PHYSICAL EXAMINATION

A good and complete PE largely depends on the approach of the examiner. The usual order in the
examination of adults is not often appropriate for young children. In general, it is best to leave
the more unpleasant or uncomfortable parts of the PE last. The clinician has to adapt to the
various situations and circumstances surrounding the examination and yet do a thorough
examination, i.e., auscultate the heart and lungs while patient is asleep and inspect throat when
patient is crying. The patient is best examined with the minimum of clothing on. Anyone
examining a pediatric patient should learn the art of playful interactions to allay anxiety of the
child and to facilitate the examination. Infants and young children can be carried by their
caretaker or patient while being examined. In uncooperative patients, the physician should
properly immobilize the patient so that certain procedures can be carried out safely.

a. General Survey: Take note of the following:

 mental state or sensorium, level of activity
 presence of cardiopulmonary distress or not, color
 ambulatory or bedridden
 nutritional state (well, under, or over nourished)
 state of hydration
 ill looking
* Refer to Table 1, Acute Illness Observational Scaleto help determine quickly
&more objectively whether the child is well, mildly ill or severely ill.

b. Vital Signs: Temperature (TºC), Cardiac Rate (CR) /Pulse Rate (PR), Respiratory rate
(RR), Blood Pressure (BP) if >3y.o.
 CR and RR should be correlated to the condition in which they were taken to be
considered clinically significant, i.e., was the child quiet, asleep, active, crying and
struggling etc.
 Oral TºC should not be taken in children who are too young and/or are unable to
understand instructions. Axillary TºCs are safer to obtain and are usually 0.5ºC lower
than oral TºC. Aural or rectal TºC can also be obtained. However, never insert rectal
thermometer into an infant who can sit up on his own, especially if it is made of glass
with mercury content.
 The pulse can be described based on: rate (per min), rhythm (regular vs irregular) &
volume (full, weak, thready or compressible).

Table 1. Acute Illness Observational Scale:

Observation item Normal (NL) Moderate impairment Severe impairment
1. Quality of cry Strong with NL Whimpering Weak
tone Or Or
Or Sobbing Moaning
Content & not Or
crying High pitched
2. Reaction to parent Cries briefly then Cries off & on Continual cry
stimulation stops Or
Or Hardly responds
Content & not
crying
 3. State variation If awake, stays Eyes close briefly Will not rouse
awake then awakes Or
Or Or Falls to sleep
If asleep & Awakens with
stimulated, then prolonged
wakes up quickly stimulation
4. Color Pink Pale hands, feet Pale
Or Or
Acrocyanosisv Blue
Or
Ashen (gray)
Or
Mottled
5. Hydration Skin NL & eyes, Skin, eyes NL & Skin doughy or tented
Mouth moist mouth slightly & eyes may be sunken
dry &
Dry eyes & mouth
6. Responses to social Smiles Brief Smile No smile, face
overtures Or Or anxious
alerts alerts briefly Or
(≤ 2 mo) (≤ 2 mo) dull, expressionless
No alerting
(≤ 2 mo)
Nelson Textbook of Pediatrics 18th ed., 2007, p 364

Table 2. Vital signs at various ages. (Source: Behrman et al. Nelson’s

Textbook of Pediatrics, Saunders, 18thed, 2007, p.389)
Age CR (beats/min) RR BP
(breaths/min)
Preterm 120 – 170 40 – 70 55 – 75/35 – 45
0-3 mo. 100 – 150 35 – 55 65 – 85/45 – 55
3-6 mo. 90 – 120 30 – 45 70 – 90/50 – 65
6-12 mo. 80 – 120 25 – 40 80 – 100/55 – 65
1-3 y 70 – 110 20 – 30 90 – 105/55 – 70
3-6 y 65 – 110 20 – 25 95 – 110/60 – 75
6-12 y 60 – 95 14 – 22 100 – 120/60 – 75
> 12 y 55 – 85 12 – 18 110 – 135/65 – 85

 Pediatric Blood Pressure (BP) Monitoring:

BP cuff should completely encircle the arm. The inflatable bladder should cover at least
2/3 of the upper arm length and 80-100% of its circumference. A more accurate cuff
size is one whose inflatable bladder width is 40% of the arm circumference midway
between the olecranon and the acromion. Using too large or too small a cuff can lead to
falsely low or high BP readings respectively.

Method:
- Encircle cuff on bare skin of upper arm (right arm preferably) snugly. Clothing on the
arm artificially raises BP.
- Center the inflatable bladder over brachial artery.
- Patient’s arm should be supported and slightly flexed at the elbow. The cubital fossa
should be at the level of the heart. The stethoscope bell should be placed over the brachial
artery pulse, proximal & medial to the cubital fossa, below the bottom edge of the cuff,
about 2 cm above the cubital fossa.
- BP should be measured after 3-5 minutes of rest in the seated position.
 - Estimate first the systolic BP (SBP) by palpation method.
- Inflate the cuff rapidly to level above the suspected SBP then deflate cuff slowly at a rate
of 2-3 mmHg/sec.
- As cuff is being deflated, the onset of the “tapping” Korotkoff sounds signifies the SBP,
while the diastolic BP (DBP) is the level at which the Korotkoff sounds disappear.
- Ideally, BP readings should also be obtained on the left arm and one lower extremity.
- BP should be measured at least twice on each occasion & the average of the systolic and
diastolic BP readings be obtained and recorded.
- BP percentile should then be determined from BP nomograms according to sex, age and
height of the patient.
Sources: Nelson Textbook of Pediatrics 18th ed., p. 1989. Update on task force report on high blood
pressure, Pediatrics 1996 Oct; 98:649-58.

c. Anthropometric data:
3 major growth parameters include:
1. Weight (wt) in Kg
2. Length (Lt) (for children < 2 y/o.) or Height (Ht) (for ≥ 2 y/o in cm)
3. Head Circumference (HC) (for < 3 y/o.) in cm

Other measurements for special circumstances:

 Chest circumference (CC) in cm
 Abdominal circumference (AC) in cm
 Arm span & U/L ratio for children with growth disorders.
How should anthropometric measurements be done?

