Overview of Pediatric Physical Assessment

Dr. Romeo Calubaquib | August 26, 2020

Trans by: Deladia, Dela Rosa, Gonzales, Preza

OUTLINE 4. Nutritional status

5. Hygiene
I. Introduction J. Be alert for congenital
A. General appearance anomalies B. APPROACH TO PEDIATRIC PATIENT
of infant or child II. System by System 1. Age appropriate interaction
B. Approach to Pediatric Physical Examination • Gentle and engaging
Patient A. Integumentary • Nonthreatening
C. Growth and B. Lymph nodes • Take the path of least resistance
Development C. Head and Neck • Quiet and soothing
Parameter D. Eyes
• Use observation liberally while taking the history
D. Growth Parameter E. Ears
• Always inform the patient of what you are about to do
and Areas of Concern F. Nose
and never lie to the patient
E. Developmental G. Throat
Assessment for Age H. Chest and Back • Minimize the use of the exam table in infants and
General Information I. Heart younger children
F. Measure Vital Signs J. Lungs C. GROWTH AND DEVELOPMENT PARAMETER
and Know How to K. Abdomen 1. Use current growth charts plotting BMI
Interpret Age L. Genitalia 2. Weigh appropriately (Dry diaper)
Appropriate Variations M. Extremities 3. Check height by placing infant on measuring table with head
G. Focus points for the N. Neurologic at the end of the board
Neonatal Examination Assessment for Age 4. Have older children take off shoes
H. Neonatal Reflexes III. Sexual Maturity Ratings 5. Measure head circumference up to two years old placing
and When They IV. Index measuring tape above eyebrows and measuring around to
Disappear V.References occipital prominence
I. Some Information on
Weight D. GROWTH PARAMETER AND AREAS OF CONCERN
I. INTRODUCTION 1. Know normal weight gains for age
2. Usual expected height velocity for
This includes the system-by-system physical assessment and 3. Family information specifically about parental stature
associated abnormalities. 4. Consider children born in other countries
Essentials of pediatric assessment 5. Be concerned about head circumferences at extremes and
1. Thorough history height/weight crossing percentiles
2. Properly interpreted vital sign E. DEVELOPMENTAL ASSESSMENT FOR AGE GENERAL
3. Properly evaluated developmental and growth parameters INFORMATION
4. Focused physical assessment
5. Anticipatory guidance/preventive health 1. Use standardized developmental screening tools assessing
• Immunizations gross motor, fine motor, language, sensory, and social
• Ingestions development
2. Be “open-ended” with questions
• Injuries
3. Use observation during the history to fill-in developmental
6. Problems list and plan
information
General points about taking a history 4. Ask about hearing concerns even with newborns
1. Chief complaint 5. Be alert to normal language milestones
2. Onset of problem 6. Screen at every well infant and child visit
3. Duration of problem
4. Progression of problem F. MEASURE VITAL SIGNS AND KNOW HOW TO
5. Aggravating or alleviating factors INTERPRET AGE
6. Associated manifestations 1. Temperature
7. Functional impairment • Can use tympanic thermometers to avoid invasive
• Changes in eating patterns techniques such as rectal thermometers past the
• Playfulness newborn and early infant ages
• School performance 2. Pulse
• Sleep habits • Apical less than 2 years old/count for one minute
8. Allergic history 3. Respiratory rate
9. Medication history • Count for one minute and be aware of periodic and
10. Immunization history abdominal breathing in infants
11. Hospitalization and/or accidents 4. Respiratory rates
12. Birth history • If possible, measure in sleeping infants
13. Developmental milestones • Be aware that fever or crying will elevate the rate
14. Family history significantly
15. Social history Normal values:
A. GENERAL APPEARANCE OF INFANT OR CHILD Premature infants: 40-60
Newborns: 30-50
1. Activity or movement Toddlers: 20-30
2. Facial features School age children: 15-25
3. Behavior when examiner enters room Adolescents: 12-20
• Developmentally appropriate 5. A Word About Blood Pressure Measurement
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 • Select a cuff with a width that covers 2/3 of the upper
arm and a length of the bladder that encircles 100% of
the arm without overlap
• Know age appropriate Normal values
6. Blood pressure parameters
• Specific charts are available in reference materials
→Harriet Lane Handbook of
→Pediatrics
→NIH guidelines
→Other authoritative sources Figure 1. Sacral dimples [ppt]
• General guidelines (systolic)
Newborn: 50-70 mmHg
4. Mongolian spots
Infant: 70-100 mmHg
Toddler to 5 years: 80-100 mmHg
Elementary school: 80-120 mmHg
Adolescent (13 years and above): 110-120 mmHg
7. Heart Rate
Table 1. Normal range of Heart Rate according to age.
AGE RANGE OF RATE
Birth 70-190
0-6 months 130
6-12 months 115 Figure 2. Mongolian spots [ppt]

