Physical Examination in Pediatrics

Physical examination is a thorough inspection or a detailed study of the entire body or some part of the body to determine the general physical or mental conditions of the body.

The setting for doing physical examination should be:

• Well lighted, warm, colorful, and comfortable room.
• Warm hands.
• Toys, pictures, and cartoons should be kept allaying apprehension of the child.
• Avoid deep yellow/blue curtains for proper evaluation of jaundice and cyanosis.

Approach

• The approach of the nurse should be gentleness, confidence, sympathy, patience, tact, compassion concern, kind look, and love for children.
• Sneaky observation of the child, offering small bright object or candy.
• Approach the child with a smile.
• Adopt a play attitude and follow an unstructured approach.
• The undressing of the child should be limited.
• Relatively traumatic examinations, such as percussion throat examination should be done in the end.
• The older child may be explained about the procedure.

Positions

Positioning during physical assessment is based on the age of child if:

• 0-3 months of age: Examination table
• 3 months to 1 year of age: Mother’s lap
• 1-3 years of age: Standing or mother’s lap
• >3 years old: Examination table

Sequence of Physical Examination

• The examination pattern should be unstructured.
• Auscultation may be done in the beginning in an infant suspected to have cardiac problems because conventional sequence would lead to crying.
• This should be followed by inspection, palpation, percussion, recording of vital signs, elicitation of deep tendon reflexes, ear, nose and throat (ENT) examination,
  be done last.
  and examination of the painful site should

General Appearance

 It is a cumulative, subjective impression of the child’s physical appearance, state of nutrition, behavior, personality, interactions with parents and nurse, posture, development, and speech.

• Note the facies (facial expression and appearance) for pain, happy, discontented, frightened, mentally deficient, or acutely ill.
• Observe the posture and position and types of body movements. For example, the child with hearing or vision loss may characteristically tilt the head in an awkward position to hear or see better. Low self-esteem child may assume a slumped, carelessness, and apathetic pose.
• Note the child’s hygiene in terms of cleanliness, unusual body odor, the condition of hair, nails, teeth, and feet and clothing.
• Nutritional status or body built should be observed, for example, slender and tall, well-built, well-defined musculature, poor muscle tone, and bony prominence.
• Assess for the child’s behavior, such as child’s personality, activity level, and reaction to stress, requests, frustration, interaction with others, degree of alertness, and response to stimuli. Note the attention span, eye contact, reaction to nurse/family members.
• Record an overall estimate of child’s speech, development, motor skills, coordination, and recent area of achievement. For example, for 18-month-old child, motor development advanced for age; climbs, runs, jumps, and manipulates small objects with ease, beginning to name many objects; uses two-word phrases and enjoys talking to self and others.

Skin

Assess for color, texture, temperature, moisture, and turgor.

Methods involved: inspection and palpation.

Inspection

• Normal color of skin
• White race: Light skinned vary from milky white and rose to a deeply hued pink.
• Dark-skinned children: Various brown, red, yellow, olive green, and bluish tones in their skin; have hyperpigmented areolas, genitals, and linea nigra.
• Asians: Yellow tone (wheatish).
• Assess for any abnormal coloration of skin.
• Inspect the entire body for nevi and vascular and other lesions. Note their location, size, distribution, characteristics, and color.
• Note the presence of hyperpigmented nevi (Mongolian spots), which appears as blue or gray, variably and irregularly shaped macules.
• Inspect for rashes and note the types of lesions, distribution, drying, scabbing, and any drainage.
• In adolescents the skin examination may reveal open or closed comedones (pimples or blackheads) across the face, chest, and back. Teens may sport tattoos, brandings, or various body piercings; inspect these areas for signs of infection.
• Document the presence of any lacerations, abrasions, or burns. Note the distribution of injury and whether it seems consistent with the mechanism described in the health history.

Palpation

• Palpate the skin for temperature, moisture, texture, turgor, and edema. Use back of your hand to assess the skin’s temperature, comparing the right side of the body to left and upper to lower. Note any difference in temperature.
• Determine the tissue turgor or elasticity in the skin, by grasping the skin on the abdomen between the thumb and index finger, pulling it taut, and quickly releasing it. Elastic tissue immediately assumes its normal position without residual marks or creases. In case of poor skin turgor, it remains suspended or tented for a few seconds before slowly falling back on the abdomen.
• When edema is present, palpate the area to determine its extent.
• Palpate for any lumps or protrusions to determine the size, firmness, or tenderness.