- Weight is preferably taken with minimal clothing on, using the same scale which has
been calibrated before use. An infant weighing scale should be used for children < 2
y/o.
- Supine length measurements require 2 observers. Place the patient flat in a supine
position on a recumbent length table or measuring board. The crown of the head should
touch the stationary vertical headboard. Align the line of vision perpendicular to the
plane of the measuring surface. With the shoulders and the buttocks flat on the surface,
align them at right angle to the long axis of the body. Extend the legs at the hips &
knees flat against the table. Rest the arms against the sides of the trunk. Ensure that the
legs remain flat on the table & shift the movable board against the heels. Extend the
legs gently & record the length to the nearest 0.1 cm.
- Height is measured using a vertical board with an attached metric rule and a horizontal
headboard that can be brought into contact with the uppermost point on the head. With
the child wearing little clothing so that body positioning can be seen, stand him on a flat
surface, with weight distributed evenly on both feet, heels together and the head
positioned so that the line of vision is perpendicular to the body. The arms hang freely
by the sides, and the head, back, buttocks and heels are in contact with the vertical
board. Anyone who cannot stand straight in this manner should be positioned vertically
so that only the buttocks and the heels or the head are in contact with the vertical board.
Ask the child to inhale deeply staying fully erect. The movable headboard is brought
onto the topmost point on the head with sufficient pressure to compress the hair. Record
measurements to the nearest 0.1 cm on the growth chart.
(Source: WHO Technical Report Series 854: “Physical Status: The use and Interpretation of
Anthropometry”, 1995)

Fig. 1. Measurement of recumbent length in infants (Source: www.cps.ca)

Fig. 2. Measurement of height (Source: www.cdc.gov)

 - HC should be measured using a nondistensible plastic tape measure placed over the
supraorbital ridge in front and extended circumferentially to include the most prominent
part of the occiput giving the largest possible measurement.
- Chest circumference should be measured in midinspiration with the tape running
horizontally around the chest using the xiphoid notch as reference point.
- Abdominal circumference is measured across the umbilicus in infants. In older
children, the subject stands with body wt evenly distributed on both feet, & with feet
about 25-30 cm apart. The measurement is taken midway between the inferior margin
of the last rib & the crest of the ilium, in a horizontal plane. AC is measured to the
nearest 0.1 cm at the end of normal expiration.
(Source: WHO Technical Report Series 854: “Physical Status: The use and Interpretation of
Anthropometry, 1995)
- Arm span is measured by asking the patient to stand straight with arms outstretched
sidewise parallel to the ground and palms facing front. Measure from the tip of the right
to the tip of the left middle finger.
- Lower (L) segment of body is measured as follows:
 0-3 y/o: with child supine, measure from umbilicus to tip of toes with feet flexed
90º at heel.
 > 3 y/o: with child standing, measure from anterior superior iliac spine to the floor
- Upper (U) segment = Lt or Ht minus lower segment

- Normal values for U/L ratio:

 At birth: 1.7
 1 month to 3 y/o: 1.3
 > 3 y/o: 1.0
- With data on Wt & Lt or Ht, calculate for body mass index (BMI) using the following
formula:

BMI = Wt in Kg ÷ (Lt or Ht in meter)²

- The Wt, Lt/Ht, Wt for Lt or Ht, BMI and HC should be plotted on 2006-2007 WHO
growth charts and their percentiles & z-scores (standard deviation scores) determined for
nutritional assessment. Assess for the following:
 wasting& overweight for 0-5 y/o by determining z-scores on Wt for Lt or Ht z-
score charts, or for 0-19 y/o, from BMI z-score charts.
 stunting in children 0-19 y/o by determining z-scores on Lt or Ht for age z-score
charts.
*See Appendices for 2006-2007 WHO Growth Charts for infants & children, their
proper use & interpretation.

d. Skin: color, tissue turgor (wrinkling or loss of elasticity), loss of subcutaneous tissue, rash or
eruptions, hemorrhages, scars, edema, jaundice.
 Skin turgor can be used to assess dehydration by pinching the skin over the anterior
abdominal wall. In the presence of dehydration, the skin does not fall back quickly and
remains in folds or tented. This sign however cannot be used in malnourished children
because of the loss of subcutaneous fat in these children.
e. Head: hair, shape or contour, scalp, fontanels, sutures
 Hair should be observed for the following:
- Quantity: increase or decreased, generalized or localized
- Color: blonde hair in phenylketonuria, albinism, flag sign in kwashiorkor
 - Texture: dry coarse hair in hypothyroidism, fine thin hair in malnutrition
- Surface characteristics: look for presence of lice and nits
- Strength: fragile hair in many congenital syndromes and fungal infections
 Abnormal swelling may indicate: hematoma, abscess, tumors, cephalhematoma, caput
succidaneum
 Sutures: overlapping, gaping
 Fontanels: There are 2 major fontanels at birth, the anterior (AF) and the posterior
fontanel (PF). The AF is normally slightly depressed and pulsatile and is best evaluated
when an infant is held upright while asleep or feeding.

Anterior fontanel Posterior fontanel

Location Midline at junction of Midline, between intersections
Coronal & sagittal sutures of occipital and parietal bones
Shape Diamond Triangular
Size at birth ~2 x 2 cm Very small or appears closed
Closure 9-18 months 6-8 wks
Table 3. Characteristics of anterior vs posterior fontanels.
PE finding Clinical implication
Small fontanel Microcephaly, craniosynostosis
Late closure or large Hypothyroidism, hydrocephalus, rickets,
Trisomy 18 syndrome
Tense/full/elevated  intracranial pressure
Depressed Dehydration

 Auscultation of the skull is important for detecting bruits which may indicate the
presence of A-V malformation or may be normal in children < 4 years old with febrile
illness.

f.Table
Face:4. Clinical correlation of the fontanel findings
 Inspect face for symmetry, expression, unusual facies, deformities, lumps & bumps.
 Adenoid facies: Term used to describe child with long face, short upper lip, pinched
nose & open mouth, often associated with pharyngeal tonsillar & adenoid hypertrophy
and chronic upper airway obstruction.
g. Eyes: lids, conjunctivae, sclerae, pupils, extraocular movements, vision, strabismus, opacities,
discharge, red orange reflex (ROR) up to 24 mo, corneal light reflex, cross-cover test.

