PEDIATRIC ASSESSMENT: FOCUS ON PHYSICAL ASSESSMENT

Pediatric Assessment: The Major Focus· Major differences between children and adults· Specific approaches and techniques to physical exam· Normal findings, variations and common pathological conditions· Interpretation of exam results

Major Concepts in Pediatric Physical Assessment· Children are not little adults· Understanding differences from adults is important· Differences relate to both growth and development patterns· Differences exist in motor skills and coordination, and in physiologic, psychosocial, behavioral,temperamental, language, and cognition areas

Skills Utilized in Working with Children· Knowledge of growth and development· Communication skills with children and their parents· Understanding of family dynamics and parent-child relationships· Knowledge of health promotion and anticipatory guidance

Major Concepts for Assessment and Health Promotion· Development· Medical history· Nutritional status· Growth and vital sign measurements· Physical assessment· Guidelines for well child supervision· Anticipatory guidance· Immunizations

Exam Settings· Outpatient (office, clinic emergency room)· Well child check· Illness visit· Inpatient· Moderate to severe illness· Anxiety and stress· School setting or health office· Children usually healthy· Illness visits primarily common acute problems and some chronic illness issues· Health screenings

Environmental Setting· Safety is primary· Pleasant, comfortable settings are helpful

· Accessible toys for young children are distracters and may reduce anxiety· Age appropriate literature or items for teens and older children provide diversion in waiting areas

Standard Measurements· Weight· Height· Head Circumference· Chest Circumference· Vital Signs· Temperature· Pulse, Heart Rate· Respiration· Blood Pressure· Gestational Age Assessment and Intrauterine Growth Charts

Sensory Issues· Smell: usually not tested; observe for unusual odors from child· Taste: usually not tested; infants often prefer sweet tasting foods· Touch: well developed in infant; if stimulated can invalidate other sensory tests· Vision: right eye (OD), left eye (OS), both eyes (OU)· Hearing: correlates with language development; localization requires both ears

Specific Evaluations· Development· Vision· Hearing· Language

Key Points to Assessment Procedure· Head to foot exam is most orderly· Vary sequence according to child’s response· Examine young children in parent’s lap· Do intrusive examinations last

Approach to Physical Exam· Consider age and developmental level; observe for “readiness” clues· Take time to get “acquainted”· Use play techniques for infants and young children· Determine best exam place ( table, parent’s lap, examiner’s lap)· Use systematic approach; but be flexible to accommodate child’s behavior· Examine least intrusive areas first (i.e., hands, arms)· Examine sensitive, painful or intrusive areas last (i.e. ears, nose, mouth)· Determine what exam you want to complete before possible crying (i.e. heart, abdomen)

Age Groups· Neonate/Newborn Birth to 28 days· Pre-term Gestational age <37 weeks· Term Gestational age 37-42 weeks· Post-term Gestational age > 42 weeks· Infant Birth to 1 year· Young, Immobile Birth to 6 months· Older, Mobile 6 to 12 months· Young Child 1-5 years· Toddler 1-3 years· Pre Schooler 3-6 years· School Age or Older Child 6-12 years· Adolescent 13 to 18/21 years· Pre-Adolescent 10-12 years

Approach to InfantsBirth to 6 months: If baby is comfortable and stress free, exam can be conducted on table. Sensorymethods, such as voice, noise makers, toys to see or touch, or skin touch attract babies. They like asmiling human face. Do quiet things first, then head to toe.6 to 12 months: Consider exam in parent’s lap due to separation or stranger anxiety (up to 4 years).“Warm up” more slowly with play techniques. Object permanence and ability to anticipate develops,so provide comfort measures after unpleasant procedures. Increased mobility leads to additional safetymeasures and limit-setting concepts, which continue with each age group.

Approach to ToddlersExam in parent’s lap, due to need for parent security. Play games. Do least intrusive things first.Save ears, nose, throat for last. Avoid “no” responses or choices they can not make. Offer simpleacceptable choices. Let them touch equipment.Approach to Pre-SchoolersKeep parent close. Some will cooperate with exam on table. Protect modesty. Use dolls, animalsor parents to “examine” first. Magical thinking may cause fearfulness or thinking equipment isalive. Let them play with equipment. Use familiar, safe, non-frightening words and approaches.

