Putting it all together… Pediatric Exam

1. Putting it all together…Pediatric Exam Modified from Mosby’s Guide to Physical Exam, 6th Ed., Ch. 24

2. Getting Started • Offer a toy or paper & pencil while taking the patient history • draw shapes (developmental assessment) • ask them questions too (mental status) • General inspection can be done in the waiting room • less apprehensive • Vitals are often done first • make it fun, build rapport

3. Child Playing Musculoskeletal & neurological exam • Observe spontaneous activities • Ask them to demonstrate skills • Building blocks, drawing shapes, etc. • Evaluate gait, jumping, hopping, ROM • Muscle strength • Climbing on parent’s lap, stooping, etc.

4. Benefit of parent’s lap… • Often feel more secure • Observe parent/child relationship *Please have child undressed except for diaper/underpants • use gown if age appropriate

5. On Parent’s Lap Upper Extremities • Inspect arms • Movement, size, shape • Observe use of hands • Number of fingers, palmar creases • Palpate radial pulses • Biceps & triceps reflex • Blood pressure

6. On Parent’s Lap(may need to have child stand) Lower Extremities • Inspect legs • Movement, size, shape, alignment, lesions • Inspect feet • Alignment, longitudinal arch, number of toes • Dorsal pedis pulse • Plantar reflex • Achilles and patellar reflexes

7. On Parent’s Lap Head and Neck • Inspect head • shape, alignment with neck, hairline, position of auricles • Palpate fontanels, sutures, depressions • Measure head circumference • Inspect neck • voluntary movement, webbing • Palpate neck • Trachea, thyroid, muscle tone, lymph nodes

8. On Parent’s Lap Chest, Heart, & Lungs • Inspect chest • size, shape, deformity, nipple & breast development • respiratory movement, precordial movement • Palpate anterior chest • maximal impulse, tactile fremitus • Auscultate lungs & count respirations • Auscultate heart • murmurs • count apical pulse

9. “Supine” – Still on Lap (diaper loosened) • Abdomen • Inspect • Bowel sounds • Palpate (liver size, etc.) • Percuss • Femoral pulse (vs. radial) • Lymph nodes • External genitalia

10. Standing • Observe posture • Adam’s test • Gait

11. Fundoscopic & Otoscopic Exams Restrain a child only as a last resort! Lessen fear… • child may handle the instrument (carefully) • “blow out” the light • perform the test on a doll or parent

12. Return to Parent’s Lap • Inspect eyes • Extraocular movements • Pupillary light reflex, red reflex, funduscopic exam • Otoscopic exam • Inspect nasal mucosa • Inspect mouth and pharynx

13. Tips • Tell a story OR ask them to tell one • Attract attention or distract… • Be patient; get down on their level • Use specific, polite directions rather than asking permission “Please open your mouth” vs. “Do you want to open your mouth?”

14. Tips • Too many adults “looming” over them will make the child less cooperative • If ticklish, place your hand on top of theirs • If using a tongue blade, moistening it will help decrease the tendency to gag

15. When assessing an ill child… • Is there a smile? • Playful, alert, responsive? • or dullness and apathy • Do they respond to soothing behavior? • Show interest in environment, toys? *These matter just as much as temperature, pulse and respirations!