Table 5. Lids’ findings & correlates:

Findings Clinical implication
Narrow palpebral fissure Ptosis
Wide palpebral fissure Exopthalmos, hyperthyroidism
Short horizontal length Trisomy 18
Lids slanted upwards Down’s syndrome
Lids slanted downwards Teacher Collin syndrome
Dennie-Morgan folds*, allergic shiners Atopy, Allergic rhinitis (AR)
*These are skin folds extending from inner canthi below the lower lids.
∞These refer to the blue-gray to purple discoloration beneath the lower lids due to venous
stasis.

 Note also for periorbital edema, drooping lids, scaliness, crusting of eyelashes,
hypertelorism.
  Conjunctivae: note for pallor, hyperemia, pterygium, subconjunctival hemorrhages,
opacities (plaques) from keratinisation in Vit. A deficiency (Bitot’s spots)
 Sclerae: ictericiae, unusual color like blue
 Pupils: size & reaction to light
 Vision: use Snellen’s chart or E chart if the patient is unable to read.
 Red orange reflex (ROR): an orange color is normally seen when flashing
ophthalmoscope light through the infant’s pupil. Absence of ROR or its replacement by
a “white reflex” should alert the clinician to the following possibilities:
- congenital cataract
- retinoblastoma
- infestation with toxocara
- retrolental fibroplasias
 Corneal light reflex (Hirschberg test): This maneuver screens for the presence of
strabismus and describes the corneal reflections of a light held in front of the child.
- A target object should be used to keep the child’s vision fixated in a forward gaze.
- Position the child so that the penlight, target object and the examiner’s line of
vision are at the same level as the child’s eyes. The distance between the penlight,
target object and the child’s eyes should be about 14-16 inches. Have the patient
focused his eyes on target object, and shine the penlight from above the target
object towards the center of the forehead just above the eyes. Note the reflections
of the light on the cornea.
- The light reflections should appear symmetrical on the child’s pupils and slightly
nasal to the center of the pupil.
- Asymmetric reflections suggest presence of eso (reflection deviated laterally on
involved eye) or exotrophia (reflection deviated medially on involved eye).
- In children who appear “cross-eyed” (pseudostrabismus) due to presence of
epicanthal fold or flat and wide nasal bridge, corneal light reflex will be normal.
 Cross-cover test: is used to check for tendency of the eyes to misalign when fusion is
interrupted.
- A target object is held 14-16 inches in front of the child. Hold the occluder in front
of the child’s right eye and hold it for a count of 3 without touching the child’s
eye. Pass the occluder over the bridge of the nose to the left eye. Watch the right
eye as it becomes uncovered for any movement. Hold the occluder over the left
eye for a count of 3, and quickly move over to the right eye again. Watch the left
eye as it becomes uncovered for any movement. This procedure should be repeated
2-3 more times.
- A child passes the test if no movement is observed on the uncovered eye.
- Any movement of the uncovered eye warrants referral or re-screening.
Source: Vision Screening Online Training Program,
www.health.state.mn.us

* Many normal infants may have imperfect coordination of the eye movement
and alignment during the early days & weeks but proper coordination should be
achieved by 3-6 months usually.

h. Ears and mastoids:

 The size, shape, location & position of the ear in relation to the rest of the head should
be noted. Normally, when an imaginary horizontal line is drawn between the two inner
canthi and that line is extended to the ears, 20% of the total length of the ear lobe
should be located above this imaginary line. If less than this, low set ear should be
strongly suspected.
 Discharge from ear canal: watery, purulent or bloody
 Inspect also the postauricular & mastoid areas.
 To ensure success, otoscopy should be done with proper positioning & immobilization
of the child. To visualize the tympanic membrane (TM), the otoscope should be
inserted in the appropriate angle into the ear canal. In newborn & infants, the direction
 of the ear canal is upward, while in older children, the direction is downward &
forward. Thus, in infants, the pinna of the ear should be pulled downwards &
posteriorly, in older children, up & back and the speculum should be inserted into the
ear canal in corresponding direction “looking your way in”, not blindly. The handle of
the otoscope should be held like a pen. When inserting the otoscope, the knuckles of the
fingers are steadied on the ipsilateral cheek of the child with the handle held
horizontally or in line with the child’s line of vision while the other hand is holding the
earlobe of the patient.

When viewing the TM, note for the following features:

- Continuity: intact or perforated
- Color: normally light pink or pearly transluscent white; peripheral redness in a
crying child,. red all over if inflamed, dull or purulent in infection
- Cone of light: if absent, signifies loss of luster of TM due to inflammation.
- Bulging or concave
- Presence of effusion, bubbles
- Mobility of TM through air tympanometry by gently blowing of air through the
otoscope using a pneumatic bulb. Impaired mobility of TM may be due to thickened
TM in chronic OM, middle ear effusion, eustachian tube dysfunction.

Fig 3. Diagram of right TM showing landmarks

i. Nose and paranasal sinuses:

 Check for patency of nares, alar flaring, presence & character of discharge, position of
septum, sinus tenderness.
 For better visualization of nasal cavity, have patient seated, tilt patient’s head up
facing the examiner, then press & lift the tip of the nose upward to enlarge the opening
of the nares. Place otoscope without the speculum near the nares with lights on & view
through the magnifying lens the nasal cavity.
 To detect sinus tenderness, press below both eyebrows and on both maxillary areas.

Table 6. Nasal findings & clinical correlate:

PE findings Clinical implications
Nasal crease on the bridge of nose AR
Pale/ violaceous congested nasal mucosa AR
Pedunculated mass within nasal cavity Nasal polyp
Unilateral nasal purulent discharge Foreign body

