Tricking Kids into the Perfect Exam:
Tips for Evaluating the Pediatric Patient
While pediatric patients may be small,
they often can be as intimidating to us
as we are to them. The factors that add
to this anxiety are relative inexperience
with children compared to adult patients,1
and the inability of younger patients
to communicate or cooperate with the
physical exam. While each physician
may vary with style points and favorite
tricks, here are a few tips for the pediatric
physical exam to improve your interaction
and comfort level.
One of the fi rst tasks as an emergency
physician is to put the patient at ease. Talk
to the child as well as the parents. For
older children, introduce yourself to them
fi rst before the parents and sit down on
the bed or chair as to not tower over them.
Try to facilitate the relationship and open
up communication by noticing something
cool about them (i.e. light-up shoes, Dora
T-shirt or fun toy).
While doing the actual physical exam, try
to use the parent’s lap as much as possible
as the child is most comfortable there. To
distract and calm them, consider telling
them a story throughout the exam or try
to make the physical exam a game – play
with the instruments. Finally, consider
having something fun in your pocket such
as stickers or a bubble-blowing pen to
make the experience more enjoyable.
In general, when evaluating any child,
observation is the best initial diagnostic
tool. The degree of alertness and
interaction, responsiveness to parents and
respiratory status are all valuable measures
of illness that may either suggest or
eliminate concerns of toxicity.
After observation, it is important to begin
the exam with auscultation of the heart
and lungs as this is usually when the child
is calm, quiet and most cooperative. Do
not forget that a negative lung auscultation
is not suffi cient to rule out signifi cant
pulmonary disease; the appearance of the
patient (tachypnea, respiratory distress) is
much more predictive.
Finally, always save the worst for last.
The last items to perform in the physical
exam should always be those things that
are most threatening to the child, including
looking in the ears and mouth.
Here are a few cases to illustrate the
importance of the physical exam and
emphasize other tips for evaluating those
age groups that provide the most anxiety
and diffi cult exam.
Newborn
Case 1: A 3-week-old male presented to the
emergency department for congestion and
cough. Mom stated that the infant was not
eating as well, but had normal wet diapers.
No fever noted at home or on exam.
As mentioned above, it is important to
observe the newborn. One of the best tips
is to undress and hold the baby. Holding
allows the clinician to assess multiple
things at once, including level of alertness,
respiratory status and tone. This initial
assessment gives the clinician a good
sense of “sick or not sick.”
It is also important to have the baby
undressed to do a careful examination,
looking for rashes, bruises, hair
tourniquets, etc. During the exam, this
newborn was observed to have an apneic
episode. The patient was admitted for
an evaluation that ultimately revealed a
diagnosis of pertussis.
Infant
Case 2: A 5-month-old male presented
with fever and fussiness. The patient
was seen fi ve days earlier with fever and
URI, diagnosed with otitis media and
discharged home with amoxicillin. Prior to
arrival, the patient had multiple episodes
of vomiting and decreased urine output.
Initial assessment revealed an illappearing,
febrile infant. While observing
the infant and beginning the physical
exam, it is important to place your hand on
the infant’s head and assess the fontanelle.
A fontanelle is measured as full, fl at, or
depressed. Cup your palm on the back of
Rose House, MD
EM/Pediatrics Resident
Indiana University
Indianapolis, IN
“In general,
when evaluating
any child,
observation is
the best initial
diagnostic tool.”
34 EMResident
the baby’s head and then move forward.
The curve of your palm should touch the
fontanelle if it is normal. If the fontanelle
doesn’t touch, it is depressed; if it pushes
your hand up, it is full.
In young infants, a bulging fontanelle may
be seen with meningitis, but meningismus
is rare before one year of age. Another
possible exam fi nding in infants with
meningitis is a paradoxical response
to consoling maneuvers like cuddling.
When a caregiver “cuddles” an infant,
the meninges are stretched and irritated
making the infant more fussy. By contrast,
the same infant will calm when laid fl at.
