Pediatric Physical Examination

A complete physical examination in the child emphasizes many characteristics which differ from those in adults. It is important to recognize these differences and also the variations among normal children.

There is no "routine" physical examination of a child. Each examination is individualized. Not only are there many physical differences which an examiner accustomed to adults might consider abnormal in a child, but also the variations among a group of children make the examiner more alert to the broad spectrum included in the term "normal." The physician adept at physical diagnosis in children is one who is aware of these variants.

Most of the observed variations can best be explained by the difference in growth rates of the organ systems as they occur from infancy to maturity. For example the lymphoid tissue is relatively well developed in infancy, becomes maximally developed during childhood, and regresses to small adult proportions at puberty. The nervous system, on the other hand, is largely developed at birth and reaches almost complete adult size by the age of five years. The genital system, however, is infantile until puberty. These and other variations will be noted throughout the discussion of the physical examination.

A question frequently asked by the mother is, "Is my child normal?" One is rarely able at a single observation of that child to tell whether or not he/she is entirely normal, though one may frequently be able to tell that the child is abnormal. Normality in Pediatrics, as in statistics, is often confused with the average, and statisticians conclude that there is considerable variation from the average in any normal static population. Normality in children includes the many differences around the average of the age of the child being studied, with adequate consideration of the child's background and environment. During a physical examination one looks for normal, variations from normal, and abnormal states. The general mental and physical state, congenital and acquired anomalies, and pathological or disease states are determined.

The record of a complete physical examination in children has special importance not found in that of adults. This record of examination represents a report of one specific time in a child's life when that child is continually and rapidly changing. Therefore, it will be used as a basis for determining whether or not that child is growing and developing normally, according to a group of standards which are learned from books, mothers, and patients. More important than a single observation of the child, is the use made of this record in following the rate of change of the child at each subsequent examination. The rate of growth, rate of development, and indeed rate of progression of difficulties or anomalies far surpasses for evaluation purposes, the single examination. The single examination is valuable, of course, for determining for the physician, the parent, and the child, the gross evaluation of the potentialities and liabilities of the child. Thus, even small and apparently insignificant variants should be noted for each child, so that their importance may be adequately assessed in later examination.

For example, if it is known that a particular child with nausea and vomiting was adequately examined two weeks before his illness, that the liver was not palpable at that time, but it is now palpable 2 cm. below the right costal margin, attention would be directed to the liver as a possible cause of the illness. In contrast, if it were known that two weeks before the acute illness the child's liver was palpable, less attention would be paid to the now palpable liver. This type of notation is especially important for so called "functional" murmurs of childhood, which are notorious for their frequent change, the significance of which may take many months and many examinations to determine.

The physical examination in a child should also be a record which can be easily interpreted by other physicians. Though the method of recording the physical examination is in a logical order, the examination itself is not necessarily performed in this order.

Approach to the Patient

Every doctor has a set of tricks of examination which he/she has developed. For an older child that may include such things as flattery of the patient's dress, conversation with the patient on their own level, and a discussion of mutual interests. For the preschooler they may take the form of distracting the patient with interesting objects and providing reassurance. For the infant, one must sometimes resort to various physical measures such as formula to keep the patient quiet. Even a two-year-old may respond to flattery, and although bribery of any kind is normally deplorable, a judiciously offered toy to play with, a cup or a doll, may create an everlasting attachment between patient and physician.

Usually, the examination is performed with the parent present. If the child is frightened or clings to the parent, sending the parent out of the room usually serves only to frighten the child more. On rare occasions, such as with adolescents, the parent may be asked to leave the room, but this should be done before the examination begins, or preferably before the doctor enters the room for the examination. This should be negotiated ahead of time with both the adolescent and the parent or caretaker.

In general, one begins a physical examination using no instruments and gradually introduces the various necessary equipment. Frequently, a tentative diagnosis can be made simply by observing the child in the mother's arms or as he/she walks or stands in the room. Decide quickly whether you think the patient looks sick or ill early on. This may be helpful when it comes time to decide on a diagnosis. This diagnosis may be confirmed following the thorough examination. Usually, the patient is examined in a crib or on a table. The examining table or bed should be large enough so that the child will have no fear of falling, and high enough so that the doctor can examine the patient in comfort.