Approach to School-Age ChildDo a head to toe exam. Respect modesty. Address questions more directly to child. Explain in

concrete terms. Medical diagrams or teaching dolls are helpful. Elicit their active participation inhistory, exam and care plan. Answer questions honestly.

Approach to AdolescentsConfidentiality, privacy, protection of modesty are important. Explain confidentiality parameters.Offer to examine alone, without parent present. Address questions to patient.Keep in mind, depression is more common in adolescents, especially girls. More commonconcerns among girls include body-image distortion, loss of appetite & weight, & lack ofsatisfaction. More common concerns among boys include irritability, social withdrawal & drop inschool performance. A health promotion system such as GAPS, Guidelines for AdolescentPreventive Services can be useful

An Additional Growth and Development Handout is Available to DownloadThis is a 5-page summary, including one chart and additional summaries of pertinent growth anddevelopment theories

General Assessment: Key Points· Note general appearance· State of wellness· Degree of illness or distress· Behavior

General Assessment:· Body: Symmetry, nutrition, build, hygiene, breath, odor, posture, movement,coordination, facial expression· Behavior: Development, attitude, affect, responsiveness/awareness,cooperation, speech, LOC (person, place, time), thought process, attention span,concentration, memory· Distress: Posture, (flexion/extension), pain, facial grimace, respiration

Skin, Hair and Nails: Skin – Key Points· Color: Jaundice, pallor, cyanosis, erythema, ecchymosis· Texture & Turgor: Degree of hydration or dehydration· Edema: Periorbital (crying, allergies, renal disease, juvenile hypothyroidism)Dependent (renal or cardiac disease)· Birth Marks· Pigmentations: Hyperpigmentation (endocrine, growth dis turbance); hypopigmentation· Infectious lesions: Viral, bacterial, fungal (erythema, macule, papule, vesicule, pustule)· Capillary bleeding: Petichiae and purpura usually indicate serious conditions· Infestations: Pediculosis, scabies, insect bites

· Pruritis: Dry skin, allergy, eczema, contact dermatitis, hepatic, renal, lesions· Trauma: Scars, ecchymosis, signs of abuse· Hand: Dermatoglyphic variations associated with syndromes

Common Skin Variations in Newborns and Infants· Thin, transparent skin, especially premature· Color Variations· Vascular Markings· Pigmentations· Lanugo (downy hair) more prominent in premature· Original hair may shed at 4-8 weeks, and be replaced

Skin Color Variations· Jaundice: Pathologic in first 24 hrs. physiologic after 24 hrs.· Acrocyanosis Cyanotic, cool extremities; warm, pink trunk· Cutis marmorata Bluish mottling due to chilling or stress· Erythema toxicum Papules, vesicles on erythematous base @24-48 hrs.· Harlequin color change Lower side of body red, upper side pale – change reverses it· Milia White papular epidermal cysts with sebaceous retention· Miliaria (4 types) Obstruction of sweat ducts from head and humidity· Neonatal acne, prickly head Miliaria – crystallina, rubra, pustulosa, profunda· Pallor Anemia or anoxia· Plethora Erythematous flush, due to polycythemia

Skin Vascular Markings· Capillary hemangiomas (telangiectasia or telangiectataic nevus ornevus simplex --- “stork bites,” “angel kisses”) --- usually fade· Nevus flammeus (“port wine stains”), nevus vasculosis ---not likely to fadeCan be associated with Sturge-Weber Syndrome· Strawberry hemangioma: bright red, lobulated tumorCavernous hemangioma: bluish red, more vascular than strawberry

Skin Pigmentations· Mongolian spots in darker pigmented infants· Pigmented nevi,· Café au Lait (<3cm and <6 in # are WNL – larger size or more spots associated withNeurofibromatosis , or Von Recklinghausen Disease) – an autosomal-dominant disorder, withtumors on peripheral or cranial nerves

Yellow Skin Color· Jaundice: Observed in sclera, skin, fingernails, soles, palms & oral mucosa .Does not blanche with pressure over chest or nose areasIs associated with liver disease, hepatitis, red cell hemolysis, biliaryObstruction & sever infection during infancy.· Carotenemia: Observed in palms, soles, face, skin

