e.

Other symptoms
Pediatrics 3B - Those manifestations that were not mentioned by the informant but
APPLIED PEDIATRICS you feel are important in order to arrive to a diagnosis
Reynaldo De Vega, MD - Example: High grade fever with bulging fontanelle may
‣ Think of increased ICP → CNS infection

Interviewing and History-taking Skills PQRST of history taking

• Precipitating / Palliative Factors
1. Establish a warm, friendly atmosphere. • Quality / Quantity
2. Maintain privacy and eliminate distractions. • Region / Radiation
3. Sustain eye contact. • Severity
4. Continue a steady logical ow of content and conversation • Timing / Onset
5. Listen carefully. • Understanding
6. Watch for important non-verbal cues.
7. Season conversation with expressions of sympathy and support. How to characterize fever?
• Low grade, high grade
Format of Pediatric History • Recurrent - Fever that lasts from a few days to a few weeks
and are separated by symptom free intervals
• Continuous - Temperature remains above normal throughout
I. Informant and reliability
a 24-hour period and does not uctuate more than 1℃ in 24
- First identi ed
hours
- Choose the more reliable informant (mother, father, grandparents,
• Intermittent - Fever is only present for some hours within the
aunties or older sisters ~ basically anybody)
24 hour period
✓ Must give consistent data
‣ Quotidian - daily
‣ Test by asking the same questions that were asked
‣ Tertian - every other day
a few hours ago or questions that were asked from
‣ Quartan - every 3rd day
the last meeting and check if there is variability in
• Remittent - Fever does not disappear; Fluctuating fever more
answers (inconsistent) or if the answers are the
than 1℃ but not touching the normal temperature
same (consistent, reliable)
✓ Can give the sequence of events of the manifestations, quality
Dr. Wunderlich established norms
of manifestations, how it started and how it ended
• Subnormal - 36.6 ℃ (97.7 ℉)
✓ 3C’s of a good informant: Consistent, chronology, con dence
• Normal - Between 36.6 ℃ and 37.4 ℃ (97.7 ℉ to 99.4 ℉)
• Subfebrile - Between 37.5 ℃ and 38 ℃ (99.5 ℉ to 199.4 ℉)
II. General data
- Name, Age, Sex, Birthday, Religion, Nationality, Present address
- Manner of delivery, Maternal blood type, Duration of labor, APGAR VI. Prenatal History
score - None in adult history taking
- Race, Number of times admitted, date of admission - Tells you what happened or what are the events during the pregnancy
- Similar from that of the adults except for two: of the mother of the baby
1. Civil status (once a pediatric aged person gets married or gets
pregnant, she is automatically disquali ed from being a pediatric a. What Para? Gravida?
patient) b. Mother’s age at the time of birth of the child - especially in the
2. Occupation - may or may not be asked depending on the age of extremes of age because there are associated problems related to
the patient because there are adolescents who are working those age groups
c. Wanted/unwanted pregnancy - case to case basis in asking
III. Chief complaint - mother’s or guardian’s words - If unwanted pregnancy, note of possible problems of malformation
- Main reason why the patient was brought for consultation due to attempted abortion
- Use the exact words of the informant d. Maternal illness/es during pregnancy - important especially during
- The only part in pediatric history wherein the words of the informant will the rst trimester where organogenesis is at it’s peak; GERMAN
be written down MEASLES - most researched illness that may cause teratogenic
- Do not write a diagnosis in the chief complaint problems
e. Drugs take during pregnancy - no drug = safe
IV. History of Present Illness - Steroids - associated with cleft palate
- De ned as the chronology of events from the onset of symptoms to the - DIlantin - associated with cleft palate or lip
time the patient was brought for consultation - Tetracycline - stains the teeth
f. Exposure to x-ray, injurious toxins including smoking and
a. Duration / onset of signs of symptoms alcoholism
- Duration: How long has it been going on? - Tobacco smoking - SGA, miscarriage, IUGR
- Onset: How and when did the illness occur? - Alcohol - precipitate abortion
‣ How - abrupt or acute, chronic or insidious - Drug abuse
‣ When - a day prior, 2 days prior etc g. Term of pregnancy
b. Intensity and frequency - Closely associated to developmental milestones and growth
- Intensity: Severity of illness; mild, moderate, severe parameters
- Frequency: Number of times the signs and symptoms occurred - Later developers may be associated to preterm birth
c. Factors that aggravate or relieve that symptoms
- Example: Abdominal pain
‣ May be a ected by food intake or physical movements Classi cation of Newborn by Weight
- Example: Headache • Extremely LBW: < 1000 g
‣ May be a ected by physical movements • Very LBW: < 1500 g
‣ Does it occur in the morning or in the evening • LBW: < 2500 g
d. General trend of the manifestations - improving or not
- May be able to guide you in relation to the prognosis, manner of
approach in the diagnosis and treatment
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Classi cation of Newborn by Gestational Age
• Small for GA: < 10th percentile
‣ Prone to hypothermia; may still be premature
• Appropriate for GA: 10th to 90th percentile
• Large for GA: > 90th percentile
‣ Infants of diabetic mothers
• SGA and LGA babies are prone to hypoglycemic episodes
and other metabolic episodes as well as to infections
Intrauterine Growth Restriction (IUGR)
• A condition in which an unborn baby is smaller than expected
• Possible to have IUGR and SGA, SGA but not IUGR, SGA but
not IUGR
VIII. Natal/Birth History
- Talks about the rst 24 hours of life of the child
a. Did the patient breathe spontaneously at birth?
- Longer time the patient does not breathe, the more problems
especially on the brain therefore, must watch for the developmental
milestones
b. APGAR score - helps identify if the patient needs resuscitation;
higher the score the better, lower the score the more dangerous
‣ Taken at 1- to 5-minutes of life
‣ Re ects the cardiopulmonary stability
< 3 - needs resuscitation
3 to 6 - asphyxiated, observe
> 7 - good, normal
9 to 10 - excellent
APGAR score at 1 minute
• Score of less then 3 - resuscitate
• How well the baby tolerated the birthing process
APGAR score at 5 minutes
• Indicated prognostic value
• LOW means that the baby is su ering from asphyxia, and
neurologic problems may follow
• How well the baby is doing outside the womb
APGAR score of 9 or more - good pulse, good grimace
APGAR score is low if:
• No cry, bluish baby
• If only pulsation is present - score is possibly 1
• No cardiac rate - score is 0
Last to check in APGAR is cardiac rate
Acrocyanosis - pink torso, blue extremities
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c. Birth weight - average Filipino BW = 3000 g / 3 kg
d. Cord coil, meconium-staining
- Re ections of a possible asphyxia
- Thick, milky meconium - severe distress
e. Appearance of the umbilical cord and placenta
f. Manner of delivery
i. Was the onset of labor spontaneous or induced?
ii. NSD / CS / or Forceps-indications
- CS - more prone to transient tachypnea of the newborn (RDS
type II)
iii. Presentation - cephalic, face, chin, breech, shoulder, footling
iv. Total duration of labor / delivery - longer in rst time mothers (10 to
12 hours); multigravida - 4 to 6 hours
v. Oligohydramnios / Polyhydramnios - normal amount of AF is 500 to
1000 mL
VII. Neonatal History
- Tells you how was the baby during the rst month of life (neonate)
a. Length of stay in the nursery
- Was the long stay due to the baby or the mother?
b. Infection, convulsion, jaundice
- Physiologic Jaundice - after 24 hours until 5 to 7 days (if premature)
- Pathologic Jaundice - 1st 24 hours of life
c. Was bili-light (phototherapy) used?
- Due to hyperbilirubinemia
d. Was the baby transfused?
e. Were there bleeding problems?
- Was there petechiae or hematoma?
- Earliest clue - bleeding or hematoma from site of injection of
Vitamin K
VI. Nutritional/Feeding Records
a. Type of feeding
- Natural breastfeeding
- Arti cial feeding includes any type of feeding other than breastfeed
(includes bottle feeding, use of dropper, and NGT)
- Mixed type of feeding
b. If bottle-fed, what type of formula is used? Preparation done?
c. Introduction to solid food (weaning)
- Ideally start at the age of 6 months
- If done earlier, the baby may become obese or have hyperviscosity
syndrome
i. Technique
ii. Types of foods
‣ 6 months - pureed, mashed, semi-solid
‣ 8 months - nger foods
‣ 10 months - critical time for lumpy foods, child should
learn how to chew
