Pediatric Examination

Physical Examination
Perform physical examination from
head to toe on a pediatric patient.
You may need to alter the order of
the examination for patient
compliance for uncooperative or
hyperactive patients.
Do not force a child to do something
that may be frightening or
uncomfortable to them.
When examining an infant, toddler,
or school-aged child it is suggested
to have a parent or guardian in the
room with you.

Physical Examination
Examination of an infant or toddler
may be preformed on the lap of the
patient.
With an adolescent, it may be more
appropriate not to have the parent in
the room with you, this may allow the
patient to feel that they can be more
candid.
To avoid possible legal issues, a male
doctor may want a female staff
member to be in the examination
room.
The doctor should verify confidentiality
laws in their particular state.

Vital Signs

Vital signs in pediatrics include

temperature, heart rate, blood
pressure, respiratory rate, weight,
length, and head circumference.

Weight
Height, weight, and head
circumference should be plotted on a
growth curve graph.
Decrease in weight percentile may be
due to decreased intake (malnutrition,
central nervous system abnormality),
malabsorption (cystic fibrosis, IBD,
celiac disease, parasitic infestation), or
an increased metabolic rate
(hyperthyroidism, congestive heart
failure).
Increase in weight is most commonly
exogenous but may also be associated
with certain genetic syndromes
(Prader- willi).

Height
A childs length (lying flat on a table)
is measured until 2 to 3 years of
age; after that it is measured as
height (standing).
Decrease height may be familial, or
may be seen in conditions affecting
weight or independent of weight
(Turner syndrome).
Increase height may be familiar or
associated with certain genetic and
endocrine abnormalities (Cerebral
gigantism).

Head Circumference
Head circumference is routinely
measured until 2 to 3 years of age.
Microcephaly may be part of a
syndrome (Rett syndrome),
congenital infection (CMV), or the
result of abnormal brain growth
(schizencephaly).
Macrocephaly may be familiar or
may represent a pathologic state
(Hydrocephalus, Canavaan disease,
AV malformation).

Blood Pressure
Blood pressure must be measured with a cuff wide
enough to cover at least 1/2 to 2/3 of the extremity and
its bladder should encircle the entire extremity.
A narrow cuff elevates the pressure, while a wide cuff
lowers it.
Systolic hypertension is seen with anxiety, renal
disease, coarctation of the aorta, essential
hypertension, and certain endocrine abnormalities.
Diastolic hypertension occurs with endocrine
abnormalities and coarctation of the aorta.
Hypotension occurs in hypovolemia and other forms of
shock.

Blood Pressure
The level of systolic blood pressure
increases gradually throughout
infancy and childhood.
2years
112/78
6years
116/80
9years
126/84
12years
136/88

96/60
98/64
106/68
114/74

Pulse
An elevated heart rate is seen in
infections, hypovolemia,
hyperthyroidism, and anxiety.
A rule of thumb is that the heart rate
increases by 10/minute for each 1
degree of temperature Centigrade.
Bradycardia is seen in hypertension,
increased intracranial pressure,
certain intoxications, or other
hypometabloic states.
It is best to examine an infants
heart first during the exam.

Heart Rate

Birth
1 - 6 months
6 - 12 months
1 - 2 years
2 - 6 years
6 - 10 years
10 - 14 years
14 - 18 years

140
130
115
110
103
95
85
82

Respiration
Tachypnea is seen with increased activity,
hypermetabolic states, fever, or respiratory distress.
A decreased respiratory rate is seen with conditions
affecting the central nervous system, including
medications/toxins, congenital malformations, and other
lesions.
A variable respiratory rate, known as periodic breathing,
is commonly seen in neonates but more than a 20
second pause is always abnormal.
Cheyne-Stokes breathing is seen with brainstem
abnormalities.

Respiratory Rate

Newborn
6 - 12 months
1 - 2 years
2 - 4 years
4 - 10 years
10 - 14 years
15 +
as adult

30 - 75
22 - 31
17 - 23
16 - 25
13 - 23
13 - 19
same

Temperature
Temperature may be elevated with
infections, tumors, hyperthyroidism,
autoimmune disease, environmental
exposures, certain medications, or
increased activity.
Temperature may be decreased with
infections (especially in neonates),
hypothyroidism, certain medications,
environmental exposures, shock, or
CNS disease affecting the
hypothalamus.
Control of heat production and heat
loss is maintained by the
thermoregulatory center in the
hypothalamus.