(not in sclera or mucous membranes)Blanches easily to pressure over chest or noseOccurs in older infants, with eating yellow vegetables· Renal Disease: Yellowing of exposed skin areas (not sclera or mucous membranes)May be associated with chronic renal disease

Hemolytic Jaundice of Newborn: Biirubin above 5ml/dl· Pathologic: Occurs first 24 hrs of life.Bilirubin increases faster than 5ml/dl/day· Physiologic: Onset after 24 hrs, with peak from 72-90 hrs.Declines at 4 to 7 days· Breast Feeding: Early onset: Onset at 2 to 4 days. Peak at 3 to 5 daysLate onset: Onset at 5-7 days. Peak at 10 to 15 days.May remain jaundiced for 3 to 12 weeks

Hair: Key Points· Assess for dis tribution, color, texture, amount, quality and for infestations· Course, dry, brittle or depigmented hair may indicate nutrition deficiency or thyroid disorder· Alopecia may be related to tinea capitus, hair pulling or persistent positioning· White eggs (nits) attached to hair shafts indicate pediculosis· Hair tufts on spine or buttocks may indicate spina bifida

Nails: Key Points· Inspect for color, shape, condition, nail biting and infection· Clubbing may indicate chronic hypoxia (respiratory or cardiac dis ease)· “Spoon” nails may indicate iron deficiency anemia· Pitted nails may indicate psoriasis· Splinter hemorrhages under nails may indicate trauma or endocarditis

HEENT: Head & Neck: Eyes: Ears: Nose, Face, Mouth & Throat· Head: Symmetry of skull and face· Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes· Eyes: Vision, placement, external and internal fundoscopic exam· Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane· Nose: Exam of nose and sinuses· Mouth: Structures of mouth, teeth and pharynx

Head: Key Points· Head Circumference (HC): Frontal Occipital Circumference (FOC)· Fontannels/sutures: Anterior closes at 10-18 months, posterior by 2 months· Symmetry & shape: Face & skull· Bruits: Temporal bruits may be significant after 5 yrs· Hair: Patterns, loss, hygiene, pediculosis in school aged child· Sinuses: Palpate for tenderness in older children· Facial expression: Saddness, signs of abuse, allergy, fatigue

· Abnormal facies: “Diagnostic facies” of common syndromes or illnesses

Head: Variations· Neonates: Molding (suture overlap) resolve 2 daysCapput succedaneum (scalp swelling) resolve 2 daysCephalohematoma (subperiosteal hemorrhage) resolve wks/months· Fontannels: Tense and bulging with increased intracranial pressure (ICP)Depressed with dehydration· Large HC/ICP: Increased HC due to increased ICP (before suture closure),tense & bulging fontannels, dilated head veins, “sunset sign.”Head may tranilluminate.May indicate hydrocephalus, intraventricular hemorrhage, trauma,meningitis or tumors.In older child, after cranial sutures close, ICP increases are more likeadult signs ( headache, vomiting, BP increases, change in LOC)· Small HC: May indicate microcephaly or craniosynostosis· Craniosynostosis: Asymmetric head shape due to premature closure of sutures.Surgical separation corrects defect.· Craniotabes: “Ping-pong” effect with pressure over temporo-parietal-occipitalareas. May be WNL, or result of hydrocephaly, rickets or infection· Macewen’s sign: “Cracked pot” sound with tapping over parietal bone.May be WNL in infants, or associated with ICP & suture separation(i.e. lead encephalopathy, tumor)· Chevostek’s sign: Spasm of facial muscle with percussion over zygomatic bone in front ofear. May be associated with hypocalcemic tetany and tetanus.· Flattened head areas: Especially occipital flattening with hair loss, may indicate persistentplacement of baby in same position.

Eyes: Key Points· Vision: Red reflex & blink in neonateVisual following at 5-6 wks180 degree tracking at 4 monthsE chart & strabismus check for preschool childSnellen charts for older children· Irritations & infections· PERRLA· Amblyopia (lazy eye): Corneal light reflex, binocular vision, cover-uncover test· EOMs: tracking 6 fields of vision· Fundoscopic exam of internal eye & retina

Eyes: Variations· Placement & symmetry: Wide set: hypertelorism – Down syndromeClose set: hypotelorismEpicanthal folds or upward slants – ethnicity, Down s.

