BATES VISUAL GUIDE TO PHYSICAL EXAMINATION

Vol. 3: Head-to-Toe Assessment: Child

Approach to the Child Patient

Hi, Im Dr. Herendeen. You must be Brady.
Yes.
Hi, nice to meet you.
Hi, Im Lisa.
The examination of children differs from the examination of adults in many significant ways.
Unlike adult patients, who typically can be counted on to follow your lead, children tend to vary
greatly in their levels of cooperation, requiring you to adapt your examination to the situation at
hand.
Therefore, you may find it necessary to adjust both the order and style of the examination to
the childs mood, behavior, and level of development.
In any event, make sure to include all the examination steps, even if they are not in the
preferred sequence. And remember: when you complete your post-examination write-up, you
will need to place the examination sequence back into its traditional order.
To do this, of course, you must become thoroughly familiar with all aspects of the examination
and understand how the various steps are interrelated.
You can increase the chances of obtaining cooperation from children by remembering the
following tips. You can begin the examination with the child sitting on the parents lap, moving
the child to the exam table for the components that require him to lie down. Let the parent
undress the child. And try to be at the childs eye level. Engage the parents, too. Solicit their help
in calming the child or otherwise assisting.
Including the parents also provides an opportunity to assess temperament and bonding.
Engage children in age appropriate conversation, using a playful, reassuring voice.
Paddle boards are fun. Do you have a good kick?
Yes.
Make a game out of the examination. For example, you might say
Can you breathe like a puppy dog and go heh-heh-heh-heh?
Let the child see and touch the tools you will use during the examination.
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Avoid asking the childs permission to examine a body part. After all, you will do the
examination regardless.
If you cannot console the child, complete the examination expeditiously. Or give the child a
short break. Mastering the techniques of examining children takes time. With practice and
experience, you will achieve technical proficiency.
In general, you will perform non-distressing maneuvers early, and potentially distressing
maneuvers near the end.

General Survey and Somatic Growth

With the patients health history in mind, and after good hand hygiene, you are ready for the
physical examination.
Begin with a general survey, inspecting the patient closelyliterally, from head-to-toein
order to form impressions for your later, written assessment.
During the general survey, you will observe for a wide range of abnormalities, including:
Behavioral problems, such as poor parent-child interactions, sibling rivalry, inappropriate
parental discipline, and an overall intense temperament.
While engaging the child in age-appropriate conversation, look for signs of developmental delay
in areas such as cognitive abilities, language, social and emotional tasks, as well as gross and fine
motor skills. This developmental assessment also becomes a key part of the neurological exam.
Observe for signs of social or environmental problems, including parental difficulties such as
stress or depression, and risk for abuse or neglect.
Somatic growth is one of the most important indicators of a childs health. A deviation from
normal may be an early sign of an underlying problem.
The most important tools for assessing somatic growth are growth charts. Growth charts display
a series of lines that enable you to establish percentile rankings for your patients, indicating
their growth relative to other children of the same chronologic age. To assess trends, plot
patients growth parameters over time.
Measure standing height (or stature). You will obtain optimum results using an accurate, wallmounted stadiometer. Have the child stand with the heels back and the head against the wall or
the back of the stadiometer.
If using a wall with a marked ruler, make sure to place a board or other flat surface across the
top of the childs head at a right angle to the ruler. Please note that stand-up weight scales with
height attachments are relatively inaccurate.

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Weigh children in their underpants or gown on a stand-up scale. Use the same scales across
successive visits to optimize comparability.
In general, head circumference is measured until the child reaches 24 months. Afterward, this
measurement may be helpful if you suspect a genetic or central nervous system disorder.
Age and sex-specific charts are now available to assess Body Mass Index for age. BMI
measurements are helpful for early detection of obesity in children older than two years old.
It is helpful to give parents their childs BMI results, together with information about the impact
of healthy eating and physical activity.