j. Mouth and throat: lips, gums, tongue, mucous membrane, dentition, palate, posterior
pharyngeal wall, tonsils
 Lips: Check for color (pale, cyanotic, cherry red), moisture or dryness, excoriations,
cleft.
 For throat exam, use bright light. Ask the patient to open mouth and say “Aaahh”.
Inspect the anterior structures, then the tongue and under, then the posterior structures
which can best be visualized using tongue depressor.
 Gums: color (reddish and bleed easily in gingivitis, reddish with hypertrophy in
children who were given phenytoin), continuity (ulcers, vesicles in herpetic
gingivostomatitis), bleeding (in purpura, trauma, leukemia)
 Tongue:
− size (large in Beckwith syndrome)
− moisture (dry with dehydration),
− color (pale, blue in central cyanosis, strawberry tongue in scarlet fever &
Kawasaki’s disease),
− milky white coatings that bleed when scratched (thrush)
 − “geographic” tongue: a benign lesion characterized by one or more smooth
bright red patches with a gray or white membranous margin on the dorsum of
a roughened tongue.
− ankyloglossia (tongue-tie): characterized by a short frenulum that may hinder
tongue movement but rarely causes feeding or speech problem. The frenulum
usually lengthens as child grows older. Surgical correction maybe indicated if
the frenulum extends all the way to the tip of the tongue.
− ulcers
− abnormal movements (tremors in thyrotoxicosis, trombone in chorea)
 Examine throat using tongue depressors. Immobilize the child if uncooperative. Hold
the tongue depressor with the dominant hand & the penlight with the other hand. The
4th& 5th fingers of the hand holding the tongue blade should rest on chin or face so
that the hand can move along with the face when the child moves his head. The tip of
the tongue blade is then placed at the center and at the junction of the anterior 2/3 and
posterior 1/3 of the tongue, pressing the tongue downward firmly to get a good view
of the oropharyngx.
* Caution: if epiglottitis is strongly suspected, do not do throat exam!
 Oropharyngeal mucosa: note for presence of thrush, vesicles, ulcers, Koplik spots
 Palate & uvula area:
− Note symmetry. Bulging on one side with uvula shift to contralateral side may
signify the presence of peritonsillar abscess or parapharyngeal tumor.
− Note for presence of cleft, rash like petechiae, vesicles, ulcers, thrush.
− High arched palate in congenital malformation syndromes
 The posterior pharyngeal area contains collection of lymphoid tissues spread out over
the surface. During upper respiratory tract infections, the lymph nodes hypertrophy
and give the surface a cobblestone appearance. Note for presence of post-nasal
drippings.
 Dentition: There are 20 milk teeth that should be present by 24 months of age. Note
color, mottling or pitting of enamel (fluorosis), dental caries.
 Note for excessive drooling. Children normally drool in the first year of life but
usually not after 18 mo of age.
 Tonsils: presence or absence, size, surface color, exudates, adherent membrane.
Tonsillar size should be correlated to the age of the patient. They are usually
“hypertrophied” during early childhood from toddler to school age period.

Table 7. Grading tonsillar size.

Grade Size of tonsils vs pharyngeal fossa width
0 No tonsils in fossa
+1 < 25%
+2 < 50%
+3 < 75%
+4 > 75%

Fig 4. Grading tonsillar size. (www.scielo.br)

 The color of healthy oral mucosa in general is usually pinkish-reddish. Congestion or

erythema of the oral mucosa should be redder than the usual. When assessing tonsils
& posterior pharyngeal wall congestion, they should be compared with the rest of the
oral mucosa.
k. Neck: venous engorgement, flexibility, rigidity, masses, lymph nodes
 Swelling: in severe diphtheria (bull neck), subcutaneous emphysema, webbing of
neck in Turner syndrome, obesity
 Position: torticollis, opisthotonus
 Masses: lymph nodes, dermoid cyst, thyroglossal duct cyst, branchial cyst, enlarged
thyroid, cystic hygroma. (All should be described as to location, size, rate of growth,
 shape, margin, surface, consistency, color, warmth, pulsation, adhesion to
surrounding structures).
 Draining lymph nodes as in scrofula
 Among overweight or obese children, look for “acanthosis nigricans”, which consists
of velvety hyperpigmented grayish coarsened skin at the neck, axilla, groin, and is
strongly associated with insulin resistance.

Table 8. Goiter grading system (WHO):

Grade PE finding
0 No goiter
Ia Goiter detectable by palpation & not visible when
neck is fully extended
Ib Goiter palpable but visible only when the neck is
fully extended
II Goiter is visible when neck is in normal position
III Very large goiter that can be recognized at a distance

l. Chest and Lungs

The chest circumference (CC) is smaller than that of the head in the first 9-12 months of life.
After 1 y/o, the CC should be larger than the HC. A small thoracic cage is seen in Ellis van
Crevald syndrome.
i. Inspection:
 Size and shape: in infancy, AP diameter is equal to transverse diameter; after 2 yrs,
transverse diameter > AP diameter.

Table 9. Chest findings and their clinical implications

Findings Clinical implications
Round/barrel chest Chronic obstructive lung disease
Shield shaped Turner’s syndrome
Pectus excavatum Congenital anomaly
Pigeon chest Normal, rickets, osteomalacia, pectus carinum
Rachitic rosary Rickets
Harrison’s groove (deep groove Chronic cardiac or pulmonary disorders
running along the sides of the chest
parallel to the lower ribs)

 Movements with respirations:

− In newborns & young infants, movement is mostly abdominal. After 4-5 yr of
age, most of the respiration is due to intercostals muscles.
 Chest retractions: subcostal, intercostals, supraclavicular

ii. Chest expansion: Assessed by placing the palms of the hand symmetrically on the
posterior surface of the chest with the thumbs touching each other in the midline. The
fingers are spread over the sides of the chest. The excursions of the palm are noted with
each inspiration. Normally, the palms move equally as demonstrated by the symmetrical
movements of the thumbs moving away from the midline with each inspiration & coming
together during expiration. When the 2 sides do not move symmetrically, the excursions
are limited on one side & the thumb does not move away from the midline on the affected
side, or the movements of the thumbs are asymmetrical. This asymmetry should suggest
the presence of effusions, or collapse, or consolidation of the lung on the side with
decreased excursions of the chest.
iii. Vocal fremitus: The child is asked to repeat the word “tres tres” or “ninety nine”
repeatedly while the examiner palpates all areas of the chest & back. The palmar or ulnar
surface of both hands should detect distinct vibrations of equal intensity on corresponding
areas of 2 sides of the chest.
 Table 10. Implications of abnormal fremitus findings:
Fremitus Clinical implications
 atelectasis, pneumothorax, pleural effusion
 Consolidation

iv. Percussion: Direct percussion with 1 finger over the chest wall is easily done on small
infants& gives valuable information but requires experience. The indirect, 2 finger
technique is the most common method for percussing the chest.

