Physical Examination Paediatrics
Kanisha Dezarn
The document provides guidance on performing a physical examination on pediatric patients. Key points include examining the patient from head to toe, altering the order as needed for compliance, and having a parent present for young children. Vital signs like temperature, pulse, respiration and blood pressure should be measured and plotted on growth charts. The head, eyes, ears, nose, mouth, throat, heart, lungs and abdomen should all be carefully examined. Specific abnormalities to watch for in each area are outlined. The document emphasizes a thorough but gentle examination tailored to the child's age and cooperation level.Read less
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Objectives: Computed tomography (CT), the reference standard for diagnosis of intraabdominal injury (IAI), carries risk including ionizing radiation. CT-sparing clinical decision rules for children have relied heavily on physical examination, but they did not include focused assessment with sonography for trauma (FAST), which has emerged into widespread use during the past decade. We sought to determine the independent associations of physical examination, laboratory studies, and FAST with identification of IAI in children and to compare the test characteristics of these diagnostic variables. We hypothesized that FAST may add incremental utility to a physical examination alone to more accurately identify children who could forgo CT scan.
Methods: We reviewed a large trauma database of all children with blunt torso trauma presenting to a freestanding pediatric emergency department during a 20-month period. We used logistic regression to evaluate the association of FAST, physical examination, and selected laboratory data with IAI in children, and we compared the test characteristics of these variables.
Conclusions: In children, FAST and physical examinations each predicted the identification of IAI. However, the combination of the two (exFAST) had greater sensitivity and NPV than either physical examination or FAST alone. This supports the use of exFAST in refining clinical predication rules in children with blunt torso trauma.
A relatively complete physical examination should be performed on each patient, regardless of the reason for the visit. Numerous medical anecdotes relate instances in which the examination revealed findings unrelated to and unexpected from the patient's chief complaint and major concerns. On occasion, a limited or inadequate examination may miss a significant condition, mass lesion, or potentially life-threatening condition.
Regardless of whether the clinician and caregiver have met previously, it is appropriate to greet everyone in a cordial manner, maintaining a professional yet friendly demeanor. Clinicians should introduce (or reintroduce) themselves and any colleagues or students observing or participating in the visit and ask those in the room to introduce themselves as well, particularly if the clinician is uncertain of the relationship between the caregiver(s) and the child.
Infants older than six months and anxious toddlers who are leery of strangers often are more comfortable when held by their caregiver. To gain the child's confidence and to avoid an early adversarial relationship, the clinician should try using a calm approach, a reassuring smile, and a toy or bright object as a diversion. An appropriate distance should be maintained during the history-taking portion. The clinician's approach should be cautious and nonthreatening once the physical examination is about to begin.
Infants younger than six months who have no stranger anxiety and children older than 30 to 36 months who are familiar with the examining clinician and/or who possess a trusting demeanor generally cooperate during the examination without being held. Physical examination of 5- to 12-year-old children usually is easy to perform because these children are not typically apprehensive and tend to be cooperative.
When appropriate, adolescent patients should have some time with the clinician in the absence of caregivers to permit more open discussion of pertinent historical information, anticipatory guidance, and preventive health care issues. (See "Guidelines for adolescent preventive services" and "Confidentiality in adolescent health care".)
Key elements in the history-taking process include establishing a warm, caring atmosphere and asking questions in a nonconfrontational, unhurried manner. The terminology and language used by the examiner should be appropriate for the health literacy of the caregiver and the patient. Good eye contact and a sense of undivided attention should be maintained. The clinician should sit opposite the caregiver and/or patient at a comfortable distance, unencumbered by large objects, such as desks or tables. Outside interruption by the medical staff and by telephone calls should be kept to a minimum. Before beginning the history, clinicians should explain that they may occasionally need to refer to the electronic or written medical record to review laboratory results, imaging reports, or other pertinent information. An effort should be made to maintain an uninterrupted dialogue, to write few notes, and as much as possible to refrain from turning their back to the patient/caregiver to look at the medical record.
