PHYSICAL EXAMINATION OF NEWBORN AND PEDIATRIC PATIENTS PEDIATRICS

Lecturer
Date of Lecture 1.2
Outline
I. Newborn Examination
II. Pediatric Physical Examination

LEGEND
 Book  Recording  Previous Trans Must know

References:
1. Video discussion: https://www.youtube.com/watch?
time_continue=892&a
mp;v=U9lM1Ejv3os&feature=emb_logo

NEWBORN EXAMINATION
BEFORE THE EXAMINATION
 When you enter the room, congratulate and introduce  Check for the fontanelles & sutures
yourself   Skull Design 
 Explain that you would like to examine their infant and ask o allows the skull to be malleable enough to fit  through
if you have come at a convenient time  the birth canal 
 If the family agrees to an exam, carefully place the infant  o often leads to a temporary deformation called 
on her back & unswaddle her from any blankets  molding 
 Check the infant’s skull for bruising and
OBSERVATION swelling
 Make a general observation of your patient  o Cephalohematoma 
o Asleep awake?   a bruise that does not cross
o Skin warm or cool to touch? 
the suture lines 
o Vital signs? 
o Difficulty breathing?   bleeding below the
 Signs of distress or illness?  periosteum, more common
o End the PE here & notify the resident or attending  in births assisted by a
physician  vacuum or forceps 
 If the baby looks well but is crying, console her by laying   increased risk of jaundice
your hand on her head or offering a pacifier if the parents  due to breakdown of Hgb as
allow the bruise resolves 
 Proceeds with the individual aspects of the exam o Caput succedaneum 
 The simplest way to examine a newborn is from head to   if the swelling crosses suture lines
toe   fluid accumulation that forms above
the periosteum due to the force of delivery
HEAD  swelling typically resolves w/In a few days of
birth  
 Gently place a hand behind the posterior portion or
o Subgaleal hemorrhage 
occiput  of the skull 
 Measure the head circumference in cm by wrapping a   rarely, more extensive swelling that crosses
measuring tape in a circle just above the eyebrows to the  suture lines due to rupture of   emissary
most prominent aspect of the occiput and back again  veins 
 Determine if her head is of normal size by plotting the   can lead to more serious complications due
circumference on a newborn birth chart  to significant blood loss in a large potential
o The HC should be in the average range for  space 
infants of the same gestational age and also fall  ∙
approximately in the same percentile as the   Finally, run your finger over the skin of the infant’s scalp
infant’s length & weight  o Cutis aplasia 
 Shape   if you feel any areas where the skin
o A newborn skull is made up of several bony  is missing or has an unusual texture 
plates that meet along flexible cranial sutures 
o Anterior fontanelle – in the center, they form a 
 congenital anomaly in which the
scalp has not formed properly 
soft spot  
o Posterior fontanelle – smaller fontanelle at the   not inherently dangerous but
back  should prompt a thorough exam for
other atypical physical features 

FACE
EARS
  First, assess the ears 

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o To check for ear placement, imagine a straight  line  Coloboma of the eye,
drawn from the outer corner of the eye  Heart abnormalities, Atresia of the
o The upper portion of the ear should meet this  line; if choana, Retardation of
not, the ears may be considered LOW SET  growth/development, Genitourinary
o Now imagine a second line, drawn perpendicular  to abnormalities, Ear abnormalities 
the first   Any infant found to have choanal
 Is the infant’s ear straight along this   atresia  should be refer to ENT specialist
axis? If it is tilted back – the ear may be   or medical geneticist
in a posterior position 
 Atypical ear position is not dangerous,   MOUTH & JAW
but may prompt consideration for an    Gently insert gloved index finger into the NB’s mouth
underlying genetic condition   A healthy baby will reflexively suck on the glove
 Next, assess ear formation   In the anterior portion of the mouth, you will feel the hard 
o Do the ears have a complete rim of palate
skin  surrounding them, called the
helix? 
o Does the skin inside the helix called the
crus,  have folds, or is it unusually
smooth? 
 Finally, check the skin beside the ears’ tragus for pits or  skin
tags 
 Ear Formation 
o variation can be normal 
o minor variants may be associated with genetic 
conditions, hearing loss or kidney anomalies

