Overview of Pediatric Physical Assessment Overview of Pediatric ...

4/5/2011FacultyOverview of PediatricPhysical AssessmentKaren M. Landers, MD, FAAPAssistant State Health OfficerPediatric ConsultantAlabama a Department e t of Public HealthSatellite Conference and Live WebcastWednesday, April 13, 20111:00 - 4:00 p.m. Central TimeProduced by the Alabama Department of Public HealthVideo Communications and Distance Learning DivisionEssentials of PediatricPhysical Assessment• Thorough history• Properly interpreted vital signs• Properly evaluated developmentaland growth parameters• Focused physical assessmentEssentials of PediatricPhysical Assessment• Anticipatory guidance/preventivehealth– Immunizations– Ingestions– Injuries• Problem list and planGeneral Points AboutTaking a History• Chief complaint• Onset of problem• Duration of problem• Progression of problem• Aggravating or alleviating factors• Associated manifestationsGeneral Points Continued• Functional impairment– Changes in eating patterns– Playfulness– School performance– Sleep habits1

4/5/2011• Allergic historyGeneral Points• Medication history• Immunization history• Hospitalization and/or accidents• Birth history• Developmental milestones• Family history• Social historyGeneral Appearance ofInfant or Child• Activity or movement• Facial features• Behavior when examiner enters room– Developmentally appropriate• Nutritional status• HygieneApproach to thePediatric Patient• Age appropriate interaction– Gentle and engaging– Nonthreatening– Take the path of least resistance– Quiet and soothingApproach to thePediatric Patient– Use observation liberally whiletaking the history– Always inform the patient of whatyou are about to do and never lieto the patient– Minimize the use of the exam tablein infants and younger childrenGrowth andDevelopment Parameters• Use current growth charts plottingBMI• Weigh appropriately– Dry diaper• Check height by placing infant onmeasuring table with head at the endof the board– Have older children take off shoesGrowth andDevelopment Parameters• Measure head circumference up totwo years old placing measuring tapeabove eyebrows and measuringaround to occipital prominence2

4/5/2011Growth Parameters andAreas of Concern• Know normal weight gains for age• Usual expected height velocity forage• Family information specifically aboutparental stature• Consider children born in othercountriesGrowth Parameters andAreas of Concern• Be concerned about headcircumferences at extremes andheight/weight crossing percentilesDevelopmental Assessmentfor Age General Information• Use standardized developmentalscreening tools assessing grossmotor, fine motor, language,sensory, and social development• Be “open-ended” with questions• Use observation during the history tofill-in developmental informationDevelopmental Assessmentfor Age General Information• Ask about hearing concerns evenwith newborns• Be alert to normal acquisition oflanguage milestones• Screen at every well infant and childvisitMeasure Vital Signs andKnow How to Interpret AgeAppropriate Variations• Temperature– Can use tympanic thermometers toavoid invasive techniques such asrectal thermometers past thenewborn and early infant agesMeasure Vital Signs andKnow How to Interpret AgeAppropriate Variations• Pulse– Apical less than 2 years old/countfor one minute3

4/5/2011AgeHeart RateRange of RateBirth 70-1900-6 months 1306-12 months 1151-2 years 1102-6 years 80-1306-10 years 75-11510-14 years 70-11014 and above 65-100Focus Points for theNeonatal Examination• Fontanels• Skin color• Facies• Tone• Symmetry– Movement, respiratory effort,abdomen• ReflexesNeonatal Reflexes andWhen They Disappear• Stepping: 2 months• Moro: 3 months• Rooting: 3-4 months• Palmar grasp: 3-4 monthsNeonatal Reflexes andWhen They Disappear• Tonic neck: 4-6 months• Plantar grasp: 8-10• Sucking: 10-12 12 months• Babinski: 2 yearsSome Information on Weight• Newborns may lose up to 10% oftheir birth weight in the first 3-4 days• Newborns gain ½ to 1 ounce per dayafter that time• Excessive or poor weight gain needsto be addressedSome Information on Weight• Infants generally double their birthweight by 5 months and triple it byone year5

4/5/2011Be Alert forCongenital AnomaliesSome Specifics in Neonates• Anterior and posterior fontanels– Anterior closes between 12 - 18months– Posterior closes by 2-5 months• Red reflex• Sacral dimples• Mongolian spotsSacral DimpleMongolian SpotMongolianblue spotsCongenital NevusSystem by SystemPhysical Examination• Integument• HEENT• Neck• Cardiovascular• Pulmonary6