Character of eyebrows· Eyelids: Ptosis, lid lag, blepharitis (stye), swellingDacryocystitis (blocked tear duct) may cause rednnes,swelling and discharge“Allergic shinner” (dark circles) may indicate allergyPerorbital edema may indicate renal problemsSunken eyes may indicate dehydration· Conjunctive: Inflammation, pallor (anemia),Cobblestone appearance may indicate allergy· Sclera: Jaundice (liver disease), injection (conjunctivitis),Hemorrhage, blue color (osteogenesis imperfecta)· Cornea: Smooth, mo ist,clear (not injected with conjunctivitis red eye)· Pupil & Iris: Brushfield’s spots (light speckling of iris) seen in Down s.Coloboma (notch at outer edge or iris) may indicate visualfield defect.· Othalmoscope: Partial or dark red reflex indicates pathology, various retinalanomalies or opacities of cornea, anterior chamber or lens(i.e. cataract)White retinal reflex indicates pathology (i.e., retinoblastoma,Retinal detachment chorioretinitis)Retinal hemorrhage is pathological, associated with a varietyof causes: Is a specific diagnostic criteria in “shaken baby”syndrome.Papilledema of increased ICP more likely in olde child, withclosed cranial sutures

Ears: Key Points· Exam last In younger children· Restrain Young children in lap, head braced against parent’s chest· Hearing: Especially if language delay or frequent otitis media· Otoscope exam: Pull auricle down & back for infants, toddlers, preschoolersPull auricle up &back for school aged & adolescentsCerumen removal may be necessaryUse pneumatic otoscopy· Tuning fork: Weber & Rinne tests to differentiate conductive vs sensorineuralhearing loss are not effective with younger children

Ears: Variations· External: Malformed auricle/pinna, or low-set or obliquely-set ears may beAssociated with many syndromes, or genitourinary & chromosomalabnormalities.· Otitis externa: Pain with movement of auricle or tragus, discharge in canal, occursMore often in summer (“swimmer’s ear”)· Otitis media: Proper position & holding of otoscope facilitates comfortableAs middle ear pressure or fluid increases, the tympanic membrane(TM) becomes less mobile with pneumatic otoscopy.

Exam of TM:TM: Dull, gray, retracted, loss of light reflex, landmarks may bemore difficult to see, with possible superior injection nearshort process of malleus is associated with blocked orobstructed eustachian tubes.TM: Dull, bulging, gray or with some injection is associated withpressure, fluid or pus accumulating in the middle ear.TM: Red, dull/thick/bulging, with landmarks not visible isassociated with acute otitis media.TM: Orange-amber color, with/without bubbles/fluid lines isassociated with serous otitis media with effusion, oftenassociated with viral URIs, or pressure changes, such as divingor flying. TM may be retracted, with landmarks easier to see.

Nose: Key Points· Exam nose & mouth after ears (after crying from ear exam)· Observe shape & structural deviations· Nares: ( check patency, mucous membranes, discharge, inferior turbinates, bleeding)· Septum: (check for deviation)· Infants are obligate nose breathers· Nasal flaring is associated with respiratory distress

Nose: Variations· Allergy: Pale, boggy mucous membranes & interior turbinates, waterydischarge, mouth breathing & “allergic salute” line across nose.· Infection: Erythematous, edematous mucous membranes, with purulent yellowor green nasal discharge· Foreign body: Foul odor or unilateral discharge· Excoriation: Irritating discharge, frequent wiping or nose picking· Structure variations: Observe flattened nose or nasolabial folds that may indicatecongenital anomolies.Asymmetry of nasolabial folds may indicate facial nerve impairment orBell’s palsy.

Sinuses: Key Points· Palpate maxillary & frontal sinus areas for tenderness of sinusitis in older children· Development of facial sinuses and location of sinus pain is listed below:Sinus Pain Location Age of Development· Maxillary cheek & upper teeth present @ birth· Ethmoid medial & deep to eye present @ birth· Frontal forehead & above eyebrow approximately 7 years· Sphenoid deep behnd eye in occiput adolescence

Mouth & Pharynx: Key Points· Inspect lips for color, symmetry, moisture, swelling, sores, fissures.

