PEDIATRIC PHYSICAL EXAM

General (GEN)

• Appearance: Distressed? Sick? Toxic?

• Behaviour: Co‐operative, agitated, level of activity (sedate, listless, alert, active, playful), communication (interactive, shy, non‐verbal), interaction with caregivers and interviewer

• Development: “pulling up to stand in crib”, “running around”

• Dysmorphic features and body habitus: look at face, ears, hands, feet, genitalia, height, weight, body fat

• Colour: cyanotic, gray, mottled, pale, pink, jaundice

• Nutritional Status: malnourished, well‐nourished, overweight, obese

• Hydration Status: Mucous membranes, tears, skin turgor, fontanelle, sunken eyes, in addition to appropriateness of vital signs. Classify: mild, moderate, severe dehydration

• Circulation: Signs of poor circulation? (e.g., cool extremities; weak, rapid pulse; poor capillary refill; cyanotic, gray, or mottled colour)

• Respiratory: Work of breathing

Normal Pediatric Vital Signs

AGE HR SYSTOLIC BP RR Newborn (<1 week) 90‐160 60‐70 30‐60 Neonate (<1 month) 90‐140 75‐90 30‐60 Infant (<1 year) 100‐190 75‐120 24‐40 Toddler (1‐2years) 90‐150 75‐120 22‐34 Preschool (3‐5years) 90‐120 75‐125 18‐30 Child (6‐12 years) 60‐120 83‐120 16‐24 Adolescent (>12 years) 70‐100 90‐130 12‐18 Adult (>18 years) 60‐100 90‐130 12‐18

• Blood pressure averages vary significantly based on age and height

• A general rule for average blood pressure in children and adolescents is: o Systolic BP 50th percentile (sBP) = 90 + 2 X age o Diastolic BP (dBP) = 2/3 X sBP

Normal Temperature Ranges Syllabus: Leduc et al. Temperature measurement in paediatrcs. Canadian Paediatric Society. 2015.

ROUTE NORMAL TEMPERATURE RANGE Rectal 36.6°C to 38°C (97.9°F to 100.4°F) Ear 35.8°C to 38°C (96.4°F to 100.4°F) Oral 35.5°C to 37.5°C (95.9°F to 99.5°F) Axillary 34.7°C to 37.3°C (94.5°F to 99.1°F)

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Temperature Measurement Techniques

AGE SUGGESTED TECHNIQUE

Birth to 2 years

1. Rectal (definitive) 2. Axillary (screening low risk children)

Over 2 years to 5 years

1. Rectal (definitive) 2. Axillary, Tympanic (or Temporal Artery if in hospital) (screening)

Older than 5 years

1. Oral (definitive) 2. Axillary, Tympanic (or Temporal Artery if in hospital) (screening)

Anthropometrics

• Weight (Wt, kg)

• Height (Ht, cm) o Supine length to 2 years, then standing height

• Head Circumference (HC, cm) o Generally do from birth to 2 years. >2 yrs, if have specific concerns

• BMI

HEENT (Triple S: size, shape, symmetry)

• Head: shape and symmetry of skull/fontanelles, dysmorphic, sutures

• Eyes: red reflex in infants, strabismus, pupillary response, fundoscopy, lids, conjunctivitis, acuity (>3 years)

• Ears: otoscope, tympanic membranes (TM x 2): clear, erythematous, bulging, effusion, retracted, ear shape, hearing

• Mouth: lips (lesions, colour), mucous membranes including gingiva, tongue, hard/soft palate

• Dentition: presence of teeth, tooth decay

• Pharynx: tonsils, erythema, exudates

• Neck: lymphadenopathy, masses, thyroid, webbing (Noonan, Turner syndrome), torticollis, nuchal rigidity/stiffness

Cardiovascular (CVS)

• Distress, cyanosis, pallor

• Perfusion o Skin colour: pink, central/peripheral cyanosis, mottling, pallor o Capillary refill time o Pulses – strength/quality, *femoral pulses

• Palpate for apical beat, heaves/thrills

• S1/S2, extra heart sounds (S3, S4)

• Murmurs o Timing (systole, diastole, continuous) o Location of maximal intensity, radiation o Pitch and quality (machinery, vibratory, etc) o Volume (I – VI / VI)

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Respiratory (RESP)

• Signs of respiratory distress: tachypnea, nasal flaring, tracheal tug, indrawing (supra clavicular/sternal/intercostal/subcostal)

• Audible stridor, wheezing, snoring

• Position of child, able to speak in full sentences (if age appropriate)

• Chest wall deformities: pectus excavatum/carinatum

• Adventitious sounds: transmitted upper airway sounds (TUAS), crackles, wheezes

• Percussion if appropriate

Abdomen (ABDO/GI)

• Inspection: scaphoid/distended, umbilical cord in infants

• Auscultation: presence of bowel sounds

• Percussion: ascites, liver span, Traube’s space for splenomegaly

• Palpation: hepatosplenomegaly, tenderness, guarding, masses

• Peritoneal signs: ask child to jump up and down or wiggle hips, to distend and retract abdomen (“Blow up your belly and then suck it in”)

• Stigmata of liver disease: jaundice, pruritis, bruising/bleeding, caput medusa, ascites, hepatosplenomegaly

Genitourinary (GU)

• Male: testes descended, hypospadias, inguinal hernias/hydrocoele, circumcised

• Female: labia majora/minora, vaginal discharge, erythema/excoriation of vulvo‐vaginitis (NO speculum exam if pre‐pubertal)

• Anal position, external inspection (digital rectal examination in kids ONLY with clinical indication)

• Tanner staging

Musculoskeletal (MSK)

• Hips: Ortolani and Barlow in infants for developmental dysplasia of the hip (DDH)

• Gait assessment, flat feet vs. toe walking vs. normal foot arches

• Standing: genu valgum “knock knee” vs genu varum “bow legged”

• Joints: erythema, swelling, alignment, warmth, joint line tenderness, active/passive range of motion

• Back: sacral dimple/hair, midline skin lesions, kyphosis, scoliosis

Neurological (NEURO)

• Overall developmental assessment o Try playing ball with younger children, or even peek‐a‐boo! o Ask child to draw a picture of self or family

• Level of consciousness (Glasgow Coma Scale if appropriate)

• Newborns: primitive reflexes, moving all limbs

• Cranial nerves: observation in infants, formal testing in older children

• Motor: strength, tone, deep tendon reflexes, coordination

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• Sensory: touch, position/vibration sense

• Cerebellar: gait (heel to toe, walk on heels, walk on toes), finger‐to‐ nose, rapid alternating movements in older children, Romberg (eyes open then closed)

Dermatological Exam (DERM)

• Jaundice, pallor, mottling, petechiae/purpura, vesicles, urticaria, eczema, diaper dermatitis, clubbing

• Rashes, birthmarks, hemangiomas, stigmata of neurocutaneous disorders