4/5/2011System by SystemPhysical Examination• Gastrointestinal• Genitourinary• Musculoskeletal• Neurologic• Inflammatory• Viral• Bacterial• Congenital• Allergic• OtherIntegumentaryGeneral Principles ofExamination of the Skin• Color– Pallor– Jaundice• Normal after 24 hours innewborn up to 7-10 days butabnormal afterwards– Variations in skin pigmentationGeneral Principles ofExamination of the Skin• Texture, turgor• Rashes• Lesions• Hair and nailsSome DescriptiveTerms of Rashes• Macular• Papular• Blanch with pressure• Excoriated• Hemorrhagic• Blistering• CysticSome DescriptiveTerms of Lesions• Hives or wheals• Scaling7

4/5/2011Some DescriptiveTerms of Lesions• Crusting/scab forming• Scars• Other– Congenital, neoplasticCandidiasisChicken PoxHerpes SimplexEczemaHemangioma8

4/5/2011MiliaUrticariaImpetigoContact DermatitisRingwormScabies9

4/5/2011SeborrheaCafé au LaitLymph Nodes• Small, nontender, English pea size,soft, and freely moveable lymphnodes are common primarily in thecervical regionEnlarged Lymph Node• Check cervical, axillary, inguinalregion for lymph nodesHead and Neck• Check for symmetry, head control ininfants, posture to one side (anindicator of torticollis), range ofmotion• Feel the anterior and posteriorfontanels• Older infantHead and Neck– Flexion, extension, rigidity– Thyroid enlargement, branchialcleft cysts10

4/5/2011Eyes• Check for shape and symmetry• Note the color of the conjunctiva• Evaluate extra ocular movements• Check pupillary reflexes• Fundiscopic for red reflex• Appropriate vision testing in theclinical settingStrabismusConjunctivitisReflex PathologyEars• Evaluate shape, position• View internal structures• Newborn hearing screening andongoing assessment of hearingincluding language developmentNormal and AbnormalTympanic Membrane11

4/5/2011Nose• Structure, position• Evidence of grunting or flaring• Color of any drainage, foul odor,color of mucosa, location of septumThroat• Color of lips, presence of fissures• Teeth– Number and condition• Gums– Color and condition• Tongue– Midline, color, graphic patternsThroat• Integrity of palate and location ofuvulaEnlarged Tonsils• Tonsillar sizeGeographic TongueChest and Back• Inspect size, shape, symmetry alongwith movement• Note any distress including use ofaccessory muscles• Note symmetry of nipples and anybreast development• Check for spinal curvature12

4/5/2011Pectus ExcavatumPectus ExcavatumDepressionin sternumNormal heart positionPectus ExcavatumPectus CarinatumDepression pushesheart to the sideHeart• Palpate over the valvular areas• Determine the PMI• Rate– Higher than adults• Rhythm noting that infants andchildren will have variation withrespiration• MurmursHeart– Systolic murmurs can be normal– Diastolic murmurs are alwaysabnormal• S1 and S213

4/5/2011Murmurs• Classic description– Grade I-VI– Descriptive terms• Crescendo, decrescendo, harsh,blowing, soft• AuscultationLungs– Do not confuse upper airwaysounds with lung sounds– Equal breath sounds– Rales, ronchi, wheezingAbdomen• Inspect the shapeUmbilical Hernia• Auscult for bowel sounds– Normal should be heard every10 - 30 seconds• Palpate for masses, tenderness• MalesGenitaliaGenitalia– Location of urethral meatus– Presence or absence ofcircumcision– Penis– Tanner staging– Anal structure– Testes• Descended, undescended, orretractile14

4/5/2011AHerniasBHypospadiusGlanularSubcoronalAnterior(50%)Anterior(50%)CDEDistalpenileMidshaftProximalpenileMiddle(30%)Middle(30%)PenoscrotalScrotalPosterior(20%)Posterior(20%)Perineal• FemalesGenitalia– Labia majora and minora notingany labial fusion in young infantsor young girls– Urethral orificeGenitalia– Vaginal orifice along with anyevidence of imperforate hymen orother abnormalities– Tanner stage– AnusNormal and Abnormal HymensExtremities• Range of motion with specificconcerns for hip movement in infants• Femoral pulses• Joint warmth, stability, swelling,tenderness, clubbing of fingers• Gait• Genu valgum or varum15

4/5/2011Evaluation of Hip Mobilityin InfantsGenu VarumGenu ValgumNeurologic Assessment for Age• Considerable information can begained by watching the child duringthe history gathering portion of theexam• Reflexes-biceps, triceps, patellar,achillesNeurologic Assessment for Age• Assess cranial nerves• For older infants and children,cerebellar functionSources for Photographsand Images• Photographic images obtained forthis presentation are used withpermission and solely for medicaleducational purposes16

4/5/2011Sources for Photographsand Images• Sources– www.rainbowpediatrics.net– www.slideworld.orgorg– Kinsburg, K., M.D.17