palm of the right hand on the back surface of the left
hand fixed on the lumbar region.
Determination of the apper border of urinary bladder by percussion. Put the
figer-plessimeter on abdominal wall parallel to pubis at the level of umbilicus and
percuss from up to down on the midline of abdomen. At the filled urinary bladder
percussion sound becomes dull above the pubis.

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 EXAMINATION OF THE NERVOUS SYSTEM
Examination of the nervous system consists of study of reflex activity, motion
activity, sensory system, sensitivity and function of cranial nerves.
General inspection and study of child’s physical and neuro-psychical
development must precede the neurologic examination of the child. Research of the
nervous system is begun with estimation of the patient’s consciousness, reaction on
surroundings, his psychological and emotional state. Pay attention on disproportion of
the separate parts of body, change of sizes and form of skull, presence of congenital
anomalies of development of spinal cord and brain.

Estimation of unconditioned reflex activity of newborns and children of

early age
Research of reflexes is executed in a warm, well lighted room on the flat semi-
rigid surface. A child must be awake, dry and not hungry. The irritants must not cause
pain. If these conditions are not observed the reflexes can be depressed owing reaction
on discomfort.
Lip reflex. At percussion by a finger on the child’s lips there is a contraction of
the circular muscle of mouth, causing stretching of lips into a trunk.
Search reflex. At irritation of skin in region of angle of mouth (do not touch the
lips) there are lowering of under lip, deviation of tongue and turning of a head in side
of irritation. Reflex is especially well expressed before feeding.
Sucking reflex. If put a nipple into a child’s mouth, he begins active sucking
motions.
Orbicularis pupillary reflex. At percussion by finger on the upper arc of the
eye socket closing of eyelid on corresponding side occurs.
Babkin's reflex. The reflex is caused by pressing with the doctor’s first finger
on the child’s palm near tenor. The reply reaction is the mouth opening and flexion of
the head.

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 Grasp reflex consists in seizing and well holding of the doctor’s finger, put in
child’s palm. Sometimes herewith it can be possible to lift a lying child (Robinson's
response). Such reflex can be caused on the lower extremities, if you will press on a
sole beside the basis of II-III fingers. That will bring about sole bending of fingers.
Moro's reflex. This reflex is activated by different methods: doctor keeps a
child on hands and sharply drops him down about 20 cm and then lifts in initial
position; you can quickly unbend the child’s lower extremities or strike your hands on
surface, where child is lying on the distance 15-20 cm both sides from his head.
Replying this action, child leads his arms sideways and unbends fingers, and then
covers himself by arms.
Babinski's reflex. Stroked stimulation of the external sole border in direction
from heel to toes causes dorsal extension of the first toy and plantar bending of other
toes, which sometimes have fan-shaped position.
Kerning’s reflex. Child lies on a back. Doctor bends child’s leg in hip and knee
joints and then tries to unbend the leg in knee joint. If reflex is positive it will be
impossible.
Support reflex. Doctor takes a child under armpits from back, supporting a
head with II-III fingers and put him on the table. Child supports on the table by his
bending in hip and knee joints legs. When child is omitted on a support, he abuts on
full soles, “stands” on the half-bent legs with unbent body.
Reflex of automatic stepping. In the position of support reflex child is slightly
inclined forward, and he begins step motions on a surface, not accompanying them
with hands motions. Sometimes feet are crossed at the level of lower third of shins.
Bauer's response. A child lies on an abdomen so that a head and body are on
one line. In such position child lifts his head on some seconds and accomplishes
crawling motions (spontaneous crawling). If you put a palm under the child’s soles,
these motions become more active, and child begins actively push off by feet from
your palms.