Accessory structures

• Inspect the hair for color, texture, quality, distribution, and elasticity.
• Normal: Lustrous, silky, strong, and elastic hair
• Poor nutrition: Stringy, dull, brittle, dry, friable, and depigmented
• Record any bald or thinning spots.
• Inspect the hair and nails for general cleanliness. Also examine for lesions, scaliness, and evidence of infestations, such as lice or ticks, signs of trauma, for example, scars and mass.
• In adolescents and preadolescents, look for growth of secondary hair.
• Inspect the nails for color, shape, texture, and quality. Normally the nails are pink, convex, smooth, and hard but flexible. The edges are usually white and extend over the fingers.
• Creases: The palms normally show three flexion creases. In some situations, such as Down’s syndrome, the two distal horizontal creases are fused to form a single horizontal crease (transpalmar crease).

Head

Inspection

• Examine the head and face for shape and symmetry.
• Some infants have a slight flattening of the back of the head since the recommended sleeping pattern is supine.
• Observe the infant’s head shape by looking down on it from above. Observe whether the head appears centered on the neck or tilts to one side.
•  Pull the infant from supine position into sitting to determine the extent of head lag.
• To determine in older infants and children, ask the child to turn the head in different directions, either by simple commands or by following a colourful object.
• Observe the infant’s face when crying, smiling, or babbling for symmetry of muscle movement.
• In older children, ask to puff out their cheeks, make kisses, look surprised, and stick out their tongue.

Palpation

• Palpate the skull for patent sutures, fontanels, fractures, and swellings.
• Normally the posterior fontanel closes by 6-8 weeks and anterior fontanel closes by 18 months. The fontanel should be neither depressed nor taut and bulging, though it is not uncommon to see it pulsate or briefly bulge if the baby cries.
• Dehydration can cause the fontanel to be shrunken; increased intracranial pressure and overhydration can cause them to bulge.
• Palpate the sutures for overriding or open and lumps or other deformities.
• Use the fingertips to palpate for occipital, postauricular, preauricular, submental, and submandibular lymph nodes, noting their size, mobility, and consistency.

Neck

Inspection

Inspect for symmetry. The infant’s neck is short; by 4 years of age the child’s neck should be similar to adult size. Webbing or excessive neck skinfold may be associated with turner’s syndrome and lax neck skin occur in Down’s syndrome.

Manipulation

Assess the flexibility through full range of motion.

• Pain or resistance to range of motion maintain indicate meningeal irritation.
• Do not assess neck mobility in trauma victim.

Palpation

• Palpate the cervical and clavicular lymph nodes with the distal part of the fingers using gentle but firm pressure in a circular motion. Tilt the head slightly upward to allow better access.
• Assess for swelling, mobility, temperature, and tenderness.
• Enlarged cervical lymph nodes frequently occur in association with upper respiratory tract infection (URTI)
• and otitis media.
• Palpate the trachea; the thyroid is usually palpable only in older children.

Eyes

External structures

Inspection

• Inspect the lids for proper placement on the eye. When the eye is open, the upper lid should fall near the upper iris. When the eyes are closed, the lids should completely cover the cornea and sclera.
• Observe the eyes for symmetry and spacing, even distribution of eyelashes and eyelids, and presence of epicanthal folds.
• Note the child’s ability to blink.
• The eyes should look symmetrical, and both should be facing forward in the midline when the child is looking directly ahead.
• The iris should be perfectly round, and the sclera should be clear. Tiny black marks in the sclera of highly pigmented people are normal.
• The cornea should be uniformly transparent.
• Inspect the inner and outer canthus and conjunctiva for inflammation, discharge, or swelling.
• Using a small pen light, inspect the function and clarity of the pupil by putting your nondominant hand on the child’s forehead and moving the light toward and away from each eye. This will elicit the blink reflex. Next observe whether the pupil contracts with the light and expands when the light is removed.
• Make the same motion with a small toy or object and direct the child to look at it. The eyes demonstrate accommodation, or focusing at different distances, if the pupil constricts as the object moves closer.
• Normal findings on examination of the pupils may be recorded as PERRLA, which stands for pupils are equal, round, and reactive to light and accommodation.
• Absence of pupillary reflexive action after age of 3 weeks may indicate blindness.
• Intermittent strabismus (crossing of the eyes) is normal up to 6 months.
  Persistent strabismus at any age or intermittent strabismus after 6 months of age should be evaluated by a pediatric ophthalmologist.
• Normal color of iris is usually established by 6 months.
• Assess eye muscle strength using two tests:
• Hirschberg test: Bring the pen light to the middle of your face and direct the child to look at it. The small dot of the reflected light seen in the iris should be symmetrically placed in each eye.
• Cover test: Cover one of the child’s eyes and instruct to focus on an interesting object. The eye should not waver. While the child is still focusing with the first eye, remove the cover from the second. Observe the uncovered eye for movement. Report any movement or drift.
• To test peripheral vision, have the child focus on a specific point or object directly in front. Bring a finger or small object from beyond the range of vision into the area of the peripheral vision. When the child sees the object from the side, while still focusing on the object or point in front, the child should say “stop.”