Fig. 5. Two finger technique of percussion. (Source: Walker, JH Kenneth et al. Clinical
Methods: The History Physical and Laboratory Exams, 3rded, Butterworth Publisher,
1990. www.ncbi.nlm.nih.gov.com)

The middle finger (pleximeter) of the left hand or nondominat hand is placed firmly (but
not hard) on the chest wall. The index or middle finger of the pleximeter finger is than
struck with the tip of the middle finger (plexor) of the right or dominant hand. The
movement of the striking finger should originate from the wrist and not from the elbow.
The striking finger should land perpendicularly to the pleximeter finger & should spring
back quickly after the strike so that the resonance generated is not dampened. For both
chest and the back, percuss from side to side, and top to bottom systematically,
comparing one side to the other checking for symmetry or asymmetry.

v. Ausculatation: Stethoscope should be placed on the bare skin of the chest wall. Warm
the chest piece first if it is cold. Use the bell in young infants as the diaphragm can pick
up sounds from larger areas. If feasible, auscultate systematically from top to bottom,
side to side, back & front and compare breath sounds (BS) for symmetry or asymmetry
in findings.
Table 11. Variations in percussion notes & clinical implications
Variations in Nature of underlying Clinical implications
percussion notes structures
Resonant Normal chest Normal
Dull Solid structures Consolidation or over the
liver
Fluid filled areas Pleural effusion
Hyperresonant Hollow or air filled areas Pneumothorax,
emphysema; maybe
expected in young infants
with thin chest wall

Table 12. Abnormal or Adventitious BS:

Adventitious Nature/Pathology I or E * phase Implications
BS
Crackles/ Explosive non-musical sounds Can be heard Associated with
rales occurring in burst, resembling in both “I” & inflammation, edema or
popping of bubbles; can be coarse or “E” phases infection of bronchi
fine. They are heard when an when air is bronchioles & alveoli.
obstructed lumen suddenly opens & forced through Early “I”* crackles
pressure on either side of the airways that suggest bronchitis or
obstruction equilibrates. are narrowed asthma; mid “I” crackles:
Fine crackles sound like crushing by fluid, bronchiectasis; late “I”
strands of hair between fingers near mucus or pus crackles: interstitial lung
your ear. disease, congestive heart
Coarse crackles are louder, lower failure, or pneumonia
 pitched, last longer & sound like
opening a Velcro fastener
Wheezes Continuous musical sound that can Usually “E”, Obstructive airway
be high pitched with a whistling but can be disease, congestive heart
quality, usually caused by turbulent heard also in failure
flow in narrow airways late “I”
Rhonchi Coarse “wheezes” that are Usually “E” Presence of secretions in
continuous & low pitched with a large airways as in
snoring or moaning quality; usually “bronchitis”
felt by palpating palms & clear on
coughing
Bronchial/ Hollow sound transmitted by sound Usually “I” Consolidation usually in
tubular BS waves from trachea through the upper lobes; in lower
consolidated area to the chest wall. lobe consolidations with
obstructed bronchi,
bronchial BS will not be
appreciated
Pleural friction Rubbing leathery sound produced by Both Pleurisy
rub friction of the pleural surfaces
Stridor Monophasic noise; usually audible Usually “I” Upper airway obstruction
even without stethoscope
Grunting Known as physiologic PEEP**; a Usually “E” Signifies underlying
defence mechanism of the child to pulmonary pathology
raise functional residual capacity by
closing the glottis at the end of
expiration; audible even without
stethoscope
*I-inspiratory, E-expiratory; **PEEP= (+) end expiratory pressure.
(Source: Bates’ Guide to Physical Exam & History Taking. 8thed, 2003;
http://www.mceus.com/resp/respabm.html.)

 Normal BS are of 3 types:

− Bronchial: heard over midline, elsewhere, it is usually pathologic
− Vesicular: normally heard over the chest, axilla & infrascapular areas
− Bronchovesicular: heard more on infants with thin chest wall
 Abnormal or Adventious BS: see Table 12.
 Altered voice sounds in lobar pneumonia:
− Bronchophony: spoken words are louder & clearer when normally, they are
muffled & indistinct.
− Egophony: spoken “ee” is heard as “ay” when normally it should be heard as
“ee”
− Whispered pectoriloquy: whispered words are heard louder & clearer when
normally, they are faint & indistinct or are not heard at all.

m. Heart & vascular system: precordium, visible pulsations, apex beat, thrills, heart sounds,
pulses.
i. Inspection:
 Precordium: adynamic or dynamic.
 Look for visible pulsations over various parts of the chest and in the epigastrium.
 Apex beat corresponds to the lowest and outermost point of the cardiac impulse
normally located at the 4th LICS MCL until 7 y/o when it shifts to the 5th LICS MCL.

Table 13. Clinical implications of chest findings.

 PE finding Clinical implication
Adynamic precordium Pericardial effusion,
Hyperdynamic precordium Fever, hyperthyroidism, volume load
as in left to right shunt, hypertension,
impending heart failure; may be normal
in a thin patient
Apex beat displaced laterally & inferiorly Cardiac enlargement
Apex beat displaced to the right Dextrocardia
Precordial bulge Cardiomegaly

ii. Palpation:
 Thrills: “purring” vibratory sensations felt by the palm placed over the precordium.
They are the palpable equivalent of murmurs & correlate with the area of maximal
auscultatory intensity of the murmur
 Substernal thrust: indicates presence of right ventricular volume or pressure overload
 Take note of character of pulses. Table 14 summarizes the clinical implications of
findings on pulses.

Table 14. Variations in pulse findings and their clinical implications.

Nature of pulses Clinical implications
pulses in all extremities Pericardial tamponade, left ventricular
outflow obstruction, dilated cardiomyopathy
Bounding Aortic run-off lesion like PDA, aortic
insufficiency, A-V malformation,cardiac
output due to anemia, thyrotoxicosis
Radial-femoral delay*, absent or weak Coarcation of aorta
femoral pulses
* Radial-femoral delay: femoral pulse is felt after radial pulse

iii. Ausculatation:
 Diaphragm of the stethoscope is placed firmly on chest wall to auscultate for high-
pitched sounds, while the bell is placed lightly to detect low pitched sounds.
 The examiner should first characterize the individual heart sounds & their variations
with respiration. The 1st heart sound (S1) is caused by closure of the AV (tricuspid &
mitral) valves & is best heard at the apex. The 2nd heart sound (S2) is caused by
closure of the semilunar (aortic & pulmonic) valves & is best heart at the upper left &
right sternal borders. Normally, S 2 is split during inspiration & less so in expiration.
The 3rd heart sound (S3) is best heard at the apex in mid-diastole. S3 is heard as gallop
rhythm in the setting of heart failure due to poor compliance of the ventricle, but may
be normal in a young patient with tachycardia.
 Murmurs should be described according to their intensity, pitch, timing (systolic or
diastolic), variation in intensity with respiration, time to peak intensity, areas of
maximal intensity, & radiation to other areas. Auscultate across the upper precordium,
down to the left or right sternal border, out to the apex & both the axillas & also over
the back.
Grading of intensity of murmur is as follows:
− I: barely audible
− II: medium intensity
− III: loud but no thrill
− IV: louder with thrill
− V: loud & audible with stethoscope barely on the chest
− VI: audible with the stethoscope off the chest