Methods of Taking
Temperature
Rectal
96.8*
98.6* F
Axillary
Lower
Oral
Lower
Infrared
rectal

to

2* F
1* F
same as

For the appropriately clothed child a

fever is considered 100.4* F rectal.
3 months of age and less always
take temperature rectally.

General Inspection
A comment should be made about
the patients general appearance.
Activity level and whether the
patient is ill, is interacting with the
surroundings, and level of distress, if
any.
Comment about unusual odors.

Head
In an infant the size and topography of
the anterior fontanel should be noted.
Ant. Fontanel is the largest 4 to 6 cm
and closes between 4 and 26 months.
Post. Fontanel is 1 to 2 cm and closes
by 2 months.

Bulging of the fontanel may indicate

increased intracranial pressure found
in infections, neoplastic diseases of the
central nervous system, or obstruction
of the ventricular circulation.
Depression of the fontanel is found in
decreased intracranial pressure and
may be a sign of dehydration.

Head
Symmetry should be examined from various
perspectives:
Plagiocephaly: is characterized by flattening of the occipital
skull.
Scaphocephaly: describes an elongated head with flattening
of the bones in the temporoparietal regions.
Cephalhematoma: term applied when there is bleeding over
the outer surface of a skull bone elevating the periosteum.
Caput succedaneum a localized pitting edema in the scalp
that may overlie sutures of the skull, usually formed during
labor as a result of circular pressure of the cervix on the
fetal occiput.
Craniosynostosis refers to premature fusion of one or more
of the sutures of the cranial bones, and should be
considered in any neonate with an asymmetric cranium.

Head
Craniotabes is a term for softening of
the skull bones, with pressure the skull
may be momentarily indented before
springing out again. The major clinical
significance is with congenital rickets.
Rarely, osteogenesis imperfecta or
congenital hypophosphatasia may be
causes. Pressure to skull makes a
sound Crack like a ping pong ball.
Macewens Sign: is characterized by a
Cracked pot sound when the
cranium is percussed with the
examining finger. A positive
Macewens sign may be evident until
fontanel closure.

Head
The shape of the head can reveal much about the
babys trip through the birth canal.
Palpate suture lines for abnormalities.
Palpate for any bumps or points of tenderness.
Examine the hair and eyebrows for texture, quantity,
and pattern.
Abnormalities in hair may be associated with systemic
disease or abnormality. Dry, course and brittle hair may
be associated with congenital hypothyroidism.
Alopecia Areata: well circumscribed areas of complete
or almost complete hair loss, the scalp is smooth w/o
signs of inflammation. Hair loss usually begins suddenly,
and total loss of scalp and body hair may develop.

Head
Tinea Capitis is a fungal infection of
the scalp characterized by a patch
of short broken off hairs and the
patches of hair loss may be scaly or
they may be marked with
inflammation, bogginess, and
pustules called kerion.

Eyes
The shape and position of the eyes
should be noted.
Any abnormal eye movement and
the ability to focus on the examiner
are important to note.
Hard to examine because of the
bright lights.

Nose
Look for deformities, obstruction of the airway, color of
the mucosa, discharge, and tenderness.
Check the nose for foreign bodies (beans, carrots,
crayons) younger children often putting foreign objects
into the various orifices of the body and they often get
stuck their.
A green, foul smelling, purulent discharge from only one
side of the nose is common with a foreign object being
left in the nose.
Purulent discharge bilaterally indicates infection.
Delivery can give nasal obstruction due to displacement
of the septal cartilage.

Nose
Flaring of the nostril almost always shows respiratory
distress.
Mucosal Assessment:
Red: Acute infection
Blue and Boggy: Allergy
Gray and Swollen: Rhinitis

Maxillary and Ethmoid are developed in infancy.

Frontal sinus developed by 5 years of age.
The size, shape and symmetry of the nose should be
noted.
A horizontal crease may be seen in the skin on the
surface of the nose, this signifies repetitive wiping of the
nose commonly seen in allergic rhinitis.

