Physical Examination of

the Neck
 Check for venous engorgement,
flexibility, rigidity, masses, lymph
nodes
 Swelling
-webbing of neck in
Severe diphtheria
Turners syndrome
 Position

torticollis opisthotonus
 Masses

Branchial cyst
Dermoid cyst
Thyroglossa
should be described as to location, size, rate of growth,
shape, margin, surface, consistency, Duct cyst
r, warmth, pulsation, adhesion to surrounding structures.
 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
Goiter grading system
(WHO)
Grade PE finding
0 No goiter
Ia Goiter detectable by palpation
and 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
Physical Examination of
the Chest and Lungs
 The chest circumference (CC) is
smaller than that of the head (HC) in
the first 9-12 months of life.
After 1 year: CC>HC
 Inspection
Size and shape:
Infancy: AP diameter = Transverse
diameter
After 2 years: AP<TD

Movements with respirations:

-newborns & infants: abdominal
-4-5 years old: most of respiration is
due to intercostal muscles
 Chest retractions:
Subcostal
Intercostals
supraclavicular
 Findings Clinical Implications
Round/Barrel chest Chronic obstructive lung
disease
Shield Shaped Turners syndrome
Pectus excavatum Congential anomaly
Pigeon chest Normal, rickets,
osteomalacia, pectus
carinatum
Rachitic rosary Rickets
Harrisons groove Chronic cardiac or
pulmonary disorders
 Chest expansion
Place palms of hand
symmetrically on the
posterior surface of the
chest with the thumbs
touching each other in
the midline.
Fingers are spread over
the sides of the chest.
The excursions of the
palm are noted with each
inspiration.
 Chest expansion
Normally the palms move equally as
demonstrated by the symmetrical
movements of the thumbs moving
away from the midline with each
inspiration and coming together
during expiration.
iii. Vocal Fremitus.
- Ask the child to repeatedly say tres
tres or ninety-nine while the
examiner palpates all areas of chest
and back.
Fremitus Clinical Implication

Increase Atelectasis,
pneumothorax,
pleural effusion
Decrease Consolidation
iv. Percussion
- Direct percussions with 1 finger over
the chest wall is easily done on small
infants and gives valuable information,
but requires experience.
- Indirect, 2-finger technique most
common method for chest percussion.
v. Auscultation
- Stethoscope should be placed on the bare
skin of the chest wall.
- Warm the chest piece first if it is cold.
- Use bell in young infants as the diaphragm
can pick up sounds from larger areas.
- If feasible, auscultate symmetrically from
top to bottom, side to side, back and front
and compare breath sounds for symmetry
or asymmetry in findings.
 Variations in Percussion Notes and
Clinical Implications
Variations in Nature of Clinical
Percussion Underlying Implications
Notes Structure
Resonant Normal chest Normal
Dull a. Solid a. Consolidation
structures or over the
liver
b. Fluid-filled b. Pleural
areas effusion
Hyperresonant Hollow or air- Pneumothorax,
filled areas emphysema;
maybe expected
in young infants
with thin chest
 Abnormal or Adventitious Breath
Sounds
Adventitio Nature or I or E Phase Implications
us BS Pathology
Crackles/Ral Explosive non- Can be heard Inflammation,
es musical sounds in both I and edem, infection of
occurring in burst, E phases bronchi,
resembling when air is bronchioles, and
popping of forced alveoli. Early I
bubbles; can be through crackles:
coarse or fine. airways that bronchitis or
Fine crackles are narrowed edema. Mid-I
sound like crushing by fluid, crackles:
strans of hair mucus or bronchiectasis.
between fingers pus. Late I crackles:
near your ear. interstitial lung
Coarse crackles dse, CHF,
are louder, lower pneumonia.
pitched, last longer
Wheez Continuous musical Usually Obstructive
es sound that can be E, but airway disease,
high-pitched with a can be CHF.
whistling quality, heard
usually caused by also in
turbulent flow in late I.
narrow airways.
Rhonch Coarse wheezes that Usually Secretions in
i are continuous, low- E. large airways as
pitched with a snoring in bronchitis.
or moaning quality;
usually felt by
palpating palms and
clear on coughing.
Bronchi Hollow sound Usually Consolidation in
al or transmitted by sound I. upper lobes and
tubular waves from trachea lower lobes with
BS through the obstructed
consolidated area to bronchi, bronchial
Pleural Rubbing leathery Both Pleurisy
friction sound produced
rub by friction of the
pleural spaces
Stridor Monophasic noise Usually Upper airway
usually audible I. obstruction
even without
stethoscope
Grunting Known as Usually Signifies
physiology PEEP, a E. underlying
defense pulmonary
mechanism of the pathology.
child to raise FRC
by closing the
glottis at the end of
expiration; audible
even without