Internal structure

• Use an ophthalmoscope to inspect the internal eye structures. Observe the glow of the pupil, which appears red (creamy colored in children with very dark eye color). Inspect the optic disk, macula, fovea, and blood vessels.
• Absence of red reflex may indicate the presence of cataracts.
• Assessment of the internal structures of the eye is best accomplished by an advanced practitioner with experience in this type of assessment.

Testing visual acuity

• The child should stand 10 ft from chart with their heels at the 10-ft line. Test the right eye first by covering the left. Children who wear glasses should be screened with them on. Tell the child to keep both eyes open during examination. Use Snellen’s chart for testing. If the child fails to read the current line, move up to the chart until a line is found that the child can pass.
  Then begin moving down the chart until the child fails to read. To pass the child should correctly identify 4-6 symbols on the line. Repeat the procedure covering the right eye.
• For children unable to read the letters and numbers use tumbling E or HOTV tests (preschool children).
• Tumbling E: The capital letter E pointing in four directions.
•  HOTV chart: It consists of a wall chart composed of letters H, O, T, and   

V. The child is given a board containing a large H, 0, and T. The examiners point to a letter on the wall chart and the child matches the correct letter on the board held in his hand.

• Allen card test: It uses common figures to test the child’s vision. The examiners walk slowly flipping through the cards and presenting different pictures as the child correctly calls out. When the child misses the figure, the examiner moves forward to confirm that the child is able to identify at that point. The figures in the card should be 20/30 in size.
•  LH symbol or Lea cards: It is a spiral bound set of flash cards. It contains large pictures of a house, apple, circle, and square. It contains the symbol size and visual acuity value for a 10-ft testing distance

In infants

• Checking for light perception by shining a light into the eyes and noting responses, such as pupillary constriction and blinking.
• Another test is to fix on and follow a target.
  Hold the infant upright while moving your face slowly from side to side.

Color vision

The tests available for color vision include the Ishihara test and the Hardy-Rand-Ritter test. Each consists of cards on which is printed a color field composed of spots of a certain confusion color. Against the field are a number of symbols similarly printed in dots but of a color likely to be confused with field color by the person with color vision impairment. As a result, the figure or letter is invisible to an affected individual but is clearly seen by a person with normal vision.

Ears

External structures

• Assess the placement of the external ears on the head. They should be symmetrical and placed no lower than the eyes. The pinna should deviate not >10° from an imaginary line that is perpendicular to a line drawn between the outer canthus of the eye and the top of the ear.
• Low-set ears may be associated with genetic abnormalities or syndrome. Note the protrusion or flattening of the ears, note the presence of pits or skin tags in the periauricular area. Observe the exterior ear canal.
• A waxy cerumen that is soft and an orangish brown color is normally found lubricating and protecting the external ear canal and should be left in place or washed gently away. Note for any drainage, pull on the auricle and palpate the mastoid process, neither of which should result in pain in healthy child.

Internal ear

• Position the child, restrain if necessary.
  Gently pull down on the earlobe of the infant and up on the outer edge of the pinna in older children to straighten the ear canal.
  Insert the appropriate-size speculum into the ear canal to visualize the canal and tympanic membrane. It should be pink, have tiny hairs, and free from scratches, drainage, foreign bodies, and edema.
• The tympanic membrane should appear pearly pink or grey and should be translucent, allowing visualization of the bony landmarks. Compress the pneumatic insufflator bulb to provide a puff of air, this causes motion of the tympanic membrane, tympanic membrane immobility, holes or perforation and the presence of tympanostomy tubes, scaring or vesicles should be assessed.
• Hearing acuity of the older children can be assessed by tuning fork test to find out the type of hearing loss.