EYES
 Begin with inspection   As your finger travels backwards, you feel the soft palate ∙
o Do they appear widely spaced?  Cleft Palate 
o Does the opening of the eye called the palpebral  o commonly isolated congenital anomaly, but can 
fissure, point upwards or downwards?  also be associated with other medical conditions 
o Subtle variations in eye spacing and rotation are  o Should be referred to ENT specialist & may need 
normal and may be inherited from healthy  parents  special help with feeding 
o may have to coax her to open her eyes by  turning off  Tongue 
the lights or cupping your hand over  her eyelids  o Is he/she able to elevate his/her tongue & push it 
o When she opens them, quickly assess the  infant’s past the lower gums? 
RED REFLEX by shining the  ophthalmoscope light o If not, he/she may have Ankyloglossia/ Tongue 
on the eye – you should  see a flash of red in each tie – a minor variant & is not a sign of a genetic 
eye, indicating the  normal presence of retinal vessels condition, but could impair an infant’s ability to 
in the eye  breastfeed; Frenotomy or release of the frenulum, 
may be indicated if breastfeeding is painful or 
 Congenital cataract or  Retinoblastoma – inefficient 
if you see an  asymmetric red reflex,
particularly if the color seen is white 
 Finally, do a brief overall examination of the infant’s mouth,
 Coloboma – missing pieces of tissue in   looking for other unusual findings such as a natal tooth.
the structure that form the eye 
o A patient with either of these findings, should be NECK
referred to both  ophthalmology & medical genetics   If there is obvious webbing or redundant skin, which  can be
found in Turner syndrome or Noonan syndrome respectively 
NOSE  Now, run your fingers over the infant’s collarbones
 Patency of the nares  o The clavicle should feel smooth without any  crepitus,
o most important feature to assess – neonates are  breaks or step-offs 
preferential nasal breathers  o Fractures of the clavicle may occur during  delivery
 History of respiratory distress?  particularly in infants who had shoulder  dystocia 
o patency can be proven by passing a small French 
catheter thru each nares  CHEST
o Transient obstruction from edema related to   Inspect the shape of the chest 
suctioning after birth – common for NB  o Does the sternum lie flat or is it concave (pectus 
 but the differential may include the following: excavatum) or convex (pectus carinatum) – more 
common in some connective tissue & cardiac 
 Choanal atresia/stenosis –
disorders e.g. Marfan Syndrome 
improper formation or narrowing of
o An isolated pectus abnormality is considered a  minor
the nasal  airways; characteristic
variant and is not cause for a genetics  referral 
finding of the genetic condition –
CHARGE syndrome   Listen to the baby’s heart 

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o You’ll use the same landmarks for auscultation as   Palpate around the abdomen, carefully assessing for  masses
you would when examining an older child or adult o Wilm’s tumor or Neuroblastoma – rare, 
 A normal newborn HR is between 120-160bpm o You may intraabdominal neoplasms 
need to listen for up to a minute before  you can clearly make
out the sounds of systole  and diastole  GROIN
 Many newborns have a continuous machine-like murmur   Unfasten the infant’s diaper 
caused by the closing of the patent ductus arteriosus  Assess the femoral pulses by placing your fingers along  the
o Benign and in full term infant, should resolve  within creases between the thigh and diaper area  
the first few days of life  o Don’t push too hard 
o Other heart murmurs, particularly those that do  not o It may take several minutes before you can feel a 
improve within days, should be further  evaluated  steady pulse on both sides 
 Heart murmur  o Aortic coarctation 
 Pre- and post-ductal oxygen saturations  if you are unable to find the pulse, or it  
(SaO2) o Four extremity blood pressures  feels weak on one side 
 EKG   can be further investigated
 Assess the infant’s respiration  by  measuring pre- and
o Periodic breathing – it is normal for infants to  take post-ductal oxygen (SaO2)
short pauses in their breathing, or breathe at  a and 4 extremity blood
slightly irregular rate  pressures 
 Auscultate along the apex of the lungs & around their  sides  At this time, you may also check for the presence of an 
and back  inguinal hernia 
o Lungs should sound equally loud with clear  passage  Now, evaluate the genitalia 
of air and no wheezes or crackles  o Female 
 A newborn respiratory rate is 30-60cpm    Labia & clitoris may appear engorged
as  a result of maternal hormones 
ABDOMEN  some NB even experience a small  
 First, inspect the abdomen  amount of vaginal discharge or bleeding 
o is it distended?   Vaginal skin tags on the
o the skin around the umbilical cord should look clean posterior fourchette 
& dry  o Male 
 Assess if the testicles are descended by  
palpating them through the scrotum 
 Hydrocele – a swollen, enlarged  
scrotum; fluid collection around the  
testes which will spontaneously resolve 
 Examine the penis for any abnormal  
curvatures, and that the foreskin fully  
covers the glans  
 Hypospadias – hooded foreskin;
ventral  
displacement of the urethral meatus 
 In all infants 
o Asses the patency of the anus by using one hand to
hold the legs and the other to gently spread apart the
o Umbilical hernia gluteal cleft 
 Many infants have an outpouching of    Replace the infant’s diaper 
skin around the umbilicus   Assess the infant’s hips to test for hip
 Evaluate whether umbilical dysplasia
o Hip dysplasia 
hernia is reducible by gently
pushing it back toward the  congenital deformation or
abdomen  misalignment 
 a hernia that feels firm, or is  more common if:  
stuck in place may be  Family history hip
incarcerated and should be dysplasia 
evaluated by a surgical
specialist    Female 
 Next, palpate the infant’s abdomen by placing one hand  on  Breech
top of the other   presentation in
 Push gently, on the right side of the abdomen, assess the  size utero  
of the liver   Assess the hips one at a time using two maneuvers 
o liver edge should either not be palpable or lie  very o Barlow  
close to the newborn’s ribs