‣ 12 months - same as family
d. Adequacy of food / milk
- Short term - baby falls asleep after feeding
- Long term - weight gain
V. Past Medical History
a. Details of any prior illness and hospitalizations
- Signs and symptoms if remembered
b. Surgery
- Diagnosis
- Procedure done
- When performed
- Complications
c. Accidents
- Dependent on the age
- Ingestions of foreign bodies usually noted at 6 months to 3 years of
age
- Ingestion of corrosive substances usually noted at 5 years old
- History of falls commonly seen at about 1 year to 3 years of age
- Recurrent - think of abuse
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 d. Adolescent V. Regional Examination
- Most di cult patients in pediatrics; gain their trust - Di cult to do especially if the patient is uncooperative
- HEADSSFIRST risk assessment - Start even if the patient is uncooperative
- Sexual habits
- Contraceptives used a. Inspection
- Pregnancies b. Palpation
- Sexually transmitted infections c. Percussion
d. Auscultation
V. Immunization History
- Know the vaccines that should be given at the certain age HEADSSFIRST
- Know the route of administration • H - Home
- Know the adverse reactions - Space
- Privacy
- Frequent geographic moves
- Neighborhood
• E - Education / School
- Frequent school changes
- Repetition of a grade / in each subject
- Teachers’ reports
- Vocational goals
- After-school educational clubs (language, speech, math, etc)
- Learning disabilities
• A - Abuse
- Physical
- Sexual
- Emotional
- Verbal
- Parental discipline
• D - Drugs
VI. Developmental History / Milestone - Tobacco, alcohol, marijuana, inhalants, “club drugs”, “rave” parties
- It is helpful to chart recent and subsequent weight and height - Drug of choice
measurements - Age at initiation
- Remember the important milestones for a certain age - Frequency
‣ 2 or 3 months - social smile (sign of interaction with the - Mode of intake
environment) - Rituals
‣ 2 to 4 months - vocalization - Alone or with peers
‣ 4 months - head control - Quit methods
‣ 6 to 7 months - rolls over (supine to prone) - Number of attempts
‣ 8 months - sits without support • S - Safety
‣ 12 months - stands alone, walks alone - Seat belts
- Helmets
VII. Social/Personal History - Sports safety measures
a. Personality characteristics - Hazardous activities
b. Personal habits - Driving while intoxicated
i. Feeding - picky eaters, know feeding practice at home • S - Sexuality / Sexual identity
ii. Sleeping - Reproductive health (use of contraceptives, presence of STIs,
iii. Toileting - training can start as early as 18 months but not feelings, pregnancy)
beyond 3 years • F - Family and Friends
iv. Games / play - FAMILY
v. Living conditions ‣ Family constellation
c. Sources of support - nancial, psychological, educational ‣ Genogram
d. School history - interaction with schoolmates, if the patient was ‣ Single / Married / Separated / Divorced / Blended family
previously excelling then suddenly had poor performance ‣ Family occupations and shifts
e. Strength / weakness ‣ History of addiction in 1st and 2nd degree relatives
‣ Parental attitude towards alcohol and drugs
VI. Family History ‣ Parental rules
a. Parents ‣ Chronically ill, mentally or physical challenged parent
i. Names / ages - FRIENDS
ii. Health status ‣ Peer cliques and con guration (“jocks”, “nerds”, “computer
iii. Are these natural parents? geeks”, “cheerleaders”)
iv. Occupation/educational attainment ‣ Gang or cult a liation
b. Siblings • I - Image
i. Number, ages, sex - Height and weight perceptions
ii. Illnesses (past or present) - Body musculature and physique
iii. Health status - Appearance
c. Others ‣ Dress
i. History of grandparents ‣ Jewelry
ii. Health history of babysitters ‣ Tattoos
‣ Body piercing as fashion trends or other statement
IV. Systems Review • R - Recreations
- Similar to adults - Sleep
- Exercise
- Organized / unstructured sports
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 - Recreational activities of cutis aplasia, a congenital anomaly in which the scalp has not
‣ TV formed properly.
‣ Video / computer games
‣ Internet FACE
‣ Church / community youth group activities (boy / girl scouts, • Ears
campus groups) - Check for ear placement by imagining a straight line drawn from
‣ How many hours per day? the outer corner of the eye. The upper portion of the ear should
‣ Days per week involved? meet this line.
• S - Spiritually and Connectedness ‣ If not, the ears may be considered low set
- Faith beliefs, importance and in uence of faith, community support - Imagine a second line, drawn perpendicular to the rst, is the
- Adherence infant’s ear straight along this axis?
- Rituals ‣ If it is tilted back, the ear may be in a posterior rotation
- Occult practices - An atypical ear position is not dangerous, but may prompt
- Community service or involvement consideration for an underlying genetic condition
• T - Threats and Violence - Assess for ear formation
- Self harm or harm to others ‣ Do the ears have a
- Running away complete rim of skin
- Cruelty to animals surrounding them, called
- Guns, ghts, arrests the helix?
- Stealing ‣ Dies the skin inside the
- Fire setting helix, called the crus, have
- Fights in school folds, or is it unusually
smooth?
Physical Examination for a Newborn ‣ Check the skin beside the
ear’s tragus for pits and
General Survey skin tags
• Asleep or awake? ‣ Minor variants may be
• Warm or cool? associated with some
• Vital signs in normal range? genetic conditions, as well
• Di culty breathing? as hearing loss or anomalies fo the kidneys, the development
• Signs of distress or illness? of which are controlled by some of the same genes as the ears
• Eyes
HEAD - Inspection
• Measure the head circumference (cm) by wrapping the tape above ‣ Do they appear widely spaced?
the eye brows to the most prominent aspect of the occiput ‣ Does the opening of the eye, called palpebral ssure, pointed
- Determine if her head is of normal size by plotting the upwards or downwards?
circumference on a newborn birth chart ‣ Check the pupils. Coax the child to open her eyes by turning
- The head circumference should be in the average range for o the lights or cupping your hands over her eyelids. When she
infants of the same gestational age, and also fall approximately in opens them, quickly assess the infant’s red re ex by shining
the same percentile as the infant’s length and weight the ophthalmoscope light on the eye. Flash of red in each eye
• What is the shape of your patient’s head? indicates the normal presence of retinal vessels in the eye.
- A newborn skull is made up of several bony plates that meet ➡ An asymmetric red re ex, particularly if the color seen is
along exible cranial sutures white, you may have detected a retinal anomaly such as a
- In the center, they form a soft spot known as the anterior congenital cataract or a
fontanelle retinal blastoma
- There is a smaller fontanelle in the back: posterior fontanelle ➡ Coloboma - missing pieces
- Cranial Sutures (CLAMS) of tissue in the structure that
‣ Coronal suture form the eye
‣ Lambdoid suture
‣ Anterior fontanelle
‣ Metopic suture • Nose
‣ Sagittal suture - Assess for patency of the nares, as neonates are preferential nasal
- This design allows the skull to be malleable enough to t through breathers
the birth canal, which often leads to a temporary deformation - If there is any history of respiratory distress or noisy breathing
called molding when feeding or crying, patency can be proven by passing a small
• Check the infant’s skull for bruising and swelling French catheter through each nares.
- A bruise that does not cross the suture line is called - It is common for newborns to have transient obstruction from
cephalohematoma which causes bleeding below the periosteum edema related to suctioning after birth, but the di erential also
and is more common in births assisted by vacuum or forceps includes choanal atresia or choanal stenosis, and improper
‣ These infants are at increased risk of jaundice due to the formation or narrowing of the nasal airways
breakdown of hemoglobin as the bruise resolves
- If the swelling crosses suture lines, it is most commonly due to
caput succedaneum, a uid accumulation that forms above the
periosteum due to the force of delivery
‣ Swelling typically resolves within a few days of birth
- Extensive swelling that crosses suture lines due to the rupture of
emissary veins is called subgaleal hemorrhage, and can lead to
more serious complications due to signi cant blood loss in a
large potential space
• Run your ngers over the skin of the infant’s scalp - feel for any areas
where the skin is missing or has an unusual texture, it may be a sign