Ears
The size and any aberration in shape of the external ear
(Pinna) should be noted.
A low position (below the level of the eyes) or small
deformed auricles may be an indication of a brain defect
or congenital kidney abnormality, especially renal
agenesis.
Inspection of the auricle and pariauricular tissues can be
done by checking the 4 Ds:

Discharge
Discoloration
Deformity
Displacement

Ears
Discharge: from the ear canal can be a result of otitis
external or chronic untreated otitis media.
Discharge may be thick and white, it may accompany a
bright pink or red canal.
To differentiate between otitis externa and otitis media,
pull on the pinna, if this elicits pain, it is most likely otitis
externa.
Prolonged moisture in the ear canal promotes bacteria
and fungal growth which predisposes the child to otitis
externa (swimmers ear).
Equal mixture of alcohol and vinegar used as a rinse will
keep the ears dry and keep bacteria from growing.

Ears
If the discharge is accompanied with
perforation of the tympanic
membrane, otitis media is suspected.
The presence of a foreign bodies in
the ear is common and if left in the
ear for a period of time may cause an
inflammatory response which may
produce a foul-smelling purulent
discharge.
Discoloration in the form of
eccymosis over the mastoid area is
called Battle Sign, and is
associated with trauma and should
be considered an emergency.

Ears
Deformity of the ears may develop from
intrauterine positioning or could be the
results of hereditary factors.
These deformities are of minor concern
unless gross deformities are present.
Gross deformities of the external ear are
often associated with anomalies of the
middle and inner ear structures.
Displacement of the auricle away from the
skull is a distressing sign associated with
mastoiditis, other signs of mastoiditis are
erythema and tenderness over the mastoid
and pinna, fever, and purulent discharge.
Other conditions associated with
displacement of the auricle are parotitis,
primary cellulitis, contact dermatitis, and
edema.

Throat
Examine the external mouth for symmetry, such as
drooping of the corner of the mouth.
The lips and mucous membrane should be examined for
evidence of cyanosis.
The tongue should be palpated for movement and
strength of suck, this evaluates the function of the
glossopharyngeal, vagus, and hypoglossal nerves
The soft palate should be examined for presence of the
gag reflex, evaluates the vagus nerve.
The hard palate should be evaluated for structure,
absence of clefts, and alignment of the arch. A high
arched palate may possibly indicates future dental
problems associated with insufficient space for teeth
( high arched palate may indicate syndromes like
Marfan syndrome).

Diphteri

Throat
The color of the oropharynx should be noted,
the size of the tonsils and tonsillar pillars and
any discharge should be noted.
Cobblestoning of the posterior pharyngeal wall
is a sign of chronic allergic disease.
The quality of the patients voice should also
be noted.
The tongue should be examined for size,
shape, color, and coating.
A coated tongue is nonspecific
A smooth tongue is found in avitaminosis
A strawberry or raspberry tongue is seen in specific
stages of Scarlet Fever.
A geographic tongue is a common finding.

Thrush

Thrush on the Tongue

Oral Thrush

Acute Tonsillitis

Diphtheria Bull Neck

Diphtheria Psudomembrane

Stomatitis

Stomatitis of the Tongue

Mastoiditis

Mastoiditis

Mumps

Throat
Examine the oral mucosa may have creamy
white reticular plaques commonly seen with
thrush caused by Candida Albicans.
A gray/white, sand grain sized dots on the
buccal mucosa opposite the lower molars,
called Koplik Spots are seen with Rubeola.
Examine the teeth for dental caries, color of
the teeth, number of teeth and for dental
occlusion.
Examine the neck for masses, enlarged
glands, tracheal tugging, carotid bruits,
mobility, and webbed neck.

Kippel Feil

Congenital Muscular
Torticollis

Thorax and Heart

Note the symmetry of the chest, asymmetric expansion

may be seen with pneumothorax or diaphragmatic
paralysis. Also note any abnormal shapes (Pectus
Excavatum or Pectus carinatum.
Barrel-shaped chest are sometimes seen in patients with
chronic obstructive pulmonary disease(chronic asthma or
cystic fibrosis).
A rechitic rosary may be seen or palpated in rickets.
Widely-spaced nipples may be a sign of Turner Syndrome.
Note the pubertal development of the breast (Tanner
staging) in females.
Note any masses, tenderness, or discharge of the breast
and describe in detail.
Breast buds are commonly seen in neonates.
The integrity of the clavicles should be noted in newborns
Males sometimes develop unilateral or bilateral breast
hypertrophy during puberty, called gynecomastia, with
milk production may or may not be
present.Approximately 40% of all males between the
ages of 10 and 16.