Nose

External structure

Compare the placement and alignment by drawing an imaginary vertical line from center point between the eyes down to the notch of the upper lip. The nose should lie exactly symmetric. Note for any deviation to one side, and asymmetry in size. Observe the alae nasi for any sign of flaring, which indicates respiratory difficulty.

Internal structures

Inspect the anterior vestibule by pushing the tip upward, tilting the head backward with the help of flashlight. Note the color of mucosal lining (red), swelling, discharge, dryness, or bleeding. Inspect the septum, which divides the vestibules equally. Note any deviation.

Test the older child’s sense of smell by having the child close the eyes and identify a familiar scent such as peppermint or coffee. Palpate the sinuses for tenderness.

Mouth and Throat

Lips: It should be moist, soft, smooth, and pink, symmetric when relaxed or tensed.

Oral cavity: Ask the child to open the mouth wide; to move the tongue in different directions for full visualization, and to say “ahh,” which depresses the tongue for full view of the back of the mouth (tonsils, uvula, and oropharynx).

The oral cavity should be pink, moist, and healthy. Observe the movement of tongue when the child cries, or babbles. Ask the older child to touch the tongue to roof of the mouth and then stick out the tongue and move it from side to side.

Teeth: Inspect for number in each dental arch, for hygiene and for occlusion or bite. Inspect for plaque, dental caries, and fluorosis.

Gum: Inspect for color, bleeding.

Palate: The arch should be dome shaped. Inspect for intactness. A narrow, flat roof or a high, arched palate affects the placement of the tongue and can cause feeding and speech problems.

Chest

Inspection

• Observe size, shape, symmetry, movement, breast development, and the bony landmarks formed by the ribs and sternum.
• Size: Measure the size by using measuring tape at the level of nipples.
• Shape: Circular during infancy. As the child grows the anteroposterior diameter to be less than the lateral diameter.
• Movement: Bilaterally symmetrical and coordinated with breathing. During inspiration, the chest rises and expands, the diaphragm descents and the costal angle increases. During expiration, the chest falls and decreases in size, the diaphragm rises and the costal angle
  narrows.
• In younger children: Respiration is principally diaphragmatic or abdominal.
• In older children: Respiration is chiefly thoracic.
• Observe the position of the nipples (slightly lateral to the midclavicular line between the 4th and 5th ribs).
• Record early or late breast development.
  In adolescent girls, palpate the breast for evidence of any masses or hard nodules.

Heart

Inspection: Note the presence of pallor, cyanosis, mottling, or edema, which may indicate a cardiovascular problem.

• Inspect the anterior chest wall from an angle comparing both sides of the rib cage with each other.
• Observe for the apical impulse. Note clubbing of the fingertips, distension of neck veins.

Palpation: Using fingertips palpate the chest for lifts and heaves or thrills, which are not normal. Palpate for apical pulse.

• Check the pulses and compare the upper body to lower part, as well as left versus right, noting strength and quality. Note the warmth of the distal extremities.
• Assess capillary filling time, by pressing the skin lightly on a central site, such as forehead or a peripheral site, such as nail beds and quickly release it. The time it takes for blanched area to return to its original color is the capillary refill time (normal <3 seconds).

Auscultation: Auscultate the heart sound with at least two positions: sitting and reclining. Auscultate the heart rate in the area of PMI. Develop a systematic approach to auscultation of the heart.

• Listen over all four valvular areas anteriorly.
  Note S1, S2, extra heart sounds, or murmurs.
• S1 is usually loudest at the mitral and tricuspid areas and increases in intensity with fever, exercise, and anemia.
• S2 is usually intense at aortic and pulmonic
  areas.
• S3 may be heard in some healthy children and is normal.
• S4 is usually considered abnormal and occurs with cardiac disease.
• Auscultate for murmurs, note the location and timing. Systolic murmur occurs in association with S1, a diastolic murmur in association with S2. Sinus arrhythmia is a common and normal finding in children and adolescents.

Abdomen

Inspection

• Inspect for size, shape, and symmetry.
• Normally, in infant and toddler the abdomen is rounded and protruded due
  to immature musculature.
• The skin should be uniformly taut without wrinkles or creases.
• Superficial veins are usually visible in light skinned, thin infants but distended veins are abnormal finding.
• Examine the umbilicus for size, hygiene, and evidence of any abnormalities, such as hernias. Observe the movement of the abdomen and peristaltic waves.