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 - Choanal atresia is a characterisctic nding of the genetic
condition CHARGE syndrome, which is an acronym for:
‣ Coloboma of the eye
‣ Heart abnormalities
‣ Atresia of the choanae
‣ Retardation of growth or development
‣ Genitourinary abnormalities
‣ Ear abnormalities
• Mouth and Jaw
- Gently insert your gloves nger into the newborn’s mouth
- A healthy baby will re exively suck on the glove
- In the anterior portion of the mouth, you will feel the soft palate
- A division or cleft in the hard palate or lip may be easy to detect by
inspection
- Clefts in the soft palate are more di cult to observe by eye
- A patient with a cleft palate or cleft lip should be referred to an ear,
nose, and throat specialist and may need special help with feeding
- Cleft palate is commonly an isolated congenital anomaly, but can
also be associated with other medical conditions
• Tongue
- Is she able to elevate her tongue and push it past the lower gums?
‣ If not, she may have ankyloglossia, more commonly known as
tongue tie
‣ Could impair the infant’s ability to breastfeed
‣ A frenotomy, or release of the frenulum, may be indicated if
breastfeeding is painful or ine cient
• Do brief overall examination of the infant’s mouth - note for unusual
ndings such as a natal tooth
NECK
• Note if there is obvious webbing of the neck or redundant skin, which
can be found in Turner syndrome or Noonan syndrome
- Patent ductus arteriosus - continuous machinelike murmur
‣ This murmurs is benign, and in a full-term infant, should
reserve within the rst few days of life
- Other heart murmurs that does not improve within days, should be
further evaluated
- The rst step to undertake when investigating an newborn heart
murmur include obtaining pre- and post-ductal oxygen
saturation, four extremity blood pressure, and an EKG
• Assess the infant’s respiration
- Periodic breathing - normal for infants to take short pauses in
their breathing or breathe at a slightly irregular rate
• Auscultate the lungs
- Start along the apex of the lungs and around their sides and back
- The lungs should sound equally loud with clear passage of air and
no wheezes or crackles
- Normal newborn respiratory rate: 30 to 60 breaths per minute
ABDOMEN
• Inspect
- Is it distended?
- The skin around the umbilical cord should look clean and dry
- Umbilical hernia - outpouching of skin around the umbilicus
‣ Evaluate whether this is reducible by gently pushing it back
toward the abdomen
- A hernia that feels rm or is stuck in place may be incarcerated and
should be evaluated by a surgical specialist
• Palpate
- Place on hand on top of the other and push gently
- On the right side, assess the size of the liver. The liver edge should
either not be palpable or lie very close to the newborn’s ribs
- Palpate around the abdomen and carefully assess for mass
- Some infants may have intra-abdominal neoplasms, such as
neuroblastoma or Wilm’s tumor