Physical examinations are performed on children by taking full advantage of opportunities as they present themselves. Anyone concerned with the physical and mental habits of children realizes that the medical student must use all the wiles available to establish rapport with the child. The order of an adequate examination, therefore, is more or less determined by the child rather than the physician.

The examination is usually performed with the patient in the most comfortable position available at the time. An infant or severely ill child who understands well, may be conveniently examined largely in the supine position. However, a six-month-old may have just learned to sit up and may be anxious to demonstrate this ability. Therefore, the examination should be done chiefly with the patient in the sitting position. Likewise, some children may prefer being examined while standing or in unusual positions, and these preferences should be respected if they will not interfere with a complete examination. Many children prefer to be examined in their parent's laps. Most children become frightened when they have to lie down.

An obstreperous or frightened patient, however, may reject all attempts at examination, but frequently even s/he can be examined completely in their parent's arms. This is especially the position of preference for many one to three-year-olds. Other children may have such parts as their ears or mouth examined while being held by the caretaker. "Blowing out the otoscope" game is a useful approach to children between one and three, and playing peek-a-boo easily distracts frightened children.

Occasionally, it may be necessary to restrain the patient for the examination of such parts as the ears or mouth. This may be done by placing the infant's arms under his back so that the weight rests on the palms. The head may be restrained by either the examiner or mother and the examination proceeds. An alternate method of restraint is mummifying the infant. The right arm is wrapped with a fold of a sheet. Both ends of the sheet are pulled tight under his back and the left arm is wrapped with the doubled sheet which is then brought back and tucked under the patient's back. The head is restrained as before.

Most pediatricians, aware that the sight of many instruments may frighten the child, start the physical examination with observation of the chest or abdomen then they auscultate, percuss and palpate these areas, and follow with the remainder of the examination. While performing the examination it often helps if the examiner allows the patient to play with the instruments to be used. When cooperation is desired for the more difficult procedures, the patient should be told firmly what he is to do, rather than be asked to do something.

Before anything frightening or painful is contemplated, the patient should be told what is to be done and what is expected. Such procedures as examination of the head, where the instruments are stuck into the ears and mouth, or the rectal examination should be reserved for the end of the examination. Rectal examination is not done routinely unless the child has symptoms referable to the lower gastrointestinal tract or abdomen.

Any discomfort caused to a patient should be for as short a time as possible. If the doctor feels that at any time in the examination there will be pain, it is important to tell the patient that he/she will "feel" something or that a "needle" will be given. We should never lie to patients, but telling children about painful events too early can produce undue anxiety. Of course, if the child is acutely ill or hyperirritable, one takes little time for the amenities and proceeds rapidly with the examination.

Occasionally, especially in the acutely ill patient, the physician may have suspicions regarding a particular diagnosis and may wish to confirm or eliminate this diagnosis before proceeding with the examination. For example, if meningitis is suspected in an infant, the fontanel may be palpated first; or if acute abdomen or congenital heart disease is suspected, the abdomen or heart might be examined first. Caution in following such a procedure is necessary. Too frequently, a relatively unimportant secondary diagnosis may be found and the examiner may forget to complete the examination that would reveal the primary diagnosis.

Caution must also be observed in following this procedure in those children with obvious skin blemishes or other gross deformities, or in those with suspected psychiatric difficulties or mental deficiency. In these children it is especially desirable to examine first those areas in which difficulty is not expected, in order to avoid drawing the attention of the child or parent to the obvious difficulty.

Ordinarily, the complete physical examination should take the experienced physician no longer than five to ten minutes to perform. Speed is necessary to avoid exhausting the patient. At each visit, regardless of the chief complaint or reason for the visit, a complete systematic examination should be performed and any abnormalities recorded. It is a striking fact that few doctors miss a diagnosis because of ignorance. Errors are caused by careless omission of simple procedures.

Above all, the successful doctor caring for children must obtain genuine pleasure from examining and dealing with them. The physician should be friendly and unhurried, and he must proceed with the examination with interest, patience, dexterity and confidence.