Fig. 6. Sites for auscultation of heart sounds. (Source: www.ecconline.com)

n. Abdomen: Abdomen can be divided into either quadrants or 9 parts to facilitate localization
of PE findings.
 Figure 7. Abdominal landmarks.

i. Inspection:
 Note size & shape of abdomen, presence of prominent vessels, striae, pulsations,
peristaltic movements, movement in relation to respiration, umbilical hernia.

Table 15. Clinical implications of various abdominal findings.

Findings Clinical implications
Scaphoid or flat Diaphragmatic hernia (in newborn), malnutrition
Full or globular or protuberant  Normally seen in infants & toddlers due to weak
abdominal musculature, relatively large abdominal
organs& lumbar lordosis.
In other instances, think of 5 F’s i.e., flat, flatus,
feces, fluid & fetus.
Peristaltic waves Maybe normal in thin individuals.
May signify presence of obstruction as in pyloric
stenosis, intussusception
Distended veins in epigastric area may indicate obstruction of
inferior
vena cava
in periumbilical areas – portal hypertension
Paradoxical abdominal movements  Diaphragmatic paralysis or impending respiratory
with breathing failure in severe status asthmaticus

 If there is abdominal distention, measure the abdominal circumference (AC).

ii. Auscultation of bowel sounds:

 Auscultation of abdomen to detect bowel sounds should be done prior to palpation and
percussion as both procedures can alter the findings. Warm the stethoscope with the
palm of your hand. Place diaphragm lightly on RLQ area or mid-abdomen and note
the character & frequency of bowel sounds. Bowel sounds are widely transmitted
through the abdomen, thus, listening in one spot is usually sufficient. However, value
of bowel sound findings are questionable because the characteristics of the sounds are
not diagnostic of specific conditions except for the high pitched sounds associated
with bowel obstruction. It is more important to observe how the bowel sounds change
over a period of time, especially in cases where bowel obstruction may progress to
strangulation of ischemia of bowel loops, at which stage, the bowel sounds may
decrease, and in post-op cases where presence of bowel sounds signify recovery of
bowel functions. (Bates’ Guide to Physical Exam & History Taking, 2003, 8th ed;
http://www.gastroresource.com/gittextbook)
 Bowel sounds are gurgling in nature and occur episodically at 5-10 seconds intervals
or longer (10-30 seconds in infants & younger children) and they number ∼ 5-34/min.
Occasionally, borborygmi (consisting of prolonged gurgles of hyperperistalsis) may be
heard. If bowel sounds are absent, auscultate for at least 1-2 minutes before concluding
so. ((Bates’ Guide to Physical Exam & History Taking, 8th ed, 2003;
http://www.meddean.luc.edu/lumen/MedEd)
 Characteristics of bowel sounds in disease conditions:
− in diarrheas &in early intestinal obstruction: increased & high pitch
− ileus: absent
− ascites & peritonitis: distant

iii. Percussion:
 Normally the abdomen sounds tympanitic on percussion except when percussed over
solid organs like the liver or a full bladder.
  When dullness is noted in areas normally tympanitic on percussion, suspect presence
of fluid or tumor. When highly tympanitic, suspect colic, intestinal obstruction, or
ileus.
 Percussion is used to:
− Detect presence of fluid in the peritoneal cavity through 2 methods, i.e, fluid
wave & shifting dullness.

1 Fluid wave:
Fig. 8. Eliciting fluid wave. The examiner palpates the flank of the abdomen with
one hand and taps on the opposite flank with fingers of the other hand. An
aide or the patient places his hand on the midline to obliterate the feeling of
stretching of the skin which may affect the transmission of the fluid waves.
If fluid is present, “waves” will be felt by the examiner.

2 Shifting dullness
Figure 9a. Eliciting shifting dullness. The patient is examined on supine position.
Examiner percusses the abdomen from midline to the right flank until
dullness is perceived. A mark is placed over the area of transition from
tympanism to dullness.

Figure 9b. The patient is then asked to roll over & lie on the right side for at least
30 seconds. After fluid has settled at the dependent portion of abdomen,
percuss again from the left towards the right flank. Note the transition
where tympanism changes to dullness and mark the spot. If fluid is present
in the abdominal cavity, the areas of dullness will shift upward.

(Source: Walker, JH Kenneth et al. Clinical Methods: The History Physical and
Laboratory Exams, 3rded, Butterworth Publisher, 1990. www.ncbi.nlm.nih.gov.com)

− determine liver size or liver span

Fig. 10a. Measuring the liver span. Percuss along the right midclavicular line
(RMCL) anteriorly with the pleximeter finger held parallel to the ribs along
intercostal space using heavy percussion. Percuss downward until resonance
shifts to dullness. Mark this space as the upper border of the liver.

Fig. 10b. Measuring the liver span. The lower edge of the liver is determined by
Either palpation as noted in the next section or percussion from the RLQ
moving upward along RMCL until the tympanitic tone changes to dullness.
Mark this area as the lower liver edge & measure the 2 points as the liver
span (in cm).(Source: Walker, JH Kenneth et al. Clinical Methods: The
History Physical and Laboratory Exams, 3rded, Butterworth Publisher,
1990. www.ncbi.nlm.nih.gov.com)

Fig. 10c. Measuring liver span, an overview.