1-2 years 110

2-6 years 80-130 5. Congenital Nevus
6-10 years 75-115
10-14 years 70-110
14 and above 65-100

G. FOCUS POINTS FOR THE NEONATAL EXAMINATION

1. Fontanels
2. Skin color
3. Facies
4. Tone
5. Symmetry Figure 3. Congenital Nevus [ppt]
• Movement, respiratory effort, abdomen
6. Reflex
II. SYSTEM BY SYSTEM PHYSICAL EXAMINATION
H. NEONATAL REFLEXES AND WHEN THEY DISAPPEAR
• Integumentary
1. Stepping: 2 months
2. Moro: 3 months • HEENT
3. Rooting: 3 4 months • Neck
4. Palmar grasp: 3-4 months • Cardiovascular
5. Tonic neck: 4-6 months • Pulmonary
6. Plantar grasp: 8-10 • Gastrointestinal
7. Sucking: 10 12 months • Genitourinary
8. Babinski: 2 years • Musculoskeletal
I. SOME INFORMATION ON WEIGHT • Neurologic

1. Newborns may lose up to 10% of their birth weight in the first 1. General Principles of Examination of the Skin
3-4 days • Color
2. Newborns gain ½ to 1 ounce per day after that time →Pallor
3. Excessive or poor weight gain needs to be addressed →Jaundice (normal after 24 hours in newborn up to 7-
4. Infants generally double their birth weight by 5 months and 10 days but abnormal afterwards)
triple it by one year →Variations in skin pigmentation
• Texture, turgor
J. BE ALERT FOR CONGENITAL ANOMALIES • Rashes
1. Some specific in neonates • Lesions
• Anterior and posterior fontanelles • Hair and nails
→Anterior closes between 12 – 18 months 2. Some Descriptive Terms of Rashes
→Posterior closes by 2-5 months • Macular
2. Red reflex
3. Sacral dimples

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 B. LYMPH NODES
1. Small, nontender, English pea size, soft, and freely moveable
lymph nodes are common primarily in the cervical region
2. Check cervical, axillary, inguinal region for lymph nodes

Figure 6. Lymph Node [ppt]

C. HEAD AND NECK

1. Check for symmetry, head control in infants, posture to one
side (an indicator of torticollis), range of motion
2. Feel the anterior and posterior fontanels
3. Older infants
• Flexion, extension, rigidity
• Thyroid enlargement, branchial cleft cysts
D. EYES
1. Check for shape and symmetry
2. Note the color of the conjunctiva
3. Evaluate extra ocular movements
4. Check pupillary reflexes
5. Fundoscopic for red reflex
Figure 4. Different Skin Condition [ppt] 6. Appropriate vision testing in the clinical setting
• Papular
• Blanch with pressure
• Excoriated
• Hemorrhagic
3. Some Descriptive Terms of Lesions
• Blistering
• Cystic
• Hives or wheals
• Scaling
• Crusting/scab forming
• Scars
• Other
→Congenital, neoplastic

Figure 7. Eye conditions [ppt]

E. EARS
1. Evaluate shape, position
2. View internal structures
3. Newborn hearing screening and ongoing assessment of
hearing including language development

Figure 8. Tympanic Membrane (Normal vs. Abnormal) [ppt]

Figure 5. Skin Disease/Disorder [ppt]

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 F. NOSE K. ABDOMEN
1. Structure, position 1. Inspect the shape
2. Evidence of grunting or flaring 2. Auscultate for bowel sounds
3. Color of any drainage, foul odor, color of mucosa, location of • Normal should be heard every 10-30 seconds
septum 3. Palpate for masses, tenderness
G. THROAT
1. Color of lips, presence of fissures
2. Teeth
3. Number and condition
4. Gums
5. Color and condition
6. Tongue
7. Midline, color, graphic patterns
8. Integrity of palate and location of uvula
9. Tonsillar size Figure 11. Umbilical Hernia [ppt]