• Clavicles
- Should feel smooth without any crepitus, breaks, or step-o s
- Fractures may occur during delivery particularly in infants who had
shoulder dystocia
CHEST
• Inspect the shape of the chest
- Does the sternum lie at or is it concave (pectus excavactum) or
is it convex (pectus carinatum)?
- These ndings are more common in some connective tissue and
cardiac disorders such as Marfans Syndrome
- An isolated pectus abnormality is considered a minor variant, and
is not cause for a genetics referral
• Auscultate the heart
- Use same landmarks as when examining an older child or adult
- Normal newborn heart rate: 120 to 160 bpm
- Listen for up to a minute before you can clearly make out the
sounds of systole and diastole
GROIN
• Assess the femoral pulses by placing your ngers along the crease
between the thigh and diaper area. Do not push too hard.
- May take several minutes before you can feel a steady pulse on
both sides
- If unable to nd the pulse or it feels very weak on one side, you
may have identi ed an aortic coarctation
- Can be further investigated by measuring pre- and post-ductal
oxygen saturation and four extremity blood pressure
• Check for the presence of inguinal hernia
• Evaluate the genitalia
- Female: labia and clitoris may appear engorged as a result of
maternal hormones, some may experience small amount of vaginal
discharge or bleeding, skin tags on the posterior fourchette
- Male: assess if the testicles are descended by palpating them
through the scrotum
‣ A swollen, enlarged scrotum is usually indicative of a
hydrocele - a uid collection around the testes which will
spontaneously resolve
‣ Examine penis for any abnormal curvature and that the foreskin
full covers the glans
‣ Hooded foreskin is often indicative of hypodpadias, or the
ventral displacement of the urethral meatus
• Assess the patency of the anus by using one hand to hold the legs and
the other to gently spread apart the gluteal cleft
• Assess the infant’s hips to test for hip dysplasia
- Hip dysplasia is a congenital deformation or misalignment of the
hip joint, and is more common in infants who have a family history
of hip dysplasia, are female, or who had a breech presentation in
utero
- Assess the hips one at a time using two maneuvers
‣ Barlow Maneuver
➡ Adduct hip by bringing the thigh toward the midline
➡ Apply gentle posterior pressure to the knee
‣ Ortolani Maneuver
➡ Flex the infant’s knees to a 90-degree position
➡ Abduct the legs by folding the thighs outwards

