1. Environment, general appearance
2. Arms, vital signs
3. Heart, lungs
4. Abdomen
5. Diaper, genitalia, anus
6. Legs, feet
7. Integumental
8. Nervous
9. Head and neck, eyes, ears, nose, throat
10. Height, weight
11. Examination tips

Environment

• Nebulizers, drugs on dresser.
• Special food, including sugar-free (DM).
• Mobility-assisting devices.
• Hospital equipment.

General appearance

• Pre-exam checklist: WIPE:
  • Wash your hands [thus warming them].
  • Introduce yourself to pt, explain what going to do.
  • Position pt [+/- on parent's knee].
  • Expose area as needed [parent should undress].
• Examine from the R side of the pt.
• Posture, body positions, body shape.
• Skin colors. See Skin Colors Reference.
• Hydration.
• Dress, hygiene.
• Alertness, happiness.
• Crying: high-pitched vs. normal.
• Any unusual behavior.
• Parent-child interaction, reaction to someone new walking entering the room (child abuse).
• Ask if tenderness anywhere, before start touching them.
• If asleep, do the heart, lungs and abdomen first.

Arms, vital signs

• Nails: See Nails Reference.
• Hands:
  • Clinical hand signs.
  • Color, warmth.
• Radial pulse.
• Femoral pulse.
• BP.
• Temperature.
• See Taking Pediatric Vital Signs Reference.
• Axillary lymph nodes.

Heart

• Inspection:
  • Precordial bulge.
  • Apical heave.
• Palpation:
  • Apex beat location.
  • Thrills, heaves.
• Auscultation:
  • Site, radiation.
  • Pitch, quality, character.
  • Intensity, rhythm, duration.
  • Changes with respiration, posture.
  • Carotid bruits.
• See Pediatric Heart Reference.

Lungs

• Inspection:
  • Spinal curvature.
  • Tanner stage (female). See Tanner Stages Reference.
  • Accessory muscles of respiration [respiratory pattern is abdominal <6yrs].
  • Intercostal respiration (respiratory obstruction).
• Palpation
  • Fremitus
• Percussion:
  • Dull and resonant areas.
• Auscultation:
  • Crackles.
  • Wheeze.

Abdomen

• Inspection:
  • Shape.
  • Visible swellings, hernias.
  • Umbilicus, veins.
  • Visible peristalsis.
• Percussion [often optional]:
  • Fluid wave, shifting dullness.
  • Liver, spleen.
• Palpation:
  • Masses.
  • Areas of ternderness, rebound, guarding.
  • Liver, spleen: <6 years may palpate up to 2cm below costal margin.
  • Kidneys, bladder.
• Auscultation:
  • Bowel sounds.

Diaper, genitalia, anus

• Only perform when indicated.
• Diaper:
  • Inspect contents.
  • Have MSU bottle ready if indicated.
• Male:
  • Testes decent, hernias.
  • Circumcision, testes, hydrocele.
• Female:
  • Vulva, clitoris.
• Both sexes:
  • Discharge.
  • Abnormalities.
  • Tanner stage.
• Anus inspection:
  • Hemorrhoids, fissures, prolapse.
  • Sphincter tone, tenderness, mass.
  • PR exam isn't done on children.

Legs, feet

• Infants: hip abduction in infants with knees flexed.
• Feet abnormalities, such as rocker-bottom feet.
• Similar signs as seen in hands, nails.

Nervous

• Can often skip these, as should already have good idea by now.
• Abnormalities during play.
• Limbs: movement, tone, limp, Gower's sign.
• Head control.
• Reflexes:
  • Moro and tonic neck reflexes <3months.
  • Babinski's sign positive <12-15 months.
  • Hypertonicity commonly is normal infants, but hypotonicity is abnormal.
  • Other reflexes: grasp, suck, root, stepping and placing.
• Meningitis signs if indicated: Kernig, Brudzinski.

Integumental

• Rashes, using proper terminology.
• See Hallmark Rashes Reference.
• See Skin Lesion Terminology Reference.

Head and neck

• Head circumference, rate of growth.
• Head asymmetry, microcephaly, macrocephaly, other visible abnormalities.
• Fontanelle, if <18 months:
  • Full vs. flat vs. depressed.

• Thyroid enlargement, other lumps.
• Neck stiffness.
• Neck lymph nodes: location, size in cm, tenderness, consistency.

Eyes

• Exam position: mother holds child on lap facing forward, one arm encircling child's arms, the other hand on child's forehead.
• Pupils: reaction to light, accommodation.
• Strabismus [aka squint].
  • Strabismus is normal before 4-6 months.
• Photophobia, proptosis, sclerae, conjunctivae, ptosis, congenital cataracts.
• Fundoscopy. See Eye Exam.

Ears

• Exam position: same as eye, but child faces the side.
• Discharge, canals, external ear tenderness.
• Test hearing.
• Otoscope to examine ear drums.

Nose

• Nares patency, septum, nasal flaring.
• Discharge, mucous membranes, sinus tenderness.

Throat

• Breath odor.
• Lips: color, fissures and dryness.
• Tongue.
• Teeth: number, arrangement, dental caries.
• Gums: color, hypertrophy (phenytoin)
• Throat: epiglottis
• Tonsils: size, signs of inflammation.

Height, weight

• Measure and plot on appropriate centile chart.

Examination tips

• Can establish rapport while checking cyanosis, dyspnea, cough.
  • Can examine teddy bear first.
• Best examination method by age:
  • Neonates, very young infants: on examining table
  • Up through preschool: lying sit on mother's lap
  • Adolescent: without family present.
• Parent, not examiner, should undress a small child.
• Kids are impatient, so a systematic full examination may get difficult. Examine the most pertinent area first.
• Record respiratory rate first, before crying starts.
• In child, breath sounds are easier to hear, but harder to localize.
• ENT exam more likely to induce a cry so these go last.
• Opportunism:
  • If child dozes, auscultation heart.
  • While parent removes shirt, examine shoulder/arm movement, head control.
  • If child kicks examiner, observe hip range of motion.
  • If cries, the deep breaths between each cry can reveal rales with stethoscope.