· Inspect buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding,lesions.· Inspect tongue & frenulum for movement, size & texture· Count teeth & inspect for caries, malocclusion and loose teeth.20 deciduous teeth, begin eruption at 6 months & continue adding approximately 1/month32 permanent teeth, erupt from 6 to 25 years, with molar eruption from 1to 25 years· Inspect uvula for symmetrical movement or bifid uvula (indicating cleft palate or WNL· Observe for quality of voice· Observe infants for rooting and sucking reflexes, Epstein pearls & thrush· Observe breath for halitosis

Mouth & Pharynx: Variations· Newborn cysts: White retention epitheleal cysts occur in the newborn:Epstein’s pearls occur along midline of palate.Bohn’s nodules occur along gum line, resembling teeth.· Vesicular eruptions: Can occur on lips, buccal mucosa & tongue, due to viral infections,such as herpes simplex cold sores or aphthous stomatitis.· Fissure/cracked lips: May be due to harsh climate or vitamin deficiencies.· Color variations: Central cyanosis can be observed in lips & mucosa..Pallor may indicate anemia.Cherry red coloration may be seen in acidosis.· White patches: White ulcerated sores on mucosa ae cankers, related to mild trauma,viral infection, mild trauma or local irritants.Koplik’s spots, small white, red rimmed eruptions on buccal mucosanext to first & second molars, appear and disappear before the onset ofMeasles (rubeola) rash.White curdy patches that cannot be scraped away, may be oralcandidiasis (thrush), and is common in infants, especially followingantibiotic therapy.· Tongue variations: A smooth, red tongue may be related to vitamin deficiencies.“Strawberry” and “Raspberry” tongue are seem in scarlet fever.A short frenulum with inability to touch tongue to upper gum ridge(“tongue tie” or ankyloglossia) may lead to later speech problems.· Palate & uvula: With gag reflex, deviation of uvula to one side suggests eitherGlossopharyngeal or vagus nerve involvement or infection ofperitonsillar or retropharyngeal abcess.An absent or bifid (notched) uvula may indicate submucosal or softpalate cleft.· Tooth markings: Brown & black spots may indicate caries.“Baby bottle” caries appear on teeth at gum line and aredue to babies taking a bottle to bed, and milk pools around the teeth.Brown-white mottling may indicte excessive fluoride intake.

Green & black staining may indicate oral iron intake contacting teethAn increase in tooth decay or evidence or eroded enamel may indicatefrequent, self-induced vomiting, especially in adolescent girls. Callousmarks on fingers/knuckles might also be observed

· Pharynx: Large tonsils, due to developmental lymph tissue hypertrophyAre common in school aged children & adolescentsLarge red tonsils covered with white exudate are suggestive ofstreptococcal tonsillitis, especially if palatal petichiae & red uvula arepresent.Thick, gray exudate may indicate diptheric tonsititisA gray, necrotic discoloration of tonsillar tissue may suggest infeftiousmononucleosis .A unilateral, red, enlarged tonsil suggests peritonsillar abcess.· Voice quality: Nasal voice may indicate enlarged adenoidsHoarse cry may indicate croup, cretinism or tetany.Shrill, high-pitched cry may indicate increased ICP, such ashead injury or meningitis.

Neck: Key Points· Check for position, lymph nodes, masses, cysts or fistulas/clefts· Suppleness & Range of Motion (ROM)· Check clavicle in newborn· Head control in infant· Trachea & thyroid in midline· Carotid arteries (bruits)· Torticollis· Webbing· Meningeal irritation

Neck: Variations· Head lag: Significant lag after 6 months may indicate cerebral palsy· Torticollis: “Stiff neck” with resistance to lateral head turn as result of injury tosternocleidomastoid muscle, more often seen in newborn· Clavicle: Check for fracture in newborn, associated with shortening, break in contour,Crepitus at fracture site, and decreased motion of arm· Webbing: Feature of “Turner’s syndrome” or other congenital abnormalities· Meningeal: Irritation indicated by nuchal rigidiy, opisthotonos, tripod position with sitting,Positive Brudzinski’s sign (with patient supine, neck flexion produces pain andflexion of hips and knees).Positive Kernig’s sign (with patient supine, hip & knee flexed, extension of kneeProduces pain & resistance· Nodes: Lymphadenopathy common with infection in older children, upper neck areas,and below angle of jaw, usually bilateral. Should not be deep cervical orclavicular.