Vital Signs
If not already taken, measure the blood pressure in children older than two years. Select a blood
pressure cuff as you would in adults. It should be wide enough to cover two-thirds of the upper
arm or leg.
Because hypertension is more common in children than previously thought, it is important to
obtain an accurate measurement. Therefore, keep in mind that children have elevated blood
pressure during exercise, crying, and anxiety. If the blood pressure is initially elevated, you can
measure it again at the end of the examination. Elevated readings must always be confirmed by
subsequent measurements.
Obtain an accurate pulse rate. Measure the heart rate over a 60-second interval. Here is an
overview of the ranges of normal heart rates.
The respiratory rate ranges from 20 to 40 per minute during early childhood and 15 to 25 during
late childhood, reaching adult levels around age 15. Alternatively, you may use your stethoscope
to measure respiratory rate on the chest or in front of the mouth.
You can observe for 60 seconds as the child sits quietly with shirt removed.
In children, auditory canal temperature recordings are preferred over other methods because
they can be obtained quickly with essentially no discomfort. Body temperature in children is less
constant than in adults.

The Skin
Examination of the skin is the same for children as for adults. Begin by inspecting and palpating
the fingernails, looking especially for any clubbing or cyanosis.
Next, inspect the skin of the childs face and upper torso, noting color, pigmentation, texture,
hair distribution and thickness, and any lesions.

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Common skin conditions in preschool children include birthmarks, nevi, and scars. Look for
these and other distinguishing characteristics, noting their placement and dimensions.

Head and Face

Tailor the examination of the childs head to their stage of growth and development. Even
before touching the child, observe the shape of the head, its symmetry and the presence of
abnormal facies, which may not become apparent until later in childhood.
So carefully examine the childs facial features, including symmetry. It is often helpful to
compare the childs face to those of the parents.
Determine whether facial features fit a recognizable syndrome. Some of the diagnostic facies
include:
Down syndrome, fetal alcohol syndrome, perennial allergic rhinitis, and hyperthyroidism.

The Eyes
Examine the childs eyes just as you would an adults. Inspect each cornea, iris, and lens. Check
the color of the conjunctiva and sclera.
The two most important parts of the eye examination for young children are to test visual acuity
in each eye and to determine whether the gaze is conjugate and symmetric.
Visual acuity may be difficult to measure in children younger than approximately 3 years of age
who cannot identify pictures on an eye chart. For children older than 3 years, however, formal
visual acuity testing is both feasible and preferred.
The examiner may assess visual acuity in broad terms by having the child read letters, numbers,
or symbols, or by using an E chart, in which the child is asked to point out which direction the
letter E is facing.
To test for conjugate gaze or to look for strabismus, you may perform several tests also used for
adults. The first of these teststhe corneal light reflex testconsists of simply observing the
reflection of a light from the childs corneas. If you shine a light in front of the childs face and
stand about 2 to 3 feet away, the reflections should be symmetrical and visible, very slightly
nasal to the center of each pupil.
The cover-uncover test may assume the form of a game. Have the child look at your smiling
face. Cover one of the childs eyes. Then move your covering hand to the childs other eye and
see if the first eye moves. Movement of the eye just uncovered may indicate an abnormality.
When testing the visual fields in young children, test one eye at a time.

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Hold the childs head in the midline while bringing an object such as a toy into the field of vision
from behind the child.

Ears and Nose

Examining the ear canal and drum can be difficult in young children who are sensitive and
fearful because they cannot observe the procedure. Many children need to be restrained during
this examination, which is why you may want to leave it for the end.
The two best positions to work from include the child lying down and restrained by the parent,
or in younger children, sitting on the parents lap, with the childs legs restrained by the parents
legs.
To view the tympanic membrane in young children, the auricle must be pulled upward, outward
and backward to afford the best observation with the otoscope.
A technique preferred by many pediatricians as a way to hold the otoscope when examining
children is to hold the childs head with one hand and with that same hand, pull on the auricle.
With the other hand, position the otoscope with the handle pointing downward.
A pneumatic otoscope allows you to assess the mobility of the tympanic membrane as you
increase or decrease the pressure in the external auditory canal by squeezing the rubber bulb.
Although formal hearing testing is necessary for accurate detection of hearing deficits in young
children
you can grossly test for hearing standing behind the child, and have them repeat your
whispered words while you cover one of the childs ear canals and rub the tragus using a circular
motion.
You tell me what you hear. Ready? [WHISPERING] Twenty-two.
Twenty-two?
Good.
Then test the other ear.
[WHISPERING] Zebra.
Zebra?
Zebra is right, good job!
Inspect the nose, using a large speculum on your otoscope. Check for nasal deviation and
polyps, and note the color and condition of the nasal mucous membranes.