This infant’s fontanelle was full and
tense. Throughout the exam, the patient
was irritable and diffi cult to console. The
infant was appropriately resuscitated and
underwent a full septic work-up, revealing
pneumococcal meningitis.
Toddler
Case 3: An 18-month-old male presents
with complaint of seizure witnessed at
home 20 minutes prior to arrival.
Many pediatric patients will present to
the emergency department after a seizure.
When evaluating this patient, it is crucial to
do a good neurological exam. The biggest
tip for the pediatric neurological exam is
to stop, look and listen. You will learn the
most from the child’s spontaneous activity,
including mental status, cranial nerves,
coordination, and motor status.
Assess patients based on developmental
milestones for their age group. If
age appropriate, make sure to watch
them walk. Also, watch the child sit
unsupported as truncal instability may be a
clue to vertiginous symptoms or cerebellar
pathology. Try to carry one thing that
could fake for a toy or draw a face on a
tongue depressor to help attract the child’s
attention.
Upon examination of this patient, he had
right-sided weakness which resolved
within an hour. The patient was diagnosed
with Todd’s paralysis and new-onset
seizure disorder.
Preschooler
Case 4: A 3-year-old female presents
with abdominal pain and fever over the
past day. Patient has some vomiting
and diarrhea. Emesis is nonbilious
and nonbloody. Diarrhea is watery
and yellow. The patient has also had
decreased oral intake and urine output. On
exam, the patient is febrile and appears
uncomfortable.
Performing a good abdominal exam is
critical for the assessment of this patient,
but can often be challenging. Children
Figure 1: Additional Tips & Tricks
General
Always undress.
Eyes
If trying to get a newborn to open their eyes, holding the infant’s head and dipping it down will cause
them to open their eyes.
Never try to pry a baby’s eyes open when they are crying as you will not be able to over power them and
will just anger them more.
Infants should fi x and follow a moving object with both eyes by 3 months of age. Use bright objects or
noises to help assess extraocular movements.
Ears
If having a hard time looking in the ears, hold arms above head.
If unable to turn their head, wiggle the otoscope light in front of their eyes and then move it to the
opposite side of the ear you want to look in. The child will often track with the light and turn their head
so their ear is then right in front of you.
Have parent stabilize the head. Use one hand to grab the pinna while holding the otoscope with the
thumb and index fi nger and using the little fi nger and heel of the hand to stabilize the otoscope against
the side of the face (See Figure 2).2
Mouth/Throat
Wetting the tongue depressor makes it taste better.
Have the child pant like a dog when doing a throat swab as it helps prevent gagging.
Heart
If worried about murmurs, gently and briefl y blow in the face of a neonate which slows down their heart
rate momentarily so that you can better ausculate for murmurs.
Lungs
If you want them to take a deep breath, can have them blow out the light on the otoscope or can ask
them to pretend to blow out the birthday candles.
cannot developmentally pinpoint the
location of abdominal pain until they are at
least four years old, and perhaps not even
then. With symptoms and an exam that are
nonspecifi c, abdominal pathology can be
very diffi cult to diagnose in this age group.
Attempt to calm and distract the patient as
much as possible.
For infants, make sure to have a pacifi er
available during the abdominal exam.
Another option for the crying infant is to use
sucrose to calm them during auscultation
and palpation. Flexing the hips will also
facilitate relaxation and a better exam. For
patients that are ticklish, you can have the
child place their hand on yours and push
down as if they are doing the exam.
For children with abdominal pain, make sure
to always undress the patient and evaluate for
rashes to assure that diseases like HenochSchönlein
Purpura (HSP) are not missed.
Also, referred pain is very common, and
pneumonia or strep throat may present with
abdominal pain of any location with focal or
diffuse pain on exam.
Using the above techniques, the patient
in the case was found to have signifi cant
tenderness without rebound. Upon further
evaluation, the patient was found to have
acute appendicitis.
The above tips and tricks should allow
for a smoother encounter with the pediatric
patient. If the tactics are not working,
do your physical exam in stages. Start
quickly with the most essential, then return
frequently to perform each additional
layer. Always remember that a graceful
approach will go a long way with assessing
children. „