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Infant Assessment Form
Infant Assessment Form
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Outline of a Pediatric Physical Examination D. Discharge 3. Edema
4. Clubbing
I.General VI. Mouth and Throat E. Gait
A. Statement about striking and/or important features. A. Lips (colors, fissures) 1. In-toeing, out-toeing
Nutritional status, B. Buccal mucosa (color, vesicles, moist or dry) 2. Bow legs, knock knee
level of consciousness C. Tongue (color, papillae, position, tremors) a. “Physiologic” bowing is frequently seen under 2
toxic or distressed D. Teeth and gums (number, condition) years of age and will spontaneously resolve
cyanosis E. Palate (intact, arch) 3. Limp
cooperation, F. Tonsils (size, color, exudates) F. Hips
hydration G. Posterior pharyngeal wall (color, lymph hyperplasia, 1. Ortolani’s and Barlow’s signs
bulging)
dysmorphology,
H. Gag reflex X. Neurologic - most accomplished through
mental state
observation alone
V. Neck A. Cranial nerves
B. Obtain accurate weight, height and OFC
A. Thyroid B. Sensation
B. Trachea position C. Cerebellum
C. Masses (cysts, nodes) D. Muscle tone and strength
D. Presence or absence of nuchal rigidity E. Reflexes
1. DTR
III. Skin and Lymphatics
VI. Lungs/Thorax 2. Superficial (abdominal and cremasteric)
A. Birthmarks - nevi, hemangiomas, mongolian spots
A. Inspection 3. Neonatal primitive
etc
1. Pattern of breathing
a. Abdominal breathing is normal in infants XI. GU
B. Rashes, petechiae, desquamation, pigmentation,
b. Period breathing is normal in infants (pause < 15 A. External genitalia
jaundice, texture, turgor
seconds) B. Hernias and Hydrocoeles
2. Respiratory rate 1. Almost all hernias are indirect
C. Lymph node enlargement, location, mobility,
3. Use of accessory muscles: retraction location, 2. Can gently palpate; do not poke finger into the
consistency
degree/flaring inguinal canal
4. Chest wall configuration C. Cryptorchidism
D. Scars or injuries, especially in patterns suggestive
1. Distinguish from hyper-retractile testis
of abuse
B. Auscultation 2. Most will spontaneously descend by several months
1. Equality of breath sounds of life
2. Rales, wheezes, rhochi D. Tanner staging in adolescents - See Tanner
IV. Head
3. Upper airway noise Staging handouts
A. Size and shape
E. Rectal and pelvic exam not done routinely –
C. Percussion and palpation often not possible and special indications may exist
B. Fontanelle(s)
rarely helpful
1. Size
VII. Cardiovascular
2. Tension - calm and in the sitting up position
A. Auscultation
1. Rhythm
C. Sutures - overriding
2. Murmurs
D. Scalp and hair
3. Quality of heart sounds
B. Pulses
V. Eyes
1. Quality in upper and lower extremities
A. General
1. Strabismus
VIII. Abdomen
2. Slant of palpebral fissures
A. Inspection
3. Hypertelorism or telecanthus
1. Shape
a. Infants usually have protuberant abdomens
B. EOM
b. Becomes more scaphoid as child matures
2. Umbilicus (infection, hernias)
C. Pupils
3. Muscular integrity (diasthasis recti)
D. Conjunctiva, sclera, cornea
B. Auscultation
E. Plugging of nasolacrimal ducts
C. Palpation
F. Red reflex
1. Tenderness - avoid tender area until end of exam
G. Visual fields - gross exam
2. Liver, spleen, kidneys
a. May be palpable in normal newborn
VI. Ears
3. Rebound, guarding
A. Position of ears
a. Have child blow up belly to touch your hand
1. Observe from front and draw line from inner canthi
to occiput
IX. Musculoskeletal
A. Back
B. Tympanic membranes
1. Sacral dimple
C. Hearing - Gross assessment only usually
2. Kyphosis, lordosis or scoliosis
B. Joints (motion, stability, swelling, tenderness)
V. Nose
C. Muscles
A. Nasal septum
D. Extremities
B. Mucosa (color, polyps)
1. Deformity
C. Sinus tenderness
2. Symmetry
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