physical assessment head to toe

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PHYSICAL ASSESSMENT I. INTEGUMENTARY ▪Inspect -skin integrity for color variations, lesions, etc. -scalp -hair (color, quantity, distribution) -nails -note smell/odors -edema (if appropriate) Palpate -temperature -texture and moisture -mobility and turgor -edema (if appropriate) II. HEAD AND FACE ▪Inspect -head/skull size, shape, configuration -face for symmetry, facial features, expressions & condition -consistency, distribution & color of hair ▪Palpate -head for size, shape & configuration -temporal arteries for elasticity and tenderness -temporomandibular joints (TMJ) when client opens & closes mouth ▪Auscultate -bilateral temporal artery ▪CN Testing -V (Trigeminal- sharp and dull sensation) -VII (Facial expressions- smile, frown, show III. NECK ▪Inspect -Neck structure and symmetry -Skin color and integrity -Appearance of lesions, masses, swelling -Tested range of motion (rom) – flexion, extension, hyperextension, lateral flexion, rotation -Carotid pulse -Jugular venous pattern and pulsations -position of trachea -thyroid gland (visible enlargement or mass) ▪Palpate -neck (sternocleidomastoid &trapezius muscles) -trachea (alignment & deviation) -thyroid gland for size, irregularity, masses - lymph nodes (pre-auricular, posterior auricular, submental, submaxillary, submandibular, tonsilar, superficial cervical nodes, anterior deep cervical chain, supraclavicular, occipital, posterior cervical) ▪CN Testing -XI (spinal accessory) IV. EYES ▪Inspect -position and alignment -eyelashes, bony orbits and brows -lacrimal apparatus -lids -sclera -conjunctiva (bulbar/ palpebral) -iris -cornea and lens ▪Special Tests -visual acuity—Rosenbaum, Snellen’s, Jaeger, E chart (CN II) - visual fields ( confrontation test) -cover and position test -extraocular movements--- H -convergence test (test for accommodation) -corneal light reflex blink / corneal reflex (CN V) -direct and consensual light reflex ▪Visual Function Test -light perception -hand movements -counting fingers ▪CN Testing -VII (Facial expressions- strength of eyebrows &eyelids) V. EARS ▪Inspect -position of ears in relation to eye -auricles, tragus, lobule of shape, position, lesions, discolorations & discharges -maneuver for appropriate for amembranege ▪Using Penlight -auditory canal (color, consistency, discharge) -checked auditory canal for color & cerumen -tympanic membrane (ear drum) for color, shape, consistency and landmarks ▪Palpated -auricles for texture, elasticity, areas of tenderness -mastoid process for tenderness VI. NOSE AND SINUSES ▪Inspect - external nose for color, shape, size & consistency ▪Using Penlight -septum alignment or deviation -mucosa for swelling, discharge, bleeding, foreign bodies ▪Transillumination test -frontal sinuses -maxillary sinuses ▪Palpate -checked patency of nares -external nose for masses, tenderness, smoothness, consistency -frontal sinuses -maxillary sinuses ▪Percuss -frontal sinuses -maxillary sinuses ▪CN Testing -I (olfactory—smell test) VII. MOUTH AND THROAT ▪Inspect -lips for color, symmetry, consistency, contour, lesions -mucosa and gums for color, integrity, adherence, lesions -salivary glands --- Wharton’s / Stensen’s duct -teeth for number, condition (oral hygiene), dental works -tongue for color, moisture, size, texture, ▪Palpate -lips and gums -salivary glands -tongue -hard(ant)/ soft(post) palates ▪CN Testing -V (Trigeminal- ability to chew aneal- ngd masticate) -VII and XII (Facial & Glossophary –and taste) -IX & X ( Glosspharyngeal & Vagus – speech, swallow, gag reflex) -XII (Hypoglossal – tongue strength) VIII. LUNGS AND THORAX *ANTERIOR CHEST ▪Inspect -color of chest -level of clavicles, sternum and costal angle -shape of chest -respiratory quality & pattern of respirationsn (rate, rhythm, depth) -intercostal spaces for bulging & retractions -use of accessory muscles for respirations ▪Palpate -tactile fremitus -tenderness, sensation, crepitus, masses, lesions -determined anterior chest expansion/ excursion ▪Percuss -tone at apices above clavicles then at intercostals spaces (comparing bilaterally) -tone at anterior intercostals spaces *POSTERIOR AND LATERAL CHEST ▪Inspect -color of chest -configuration & shape of scapulae & chest wall -use of accessory muscles when breathing ▪Palpate -tactile fremitus -tenderness, sensation, crepitus, masses, lesions -determined diaphragmatic excursions ▪Percuss -tone at posterior intercostals spaces (bilaterally) ▪Auscultate -posterior breath sounds and adventitious breath sounds -posterior voice sounds – bronchophony ( 99), egophony (eee) , whispered pectoriloquy (1,2,3) -noted & describe cough & sputum, if present IX. BREAST AND AXILLAE ▪Inspect -retractions or dimpling of nipples, through specific functioning or maneuvers instructed to client -color of breast -size, symmetry, texture & superficial venous pattern of breasts -color of areola & nipples -position of areola & nipples -montgromery tubercles, discharges, nipple inversion (if any) ▪Palpate