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 ‣ If you feel a clunk or dislocation, close follow-up should be • Moro re ex
arranged with the primary care physician or an orthopedic - Hold the infant’s hands and pull forward until her head is a few
surgeon, depending on the severity of the nding centimeters above the bassinet
• All neonates with risk factors should have a hip ultrasound at - Drop her head gently into your other hand
four to six weeks of life, regardless of a normal hip exam - Her hand should open, and her upper extremities should extend
then retract
EXTREMITIES • Palmar grasp re ex
• Are there 10 ngers and 10 toes? - Easily listed by pushing your ngertip into the baby’s palm, causing
her to wrap her ngers around yours
• Many infants have a small nubbin of • Rooting re ex
skin attached to the exterior of the fth - Evaluated by stroking the infant’s cheek, leading her to start
nger (normal nding, may be inherited suckling her mouth in anticipation of a feed

Physical Examination for a Neonate

• What about the length of the digits? Approach to Examination

- Brachydactyly - short ngers • After gathering the equipment, consider your approach to the exam
- Arachnodactyly - long ngers • Plan to keep neonate warm
• Handle him gently
• Assess the palms • Keep him calm
- Single transverse palmar crease - a lone, horizontal crease in the • Adjust the order of the exam as required by the neonate’s sleep/
palm wakefulness state or physical condition
‣ More common in infants with neurologic conditions such as
Down syndrome (found in 1% of the general population) Because the physical examination shares many techniques common with
• A minor variant in hand morphology should not prompt referral to gestational age assessment, gestational age assessments will be
genetics, unless it is one nding among a constellation of others described here and marked by this logo. ( )
• Major anomalies of the hand or feet, however, such as missing or extra
digits, should prompt further investigation Keep in mind that the gestational age assessment is most accurate in the
rst 12 hours after birth.
BACK
• Common for infants to have blue-gray macules on their back that fade Immediately before the physical assessment, undress the neonate on an
over time examination table with an overhead heating element and good lighting or
• Erythema Toxicum on a warming table.
- Normal newborn rashes
- Look like pustules on an erythemtous base HEAD-TO-TOE EXAMINATION
- Appear between 24 to 48 hours of life While the neonate is quiet, assess his general appearance. Note the
• Sacral Area following:
- Dimple - check if you can clearly visualize the base of the • Breathing pattern
indentation. If you cannot, the infant may have a spinal cord • Posture including body symmetry and spontaneous position
abnormality, known as a thethered cord or spinal bi da occulta • Muscle tone including exion and spontaneous movement
- Conspicuous patch of hair on the lower back or an asymmetric • Skin color and characteristics - should be pink to pinkish brown
gluteal cleft - If jaundice is present, note its degree
- Observe for dry peeling skin, lanugo, vernix, birthmarks, rashes, or
NEUROLOGIC lesions
• Awake or asleep • Palpate skin texture and turgor
• Irritable or calm
• Consolable or inconsolable Mongolian Spots
• Test muscle tone • Common variation in normal pigmentation in
- Pull her toward you black, asian and hispanic neonates
- Does her body feel sti and hypertonic or overly oppy and
hypotonic? General Appearance
- Does her head come up with her body to a sitting position, or does • Neonate’s state should be alert and responsive
it lag behind? • If the neonate cries, characterize his cry (should be strong and lusty)

Vital Signs and Measurements

Respiratory Rate
• If the neonate is quiet, check the RR by counting abdominal
movements for 1 minute because the pattern can vary greatly
• Normally, the RR is 40-60 breaths per minute

Heart Rate
• Use a warm, neonatal stethoscope to auscultate the apical pulse for a
full minute
• Assess motor function by observation • Normal HR is 80-160 bpm
- Does she move all her extremities well? • Point of Maximal Impulse should be located lateral to the midclavicular
- Is her face symmetric? line at the 3rd or 4th ICS
• Sensation can be determined by noticing how she responds to your
touch. Temperature
• Primitive re exes • Using an axillary thermometer, take the neonate’s temperature which
- Unique aspect of newborn exam should be T 35.5-37.5℃
- Note for symmetry
‣ Asymmetry may indicate a neurologic or orthopedic condition