Table 16. Expected Liver Span of Infants & Children

Males Females
Age/yr Mean SEM Age/yr Mean SEM
estimated estimated
liver span liver span
0.5(6mo) 2.4 2.5 0.5(6mo) 2.6 2.6
1 2.8 2.0 1 3.1 2.1
2 3.5 1.6 2 3.6 1.7
3 4.0 1.6 3 4.0 1.7
4 4.4 1.6 4 4.3 1.6
5 4.8 1.5 5 4.5 1.6
 6 5.1 1.5 6 4.8 1.6
8 5.6 1.5 8 5.1 1.6
10 6.1 1.6 10 5.4 1.7
12 6.5 1.8 12 5.6 1.8
14 6.8 2.0 14 5.8 2.1
16 7.1 2.2 16 6.0 2.3
18 7.4 2.5 18 6.1 2.6
20 7.7 2.8 20 6.3 2.9
*SEM- standard error of the mean
(Source: Athreya, BH, Silverman, BK & Spitzer, AR. Pediatric Physical
Diagnosis. 1985, Appleton Century Crofts)

iv. Palpation:
 Preferably have the patient lie supine with both lower extremities semi-flexed at the
knees & hips. If using the right hand to palpate, stand on the right side of the patient.
Warm the hands before palpating the patient. Distract the child when palpating the
abdomen. Ask patient to inhale slowly & deeply as this relaxes the abdomen, then use
the flat side of the fingers of the examiner’s dominant hand to palpate the abdomen.
In a crying infant, place hand on abdomen & press fingers to palpate when infant
takes a deep breath after crying. In ticklish patients, place your hand on top of the
patient’s hand with your index finger overlapping. Palpate the child’s abdomen with
both the child’s & your overlapping index finger or fingers.
 In patients with abdominal pain, ask the patient first to pinpoint the area of maximal
pain. The clinician should start palpating away from the site of pain proceeding gently
to the painful area. Direct tenderness is present if pain in elicited on pressure.
Rebound or indirect tenderness is present if pain is felt or is greater on release of
fingers and is indicative of peritoneal irritation.
 In infants and young children who are unable to verbalize their feelings or who
complain a lot, the examiner should observe closely the facial expression while
palpating or percussing the abdomen. Wincing, grimacing or sudden crying while the
fingers are being pressed down are strongly suggestive of real pain and underlying
pathology.
 In determining the liver size below the right subcostal margin, first look for the lower
liver edge by palpating from the RLO upward along the RMCL until the liver edge is
palpated. The distance between the subcostal margin and the liver edge is measured in
cm along the RCML. In marked hepatomegaly, the left lobe of the liver can be
palpated over the epigastrium extending to the left subcostal area. In infants and
young children, the liver is normally palpable with the following variations in sizes
(length along RMCL below right subcostal margin):
0-6 months: 3.0 – 3.5 cm
6 months-4 y: 0 – 3 cm
4-10 y: < 2 cm
> 10 y: < 1 cm
 The spleen is usually not palpable unless it is enlarged at least 2-3 times its size.
Occasionally, the splenic tip maybe palpable in some infants and children. The spleen
is best examined in a supine patient by palpating from the RLQ to the left costal
margin using the right hand as the patient inspires deeply. The rationale for this
approach is because the spleen enlarges below the rib cage across the abdomen
toward the RLQ. The left hand may be used to lift the left rib cage and flank. If the
spleen is not palpable on supine position, the examiner may do the “Short’s
maneuver” by having patient lie on the right lateral decubitus. The examiner’s left
hand is placed over the left lower ribs on the midscapular line pushing the spleen
forward. The right hand is used to palpate the spleen starting from the RLQ
proceeding diagonally toward the left upper quadrant. Another method (Castell’s) for
detecting mild splenomegaly is to percuss the lowest intercostal space on the anterior
axillary line with patient on supine position. Normally, resonance is noted. With
 splenomegaly, the percussion yields dullness during maximal inspiration. The spleen,
when palpable, usually slides downward during inspiration and moves upward during
expiration. It is also characterized by the presence of splenic notches on its medial
edge. (http://www.gastroresource.com/gitextbook)

* Caution:In patients with large spleen, palpation should be gentle as heavy

pressure may cause splenic rupture.

Figure 11. Palpating for the spleen. (Source: Walker, JH Kenneth et al. Clinical
Methods: The History Physical and Laboratory Exams, 3rded, Butterworth
Publisher, 1990. www.ncbi.nlm.nih.gov.com)

 Palpate for other intra-abdominal organs or masses & describe their characteristics as
to the following: location, upper & lower borders, do they cross midline or are they in
midline, are they attached to abdominal wall, are they firm, hard, soft or cystic, do
they move with respiration, are they movable, are there bruits or murmur, or are they
pulsatile?
 Other important signs in abdominal exam:
− Psoas sign: This is done by placing your hand on the patient’s right knee and
asking him to flex his right hip against resistance. Increased abdominal pain
constitutes a (+) psoas sign and is indicative of appendicitis.
− Obturator sign: This is done by raising the patient’s right leg with flexed knee,
then rotating the leg internally at the hip. Increased abdominal pain indicates a
(+) test and suggest appendicitis.

o. Kidneys:
 Palpation of kidneys:
− Have patient lie supine and the abdomen relaxed.
− Place the palm of one hand posteriorly at the flank, pushing the kidneys
forward.
− With the other hand placed anteriorly below the costal margin, push the
abdominal wall backwards and upwards. The kidney is best felt at deep
inspiration. The kidney is fixed and does not move with respiration.
− Occasionally, the left kidney can be palpable in thin or malnourished children.
 Elicitation of costovertebral angle (CVA) tenderness (done only in older children or
adolescents):
− Have patient sit up on examining table.
− Use the heel of the closed fist (ulnar side) to strike the patient firmly on the
CVA (angle between the 12th rib and transverse process of upper lumbar
vertebrae).
− Another technique is to place the palm of one hand over the CVA and use the
heel of your closed fist to strike the dorsal aspect of the hand over the CVA.
− Compare left and right side.
− Presence of tenderness indicates renal inflammation, most often, an infection.
(Source: Basic Clinical Skills, Integrated Medical Curriculum website)