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PHYSICAL ASSESSMENT I. INTEGUMENTARY Inspect -skin integrity for color variations, lesions, etc. -scalp -hair (color, quantity, distribution) -nails -note smell/odors -edema (if appropriate)u extureIII. NECK Inspect -Neck structure and symmetry -Skin color and integrity -Appearance of lesions, masses, swelling -Tested range of motion (rom) ² flexion, extension, hyperextension, lateral flexion, rotation -Carotid pulse -Jugular venous pattern and pulsations -position of trachea -thyroid gland

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Page 1: Physical Assessment Head to toe

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PHYSICAL ASSESSMENT

I. INTEGUMENTARY ▪Inspect-skin integrity for color variations, lesions, etc.-scalp-hair (color, quantity, distribution)-nails-note smell/odors-edema (if appropriate)

▪Palpate-temperature-texture and moisture-mobility and turgor-edema (if appropriate)

II. HEAD AND FACE ▪Inspect-head/skull size, shape, configuration-face for symmetry, facial features, expressions & condition-consistency, distribution & color of hair

▪Palpate-head for size, shape & configuration-temporal arteries for elasticity and tenderness-temporomandibular joints (TMJ) when client opens & closes mouth

▪Auscultate-bilateral temporal artery

▪CN Testing-V (Trigeminal- sharp and dull sensation)-VII (Facial expressions- smile, frown, show teeth, blow out cheeks, raise eyebrows, tightly close eyes)

III. NECK ▪Inspect-Neck structure and symmetry-Skin color and integrity-Appearance of lesions, masses, swelling-Tested range of motion (rom) – flexion, extension, hyperextension, lateral flexion, rotation-Carotid pulse-Jugular venous pattern and pulsations-position of trachea-thyroid gland (visible enlargement or mass)

▪Palpate-neck (sternocleidomastoid &trapezius muscles)-trachea (alignment & deviation)-thyroid gland for size, irregularity, masses- lymph nodes (pre-auricular, posterior auricular, submental, submaxillary, submandibular, tonsilar, superficial cervical nodes, anterior deep cervical chain, supraclavicular, occipital, posterior cervical)

▪CN Testing-XI (spinal accessory)

IV. EYES ▪Inspect-position and alignment-eyelashes, bony orbits and brows-lacrimal apparatus-lids-sclera-conjunctiva (bulbar/ palpebral)-iris-cornea and lens- pupil

▪Palpate-bony orbit-eyelids / eyeballs-lacrimal apparatus

▪Special Tests-visual acuity—Rosenbaum, Snellen’s, Jaeger, E chart (CN II)- visual fields ( confrontation test)-cover and position test-extraocular movements--- H-convergence test (test for accommodation)-corneal light reflex blink / corneal reflex (CN V)-direct and consensual light reflex