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 Gallant’s response. Child lies on a side, a doctor draws by the first and index
finger on paravertebral lines in direction from neck to the breech. Stimulation of skin
is caused by arching of body. Sometimes child’s legs unbend and move aside.
Peres’s reflex. Child lies on an abdomen, doctor draws by II finger on the
spinous processes of vertebrae in the direction from coccyx to neck, that causes
arching of body, bending of upper and lower extremities, lifting of a head, a pelvis,
sometimes urination, defecation and cry. This reflex is painful, therefore it should be
tested the last.
Position of child’s body and his head has influence on the muscular tonus. This
influence is mediated through the tonic neck and labyrinthine reflexes.
Labyrinthine tonic reflex. Reflex is activated by change of position of the head
in a space. Child, lying on a back, has hypertension of extensor muscles of neck,
back, legs. If child is turn on an abdomen, there will observed increasing of the flexor
muscles tonus of neck, back, extremities.
Symmetric tonic neck reflex. At passive bending of head in new-born, lying on
a back, there is an increase of tone of flexor muscles in arms and extensor muscles in
legs. There are inverse relations at unbending of a head. Changing of muscle tone is
possible to determine by increasing or decreasing of resistance at passive unbending
of extremities.
Asymmetric tonic neck reflex. This reflex is checking in the position of child
on a back, his head is turned aside and his chin touches a shoulder.
Thus, occurs decreasing of muscle tone in the extremities on which side the
child’s face is turned (sometimes can be their brief unbending), and increasing of
muscle tone in opposite extremities.

Mesencephalic righting reflexes

Body erector reaction. When child’s feet touch a support erection of head
occurs.

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 Upper Landau's reflex. Child in the position on an abdomen lifts his head,
upper part of body, supporting on a plane by hands, keeps in this position.
Lower Landau's reflex. In the position on an abdomen child unbends and lifts
his legs.

Tendon and periosteal reflexes

These reflexes are caused by stimulation of muscles proprioceptors, tendons,
ligaments, periosteum. For their study special hammer is used, for infants it is
possible to cause these reflexes by tapping with III finger of hand.
Carporadial reflex is the periosteal and it is caused by blow with hammer on
styloid process of radius. The result is the light pronation of hand and bending of
fingers.
For activating the bending biceps reflex doctor takes the child’s hand, half-bent
in the elbow joint, in his left hand and by right hand makes a blow with hammer on a
tendon under an elbow joint. Herewith forearm bending occurs.
Extending triceps reflex – forearm extending - is activated by blow with
hammer on tendon of the triceps under an elbow. The hand position is the same, as for
activating of the bending biceps reflex.
For little children knee reflex is better to cause in lying position. Doctor put his
left hand under a knee, raising it gently, and makes the jerky blow on tendon of
patella. For elder children it is possible to check this reflex in sitting position. To
avoid the active muscular tension, draw child’s attention away by talking or ask him
to count. The reflex show itself in shin extending.
Achilles reflex is activated by blow with hummer on Achilles tendon. The
result is sole bending of foot. This reflex is researched when child lay on back,
herewith shin bends, foot is unbended slightly (by the doctor’s left hand). The elder
children are kneeled on couch (or chair) so as his feet hung down.

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 Reduction of the tendon and periosteal reflexes (hyporeflexia) can be connected
with defeat of peripheral nerves, front and back nerve radixes, gray substance of the
spinal marrow, muscular system, intracranial pressure increasing. Increasing of the
reflexes (hyperreflexia) is observed at defeat of pyramidal tracts, hypertension
syndrome in hyperactive children.

Superficial reflexes from skin and mucous membranes

Abdominal reflexes are activated by stroke stimulation of the skin on abdomen
parallel the right and left costal margins (upper reflex), horizontally on both sides
from umbilicus (middle reflex) and parallel the inguinal fold (low reflex). Abdominal
muscles contract in response to stimulation.
Cremasteric reflex. In response to stroke stimulation of skin of internal surface
of upper part of thigh there is contraction of testicular levator muscle.
Gluteal reflex consists in contract of gluteal muscles at the stroke stimulation
of skin on gluteus.
Anal reflex is contract of external muscles sphincter of rectum in response to a
prick near an anus.
Disappearance of skin reflexes is the permanent symptom of defeat of
pyramidal tracts or peripheral nerves, forming these reflex arches. Asymmetry of
abdominal reflexes is possible at the acute diseases of abdominal organs (acute
appendicitis, perforated ulcer), stimulating tension of front abdominal wall.

MOTION SPHERE
At researching of the motion sphere estimate position of patient, position of his
extremities, motive activity at active and passive motions, muscle strength and state
of muscular tonus.