· Mumps: Parotitis produces swelling over angle of jaw, usually unilateral,with redness & swelling of Stensen’s parotid duct in mouth & pain withsour tastes.· Thyroid Ascends with swallowing (not normally palpable in young child).Check bruits, nodules or goiter (& accelerated growth, staring eyes)

Lymph Nodes: Key Points· Inspect & palpate lymph nodes for size, color, location, temperature, consistency, tenderness,firmness & mobility.· Nodes are proportionately large in older children & adolescents, and smaller in the elderly.· Lymphadenopathy in the head & upper neck area are common with various infections:(Occiptal, pre & post auricular, superficial anterior cervical, posterior cervical, tonsillar,submandibular, submaxillary, submental, sublingual)· Inguinal lymphadenopathy may be observed in some diapered children, but not usuallyotherwise.· Deep cervical, supraclavicular, infraclavicular, axillary & epitrochlear lymphadenopathy mayindicate pathology.

Thorax & Lungs: Key Points· Structure: Observe for shape, symmetry & posture· Chest deformities: can be WNL, but significance varies with severity etiology· AP diameter: round chest or 1:1 ratior during infancy, with transverse diameterincreasing, with AP:lateral ration 1:2 during school age years.· Pectus carinatum or pigeon breast: concavity of sternum· Pectus excavatum or funnel chest protrusive sternum· Harrison;s Groove: horizontal ression groove of lower ribs with lower rib flarring,may indicate vitamin D deficiency (richets)· Beading or richitic rosary: protrusive deformities along costochondral junctions,may indicate vitamin D defenciency (richets)

Breast: Key Points· Inspection: size, color, symmeetry, color, nipples/accessory nipples, dimpling· Palpation: masses, consistency, elasticity, nipple discharge· Male gynecomastia· Self Exam

Tanner Stages for Female:I Prepubertal, elevation of papilla onlyII Breast bud, elevation of breast & papilla as small mount, enlargement of areolaIII Further enlargement of breast & areola, no separation of contoursIV Areola projected as secondary moundV Mature, recession of areolar mound to breast contour, projection of papilla only

Lungs & Respiratory Status: Key Points· Symmetry of expansion, decreased expansion (pneumonia, pneumothorax, FB)· Prolonged expiratory phase· Resp rate (>40 at rest, after neonate period = respiratory distress)· Color: cyanosis or mottling· Clubbing· Nasal flaring· Grunting (expiratory)· Stridor (inspiratory): croup· Snoring (expiratory): upper airway obstruction, allergy, enlarged lymph tissue· Retractions· Respiratory movement: males abdominal, females thoracic-costal,elderly shallow, infants abdominal· Dyspnea· Orthopnea· Fremitus: Increase: pneumonia, atelectasis, massDecrease: asthma, pneumothorax or FB· Dullness to percussion: fluid or mass· Quality: vesicular (bronchioles, alveoli)bronchovesicular (bronchi)bronchial (trachea)· Adventitious (adventiginous) sounds· Crackles (rales)· Rhonchi (course breath sounds)· Wheeze· Pleural friction rub

Cardiovascular: Key Points· Vital signs: compare with normal/age values· Peripheral pulses: apical, carotid, radial/brachial, femoral, pedal· Rate, rhythm: compare cardiac rhythm with pulse· Peripheral vascular: color, temperature, edema, skin texture/changes· Capillary refill: immediate· Peripheral pulses: femoral pulses absent or diminished in aortic stenosis· Deep vein thrombosis: Homan's sign· Skin: pallor, cyanosis (lips, nail beds, ear lobes)· Clubbing· Pulsating neck vessels (JVD)· Bulging chest· Elevated BP· Thrills· Bruits

Heart· Rate, rhythm, heart sounds· Size, PMI

· Auscultation: sitting, lying, left recumbent & bending forward· PMI: Lt. ventricular contraction during systole· location & size of heart: midclavicular 5th intercostal space (4th/infant)

StethoscopeDiaphragm: high pitch, S1Bell: low pitch, S2S1: Mitral & Tricuspid AV valves close (ventricles are full,prior to ventricular contraction--systole begins,best at apexS2: Aortic & Pulmonary semilunar valves close -- ventricles eject--after ventricular contraction--diastole begins, atrial filling beginsS2: may be split--widens during inspiration (increase venous return--increase filling time--delayed pulmonic closing)S3: can be functional sound in childhoodS4: not normally audible, associated with cardiac abnormalities