▪Visual Function Test-light perception-hand movements-counting fingers

▪CN Testing-VII (Facial expressions- strength of eyebrows &eyelids)

V. EARS ▪Inspect-position of ears in relation to eye-auricles, tragus, lobule of shape, position, lesions, discolorations & discharges-maneuver for appropriate for amembranege

▪Using Penlight-auditory canal (color, consistency, discharge)-checked auditory canal for color & cerumen-tympanic membrane (ear drum) for color, shape, consistency and landmarks

▪Palpated-auricles for texture, elasticity, areas of tenderness-mastoid process for tenderness

▪CN Testing-voice- whisper test-watch tick testTuning fork test-Weber’s test for diminished hearing in one ear-Rinne’s test to compare cone & air conduction (tuning on mastoid; then in front of the ears)

VI. NOSE AND SINUSES ▪Inspect- external nose for color, shape, size & consistency

▪Using Penlight-septum alignment or deviation-mucosa for swelling, discharge, bleeding, foreign bodies

▪Transillumination test-frontal sinuses-maxillary sinuses

▪Palpate-checked patency of nares-external nose for masses, tenderness, smoothness, consistency-frontal sinuses-maxillary sinuses

▪Percuss-frontal sinuses-maxillary sinuses

▪CN Testing-I (olfactory—smell test)

VII. MOUTH AND THROAT ▪Inspect-lips for color, symmetry, consistency, contour, lesions-mucosa and gums for color, integrity, adherence, lesions-salivary glands --- Wharton’s / Stensen’s duct-teeth for number, condition (oral hygiene), dental works-tongue for color, moisture, size, texture, coating, vessels-labial and lingual frenulums-hard(ant)/ soft(post) palates for color, integrity-breath and breath sounds-uvula and tonsils (color, continuity, integrity, lesions, inflammation, size)-posterior pharyngeal wall

▪Palpate-lips and gums-salivary glands-tongue-hard(ant)/ soft(post) palates

▪CN Testing-V (Trigeminal- ability to chew aneal- ngd masticate)-VII and XII (Facial & Glossophary –and taste)-IX & X ( Glosspharyngeal & Vagus – speech, swallow, gag reflex)-XII (Hypoglossal – tongue strength)

VIII. LUNGS AND THORAX *ANTERIOR CHEST

▪Inspect-color of chest-level of clavicles, sternum and costal angle-shape of chest-respiratory quality & pattern of respirationsn (rate, rhythm, depth)-intercostal spaces for bulging & retractions-use of accessory muscles for respirations

▪Palpate-tactile fremitus-tenderness, sensation, crepitus, masses, lesions-determined anterior chest expansion/ excursion

▪Percuss-tone at apices above clavicles then at intercostals spaces (comparing bilaterally)-tone at anterior intercostals spaces

▪Auscultate-anterior breath sounds and adventitious breath sounds-anterior voice sounds – bronchophony (99), egophony (eee) , whispered pectoriloquy (1,2,3)-noted & describe cough & sputum, if present

*POSTERIOR AND LATERAL CHEST▪Inspect-color of chest-configuration & shape of scapulae & chest wall-use of accessory muscles when breathing

▪Palpate-tactile fremitus-tenderness, sensation, crepitus, masses, lesions-determined diaphragmatic excursions

▪Percuss-tone at posterior intercostals spaces (bilaterally)

▪Auscultate-posterior breath sounds and adventitious breath sounds-posterior voice sounds – bronchophony (99), egophony (eee) , whispered pectoriloquy (1,2,3)-noted & describe cough & sputum, if present

IX. BREAST AND AXILLAE ▪Inspect-retractions or dimpling of nipples, through specific functioning or maneuvers instructed to client-color of breast-size, symmetry, texture & superficial venous pattern of breasts-color of areola & nipples-position of areola & nipples-montgromery tubercles, discharges, nipple inversion (if any)

