1. Environmentgeneral appearance
2. Armsvital signs
3. Heartlungs
4. Abdomen
5. Diapergenitaliaanus
6. Legsfeet
7. Integumental
8. Nervous
9. Head and neckeyesearsnosethroat
10. Heightweight
11. Examination tips

Environment

• Nebulizersdrugs on dresser.
• Special foodincluding sugar-free (DM).
• Mobility-assisting devices.
• Hospital equipment.

General appearance

• Pre-exam checklist: WIPE:
  • Wash your hands [thus warming them].
  • Introduce yourself to ptexplain what going to do.
  • Position pt [+/- on parent's knee].
  • Expose area as needed [parent should undress].
• Examine from the R side of the pt.
• Posturebody positionsbody shape.
• Skin colors. See Skin Colors Reference.
• Hydration.
• Dresshygiene.
• Alertnesshappiness.
• Crying: high-pitched vs. normal.
• Any unusual behavior.
• Parent-child interactionreaction to someone new walking entering the room (childabuse).
• Ask if tenderness anywherebefore start touching them.
• If asleepdo the heartlungs and abdomen first.

Armsvital signs

• Nails: See Nails Reference.
• Hands:
  • Clinical hand signs.
  • Colorwarmth.
• Radial pulse.
• Femoral pulse.
• BP.
• Temperature.
• See Taking Pediatric Vital Signs Reference.
• Axillary lymph nodes.

Heart

• Inspection:
  • Precordial bulge.
  • Apical heave.
• Palpation:
  • Apex beat location.
  • Thrillsheaves.
• Auscultation:
  • Siteradiation.
  • Pitchqualitycharacter.
  • Intensityrhythmduration.
  • Changes with respirationposture.
  • Carotid bruits.
• See Pediatric Heart Reference.

Lungs

• Inspection:
  • Spinal curvature.
  • Tanner stage (female). See Tanner StagesReference.
  • Accessory muscles of respiration [respiratory pattern is abdominal <6yrs].
  • Intercostal respiration (respiratory obstruction).
• Palpation
  • Fremitus
• Percussion:
  • Dull and resonant areas.
• Auscultation:
  • Crackles.
  • Wheeze.

Abdomen

• Inspection:
  • Shape.
  • Visible swellingshernias.
  • Umbilicusveins.
  • Visible peristalsis.
• Percussion [often optional]:
  • Fluid waveshifting dullness.
  • Liverspleen.
• Palpation:
  • Masses.
  • Areas of terndernessreboundguarding.
  • Liverspleen: <6 years may palpate up to 2cm below costal margin.
  • Kidneysbladder.
• Auscultation:
  • Bowel sounds.

Diapergenitaliaanus

• Only perform when indicated.
• Diaper:
  • Inspect contents.
  • Have MSU bottle ready if indicated.
• Male:
  • Testes decenthernias.
  • Circumcisiontesteshydrocele.
• Female:
  • Vulvaclitoris.
• Both sexes:
  • Discharge.
  • Abnormalities.
  • Tanner stage.
• Anus inspection:
  • Hemorrhoidsfissuresprolapse.
  • Sphincter tonetendernessmass.
  • PR exam isn't done on children.

Legsfeet

• Infants: hip abduction in infants with knees flexed.
• Feet abnormalitiessuch as rocker-bottom feet.
• Similar signs as seen in handsnails.

Nervous

• Can often skip theseas should already have good idea by now.
• Abnormalities during play.
• Limbs: movementtonelimpGower's sign.
• Head control.
• Reflexes:
  • Moro and tonic neck reflexes <3months.
  • Babinski's sign positive <12-15 months.
  • Hypertonicity commonly is normal infantsbut hypotonicity is abnormal.
  • Other reflexes: graspsuckrootstepping and placing.
• Meningitis signs if indicated: KernigBrudzinski.

Integumental

• Rashesusing proper terminology.
• See Hallmark Rashes Reference.
• See Skin Lesion Terminology Reference.

Head and neck

• Head circumferencerate of growth.
• Head asymmetrymicrocephalymacrocephalyother visible abnormalities.
• Fontanelleif <18 months:
  • Full vs. flat vs. depressed.

• Thyroid enlargementother lumps.
• Neck stiffness.
• Neck lymph nodes: locationsize in cmtendernessconsistency.

Eyes

• Exam position: mother holds child on lap facing forwardone arm encircling child'sarmsthe other hand on child's forehead.
• Pupils: reaction to lightaccommodation.
• Strabismus [aka squint].
  • Strabismus is normal before 4-6 months.
• Photophobiaproptosisscleraeconjunctivaeptosiscongenital cataracts.
• Fundoscopy. See Eye Exam.

Ears

• Exam position: same as eyebut child faces the side.
• Dischargecanalsexternal ear tenderness.
• Test hearing.
• Otoscope to examine ear drums.

Nose

• Nares patencyseptumnasal flaring.
• Dischargemucous membranessinus tenderness.

Throat

• Breath odor.
• Lips: colorfissures and dryness.
• Tongue.
• Teeth: numberarrangementdental caries.
• Gums: colorhypertrophy (phenytoin)
• Throat: epiglottis
• Tonsils: sizesigns of inflammation.

Heightweight

• Measure and plot on appropriate centile chart.

Examination tips

• Can establish rapport while checking cyanosisdyspneacough.
  • Can examine teddy bear first.
• Best examination method by age:
  • Neonatesvery young infants: on examining table
  • Up through preschool: lying sit on mother's lap
  • Adolescent: without family present.
• Parentnot examinershould undress a small child.
• Kids are impatientso a systematic full examination may get difficult. Examine the mostpertinent area first.
• Record respiratory rate firstbefore crying starts.
• In childbreath sounds are easier to hearbut harder to localize.
• ENT exam more likely to induce a cry so these go last.
• Opportunism:
  • If child dozesauscultation heart.
  • While parent removes shirtexamine shoulder/arm movementhead control.
  • If child kicks examinerobserve hip range of motion.
  • If criesthe deep breaths between each cry can reveal rales with stethoscope.

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