Murmurs:may be systolic, diastolic or continuous(timing, location, quality (course, harsh, blowing, high pitched)GRADE: I - faint, may not be heard sittingII - readily heard with stethoscopeIII - loud, no thrillIV - loud with stethoscope, thrillV - loud with stethoscope barely to chest, thrillVI - loud with stethoscope not touching chest, thrill

Functional Murmurs:Change or disappear with position change (usually loudest supine)Low grade, soft or musicalIntensity range from I-III/VISystolic (never diastolic)Do not radiateCOMMON FUNCTIONAL MURMURS:Cardiac murmurs occurring in absence of significant heart disease or structuralabnormality· Still’s Murmur: 2 years – adolescence; midway between apex & LLSB,Grade I-II/VI, mid-systolic, soft, low pitched, louder in supine position; may beLouder with fever or tachycardia· Basal systolic ejection murmur: high pitched, blowing, systolic, bestheard in pulmonic area, in supine position

· Physiologic peripheral pulmonic stenosis, or pulmonary outflowmurmur: disappears during infancy as pulmonary arteries enlarage; shortsystolic, grade I-II/VI, heard best in axillae· Venous hum: usually after 3 yrs, UR&LSB & lower neck, continuous musicalhum Grade I-III/VI; heard best in infra & supraclavicular areas; loudest in sitting

position & decreases in supine position or with turning child’s head oroccluding jugular vessels

Organic Murmurs & sounds:· Diastolic murmurs: always organic· Systolic murmurs: may be functional or organic· Friction rubs· Before 3 yrs, usually congenital· After 3 yrs often acquired· Rheumatic fever· Kawasaki disease

Abdomen: Key Points· Contour· Peristalsis· Skin: color, veins· Umbilicus· Tenderness· Ridigity· Tympany· Dullness· Hernias: umbilical, inguinal, femoral· Masses - size, shape, dullness, position, mobility· Liver· Spleen· Kidneys· Bladder

Genitourinary and Reproductive: Key PointsBreast: as previousFemale Genitalia· External genitalia: Pelvic 16-18 years or when sexually active· Mons pubic, prepuce (clitoral hood), clitoris, labia minora/majora,vagina, Skene's & Bartholin's ducts, anus· Size, color, skin integrity, masses· Redness, swelling, labial adhesions/fusion, lesions, discharge (foul-smelling)

Tanner StagesI Prepubertal. No true pubic hairII Sparse growth of slightly pigmented, downy hair, slightly curled, along labiaIII Increas in hair, courser, curled, darkerIV Adult-type hair, but limited area. No spread to thighsV Adult distsribution & quantity with spread to thighs

Male Genitalia· Penis: Size, color, skin integrity, circumcision

· Urethral meatus: Shape, placement, discharge, ulceration, dischargemeatal stenosis, hypospadias, epispadias· Scrotum: Color, size, symmetry, edema, masses, lesions, tenderness,· testes descended bilaterally· Pubic hair

Tanner StagesI Prepuberal, no true pubic hair, testes, scrotum, penis childhood sizeII Sparse, slightly curled, downy hair (base of penis/along labiaEnlargement of testes & scrotum, scrotal skin reddens & coursensIII Hair courser, curled, darker. Enlargement of penis (length),further growth scrotum/ testesIV Adult type hair, no spread to medial thighs. Enlargement of penis(width/length), enlargement of glans, scrotal skin darkensV Adult hair distribution (triangle) & adult genital development

Musculoskeletal: Key Points· Alignment, contour, strength, weakness & symmetry· Limb, joint mobility: ROM, stiffness, contractures -Neck, shoulder, elbow, wrist, hip, knee, ankle, foot· Digits· Dermatoglyphics

Problem Areas· Spinal changes: scoliosis, kyphosis, lordosis· Scoliosis: pre-adolescent growthlateral curvaturecontralateral hip humpprominent scapulaasymmetry: shoulder, arms, hips· Congenital hip dislocation or dysplasia: check hip abduction & symmetry· asymmetrical hip abduction· asymmetrical thigh & gluteal folds· Ortolani's click· Barlow's test· Trendelenburg gait· Allis' sign· Trendelenburg sign & gait: indicates hip disease in ambulatory child· Asymmetries or weaknesses