▪Palpate-breast according to recommend method (concentric, vertical, radial/pie)-tail of Spence-areola & nipples for discharge

Page 2: Physical Assessment Head to toe

▪Axillae-noted position for axilla palpation-noted axilla condition-palpates axillae for rashes, infection & anterior, central & posterior lymph nodes-taught breast self examination (BSE)

X. HEART ▪Inspect-precordium movement @MCL, 5th ICS-jugular veins-heart landmarks (pulmonic, aortic, Erb’s point, tricuspid, mitral)

▪Palpate-carotid pulse one at a time-precodium-apex, left sterna border, & base of the heart for any abnormalities

▪Auscultate-carotid artery-utilized correct positioning for the auscultation (left side-lying, leaning forward)-traditional heart landmarks (pulmonic, aortic, Erb’s point, tricuspid, mitral)-note heart rate & rhythm --- S1 & S2 sound --- identify irregular/ abnormal heart sounds (murmur, atrial/ventricular gallops.)

▪Special Test-Hepatojugular reflex-Pulse deficit

*PERIPHRAL CIRCULATION▪IDENTIFY,PAgLPATE & GRADE - temporal, carotid, radial, brachial,ulnar, femoral, popliteal, dorsalis pedis(pedal) posterior tibial.

▪special test-allen, burger, trendelenburg, manual compression test, capillary refill, homan’s & edema (grade if present)

XI. ABDOMEN -empty bladder▪Inspect-overall abdominal skin color-vascularity; striae, lesions, rashes-hair distributions-symmetry & contour of abdomen-surface movements (peristaltic waves or any pulsation) -location, contour & color of umbilicus-measured abdominal girth

▪Auscultate-bowel sounds over four quadrants

▪Percuss-tone over 4 quadrants-liver location, size &span-spleen location & size-kidneys-bladder-perform shifting dullness (test for ascites), if needed of indicated

▪Light Palpate-4 quadrants to identify tenderness & muscular resistance

▪Deep Palpate-4 quadrants for masses-umbilicus-liver-spleen-kidneys-bladder

▪Special Tests-blumberg’s tets (rebound tenderness)-iliopsoas-obturator-hypersensitivity-inspiratory arrest (murphy’s)-ballotement (w/ variations, either single-hand/ bimanual method)

XII. NUTRITION --24 hour diet recall- Identified current order diet -assessed appetite basing on the meal percentage charting-identify body built (ectomorph, endomorpg, mesomorph) --wrist size -- wrist circumference ( height to wrist ration[HWHR])-checked height-checked weight-Determined ideal body weight-calculate body mass index (BMI)-measure weight circumference-calculate waist-to-hip ratio (WHR)

▪Hydration status-intake and output-skin moisture-skin turgor-identified s/sx of fluid volume deficit (dehydration) and fluid volume excess (fluid overload/ overhydration)

XIII. MUSCULOSKELETAL ▪Inspect- Posture-Spine alignment-gait-Tested Range of Motion (ROM) of joints to upper and lower extremities- Performed "nudge test' for the elderly or handicap- Muscle size, shape, symmetry

▪Graded Muscle strength- Left upper extremity- Right upper extremity- Left lower extremity- Right lower extremity- Enumerated at least 5 Activities of Daily Living (ADLs) affected(with limitations) basing on client's condition --- bed mobility, eating, toy, transfer, walk in room, walk in corridor, locomotion on/off unit, dressing, toilet use, personal hygiene, bathing

- Enumerated at least 3 Instrumental Activities of Daily Living(IADLs) affected (with limitations) basing on client's condition---housekeeping, use of telephone, managing money, preparing meals, driving/traveling, shopping, taking medication, laundry, taking out garbage

▪Palpate- Joints for mobility, smoothness, symmetry. Noted edema, heat, tenderness, pain, nodules, or crepitus.