Skilled clinicians employ different techniques to gain pediatric patient cooperation. The use of toys, distracting objects, and pictures helps in the examination of young children, infants, and toddlers. Engaging the two- to four-year-old in stories or a discussion of imaginary animals frequently creates an effective diversion. Food, in the form of chewable snacks or liquid refreshments, can be used as a means of pacification, depending upon the stage of the examination.
When an otherwise typically behaving child older than four years fails to cooperate for an examination, even in the presence of a familiar caregiver, it may be an indication of either an earlier traumatic encounter between the patient and another examiner or that the current examining clinician should try a different approach. The possibility of an underlying psychosocial problem or behavior disorder should be considered if a child older than four years is extremely uncooperative or combative.
For patients old enough to understand but who appear apprehensive, the examiner should explain what is going to be done during the examination and allow them to look at and touch any of the instruments to be used. Older patients should be warned in advance of potential pain or discomfort.
If the patient has a complaint, sign, or symptom that appears to involve a particular part of the anatomy, that part of the examination should be performed last. As an example, consider a patient complaining of right-lower-quadrant abdominal pain thought to be attributable to appendicitis; by not examining that part of the body first, the clinician may be able to divert the patient's attention away from the involved area and rule out other possible causes for the pain.
Patient privacy should be respected. If a patient objects to being unclothed or to wearing an examination gown, allow them to remain clothed until a specific part of the anatomy must be checked. When an area needs to be examined, the patient should be asked to remove or pull free the garments that are hindering visualization, palpation, or auscultation.
The order in which the physical examination is conducted often is age-specific and depends upon examiner preference. For an infant and younger child, the clinician may prefer to begin by examining the eyes, noting the red-light reflex, extraocular eye muscle movements, and visual tracking and then move to other parts of the body or organ systems before finally performing the often sensitive ear examination. For the older, more cooperative child, the examination might begin at the head and progress down the body, with the neurologic examination performed last. In general, the portions of the pediatric examination that require the most patient cooperation, such as blood pressure measurement, lung and heart auscultation, and eye and neurologic examinations, are performed initially. These examinations are followed by the more bothersome portions, including abdominal and ear examinations and measurement of head circumference.
The evaluation of children with abnormal height (length) is discussed separately. (See "Diagnostic approach to children and adolescents with short stature" and "The child with tall stature and/or abnormally rapid growth".)
The normal range for the respiratory rate depends upon the age of the child. A systematic review of 20 studies provided respiratory rate percentiles for healthy children who were typically awake and at rest (table 1) [18]. A sustained breathing rate in excess of the upper limit of normal generally indicates primary respiratory tract disease; it may also occur secondary to a metabolic disorder, infectious disease, high fever, or underlying heart disease. Although the respiratory rate may increase with fever [19-21], the relationship between temperature and respiratory rate is not linear. Thus, a simple rule for use in clinical decision making is not possible.
Like the respiratory rate, the normal heart rate varies with age. A systematic review of 59 studies provided heart rate percentiles for healthy children who were typically awake and at rest (table 1) [18]. A heart rate above the upper limit of normal may indicate primary cardiac disease; it also can occur secondary to an underlying systemic or metabolic disorder, infectious disease, or high fever.
Blood pressure generally is not measured in children younger than three years unless they have evidence of underlying renal disease (eg, tumor, nephrotic syndrome, glomerulonephritis, pyelonephritis, renal artery stenosis), suspicion of acute cardiovascular disease (eg, coarctation of the aorta, patent ductus arteriosus), or acute illness. Obtaining an accurate blood pressure reading in children younger than three often is difficult. (See "Clinical manifestations and diagnosis of coarctation of the aorta" and "Patent ductus arteriosus (PDA) in term infants, children, and adults: Clinical manifestations and diagnosis".)