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 Weight ROOTING REFLEX
• With a platform balance scale, weigh the neonate to the nearest 10 • Brush the neonate’s cheek near his mouth, he should turn his head
grams toward that side and open his mouth
• A full term neonate should weigh 2,500-4,000 grams to be appropriate
for his gestational age SUCKING REFLEX
• Place your gloved little nger gently on the neonate’s mouth
Length • He should suck on it strongly
• For accurate measurement, extend one leg by pushing the knee down
until the leg is at Hard and Soft Palates
• A full term neonate should be 48-53 cms long • Use your gloved nger to palpate the hard and soft palates which
should be continuous
Head Circumference
• Using a tape measure, assess the head circumference by measuring NECK
around the occipital area just above the eyebrows at the widest point • Lift the shoulders and let his head tilt back
• Normally, the neck is symmetrical, has multiple skin folds, and display
HEAD AND FACE a full range of motion
• To assess the head, observe its shape and symmetry • Palpate the trachea which should be midline
• Noting any molding or any overriding of the cranial bone which is • Lymph nodes are normally not palpable
normal • Thyroid gland is di cult to palpate unless enlarged
• Observe for cranial swelling and fontanelle bulging • You should detect no masses or lumps
• Palpate clavicles which should feel no crepitus or lumps
Fontanels
• With the neonate upright, gently palpate the fontanels, suture lines and CHEST
cranial bones • Inspect Con guration
• The fontanels should be soft and at - The thorax should be rounded with a prominent xyphoid process
• The suture lines should feel like ridges and be movable, not xed - For the rst few hours after birth, the neonate’s precordium may be
due to a thin chest wall
Facial Features • Note for neonate’s chest movement
• Note the positioning and symmetry of the neonate’s facial features at - Symmetrical
rest and with crying or sucking - No labored breathing nor retractions
• Should be in proportion, symmetrical, and fully formed
Nipples and Breast Tissue
EYES AND EARS • Normally aligned
Eyelids • Palpate for breast enlargement and scant white discharge which
• While the neonate’s eyes are open, observe the eyelids which may be usually resolves within a week
pu y
• Observe eye size and shape which should be symmetrical Breath Sounds
• Irises should be evenly colored • Using a neonatal stethoscope, auscultate breath sounds
• Corneas should be bright and shiny systematically, comparing sounds
• Sclera should be bluish white • Listen to the neonate’s intercostal spaces, not his ribs
• In a darkened room, use a ne point light (pen light or otoscope) to • Should hear no abnormal breath sound or audible noises such as
elicit pupillary light re ex in which the pupils constrict equally in grunting
response to the light
• Corneal light re ex → light is re ected on the same spot on each eye Heart Sounds
• Red Re ex • Using the diaphragm, auscultate the heart sounds starting at the PMI
- Use an ophthalmoscope • Auscultate in the:
- As the neonate looks at the light, a red glow should ll his pupils - Aortic Area
- In a dark skin toned neonate, the red re ex may normally appear - Pulmonic Area
pale or grayish - Tricuspid Area
Ears - Mitral Area
• Observe the position of the neonate’s ears by drawing an imaginary • Using the bell, auscultate heart sounds in these areas again. Expect
line from the corner of the eye to the occiput the heart sounds to be relatively loud, because of the neonate’s thin
• The pinna should be at this line chest wall
• Ears should be within 10° of vertical • You may also hear a grade 1 or 2 systolic murmur in the rst 2-3 days
• Inspect size, shape, and alignment of the ears noting any skin tags or after birth
pits
• Palpate auricles which should be exible ABDOMEN
• Auscultate for bowel sounds which should be heard in all four
NOSE AND MOUTH quadrants
Nose • Size and Shape: which normally is round, symmetrical, protuberant,
• Position and Shape: inspect the neonate’s nose which should be and moves with respirations
midline and symmetrical and may be slightly attened • Inspect umbilical cord stump
• Be aware that a black or asian neonate normally has a at nasal bridge - At birth, it should be white, containing 2 umbilical arteries and 1
• Watch the neonate breathe while quiet vein
• You should see no aring or narrowing of nasal passages - By 10-14 days after birth, it should fall o and the base should
have no drainage or erythema
Mouth • Before palpating, ex the neonates knees and hips with one hand to
• Inspect the lips which should be symmetrical and pink relax the abdominal muscles
• Mouth should be in the midline and symmetrical • Use your other hand to check the muscle tone which should be soft
• Tongue should be proportionately sized • Palpate liver’s edge 1-2 cms below the right costal margin and spleen
• Frenulum should allow normal tongue movement tip at the left costal margin
• Gums and mucosa should be pink and moist • Palpate all four quadrants systematically to detect any masses