▪Special test-Straight Leg Raising (LaSegue's Test)-Length Discrepancy- Ballottement-Bulge sign/ milking- Balloon Sign

XIV. MALE GENITOUNRINARY▪Inspect- Pubic hair distribution (amount, texture/ cleanliness/ foreign, body)-Penis (circumcised/uncircumcised)base of penis-Skin and shaft of penis for rashes, lesions, lumps, hardened or tender areas- Glans for size, shape, lesions, or redness and location of urinary meatus, and discharge-Scrotal skin for color, integrity and lesions- Scrotum for size, shape, and position - Transilluminated scrotal contents for red glow, swelling, or masses, if a mass is found during inspection and palpation. - Identified sexual maturity according to Tanner's Sexual Maturity Rating Scale - With client standing, instructed to bears down, inspected for bulges in inguinal and femoral areas

▪Palpate- Shaft of penis-Urethral discharge by gently squeezing the glans-scrotom- Bilateral testes

-Epididymis-Spermatic cord-Inguinal and femoral areas-while client shifted weight to each corresponding side, palpated for inguinal hernia-taught testicular self-examination (TSE)

*ANUS & RECTUM▪Inspect- Perianal area for lumps, ulcer, lesions, hemorrhoids, rashes, redness, fissures, or thickening of epithelium- Sacrococcygeal area for swelling, redness, dimpling, or hair- Instructed client to bear down or perform Valsalva maneuver, and inspected for bulges or lesions

▪Palpate- External sphincter for tenderness, nodules, and hardness- Rectum for tenderness, irregularities, nodules, and hardness- Prostate for size, shape, tenderness, and consistency- Inspected and described characteristics of stool, if any- Collected and/or tested feces for occult blood, if noted, or needed

XV. FEMALE GENITOUNRINARY▪Inspect- Pubic hair distribution, density, growth- Mons pubis, labia majora, and perineum for vascularity, moisture, symmetry, lesions, swelling, excoriations, and discharge- Labia minora, clitoris, urethral meatus, and vaginal opening for lesions, swelling or discharge- Identified sexual maturity according to Tanner's Sexual Maturity Rating

▪With speculum>- Vagina for color, consistency, and discharge- Cervix for lesions and discharge- Collects specimen as indicated or appropriate

▪Palpate- labia (masses, tenderness)-Bartholin's glands, urethra, and Skene's glands- Size of vagina, and vaginal musculature- Femoral and inguinal hernia

▪Bimanual Palpate- Cervix for contour, consistency, mobility, and tenderness- Uterus for size, position, shape, and consistency- Ovaries for size and shape

*ANUS & RECTUM▪Inspect- Perianal area for lumps, ulcer, lesions, hemorrhoids, rashes, redness, fissures, or thickening of epithelium- Sacrococcygeal area for swelling, redness, dimpling, or hair- Instructed client to bear down or perform Valsalva maneuver, and inspected for bulges or lesions

▪Palpate- External sphincter for tenderness, nodules, and hardness- Rectum for tenderness, irregularities, nodules, and hardness- Inspected and described characteristics of stool, if any- Collected and/or tested feces for occult blood, if noted, or needed

Page 3: Physical Assessment Head to toe

XVI. NEUROLOGIC

- Checked and determined LOC-Performed GCS- Checked and determined pupillary reaction and size- Checked and graded bilateral hand grasp strength-Romberg's test, as indicated or appropriate- Performed at least 3 cerebellar testing relevant to client s condition

-gait-heel to toe (tandem walking)- walk on tip toes- walk on heels- hop on one foot (then with the other)

- Performed at least 3 test tor coordination relevant to client's condition

- Finger to nose- Finger to nose and to the nurse’s finger- Finger to fingers- Rapid afternating hand movements (RAHM)

-heel to shin-draw a circle or figure of 8 with each foot on the ground or air- rapidly flex and extend each foot- touch the finger of the nurse with the large toe of each foot

- Checked at least 3 sensory testing relevant to client's condition

-pain (sharp/dull)-temperature-light touch-vibration-position, joint mobility(kinesthesia)-tactile discrimination (streogenesis)-number identification (graphethesia)-2 point discrimination-extinction-point location