Pectus Excavatum

Pectus Excavatum

Pigeon Breast

Gynecomastia

Gynecomastia

Thorax and Heart

Female breast usually develop

asymmetrically.
Inspect the thorax for color,
respiration, type of breathing.
Auscultate breath sounds (rate, ease,
depth, rhythm).
Palpate thorax (tenderness,
respiratory excursion, vocal or tactile
fremitus, and areas of abnormality)
Measure chest circumference at
nipple line.
Auscultate the heart (murmurs, rubs,
clicks, or gallops) should be noted.
The point of maximum impulse is at
the forth intercostal space until about
age 7.

Thorax and Heart

A history of excessive perspiration and
difficulties in feeding are two of the most
common complaints of early congestive
heart failure.
Important questions to ask the parent:
How has the infant been feeding?
Does he or she get out of breath or appear
exhausted?
Has the childs growth pattern changed
recently?
Does the child tire easily, with eating or
with playing?
Does the child perspire excessively,
especially with efforts such as feeding?
Does the infant breathe rapidly, even at
rest.

Upper Extremity
Examination of the upper extremities should
include inspection for normal anatomy and
limb position, palpation for structural integrity,
and joint range of motion.
The extremities should be examined for
clubbing, cyanosis, and edema.
Acrocyanosis is a common finding in neonates,
characterized by cyanotic discoloration,
coldness, and sweating of the extremities,
especially the hands.
Any deformities or extra digits should be
noted.
Range of motion, swelling, erythema, and
warmth should be noted of any joint.
Check for signs of contusions, abrasions, and
edema which are common signs of trauma.

Polydactyly

Polydactyly

Upper Extremity
Check for muscle tone and strength
of the upper extremity.
Evaluate all range of motion of each
joint.

Abdomen
Inspection is the most important first step.
The order of examination has been changed slightly in
that palpation is done last.
It is a good idea, before performing abdominal
examination, to ask the child if they need to use the
restroom.
For the examination of the infant or toddler the knees
may be bent in order to relax the abdomen and the
childs arms down at their sides.
Inspect for rashes, scars, lesions, or discoloration.
Observe overall contour and symmetry.
Inspect the umbilicus for shape, signs of inflammation
or hernia

Abdomen
Auscultation of the abdomen should
be done before palpation or
percussion since the latter may alter
the frequency and quality of bowel
sounds.
Listen to the 4 quadrants noting the
frequency and quality of the bowel
sounds.
Abnormal sounds:
gurgles
clicks
growls

Frequency of sounds is from 5 to 34

times per minute.

Abdomen
An increase in frequency or pitch of bowel sounds may
be associated with intestinal obstruction or diarrhea.
Decreased or absent sounds may be associated with
paralytic ileus or peritonitis.
To be certain that bowel sounds are absent listen for 2
minutes in the area just inferior and to the right of the
umbilicus.
Percussion in the pediatric patient is the same as the
adult patient.
Because children tend to swallow a lot of air when
eating or crying the stomach and intestines has a great
amount of air in them.

Abdomen
A distended abdomen may signify an obstruction,
infection, celiac disease, ascites, or an abdominal mass.
Palpation will reveal masses (note size and location)
hepatosplenomegaly, and any sources of pain.
If the liver is felt below the costal margin (it commonly
is 1 cm below the margin) its span in the midclavicular
line should be percussed.
Danforths sign is right shoulder pain with RUQ
palpation (represents an irritated diaphragm) is strongly
suggestive of liver injury.
Kehrs sign is left shoulder pain with LUQ palpation
(represents an irritated diaphragm) is strongly
suggestive of splenic injury.