Auscultation

• Listen for bowel sounds, such as metallic clicks and gurgles.
• Their frequency per minute should be recorded (e.g., 5 sounds/min). It may be stimulated by stroking the abdominal surface with a finger nail.
• Report absence of bowel sounds or hyperperistalsis.

Palpation

• Superficial: Lightly place your hand against the skin and feel each quadrant, noting any areas of tenderness, muscle tone, and superficial lesions, such as cysts.
• Deep: It is used for palpating organs and large blood vessels and for detecting masses and tenderness that were not discovered during superficial palpation. Place one hand on top of the other and palpate from the lower quadrants to the upper. The edge of the liver may be felt at the right costal margin. The descending colon may be felt in the left lower quadrant as a small column and the bladder as a soft balloon below the umbilicus. The kidneys are rarely palpable. The abdomen should be soft and nontender. Palpate the inguinal area, the costal margins, and tympany over the remainder of the abdomen. A full bladder may yield dullness to percussion.

Genitalia and Anus

• Provide privacy; keep the child covered as much as possible.
• In adolescents, it should be examined at last.

Male

• Inspect the penis and scrotum for size, color, skin integrity, and obvious masses.
• Note the external appearance of the glans and shaft of the penis, the prepuce and the urethral meatus. Examine for signs of swelling, skin lesions, inflammation, etc.
• The urethral meatus is carefully examined for location and evidence of discharge.
• Hair distribution is also noted.
• Note the location and size of the scrotum.
  It should hang freely from the perineum behind the penis, and the left scrotum normally hangs lower than the right. The skin is loose and highly rugated. In adolescents, it will be deeply pigmented.
  Palpate for identification of the testes, epididymis, and inguinal hernia. The testes are felt as small, ovoid bodies about 1.5- to 2-cm long.
• Prevent cremasteric reflex by warming hands.

Female genitalia

• Examine for size and location of the structures of the vulva. Determine the presence and distribution of pubic hair.
• Inspect the labia majora and minora for size, color, and skin integrity. Redness or swelling may occur with infection, sexual abuse, or masturbation. Lesions indicate sexually transmitted diseases (STDs)
• Gently spread the labia to inspect the clitoris, urethral meatus, and vaginal opening for edema or redness.
• Observe for any vaginal discharge. A small amount of clear mucus-like discharge is normal. Palpate the Bartholin glands and ducts for cysts.

Anus

• Inspect for fissures, rash, hemorrhoids, prolapse, or skin tags. It should appear moist and hairless.
• Gently stroke the anal area to elicit anal reflex. Inspect anal sphincter tone by inserting a gloved finger lubricated with water-soluble jelly just inside the anal sphincter. Note the general firmness of the buttocks and symmetry of the gluteal folds.

Back

• Note the general curvature of the spine in resting posture. The spine should be flexible, with good muscle tone and no rigidity.
• Assess the back and hip and shoulder height for symmetry. Examine the preadolescent and adolescent for development of scoliosis.
• Note mobility of the vertebral column by having child bend forward and side to side.
  Inspect for discoloration, tufts of hair, or dimples. Movement of cervical spine should be effortless.

Extremities

• Inspect each extremity for symmetry of length and size; refer any deviation for orthopedic evaluation.
• Count the fingers and toes to notice polydactyl (extra digit) or syndactyly (fusion of digits).
• Inspect for temperature and colour.
• Assess the shape of bones. The infant’s feet and legs appear bowed and secondary to in utero positioning but can be straightened
• through passive exercise. Bowing of legs is common in toddler. When it persists past the time, it is termed genu varum (bowlegs).
• Genu valgum (knock knees) is usually present until the child is 7 years old.
• Observe the child walking, noting any difficulty with leg position or balance.
• Note the normal flat foot in the toddler and young child. The arch develops as the child grows and the muscles become less lax.
• Check the mobility of the joints by performing range of motion. Determine the upper extremity strength by having the child push up or down against the examiner’s outstretched hand and lower extremity by having the child push against the examiner’s hands with the soles of the forefoot.
• Inability to straighten the foot to midline may indicate club foot.
• Palpate the joints for heat, tenderness, and swelling

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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