- Checked at least 3 superficial reflexes relevant to client's condition

-abdominal -cremasteric (male clx)-bulbocavernosus (male clx)-plantar/ babinski-anal

-Checked and graded at least 3 deep tendon reflexes relevant to client's condition

-biceps-triceps-brachioraadialis-patellar-ankle jerk (achilles’)

Others:-brudzinski-kernig’s sign

- Performed other neurologic tests relevant to client's condition;

XVII. MENTAL STATUS

Assessed for the following:

1. Mood and emotional state (affect)2. Facial expressions3. Speech and language abilities4. Orientation to person, time, place5. Concentration, ability to focus and follow directions6. Recall of unrelated information in 5 or 10 minute period7. Recent memory of happenings today8. Remote memory9. Calculation (Digit Span)10. Thought content and process11. Visual perception and constructional ability12, Judgment and abstract reasoning

Differences of a Pediatric History Compared to an Adult History: I. Content Differences A. Prenatal and birth history B. Developmental history C. Social history of family - environmental risks D. Immunization history

II. Parent as Historian A. Parent’s interpretation of signs, symptoms 1. Children above the age of 4 may be able to

provide some of their own history 2. Reliability of parents’ observations varies 3. Adjust wording of questions - “When did you first notice Johnny was limping”? instead of “When did Johnny’s hip pain start”? B. Observation of parent-child interactions 1. Distractions to parents may interfere with history

taking 2. Quality of relationship C. Parental behaviors/emotions are important 1. Parental guilt - nonjudgmental/reassurance 2. The irate parent: causes

Outline of the Pediatric History:

I. Chief Complaint - Brief statement of primary problem (including duration) that caused family to seek medical attention

II. History of Present Illness - Initial statement identifying the historian, that

person’s relationship to patient and their reliability Age sex race other important identifying information about

patient Concise chronological account of the illness,

including any previous treatment with full description of symptoms (pertinent positives) and pertinent negatives. It belongs here if it is relates to the differential diagnosis for the chief complaint.

III. Past Medical History Major medical illnesses Major surgical illnesses-list operations and dates Trauma-fractures, lacerations Previous hospital admissions with dates and

diagnoses Current medications Known allergies (not just drugs) Immunization status - be specific, not just up to

date

IV. Pregnancy and Birth History Maternal health during pregnancy: bleeding, trauma,

hypertension, fevers, infectious illnesses, medications, drugs, alcohol, smoking, rupture of membranes

Gestational age at delivery Labor and delivery - length of labor, fetal distress,

type of delivery (vaginal, cesarean section), use of forceps, anesthesia, breech delivery

Neonatal period - Apgar scores, breathing problems, use of oxygen, need for intensive care, hyperbilirubinemia, birth injuries, feeding problems, length of stay, birth weight

V. Developmental History Ages at which milestones were achieved and current

developmental abilities - smiling, rolling, sitting alone, crawling, walking, running, 1st word, toilet training, riding tricycle, etc (see developmental charts)

School-present grade, specific problems, interaction with peers

Behavior - enuresis, temper tantrums, thumb sucking, pica, nightmares etc.

VI. Feeding History -Breast or bottle fed, types of formula, frequency and

amount, reasons for any changes in formula Solids - when introduced, problems created by

specific types Fluoride use VII. Review of Systems: (usually very

abbreviated for infants and younger children) oWeight - recent changes, weight at birth oSkin and Lymph - rashes, adenopathy, lumps,

HEENT - headaches, concussions, unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, mouth breathing, snoring, apnea, oral thrush, epistaxis, caries

Cardiac - cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, palpitations

Respiratory - pneumonia, bronchiolitis, wheezing, chronic cough, sputum, hemoptysis, TB

GI - stool color and character, diarrhea, constipation, vomiting, hematemesis, jaundice, abdominal pain, colic, appetite

GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary stream, polyuria, previous infections, facial edema

Musculoskeletal - joint pains or swelling, fevers, scoliosis, myalgia or weakness, injuries, gait changes

Pubertal - secondary sexual characteristics, menses and menstrual problems, pregnancies, sexual activity

Allergy - urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions

VIII. Family History - Illnesses - cardiac disease, hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy and asthma, epilepsy - Mental retardation, congenital anomalies, chromosomal problems, growth problems, consanguinity, ethnic background

IX. Social - Living situation and conditions - daycare, safety issues - Composition of family - Occupation of parents

Differences in Performing A Pediatric Physical Examination Compared to an Adult:I. General Approach Gather as much data as possible by observation first Position of child: parent’s lap vs. exam table Stay at the child’s level as much as possible. Do not

tower!! Order of exam: least distressing to most distressing Rapport with child 1. Include child - explain to the child’s level 2. Distraction is a valuable tool Examine painful area last-get general impression of

overall attitude Be honest. If something is going to hurt, tell them

that in a calm fashion. Don’t lie or you lose credibility!

Understand developmental stages’ impact on child’s response. For example, stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult.

II. Vital signs A. Normals differ from adults, and vary according to age 1. See “code card” for charts of age-adjusted normals B. Temperature 1. Tympanic vs. oral vs. axillary vs. rectal C. Heart rate 1. Auscultate or palpate apical pulse or palpate femoral pulse in infant 2. Palpate antecubital or radial pulse in older child D. Respiratory rate -Observe for a minute. Infants normally have periodic breathing so that observing for only 15 seconds will result in a skewed number. E. Blood pressure 1. Appropriate size cuff - 2/3 width of upper arm 2. Site F. Growth parameters - must plot on appropriate growth curve 1. Weight 2. Height/length 3. OFC: Across frontal-occipital prominence so greatest diameter (Occipital Frontal Circumference)

Page 4: Physical Assessment Head to toe

III. Unique findings in pediatric patients (See outline below

Outline of a Pediatric Physical Examination

I. Vitals - see above

II. General Statement about striking and/or important features.

Nutritional status, level of consciousness, toxic or distressed, cyanosis, cooperation, hydration, dysmorphology, mental state

Obtain accurate weight, height and OFC

III. Skin and Lymphatics Birthmarks - nevi, hemangiomas, mongolian spots

etc Rashes, petechiae, desquamation, pigmentation,

jaundice, texture, turgor Lymph node enlargement, location, mobility,

consistency Scars or injuries, especially in patterns suggestive of

abuse

IV. Head Size and shape Fontanelle(s) 1. Size 2. Tension - calm and in the sitting up position Sutures - overriding Scalp and hair

V. Eyes General 1. Strabismus 2. Slant of palpebral fissures 3. Hypertelorism or telecanthus EOM Pupils Conjunctiva, sclera, cornea Plugging of nasolacrimal ducts Red reflex Visual fields - gross exam

VI. Ears Position of ears

- Observe from front and draw line from inner canthi to occiput

Tympanic membranes Hearing - Gross assessment only usually

V. Nose Nasal septum Mucosa (color, polyps) Sinus tenderness Discharge

VI. Mouth and Throat Lips (colors, fissures) Buccal mucosa (color, vesicles, moist or dry) Tongue (color, papillae, position, tremors) Teeth and gums (number, condition) Palate (intact, arch) Tonsils (size, color, exudates) Posterior pharyngeal wall (color, lymph hyperplasia,

bulging) Gag reflex

VII. Neck Thyroid Trachea position Masses (cysts, nodes) Presence or absence of nuchal rigidity

VIII. Lungs/Thorax A. Inspection 1. Pattern of breathing a. Abdominal breathing is normal in infants b. Period breathing is normal in infants (pause < 15 seconds) 2. Respiratory rate 3. Use of accessory muscles: retraction location, degree/flaring 4. Chest wall configuration