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Pale, boggy nasal mucous membranes are found in children with chronic, perennial allergic
rhinitis.

Mouth and Pharynx

When examining the mouths of young children, you should wear gloves.
Ingenuity may be necessary to make the child open his mouth. Here are some tips to encourage
the childs cooperation:
Turn the examination into a game. Say:
Can you breathe like a puppy dog and go, heh-heh-heh-heh?
Dont show the tongue blade unless absolutely necessary. The child who can say ahhh usually
offers a sufficient, albeit brief, view of the posterior pharynx, rendering a tongue blade
unnecessary.
Offer enthusiastic praise when children open their mouths a little, and encourage them to open
even wider.
With the childs mouth open, examine the upper and lower lips.
Examine the tongue, including the underside. Note the size, position, symmetry and appearance
of the tonsils. The peak growth of tonsillar tissue is between 8 and 16 years.
Then lift the upper lip to examine the upper teeth. Look for staining or signs of erosion, which
often first appear here, and which may signify the need for a dental referral.
Finally, note the quality of the childs voice. Certain abnormalities can change the pitch and
quality of the voice.
Examination of a childs neck, including the sternomastoid muscles, is the same as that for
adults.
The vast majority of enlarged lymph nodes in children are due to infections and not malignant
disease. Lymphadenopathy is common in childhood.
Check the neck for mobility. Ensure that the neck is supple and easily mobile in all directions.
This is particularly important when the child is holding the head asymmetrically, and when
central nervous system disease such as meningitis is suspected. Normally, children should be
able to sit upright and touch their chins to their chests.
In children, nuchal rigidity is a more reliable indicator of meningeal irritation than is Brudzinskis
sign or Kernigs sign. Nearly all children with nuchal rigidity are extremely sick, irritable, and
difficult to examine.

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Thorax and Lungs

As children age, the lung examination becomes similar to that for adults. Auscultation usually is
easiest when a child barely notices.
Carefully assess respirations and the pattern of breathing. An important tip is not to rush to the
stethoscope but rather to first observe the child carefully. Assess the relative proportion of time
spent on inspiration versus expiration. The normal ratio is one to one.
Prolonged inspirations or expirations are a clue to disease location. For example, prolonged
expiration is a frequent sign of asthma or lower airway obstruction.
Note any effort or work of breathing, including nasal flaring and grunting. Although, as
children grow, these signs grow less helpful in assessing for respiratory pathology.
Palpation, percussion, and auscultation achieve greater importance in a careful examination of
the thorax and lungs.
Examination of the heart and vascular system in infants and children is similar to adults, but you
must use your knowledge of the developmental stage of each child to make the examination
easier and more productive.
Let children move the stethoscope themselves, going back to listen properly.
Measure the blood pressure in the right arm. If the child is three to four years old, measure it in
both arms and one leg at a time to check for possible coarctation of the aorta
It is important to keep in mind that most school-aged children have a benign heart murmur at
some point in their lives. The most common, Stills murmur, is a grade I-II/VI, musical, vibratory,
early and midsystolic murmur with multiple overtones, located over the mid or lower sternal
border but also frequently heard over the carotid arteries.
Compression of the carotid artery usually causes the precordial murmur to disappear. The
murmur will also diminish as the child goes from supine to sitting to standing.
Also in preschool or school-aged children, you may detect a venous hum. This is a soft, hollow,
continuous sound, louder in diastole, heard just below the right clavicle. It can be completely
eliminated by maneuvers that affect venous return, such as lying supine, changing head
position, or performing jugular venous compression. A venous hum has the same quality as
breath sounds and therefore is frequently overlooked.
The murmur heard in the carotid area or just above the clavicles, is known as the carotid bruit. It
is early and midsystolic, with a slightly harsh quality. It is usually louder on the left and may be
heard alone or in combination with Stills murmur.
It may also be completely eradicated by carotid artery compression.