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 SENSITIVE SPHERE
Research of the sensitive sphere includes estimation of tactile, temperature and
pain sensitivity, kinesthesia.
Saving of tactile sensitivity is tested by touching to the child’s skin by the piece
of cotton wool or brush. At research of this type of sensitivity elder child is asked to
close his eyes and answer on a perceptible touch «yes».
Temperature sensitivity is determined by apply of the test tubes with cold and
warm water to skin. Little children react on temperature stimulation with motive
anxiety and weeping. Elder child with the closed eyes answers «warm» or «cold» at a
touch.
Pain sensitivity: child is asked to close eyes and inflict him pricks by a needle,
alternating them with the touching with a dull end of needle. At saving of pain
sensitivity child distinguishes stimulations, answering «sharp» or «blunt».
Kinesthesia (covers the deep sensitivity) gives a view of position of the body
parts in space. Research is executed at the closed eyes of child. Doctor makes bending
and unbending of finger on a hand or leg of patient. Child must say or show on other
hand (leg), what finger is operated and in what direction.
Deviation of vestibular apparatus is determined by shaky gait, deviation of
body coordination, nystagmus, symptom of twirling and deviating of hands. Ability to
keep body balance is checked by the Romberg’s test: patient is stood straight with the
dropped hands, feet together. In this pose for patients with positive symptom there is
wobbling of body, increasing when patient closes eyes, looks up or stands on one foot.
For research of swing symptom doctor stretches out index finger and asks patient to
touch it by his index finger. At deviation of coordination patient misses. The finger-
nose test is executed similarly — a patient is asked to close eyes and touch the nose
tip by the index finger, preliminary taking hand aside. For execution of the knee-heel
test patient lies on a back with the closed eyes and try to touch to a knee of one leg by

48
a heel of other, and move a heel on the front surface of shin downward. At pathology
patient can not execute this test or a heel at downward motion slides off from a shin.
At raised muscular irritability the symptoms typical for spasmophilia appear:
1. Chvostek's symptom: percussing with a hammer on the fossa canina brings
contraction of muscles of eyelid, and sometimes – of upper lip.
2. Trousseau's sign: at putting a tourniquet or squeezing of the child’s shoulder
middle, his hand shapes of the obstetrician’s hand form (carpal spasm).
3. Lust's symptom: at percussion on the region of the head of fibula (outside
and below the knee joint) extension and drawing acted of the foot appears to the
account of stimulation of the fibular nerve ("ballerina’s leg" or pedal spasm).

Meningeal symptoms: rigid neck and positive Brudzinsky’s and Kerning’s

symptoms.
1. rigid neck: at bending of the head patient feels the pain in back of the head -
reflex neck muscles tension makes the bending impossible.
2. Brudzinsky’s symptom:
a) upper: child lies on back with extended legs. At passive bending of child’s
head, reflex bending of the lower extremities in hip and knee joints is observed.
Upper extremities often bend simultaneously.
b) middle or pubic: at pressing on the pubic region the lower extremities
reflexly bend in hip and knee joints.
c) low: at the passive bending in the hip and knee joints of one leg bending of
other leg occurs;
3. Kernig’s symptom: impossibility of the complete unbending of leg in a
knee-joint when it is bended under the right angle in the hip-joint.

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 SENSE ORGANS
For determination of the organ of sight function the visual acuity, chromatic
sensitivity and inspection of eyes are executed. Pay attention on the width of
palpebral fissure, form of pupils, their size, reaction on light, presence of strabismus.
Examination of the organ of hearing included external examination of auricle
and visible part of the external acoustic meatus, determination of auditory function. In
the elder age perception of loud and whisper speech is determined (on the distance of
6 m). For the children of early age doctor should pay attention on child’s reaction on
the auditory stimulus (concentration or turn of the head toward the sound source).
Research of the olfactory function is executed as follows: bring a smelling
matter, not irritating a mucous membrane, to the child’s nose. Child reacts by mimicry
of displeasure, cry or motor anxiety. The elder child is offered to smell the identically
painted solutions with smell and odorless. It is necessary to define the smell solution.
Taste is examined by putting on tongue sweet, bitter, sour and salt solutions.
Estimate the reaction of child: positive – on sweet, negative – on bitter, salt, sour.
Elder child defines his feelings by words.