Pediatrics 3B Pinky Square 7 of 11

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 • Place one hand under the neonate’s ank and press down with the GENITALIA
other hand to palpate the kidneys MALE NEONATE
• Inspect the femoral area which should have no bulges then palpate Penis
femoral pulses and inguinal lymph nodes • Normally 2-3 cms long and has a meatus centered at its tip
• If circumcised, the glans should look smooth
UPPER EXTREMITIES • If not circumcised, the foreskin should not be retracting
• Inspect the upper extremities and check the range of motion and Scrotum
muscle tone • Inspect and palpate the scrotum
• In a full term neonate, they should be well exed and should move • You should see deep rugae and should feel testis on both sides of a
smoothly and symmetrical pendulous scrotal sac
• Assess for Scarf Sign • In a white neonate, the scrotum should look pink
- By drawing each arm across the neonate’s chest • In a dark skinned neonate, it should appear dark brown
- In a full term neonate, the elbow should not reach midline • In any neonate, the scrotum should have no bulges
• Check for Arm Recoil
- Flex the neonate’s arms for 5 seconds then extend them by pulling FEMALE NEONATE
his hands and releasing them Labia Majora
- A full term neonate’s arms should ex briskly and fully • Inspect the external genitalia
• Assess Square Window Sign • Normally, the labia majora are swollen and cover the labia minora and
- Flex the neonate’s hand on his forearm between your thumb and clitoris
index nger • With your thumbs on the labia majora, push laterally. The hymen should
- The angle between the forearm and palm should be nearly 0° in a appear thick and may have a hymenal tag
full term neonate • You may see a vaginal discharge, but should nd no bulges
• Carefully inspect the hands which should be in a normal color
• Have nails that cover the nail beds NEUROMUSCULAR SYSTEM
• No extra ngers or webbing DOLL’S EYE REFLEX
• Note any palmar creases • First rotate the neonate’s head slowly from side to side to assess the
doll’s eye re ex
PALMAR GRASP REFLEX • Normally, his eyes shift to the opposite direction
• Place your index ngers in the neonate’s palms
• His hands should grasp your ngers tightly Muscle Strength
• Lift the neonate under the axilla and hold him facing you at eye level
Head Lag • The neonate should wedge securely between your hands without
• While the neonate holds your ngers, wrap your hands around his slipping
hands and pull slowly, and note the head lag
• Normally, head lag is minimal SPINE
• Hold the neonate prone in your hands or place him prone on the
Radial and Brachial Pulses examining table
• Palpate the radial and brachial pulses with your index ngers • Inspect the length of the spine which should be straight
• Pulses should be regular and strong • Symmetrical gluteal folds
• When palpated simultaneously on both arms, they should be equal in • No sinus openings, protrusions, or tufts of hair
strength and similar to femoral pulses
TRUNCAL INCURVATION REFLEX
LOWER EXTREMITIES • Press rmly on one side of the thoracic spine
• Inspect the lower extremities and assess their range of motion and • Neonate’s pelvis should ex toward the stimulated side
muscle tone
• They should be well exed and should move smoothly and symmetrical RECTUM
• Place the neonate prone on the table
Ortolani’s Maneuver • Observe the buttocks which should be rm and rounded, with no
• Flex the neonate’s hips and knees then abduct both legs masses or lesions
simultaneously until they nearly touch the table • Spread the buttocks and inspect the anal opening which should be
• A palpable clump indicates hip dislocation patent
• Immediately perform Barlow’s maneuver
Final Procedures
Barlow’s Maneuver • To complete the examination, perform the procedures that are likely to
• From the abducted position, bring the knees together and push cause crying
laterally on the upper inner thigh • Blood pressure with oscillometric device
• A clump indicates an unstable hip joint • Moro Re ex by suddenly making a loud noise. The neonate should
extend and abduct his arms and legs and then bring in both arms and
Heel-To-Ear Maneuver legs
• With the neonate’s pelvis at, gently move one foot close to his head
• In a full term neonate, the heel-to-ear maneuver creates an 90° or less Summary
between the foot and head • After examining the neonate, review your ndings with his parents
• Answer any questions they may have (Q&A)
Popliteal Angle • Teach them how to promote their neonate’s health and development
• Move the neonate’s knee toward his chest and extend the leg gently - Immunizations
• Popliteal angle should be less than 90° in a full term neonate