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 First, adduct hip by bringing the  conspicuous patch of hair on the lower back 
thigh toward the midline   asymmetric gluteal cleft 
 Then, apply a gentle posterior
pressure to the knee – Posterior NEUROLOGIC
dislocation  Mental status 
o Ortolani 
o Awake or asleep 
 Flex the infant’s knees to a 90-
degree position  o Irritable or calm 
 Then, abduct the legs by folding o Consolable or inconsolable 
the thigh outwards   Muscle tone
o Pull the baby toward you  
o Does his/her body feel stiff and hypertonic,
or  overly floppy and hypotonic? 
o Does her head come up with his/her body to
a  sitting position or does it lag behind? 
 Motor Function then retract 
o Assess by observation 
o Does she move all her extremities well? 
o Is her face symmetric? 
 Sensation 
 If you feel a clunk or dislocation, follow up with the o can be determined by noticing how she
primary  care physician or an orthopedic surgeon responds  to your touch 
depending on the  severity of the finding  
 Primitive Reflexes
 All neonates with the risk factors should have a hip
ultrasound at 4-6weeks of life regardless of a normal hip  o Unique aspect of the NB exam 
exam  o Note if they are symmetric, as asymmetric
may  indicate neurologic or orthopedic
EXTREMITIES condition 
 Are there 10 fingers and 10 toes?  o MORO REFLEX 
o Polydactyly Type B – small nubbin skin attached  the  Hold the infant & pull forward until
exterior of the 5 finger; this is a normal  finding and
th
a few cm  above bassinet 
may have been inherited 
 Drop his/her head gently into your
 What about the length of the fingers? 
other  hand 
o Brachydactyly – fingers appear short 
o Arachnodactyly – fingers appear long   hands should open 
 Assess the palms   upper extremities should
o Single transverse palmar crease  extend 
 a lone, horizontal crease in the palm  
 more common in infants with o PALMAR GRASP REFLEX 
neurologic conditions e.g. Down Syndrome   Easily listed by pushing your
 also found in ~1% of general population  fingertip into the baby’s palm,
o A minor variant in hand morphology should not  causing him/her to wrap his/her
prompt referral to genetics, unless it is one  finding fingers around yours 
among a constellation of others  o ROOTING REFLEX 
o Major anomalies of the hands or feet however,  such ∙ Evaluated by stroking the infant’s check, 
as missing or extra digits, should prompt  further leading her to start suckling his/her 
investigation  mouth in anticipation of a feed 

BACK AFTER THE EXAMINATION

 Gently turn the infant over to inspect her back  Change the diaper if dirty and re-swaddle the baby
o Blue-grey macules – common, fade over time  Place her on top of a blanket, wrap one corner of the
o Erythema toxicum – pustules on an erythematous  blanket around her body, fold the bottom of the blanket up
base; appears at 24-48hrs of life   toward his/her chest and finally, the remaining side of the
o Sacral dimple – check if you can clearly visualize  blanket around her & beneath her back 
base of the indentation; if not, the infant may  have:  Thank the family for allowing you to examine their new
 Tethered cord  baby, and ask if they have any questions 
 Spina bifida occulta 
Other findings concerning for a spinal cord abnormality:  PEDIATRIC PHYSICAL EXAMINATION

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RESPIRATORY SYSTEM
OBSERVATION

 Observe the patient sitting on primary caregiver’s lap

 Sit down – puts you on same eye level as patient, less
intimidating
 Stay at a distance – gives patient the opportunity to
see the examiner
 Observe for breathing apparatuses, etc.
o Oxygen, inhaler
e. Percussion
EXAMINATION f. Back – auscultate, percuss both sides (left and
1. Wash your hands right)
2. Examine patient’s hands
a. Capillary refill time
 Should be <2s = well perfused

GENERAL OBSERVATION
3. Assess hydration  General well-being
a. Fontanelle  Color
b. Mouth – damp and wet  Accessory equipment
c. Skin turgor
 Perfusion status
 Hydration status

SPECIFIC OBSERVATION
 Look for signs of respiratory distress
 Count RR
 Chest expansion
 Listen – cough, noisy breathing

AUSCULTATION & PERCUSSION

4. Chest
a. Breathing sounds – quiet, not noisy
 If noisy, it may indicate abnormality
b. Check for cough
c. Undress
 Observe for:
- Chest expansion
Respiratory distress- retractions
 Count for RR for 30 seconds At the back of the chest, do not auscultate on the area of the
• Newborns have faster RR spine.
compared to adults and it
gradually decreases towards
Table 1. Respiratory Rate
adolescence
d. Auscultate Normal Respiratory Rate
 At the edges of the chest (heart < 1 yr 30-40 bpm
occupies large surface area) 2-5 yrs 25-30 bpm
5-12 yrs 20-25 bpm
>12 yrs 15-20 bpm

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APPENDIX