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Breasts and Abdomen

Examination of the breasts in young children consists solely of inspection, because in both sexes
there is little breast tissue.
To examine the abdomen of a young child, have the patient lie supine with knees flexed. Many
children are ticklish, so distraction can be important. Chatting with the child can help him relax,
as can placing your whole hand flush on the abdominal surface for a few moments without
probing.
For particularly sensitive children, try placing the childs hand under yours. Eventually you will
be able to remove the childs hand and palpate the abdomen freely.
Palpate lightly in all areas, then deeply, leaving the site of potential pathology to the end. Begin
palpating low on the abdomen, moving your hand upward so that you do not miss the edge of
the liver or spleen.
One method to determine the lower border of the liver involves the scratch test. Place the
diaphragm of your stethoscope just above the right costal margin at the midclavicular line.
With your fingernail, lightly scratch the skin of the abdomen along the midclavicular line, moving
from below the umbilicus toward the costal margin. When your scratching finger reaches the
livers edge, you will hear a change in the scratching sound as it passes through the liver to your
stethoscope.
The spleen, like the liver, is felt easily in most children. It too, is soft with a sharp edge and
projects downward like a tongue from under the left costal margin. The spleen is moveable and
rarely extends more than one-to-two centimeters below the costal margin.
Palpate the other abdominal structures. You will commonly note pulsations in the epigastrium
caused by the aorta. This is felt most easily to the left of the midline, on deep palpation.

Male Child Genitalia

Begin examination of the male genitalia by inspecting the penis. The size in prepubertal children
has little significance unless it is abnormally large. In obese boys, the fat pad over the symphysis
pubis may obscure the penis.
There is an art to palpation of the young males scrotum and testes, because many have an
extremely active cremasteric reflex that may cause the testis to retract upwards into the
inguinal canal, and thereby appear to be undescended. Therefore, examine the male child when
he is relaxed, because anxiety stimulates the cremasteric reflex.
With warm hands, palpate the lower abdomen, working your way downward toward the
scrotum along the inguinal canal.

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A useful technique is to increase intra-abdominal pressure by asking the child to do a sit-up. If

you can detect the testis in the scrotum, it is descended even if it spends much time in the
inguinal canal.
Examine the inguinal canal as you would for adults, noting any swelling that may reflect an
inguinal hernia. Have the boy increase abdominal pressure and note whether a bulge in the
inguinal canal increases.

Female Child Genitalia

The female genitalia examination can be anxiety provoking for the older child and adolescent,
but if not performed, a significant finding may be missed.
The examination of external female genitalia is the same for all ages of children. Use a calm,
gentle approach, including a developmentally appropriate explanation as you do the
examination. A bright light source is essential. Most children can be examined in the supine,
frog-leg position.
If the child seems reluctant, it may be helpful to have the parent sit on the examination table
with the child. Or, the examination may be performed while the child sits in the parents lap, as
shown here.
Examine the genitalia in an efficient and systematic manner. Inspect the external genitalia for
pubic hair, the size of the clitoris, the color and size of the labia majora, and any rashes, bruises,
or other lesions.
Next, visualize the structures by separating the labia with your fingers, as shown here.
You can also apply gentle traction by grasping the labia between your thumb and index finger of
each hand and separating the labia majora laterally and posteriorly to examine the inner
structures.
Note the condition of the labia minora, urethra, hymen, and proximal vagina. If you are unable
to visualize the edges of the hymen, ask the child to take a deep breath to relax the abdominal
muscles.
Another useful technique is to position the patient in a knee-chest position as shown here.
Avoid touching the hymenal edges because the hymen is very tender without the protective
effects of hormones.
Examine for discharge, labial adhesions, estrogenization, hymenal variations, and hygiene.
The physical examination may reveal signs of sexual abuse, and may require more complete
evaluation by an expert in the field.

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The rectal examination is not routine, but should be done whenever intra-abdominal, pelvic or
perirectal disease is suspected.