Feet and Toes

• Inspect the feet which should have no extra toes or webbing

Plantar Surface of Feet

• A full term neonate should display deep creases for the entire sole of
both feet
Pediatrics 3B Pinky Square 8 of 11
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Physical Examination for a Child ‣ The child should see the moving target at the same time you
• Before starting, ask for age and observe for developmental stage do
• Do techniques to engage the child by explaining each step - Conjunctivae and sclerae
‣ Note the clarity, color, and pigmentation
General Survey ‣ Black child’s sclerae - may appear brownish
• General appearance ‣ White child’s sclerae - may appear pinkish
- Ability to amuse herself - Gently press on the lacrimal sac to detect infection or blockage
- Parent-child interaction - Use an ophthalmoscope to check for the red eye re ex and inspect
- Gross and ne motor skills the fundus
• Overview observations - Visual acuity and elds > 3 years old
- Physical appearance ‣ Using a picture chart or Snellen Chart
- Observe for the child’s behavior including alertness and response ‣ Normally a child has a 20/20 vision by age 7
to stimuli • Ears
- Activity level - Size, shape, position - low set
- Developmental milestones ‣ Top of the pinna should meet the line drawn from the corner of
- Posture the eye to the occiput
- Leg and foot alignment - Palpate each auricle
- Speech - Otoscopy - (MUST) visualize TM and ear canal
- Vision and hearing ‣ Inspect the TM for color, light re ex, bony landmarks, mobility,
- Social interaction perforation, bulging, retraction and scars
• Nutritional status - Hearing examination - use of tuning fork (Weber and Rinne Tests)
• Hydration ‣ Whispered voice test - repeat each word after you whisper
• Level of consciousness ‣ Weber test - placed on the child’s scalp on the midline
• Vital signs ‣ Rinne test - placed on the mastoid process to test bone
- Cardiac rate - 120 to 160 beats per minute conduction then near the ear to test air conduction
- Radial and femoral pulse must have same strength - Use an audiometer to measure the child’s threshold for hearing for
- Respiratory rate - 40 to 60 cycles per minute pure tone frequencies and loudness
‣ Respiration remains abdominal until the age 7 • Nose
- Temperature - preferably with an electric oral or tympanic - Inspect the external nose
thermometer - Test the nostril patency
- Blood pressure - not routinely done - Inspect the nares
‣ average BP for a 5 year old - 95/65 mmHg - Check for turbinates
• Anthropometric measurements - Nasal septum - midline, deviated
- Weight - Nasal mucosa and discharge
- Length • Throat
- Head circumference - Lip, buccal mucosa - color, pale, blue
‣ Place the measuring tape over the child’s prominent occipital - Tongue, teeth and gums
and frontal bones to obtain the greatest circumference ‣ By age 2 and a half to 3, the child must have 20 deciduous
‣ Plot the measurement teeth
- Chest circumference - Palate - assess the arch, presence of cleft
- Abdominal circumference - Uvula
- BMI - Tonsils - size, color, exudates
• Neck
SKIN - Observe the size, shape and range of motion
- Short, long, webbed
• Birthmarks including changes over the years
- Thyroid
• Rashes, petechiae, desquamation
- Lymph nodes - size, location, mobility
• Scars and injuries (signs of abuse)
‣ Palpate the cervical LN - usually larger than the adults, less
than 1 cm in size, discrete, and easily moveable
HEENT - Palpate the trachea and thyroid gland (normally palpable)
• Head
CHEST: HEART AND LUNGS
- Position, size and shape
• Shape of the chest
- Scalp and hair
• Inspect the size, shape and con guration of the thorax
- Facial symmetry
• By age 6, the diameter is thorax is reaches the adult ratio of 1 to 2
- Fontanelles and sutures
• Heart
- Facial skin - compared to the skin in other regions, note for color
- PMI
changes, lesions, or abnormal pigmentations
- Heaves and thrills
- Palpate the scalp using your nger tapes
• Eyes - Heart sounds, murmurs - in the aortic, pulmonic, tricuspid and
mitral area
- Begin by inspecting the external eye structures
- Apical impulse ay the 4th ICS LMCL of a 5 year old
‣ Note for any palpebral slant
- Note hearth rate and rhythm
- Pupils - shape, equality and size
- May note of physiologic S3
‣ Pupillary light re ex
- 2 common ndings in normal children
‣ Corneal light re ex
‣ Continuous low pitch venous hum
- Test for the EOM
‣ Innocent systolic murmur
‣ Six cardinal positions of gaze
• Lungs
‣ Only the eyes should follow the light
- Symmetry in expansion
- Strabismus, palpebral ssures, hypertelorism
- Tactile and vocal fremitus
‣ Cover test to check for strabismus - (+) movement =
- Breath sounds, rales, wheezes
strabismus
- Auscultate from top to bottom and compare sides
- Assess peripheral vision by doing confrontation test
- Normally, bronchovesicular breath sounds are heard on the
peripheral lung elds of a child under age 5 or 6
Pediatrics 3B Pinky Square 9 of 11
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 Neurologic Examination
ABDOMEN • Cerebrum - orientation to person, time and space
• Note for size and shape of the abdomen and the periumbilical area • Cerebellum - nystagmus, gait and balance
• After age 4, lumbar lordosis causes the child to have a pott belly when • Cranial nerves
standing but a at abdomen when supone I. - Sense of smell
• Fat, globular, distended II. - Pupils reactive to light, VA, VF, fundoscopy
• Bowel sounds, uid wave III. IV. VI. - Ocular movements, doll’s eyes, ptosis
• Light and deep palpation for spleen and liver, masses, skin turgor, V. - Clench teeth, chew, jaw jerk re ex
muscle tone VI. - Symmetry, show teeth, wrinkle forehead
- Liver is palpable 1 to 2 cm below the right costal margin, edge VIII. - Clank keys, rub ngers or rustling paper; Weber and Rinne test
should feel soft and sharp and move easily IX. X - Gag re ex
- Spleen should be soft, sharp and movable XI. - Shrug shoulder
- Tip of right kidney may be palpated, but not the left XII. - Tongue midline, movements
• Palpate for femoral pulse and inguinal lymph notes on both sides • Motor and Sensory
• Re exes
EXTREMITIES
• Pulses - dorsalis pedis
IMAGES
• Deformities
• Atrophy, hypertrophy
• Wasting
• Have the child stand and demonstrate range of motion
• Compare the posterior creases symmetry
• Observe the alignment of legs and feet
- Genu varum or bow leg - normal for 1 year
- Genu valgum or knocked knee - normal in 2 to 3 and a half years
• Observe the toes and the longitudinal arch of the soles
- Note at foot which is common in ages between 12 and 30 months
- Note for pigeon toes which usually self correct by age 3
• Ask the child to stand on one foot and then the other, can stand on one
foot for 8 to 12 seconds for age 5
• Can hop by age 4
• Changing positions - note the muscles of the arms, abdomen, legs and
neck
• While the child is standing, note the alignment, mobility, and symmetry
of the hips
• With the child seated, elicit the quadriceps / patellar re ex, achilles
re ex, plantar re ex
• Still seated, examine the arms of the child
- Assess the alignment and condition of the child’s arms, hands and
ngers
- Note for palmar creases
- Elicit the biceps re ex and triceps re ex in each arm

GENITALIA
• Normal looking or ambiguous
• Descended testes
• SMR
• Abnormal discharge
• Signs of abuse
• For a young girl, examine her in a frog leg position without a drape
- Expected ndings: intact structures, vagina, patent hymen
- Between 2 months and 7 years: at labia majora, thin labia minora,
small clitoris, thin hymen, no irritation or discharge
• For a young boy, inspect the penis and scrotum
- Expected ndings: intact structures, centrally positioned meatus,
retractable foreskin if not circumcised
- Palpate the scrotum for testicles, epididymis, spermatic cord
- If testicles cannot be felt, have the child sit in cross legs (indian sit)
to have the cremasteric muscle relax and let them descent or try
warming your hands and blocking the inguinal canal
- Inspect the ingiuinal area for a bulge to detect a hernia
‣ Check for a bulge that is signi cantly greater on one side of the
scrotum
‣ OR palpate the inguinal are using your little nger to reach the
external inguinal ring

Pediatrics 3B Pinky Square 10 of 11

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 SOURCES:
• 2021 PPT and recorded lecture of Dr. De Vega
• STP Trans (History taking Part), PARBS table for vaccination
• Sources for PE (from videos posted in moodle)
- “Newborn Exam” by Nina Gold for OPENPediatrics
- Head to Toe Exam of the Neonate
- Head to Toe Physical Assessment of a Child

! Use at your own risk !

Pediatrics 3B Pinky Square 11 of 11