L. GENITALIA
Male
• Presence or absence of circumcision
• Penis
• Testes
→Descended, undescended, or retractile
• Location of urethral meatus
Figure 9. Enlarged Tonsils and Geographic Tongue [ppt]
• Tanner staging
H. CHEST AND BACK • Anal structure
1. Inspect size, shape, symmetry along with movement
2. Note any distress including use of accessory muscles
3. Note symmetry of nipples and any breast development
4. Check for spinal curvature

Figure 12. Defects [ppt]

Female
• Labia majora and minora noting any labial fusion in young
infants or young girls
• Urethral orifice
Figure 10. Pectus Excavatum vs. Pectus Carinatum[ppt] • Vaginal orifice along with any evidence of imperforate
hymen or other abnormalities
I. HEART • Tanner stage Anus
1. Palpate over the valvular areas
2. Determine the PMI
• Rate
→Higher than adults
• Rhythm noting that infants and children will have
variation with respiration
• Murmurs
→Systolic murmurs can be normal
→Diastolic murmurs are always abnormal
→S1 and S2
→Classic description:
▪ Grade I-VI Figure 12. Hymen [ppt]
▪ Descriptive terms
- Crescendo M. EXTREMITIES
- Decrescendo
- Harsh 1. Range of motion with specific concerns for hip movement in
- Blowing infants
- Soft 2. Femoral pulses
3. Joint warmth, stability, swelling, tenderness, clubbing of
J. LUNGS fingers
1. Auscultation 4. Gait
• Auscultation 5. Genu valgum or varum
• Do not confuse upper airway sounds with lung sounds
• Equal breath sounds
• Rales, ronchi, wheezing

Trans # 2.2 Overview of Pediatric Physical Assessment 4 of 7

 Figure 13. Evaluation of Hip Mobility in Infants [ppt]

Figure 14. Genu Varum vs Genu Valgum [ppt]

N. NEUROLOGIC ASSESSMENT FOR AGE

1. Considerable information can be gained by watching the child
during the history gathering portion of the exam
2. Reflexes-biceps, triceps, patellar, achilles
3. Assess cranial nerves
4. For older infants and children, cerebellar function

III. SEXUAL MATURITY RATINGS

• Sexual maturity ratings (SMRs) are widely used to assess

adolescents’ physical development during puberty in five
stages (from preadolescent to adult).
• Also known as Tanner stages, SMRs are a way of assessing
the degree of maturation of secondary sexual characteristics.
• The developmental stages of the adolescent's sexual
characteristics should be rated separately (i.e., one stage for
pubic hair and one for breasts in females, one stage for pubic
hair and one for genitals in males), because these
characteristics may differ in their degree of maturity.

Trans # 2.2 Overview of Pediatric Physical Assessment 5 of 7

 1. Male
Table 2. Sexual Maturity Ratings (SMRs) - MALE

SMR Pubic Hair Penis Testes

STAGE 1 Preadolescent Preadolescent Preadolescent

Scanty, long, slightly Beginning enlargement of

STAGE 2 pigmented, primarily Slight or no enlargement testes and scrotum; scrotal skin
at base of penis reddened, texture altered

Darker, coarser, starts Further enlargement of testes

STAGE 3 Longer and scrotum
to curl, small amount

Coarse, curly;
resembles adult type Larger in breadth, glans penis Testes and scrotum nearly
STAGE 4 adult
but covers smaller develops
area

Adult quantity and

distribution, spread to Adult
STAGE 5 Adult
medial surface of
thighs

2. Female
Table 2. Sexual Maturity Ratings (SMRs) - FEMALE

SMR Pubic Hair Breast

STAGE 1 Preadolescent Preadolescent; elevation of papilla only

Sparse, slightly pigmented,

STAGE 2 Breast and papilla elevated as small mound; areola diameter increased
straight, at medial border of labia

Darker, beginning to curl,

STAGE 3 Breast and areola enlarged with no separation of their contours
increased amount

Coarse, curly, abundant, but Projection of areola and papilla to form secondary mound above the level of
STAGE 4
amount less than in adult the breast

STAGE 5 Adult feminine triangle, spread to \Mature; projection of papilla only, areola has recessed to the general contour
medial surface of thighs of the breast

Trans # 2.2 Overview of Pediatric Physical Assessment 6 of 7

 IV. INDEX

Figure 15. New Ballard Scoring System [ppt]

V. REFERENCES
• Lecture of Dr. Calubaquib

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