p. Inguinal regions:
 Hydrocoele, undescended testes, and lymph nodes are common causes of swelling in
the inguinal region. If masses are present, take note of fluctuations in size in relation
to coughing or crying and whether they spontaneously resolve or not.
− Indirect inguinal hernia is the most common cause of swelling over the
inguinal area, occurring more often in males, and presents as bulge in the
inguinal area extending into the scrotum. It usually enlarges when the child
cries or strains, and gets smaller when the child quiets down.
q. Genitalia
i. Male genitalia:
 Prepuse should be easily retractable so that when the preputial folds are held up by
both hands with the patient in supine position, a tunnel is formed and the metal
opening can be seen at the end of the tunnel.
 Phimosis is present if the preputial sac is very narrow and cannot be retracted.
 The urethra opens at the tip of the penis.
Hypospadia is present if meatus is located on the under surface of urethra.
Epispadia is present if urethral orifice is on the dorsal surface of the penis.
 The left side of the scrotum is usually at a lower level than the right, but both sides
should be about equal in size. If unequal, the larger side may be abnormal due to
presence of hydrocoele, hernia or enlarged testes, the smaller side may be associated
with absent testes (cryptorchidism). Palpation of the scrotal sacs should help
determine which side is abnormal.
 Majority of undescended testes descend during the 1st 3 months of life. If a testis has
not descended by 4 months, it will most likely remain undescended.
 Testicular volume is best determined using Prader’s orchidometer. However, in the
absence of an orchidometer, the following formula can be used to estimate testicular
volume: (length x width) ÷ 2
 Swelling of the scrotum may signify the presence of either hydrocele or hernia or
both.

Table 17. Differences between hydrocele & hernia.

Pathology Transillumination
Hydrocoele* Fluid enters through +
processus vaginalis
Hernia* Abdominal contents enter -
through processus vaginalis
*Note that both hydrocoele and hernias may be localized to the inguinal
areas only.

ii. Female genitalia:

 Gynecologic exam of the pediatric or adolescent patient if necessary, should be
treated with extra gentle care to prevent psychological trauma. The procedure should
be well explained first to the patient. Inspect first the vulvovaginal area, preferably
with the patient in frog leg position, followed by the knee-chest position with valsalva
maneuver to allow adequate assessment of the introital lower third vaginal area.
Gentle traction on the labia upward and outward helps expose the vaginal introitus for
assessment. Presence of discharge, laceration should be noted. It is also important to
note that normal hymen may appear in different variations., i.e., imperforate,
microperforate or septate.
 In older children, examination of the genitalia can be facilitated by allowing the
mother to help you in the examination. First put the child in supine position with
knees flexed. Ask the mother to gently lift the labia majora so as to expose the vaginal
introitus for assessment. This method puts the child at ease.
iii. For both adolescent male & females, do sexual maturity testing if indicated. See Appendix.

r. Anus and rectum:

 Prepare the child for the exam. Place on left lateral decubitus with legs flexed against
the abdomen to expose anus.
 Look for location, patency, fissures, tags, hemorrhoids, presence of pinworms,
prolapse, etc.
 If rectal exam is necessary, it is best carried out with child in left lateral decubitus
with right leg drawn up into his/her abdomen and the head curled down as in fetal
position. Use gloved index finger in older children and little finger in young infants
 for digital exam. Apply lubricant on finger tip before inserting finger. Assess
sphincter tone, presence of mass or impacted feces and tenderness.
s. Extremities: Check for clubbing, cyanosis, swelling and mobility of joints deformities, and in
newborns, test for congenital hip dislocation
 Clubbing can be detected by 2 methods:
− 1st method: look at the fingers from the side in profile. The vertical ht at the
proximal edge of the nail (A) should be equal to or just < than the height at the
distal interphalangeal (DIP) joint (B) in normal children. In clubbing “A” is >
than B.

Fig 12. Clubbing of fingers

− 2nd method: Schamroth’s sign: Appose the dorsal surfaces of the terminal
phalanges of corresponding fingers. Normally, there is a diamond-shaped
space at the base of the nail bed. In clubbing the space is lost.

Fig. 13. Schamroth’s sign (www.medscape.com)

t. Spine:
 Inspect the spine for deformities, sacrococcygeal dimple, pilonidal sinus, and local
tenderness.
 Palpate the spine for local tenderness especially if osteomyelitis or vertebral tumor is
suspected. Tenderness between the vertebrae may be elicited in disc inflammation.
 Screen for scoliosis by inspecting the back. Suspect scoliosis if shoulder is elevated
on one side, with prominent scapula on side of involvement, and with leg length
discrepancy. “Bend forward” test can be done by asking patient to bend forward with
both hands hanging down as if to touch the feet. A hump will be seen by the examiner
from the patient’s back if scoliosis is present.

Fig 14. Test for scoliosis. (www2.massgeneral.org)

u. Lymph nodes:
 Check size, number, location, consistency, tenderness, mobility, discrete or matted.
 Most lymph nodes are not usually palpable in the newborn. As the child grows older
and gets exposed to antigenic stimulation, lymphoid tissues increase in volume so that
the cervical, axillary and inguinal lymph nodes become palpable in childhood
especially during infections. They are not considered enlarged unless they exceed 1
cm for cervical and axillary nodes and > 1.5 cm for inguinal nodes.
 Regional adenopathy is usually the result of infection in the involved node &/ or its
drainage area.
 Generalized lymphadenopathy characterized by enlargement of > 2 noncontiguous
node regions, is usually caused by systemic diseases like infections,
lymphoproliferative diseases, metabolic storage diseases, histiocytic disorders,
hypersensitivity reactions, connective tissue diseases.
 Differentiating lymphadenopathy due to acute bacterial infections, TB and malignant
causes:
− acute bacterial infections: usually tender, sometimes with erythema and
warmth of the overlying skin.
− TB: maybe matted, sometimes with draining sinus.
− malignancy: usually firm & nontender, may be matted or fixed to the skin or
underlying structures.

Fig. 15. Lymph nodes of the head and neck region. (www.bcm.edu)
References:
− Athreya, BH and BK Silverman. Pediatric Physical Diagnosis.
Appleton-Century-Crofts, Connecticut, 1985.
− Bickley, LS & Szilagyi, PG. Bates’ Guide to Physical Exam and History Taking, 8th ed.
Philadelphia, Lippincott, Williams & Wilkins, 2003.
− Kliegman, RM, Behrman, RE et al. Nelson’s Textbook of Pediatrics, Saunders,
Philadelphia, 2007, 18thed.
− Park, MK & Troxler, RG.Pediatric Cardiology for Practitioners, 4th ed., St. Louis,
Missouri, Mosby, 2002.
− Walker, JH Kenneth et al. Clinical Methods: The History Physical and Laboratory
Exams, 3rd ed, Butterworth Publisher, 1990. (www.ncbi.nlm.nih.gov.com)