· Limp· Legg-Calve` Perthes:peak age 7 years: boys > girlsHip or knee painMay have history of trauma+ Trendelenburg

· Slipped Capital Femoral EpiphysisAdolescents: boys > girlsObeseHip or knee pain· Joint infection· Feet/legs: Variations may begin in feet, tibia or upper let & hip areaFeet turning in: varusFeet turning out: valgus· Legs:Bowleg (genu varum -- knees 2 inches apart)Knock-knee (genu valgum -- ankles 3 inches apart)· Movement limitation:crepitus with joint movementmeningeal signs, such as stiff neck, opisthotonous· Muscular dystrophyProgressive muscular weakness (Gower’s sign)· Cerebral palsy or other muscular diseasePes equinus (weight bearing on toes)Short heel cords

Neurological Evaluation: Key Points· Cerebral Function:· "Mental status" appearance, behavior, cooperation· LOC, language, emotional status, social response, attention span· Cerebellar Function· Balance, gait & leg coordination, ataxia, posture, tremors· Finger to nose (fingers to thumb) 3-4 yrs· Finger to examiner's finger 4-6 yrs· Ability to stand with eyes closed (Romberg) 3-4 yrs· Rapid alternations of hands (prone, supine) school age· Tandum walk 4-6 yrs· Walk on toes, heels school age· Stand on one foot 3-6 yrs· Motor Function: Gross motor & fine motor movements· Muscle size, symmetry, strength, tone, movement· Involuntary movements, posture· Developmental maturation

· Sensory function· Tested in cranial nerves· Sharp-dull· 2 point discrimination· Stereognosis· Graphesthesia· Infants: responsive to touch, vision, hearing, smellPresent only one sensory stimulation at a time, if testing

· ReflexesDeep tendon: Biceps C5, C6Triceps C6, C7, C8Brachioradialis C5, C6Patellar L2, L3, L4Achilles S1, S2Superficial: Cremasteric T12, L1, L2Abdominal T7, T8, T9, T10, T11Infant Automatisms: Primitive Reflexes· Cranial NervesC1 SmellC2 Visual acuity, visual fields, fundusC3, 4, 6 EOM, 6 fields of gazeC5 Sensory to face: Motor--clench teeth,Corneal reflex---is C5 & C7C7 Raise eyebrows, frown, close eyestight, show teeth, smile, puff cheeks,Taste--anterior 2/3 tongueC8 Hearing & equilibriumC9 "ah" equal movement of soft palate & uvulaC10 Gag, Taste, posterior 1/3 tongueC11 Shoulder shrug & head turn with resistanceC12 Tongue movement· Infant Reflexes: Most disappear between 4-6 months of age· Blink (dazzle)Blinks to bright light, 1st year of life, absence indicates blindness· RootTurns direction cheek is stroked, disappears 3-4 months, may persist longer, absenceindicates neruologic disorder· SuckSucks in response to stimuli, may persist during infancy, weak or absent reflexindicates developmental/neurological disorder· ExtrusionTongue extends out when t ouched, disappears at 4 months, persistent extrusion mayindicate Down’s· Moro & StartleArms & legs extend symmetrically & arms return to midline, when stimulated byposition change or sudden noise, disappears by 4-6 months, absence or asymmetry ofresponses indicate injury, neurological disorder or hearing loss20· Galant's (trunk incurvation)Back moves toward paraspinal side stimulated, present for 4-8 weeks, absencemay indicate spinal cord lesions· Dance or stepFeet withdraw or step up, when foot touched to surface, present 4-8 weeks,persistence indicates neurological problem

· Palmar graspFinger’s curve around object placed in palm or palmar aspect of fingers, disappears 3-4months, persistence indicates neurologic disorder· Tonic neckFencing position: head turn-arm extend, leg extend to same side & all reverse withchange to opposite side, appears strongest at 2 months & disappears by 6 months,persistence indicates neurological problem· Neck rightingWhen supine, shoulders, trunk pelvis turn to direction head is turned, absence orpersistence beyond 6 months indicates neurological disorder· CrawlingSymmetrical crawling movements when prone, asymmetries indicate neurologicaldisorder· Babinski+ for toe fanning, present until child walks well, or at 2 years of age

By: Dave Jay S. Manriquez RN.