EXAMINATION OF THE ENDOCRINE SYSTEM

Examination of the endocrine system includes estimation of physical and sexual
development of child, and also detection of the symptoms of hypo- and hyperfunction
of endocrine glands in child. The thyroid gland is accessible to direct examination.

INSPECTION: First of all general inspection of child must detected

constitution, physical development (high, middle, low; harmonious, disharmonious).
The special attention is spared the growth estimation, detecting such abnormality as
nanism and gigantism. It is necessary to estimate the level and evenness of adipose
tissue, type of the subcutaneous fat distributing (male, female); presence or absence of

50
the dysplastic stigmas, state of skin and skin appendages (color, humidity, presence of
stria, hair distribution). Determine the type of structure of externalia (male, female).

Estimation of the sexual development of child

Determination of the sexual development of child includes estimation of the
secondary sexual characters.
Formulas of sexual development:
Sexual formula for girls: Ax, P, Ma, Me.
Sexual formula for boys: Ax, P, F, L, V.
where: Ax – level of hair development in axillary area (Ah0 - Ah4);
P – level of hair development on pubis (R0 - R5);
Ma – level of the mammary glands development (Ma0 - Ma3);
Me – characteristics of the menstrual cycle: beginning, cyclicity, painfulness (Me0-
Me3);
L – development of the thyroid cartilage of larynx (L0 - L2);
V – timbre of voice (V0 - V2);
F – hair distribution on the face (F0 - F5).

For detecting the thyroid increased for children inspection and palpation are
used. Palpation of thyroid: the first fingers are situated on the front surface of thyroid,
and other fingers are on the posteriolateral surface the sternocleidomastoid muscle.
Fingers motion is sliding. In palpation the most sensitive are index, long and ring
fingers, but in spite this, in practice palpation of thyroid by the first finger is widely
spread. Herewith right lobe is palpated by the first finger of right hand, left – by the
first finger of the left hand. Essence of the method: for reception of the necessary
features move aside of the sternocleidomastoid muscle and tissue of the thyroid is
pressed to trachea.

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 The isthmus of thyroid is palpated from the front by the index (long) finger of
one hand with sliding motions parallel the centerline of necks toward from top to
bottom at the level of the thyroid localization. Patient is asked to make several
swallows. At these motions thyroid begins to move between the doctor’s fingers. If at
swallowing moving thyroid is observed visual, the swallow symptom will be positive.
At palpation it is necessary to note the level of increase, elasticity, homogeneity of
gland, painfulness.
Levels of thyroid increase:
According recommendations by WHO (1994) there are distinguished:
- Level 0 – size of thyroid (isthmus of thyroid) does not exceed the size of
terminal phalanx of the patient’s first finger.
- Level I – thyroid is palpated, its lobes sizes are more than the patient’s first
finger. Visual increase of thyroid is not present.
- Level II – at large size, determined by palpation, thyroid is clear visualized.
There are followings eye symptoms at thyroid pathology:
1. exophthalmus
2. Delrimple’s symptom: widely exposed eyes – expression of anger;
3. Graefe's sign – «setting sun»: at looking down white strip appears between
eyelid and iris;
4. Mebius's symptom – abnormality of eyeballs convergation;
5. Stellwag's symptom – rare blinking ;
6. Rosenbach's symptom – trembling of the closed eyelids.

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 LITERATURE
Basic:
1. Kapitan T. Propaedeutics of children’s diseases and nursing of the child. – Vinnitsa,
2012. – 808 pp.
2. Pediatry. Guidance aid / Edited by professor O.Tiazhka. – Kyiv, 2007. – 160 pp.
Additional:
1. Dworkin Р.Н. Pediatrics. - Baltimore: Williams&Wilkins, 1987. - 260 pp.
2. Essential pediatrics. O.P. Ghai, MD. – 5 th edition. MEHTA PUBLISHERS, New
Delhi, 2000. – 582 pp.
3. Gill D., O'Brien N. Paediatric clinical examination. - Edinburg, 1988.-
197 pp.
4. Robert M. Kliegman, Hal B. Jenson, Karen J. Marcdante, Richard E. Berhman.
Nelson. Essential of Pediatrics, 5th edition. – Printed in China, 2006. – 994 pp.
5. Willms J.L., Lewis J. Introduction to clinical medicine.-Baltimore:
Williams.Wilkins, 1991.- 260 pp.

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