Abdomen
Rovsings sign is RLQ pain with LLQ
palpation is suggestive of
appendicitis.
McBurneys point is 2/3 of the way
from the umbilicus to the anterior
superior iliac crest in the RLQ and
tenderness there is also suggestive
of acute appendicitis.

Rectum
A chaperone may be necessary.
The anus should be inspected for position (an
imperforated anus is associated with a host of other
anomalies; an abnormally places anus can also be
associated with constipation or encopresis, depending
on the position of the orifice with respect to the
sphincter).
Any fissures, trauma, or parasites should be noted.
A rectal prolapse may be seen with many conditions
including malnutrition, constipation, and cystic fibrosis.
The rectal exam is mandatory for any child complaining
of abdominal pain, encopresis, constipation,
hematochezia, or melena.

Rectum
A lubricated small finger is
used to palpate for any
masses, tone of the sphincter,
and any focal pain, as may be
seen with appendicitis.
The stool should be tested for
occult blood.
Rectal examination on infants
and young children should be
performed in the supine
position.

Genitalia
Patients should always be examined
is the presence of a parent or a
caretaker or in the case of a pre-teen
or teenager with a staff member
present.
It is not common for Doctors of
Chiropractic to do female genitalia or
pelvic exam.
It is common for the D.C. to give a
hernia examination and Tanner
Staging for school or sports
physicals.
Tanner Staging is the measurement
for sexual maturation.

Lower Extremity
Visually inspect the lower extremity for abrasions,
contusions, rashes, edema, cyanosis, clubbing, and
discoloration.
Visually inspect for any abnormalities or deformities
(any extra digits should be noted).
Measure the extremity as to circumfrencial
measurements, actual leg length (ASIS to Medial
malleolus) and apparent leg length (Umbilicus to Medial
Malleoolus).
A way to determine true leg length is to take a
Scanogram (this is a x-ray procedure where three views
are taken of the extremities the first is through the head
of the femurs, the second is through the knees, and the
third is through the ankles) using a Bell Thompson Ruler.

Lower Extremity
Range of motion should be
preformed and any joint swelling,
erythemia, and warmth should be
noted.
Hips are routinely examined in
infants (see orthopedic sect.)
Foot abnormalities are common in
infancy but not in later life.
The peripheral pulses, especially the
femoral pulses.

Orthopedic Testing
Infant orthopedic testing should include
all rang of motion testing, static and
motion palpation.
Ortolanis Test is a common test
performed on the infant.
It is a reduction test.
With the baby relaxed in the supine
position, the hips and knees are
flexed to 90*, the examiner grasp
the babys thigh with middle finger
over the greater trochanter and lifts
the thigh an simultaneously gently
abducting the thigh, thus reducing
the dislocation and a clunk will be
observed

Orthopedic Testing
Barlows Test is a provocative test
(dislocation) also called Reverse
Ortolanis test.
Barlows Test is performed to
discover any hip instability.
The babys thigh is grasped with the
middle finger along the babys thigh
adducted and with a gentle
downward pressure.
Dislocation is palpable as the
femoral head slips out of the
acetabulum.

Orthopedic Testing
Allis or Galeazzis Sign is another orthopedic test used
to test for a dislocatable hip and is preformed by flexing
the childs knees and hips placing feet on the table the
lower one the femoral head lies posterior to the
acetabulum.
Another test for a dislocated hip, shortening of the thigh
will bunch up the soft tissue and will accentuation of the
skin folds.
Telescoping of the thigh is elicited because the femoral
head is not contained within the acetabulum.
Trendelenburgs Test with the child standing with weight
on the affected side the normal hip drops down,
indicating weakness of the abductor muscles of the
affected side.

Neurological Testing
Much of the neurologic exam comes from observation of
the child.
Any limitation in the use of the hands, legs, or pupillary
light response.
Babinski Reflex the babys foot is stroked from heel
toward the toes. The big toe should lift up, while the
other toes fan out: absence of the reflex may suggest
immaturity of the CNS, defective spinal cord, or other
problems. This reflex may be seen up to age 12 to 24
months. Then it will reverse with toes curling downward.
Dolls Eye while manually turning babys head, his eyes
will stay fixed, instead of moving with the head. While
normally vanishing around one month of age, if it
reappears later, there may be damage to the CNS.

Emotional Attitudes