Auscultation 1. Equality of breath sounds 2. Rales, wheezes, rhochi 3. Upper airway noise Percussion and palpation often not possible and rarely helpful

IX. Cardiovascular Auscultation 1. Rhythm 2. Murmurs 3. Quality of heart sounds Pulses 1. Quality in upper and lower extremities

X. Abdomen Inspection 1. Shape a. Infants usually have protuberant abdomens b. Becomes more scaphoid as child matures 2. Umbilicus (infection, hernias) 3. Muscular integrity (diasthasis recti) Auscultation Palpation 1. Tenderness - avoid tender area until end of exam 2. Liver, spleen, kidneys a. May be palpable in normal newborn 3. Rebound, guarding a. Have child blow up belly to touch your hand

XI. Musculoskeletal Back 1. Sacral dimple 2. Kyphosis, lordosis or scoliosis Joints (motion, stability, swelling, tenderness) Muscles Extremities

1. Deformity 2. Symmetry 3. Edema 4. Clubbing

Gait 1. In-toeing, out-toeing 2. Bow legs, knock knee a. “Physiologic” bowing is frequently seen under 2 years of age and will spontaneously resolve 3. Limp Hips 1. Ortolani’s and Barlow’s signs

XII. Neurologic - most accomplished through observation alone A. Cranial nerves B. Sensation C. Cerebellum D. Muscle tone and strength E. Reflexes 1. DTR 2. Superficial (abdominal and cremasteric) 3. Neonatal primitive

XII. GU A. External genitalia

B. Hernias and Hydrocoeles 1. Almost all hernias are indirect 2. Can gently palpate; do not poke finger into the inguinal canal C. Cryptorchidism 1. Distinguish from hyper-retractile testis 2. Most will spontaneously descend by several months of life D. Tanner staging in adolescents - See Tanner Staging handouts E. Rectal and pelvic exam not done routinely - special indications may exist

Introductory information Introduce, establish rapport. Name, age, gender. Person giving the history (parent, etc). Origin.

Presenting complaint Description of the presenting complaint, in

chronological order. Including whether came in through casualty or

admitted by GP.

History of presenting complaint SOCRATES: Time course: seasonal or diurnal fluctuation. Exacerbating factors: foods. Referral by GP vs. came in through casualty. Relevant negatives. If using slang, ask for clarification.

Past medical, surgical history, Birth history Length of gestation. Age and parity of mother at delivery. Any maternal insults [alcohol, smoking] or illnesses

during gestation. Where born: city, hospital. Birth weight, mode of delivery, difficulties in

delivery. Resuscitation, intensive care requirement at birth. Cyanosis, pallor, jaundice, convulsions, birthmarks,

malformations, feeding or respiratory difficulties. Apgar score at birth if known. How baby was fed in first few days. Whether child went home with mother.

Nutritional history Breast-fed vs. bottle-fedo When breast started, stopped.o If formula: type, amount, pre-mixed vs

concentrate [and dilution used]. Vitamin supplements. Age when beikost started. Appetite and growth. Current diet.

Immunization history See Immunization Schedule Reference. Get dates of each.

Illnesses and operations Past illnesses, operations. Childhood illness, obs/gyn.oTests and treatment prescribed for these.oProblems with the anesthetic insurgery.

Developmental history Gross motor. Fine motor. Vision, speech, hearing. Social. See Developmental Milestones Reference.

Education history Start of school attendance. Where attend school. Special needs requirements. Impact of symptoms: absent school days.

Family history The current complaint in parents/ siblings: health, cause

of death, age of onset, age of death. Parents/siblings: age, health, where living. Height and weight of parents. Hereditary dz suspected: do a family tree.

3 days BCG

2 months DTP Live polio Hib

3 months DTP Live polio Hib

4 months DTP Live polio Hib

12-18 months MMR

3-5 years MMR Live polio booster Diphtheria booster Tetanus booster

10-14 years Rubella [girls] BCG [sometimes]

15-18 years Live polio booster Diphtheria

booster Tetanus booster