Musculoskeletal System
In older children, abnormalities of the upper extremities are rare in the absence of injury. The
normal young child has increased lumbar concavity, decreased thoracic convexity, and often a
protuberant abdomen.
You will detect most abnormalities by watching carefully from both the front and behind as the
child stands and walks barefoot, touches his toes and runs a short distance.
To check for scoliosis, perform the Adams Bend Test if the child is at least six years old. Have
the child stand with his bare feet together and bend forward with the knees straight and the
arms hanging straight down.
Look for any asymmetry in positioning. If you detect scoliosis, use a scoliometer to test for the
degree of scoliosis.
Finally, check for leg length discrepancy by having the child stand straight as you observe from
behind. Place your hands on his iliac crests. Your hands should be perfectly parallel to the floor.
Test for severe hip disease by observing from behind as the child shifts weight from one leg to
the other. A pelvis that remains level when weight is borne on the unaffected side is a negative
Trendelenbergs sign.
But with an abnormal positive sign in severe hip disease, the pelvis tilts toward the unaffected
hip during weight bearing on the affected side.
For children age eight or older, perform a sports pre-participation screening musculoskeletal
examination. Organized sports often require this medical clearance in order for the child to
participate. Refer to the textbook for the details of this examination.

Nervous System
The neurological examination of the child includes the basic components evaluated in adults,
with the addition of a developmental examination.
The sensory examination can be performed by slightly tickling the childs skin using a cotton ball
or soft object and asking the child to indicate when he feels it. Make sure the childs eyes are
closed, and dont use a pin, because it will scare the child.
Observe the childs gait and coordination while the child is walking and running. Note any
asymmetries, weakness, undue tripping or clumsiness.

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To check for gross motor development and balance, ask the child to balance on one foot and to
hop. You might try asking him to walk on his heels, if he is old enough to perform this maneuver.
If you are concerned about the childs strength, have the child lie on the floor and then stand up
and closely observe the stages. Most normal children will first sit up, then flex the knees and
extend the arms to the side to push off from the floor and stand up.
Hand preference is demonstrated by most children by age two. Check for weakness in the nonpreferred upper extremity.
Test for deep tendon reflexes as in adults. You can show the child the reflex hammer, treating it
like a toy so he is not frightened. Distract the child or ask him to close his eyes so he does not
see the impact of the hammer and provide a false reaction.
To check for fine motor development, ask the child to copy an X or a square, or draw a person
(which should display several body parts). Then, discuss their pictures to test for cognition and
language as well.
The cerebellar examination can be performed by asking the child to touch your finger and then
his nose, and by having him perform rapid hand movements. Children older than five years old
should be able to tell right from left, so you can assign them right-left discrimination tasks as
well.
The cranial nerves can be assessed using developmentally appropriate strategies.
Cranial Nerve I, which mediates sense of smell, is generally not tested at this age.
Cranial Nerve II, which mediates vision, is usually assessed in part by testing for visual acuity.
Use the Snellen chart or E chart for those children ages three years and older.
Cranial Nerve II, along with Cranial Nerve III, controls response to light. You will have tested for
this previously, during the childs eye assessment.
Cranial Nerves III, IV, and VI, which mediate extraocular movement, can be tested by having the
child track light, or an object, as in your earlier eye assessment.
The motor portion of Cranial Nerve V innervates the muscles of mastication, while the sensory
portion mediates facial sensation and the sensory part of the corneal reflex. Cranial Nerve V may
be assessed by having the child smile.
Cranial Nerve VII innervates all muscles of facial movement and expression and should be
assessed by asking the child to make faces.
Cranial Nerve VIII mediates hearing and vestibular function, and should be assessed in a formal
hearing testing session.

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Cranial Nerves IX and X mediate the sensory and motor functions of the palate, pharynx, and
larynx. These nerves are assessed by asking the child to stick out his whole tongue and move it
back and forth.
Cranial Nerve XI innervates the sternomastoid muscles and upper trapezius muscles and is
assessed by having the child push your hand away with his head.
Cranial Nerve XII mediates motor functions of the tongue, affecting articulation of words. To
assess, observe the childs speaking ability.

Recording Your Findings

Remember that a clear, well-organized clinical recordemploying language that is neutral,
professional, and succinctis one of the most important adjuncts to patient care.
[TYPING] HEENT was normal. Neck was supple. Lungs were clear. Heart, regular rhythm with no
murmur. Abdomen was soft.
After practice and further review of this video, make sure you have mastered the important
learning objectives for examining children.

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