Examination - Paediatrics

Examination

·        Principles:

o   Leave nasty things till last

o   Observe

o   Get on floor and use games

o   Wait until child familiar with environment but start before bored

o   Don‟t touch child until rapport established

o   Use your own toys – they‟re novel

o   Get parents to undress them (or do anything else that is nasty)

o   Get them to draw pictures while taking the history 

·        They‟re likely to be scared (depending on previous experience). Build rapport, play games, talk with child not through parent. Don‟t wear stethoscope around neck

·        Show them what you want rather than telling them

·        Blood pressure:

o   Is important – always do it

o   Getting them calm is hard – usually anxious ® artefacts common

o   Cuff: Bladder should nearly encircle the arm.  Width is 2/3 length from should to elbow

·        Chest exam: 

o   Percussion more sensitive than auscultation (won‟t show anything in the absence of respiratory signs/symptoms)

o   Percussion will tell you about hyperinflation, fluid, mediastinal shift

o   Ausciltate heart early in the exam – but not first 

·        Abdominal exam: Get child to suck in and push out tummy to check for tenderness – then you won‟t have to hurt them yourself.

·        Differences in a baby: 

o   More liver in the abdomen (2 finger breaths is normal). Don‟t press too hard – moves with respiration

o  Pelvic organs higher (eg bladder) 

o  Pulses: Radial/ Brachial – take both sides. Must palpate femoral pulse. If feet aren‟t white don‟t take peripheral pulses

·        Teenage girls: examine chest underneath clothes

Normal Values

·        Stethoscope around your neck adds 10!

·        Haemoglobin: at birth: 170, day 5: 200, 12 weeks: 120 (lower limit of normal is 90 – 100)

Examination outline

·        Height, Weight and Head Circumference (and plot them)

·        General:

o  Sick or well

o  Dysmorphic features

o  Obvious distress

o  Temperature

o  Colour/rashes/anaemia/cyanosis/jaundice 

o  Lymph nodes: Check anterior and posterior cervical chains, subhyoid, sub-occipital, sub-mandibular, sub-lingual, axillary, inguinal and epitrochlear

o  Hydration/perfusion

·        Cardiovascular:

o  Pulses: radial, femoral, synchrony, sinus arrhythmia (normal in all children)

o  Blood pressure (NB use correct cuff size)

o  JVP: often hard to see

o  Peripheral oedema (Periorbital in babies) 

o  Liver enlargement ® right ventricular failure

o  Feel the cardiac impulse: Apex may be more lateral in children.  Thrills

o  Auscultation

·        Respiratory:

o  Ears, throat, nose, sinuses

o  Clubbing

o  Chest deformity

o  Respiratory rate, effort and accessory muscle use, grunting, ability to talk in sentences 

o  Intercostal, sub-sternal and supraclavicular indrawing, hyperinflation, Harrison‟s sulcus (lower ribs pulled in ® chronic airways disease), pigeon chest (Þ chronic ­ in AP diameter), tracheal tug, nasal flaring 

o  Auscultation, including cardiac dullness (Þ hyperinflation).  Tracheal position rarely of value

·        Abdominal:

o  Inspection, movements, scars, hernia

o  Liver, spleen and kidneys

o  Bladder

o  Masses

o  Tenderness

o  External genitalia

o  Examine anus (PR rarely required)

·        Neurological:

o  Developmental assessment: See Topic: Child Development

o  Neurological Exam: See Topic: Neurological Exam in Children

·        Joints

·        Skin