There are no short cuts for physical diagnosis. It is learnt only by practice, not a dull, dreary monotonous practice but practice with all the five senses aleart.
Principles and Art of Examination of Children
Physical examination is subjective (provide soft data) and its yield depends upon the experience, skills, thoroughness and the time spent by the pediatrician for making the clinical assessment. Eyes, ears, nose and palpating fingers are the real gems of a physician and intact analytical brain is the necklace. Sharp, sensitive and well conditioned special senses are crucial for making correct observations. Sight (sharp and keen observation), hearing (listen, percussion, auscultation), smell (sickness, fetor hepaticus, uremia, ketosis, poisons, pus, metabolic disorders etc.), taste (least important), touch (gentleness, healing, sensitive and delicated hands with long fingers), analytical or synthetic mind and intuition are essential attributes of a successful physician.
Stethoscope, torch, spatula, thermometer, percussion hammer, fibreglass tape measure, white plastic ruler, diagnostic set, sphygmomanometer, developmental assessment tools, weighing machine and a wall chart for measurement of height should be available. The tools of different sizes are required because pediatricians are expected to deal with a preterm baby of under 1.0 kg and an adolescent of over 40 kg.
Well lighted, warm, colorful, comfortable room and warm hands are essential. The physical examination is often unsuccessful if the examiner has cold hands, cold instruments and cold manner. Toys, pictures and cartoons should be kept to allay apprehension of the child. Avoid deep yellow/blue curtains fo proper evaluation of jaundice and cyanosis.
Gentleness, confidence, sympathy, patience, tact, compassion, concern, kind look and love for children are essential attributes of a pediatrician. A good pediatrican begins his examination as soon as mother enters the consultation room and while eliciting history. During interview “sneaky” observation of the child, offering small bright objects or candy, “intelligent neglect”, respect to the mother/attendant to gain her/ child’s confidence are essential. The experienced pediatrician should be able to assess and grade whether child looks well, mildly ill or gravely sick requiring urgent attention.
Children should be treated as children and not patients. You should adopt play attitude, and do not frighten them with injections. The pediatrician should literally come down to the level of the child, both physically and mentally to elicit cooperation. If you are unable to obtain the cooperation of the child it is usually due to your fault either due to lack of tact or unskillful approach. The previous experience with other physicians, nature of illness tact of physician, unnecessary removal of clothes, sequence of examination etc. are crucial determinants whether a child is likely to cooperate or not. Unnecessary and complete undressing of the child is undesirable and often compromises cooperation. The undressing should be limited to removal of some clothes at a time to facilitate specific aspects of examination. Postpone examination or examine after sedation if a child is uncooperative. The relatively traumatic examination like percussion, throat and rectal examination should be done in the end. The older child may be explained the procedure if it is unpleasant. The child should be given a firm direction to follow instead of making a meek request which gives him the option to refuse to cooperate.
Position for Examination
To elicit maximum cooperation, children at different ages are best examined in different positions as per following recommendations. Most children feel comfortable sitting or standing during the examination rather than lying supine. When the child appears friendly and not frightened, he may be placed on the examination table.
0- 3 months: Examination table
3 months -1 year: Mother’s lap
1- 3 years: Standing or mother’s lap
After 3 year: Examination table
Adolescent girl: Female attendant or nurse should be present at the time of examination.
Spend maximum time on observation. You can observe the whole infant at a time and it is least disturbing to the child and most informative. Attitude and posture (bed-ridden or ambulatory, opisthotonus or emprosthotonus, side posture, orthopneic, motionless, restless, comfortable), expression and mental state (fully conscious, drowsy, delirious, stuporosed or semicomatosed, coma) abnormal movements, signs of meningeal irritation, peculiar odour and nature of cry should be observed. Never ignore the nonverbal communication of the patient. Pay due attention to the looks and anxiety on the patient’s face, the lowering of his eyes, the tremble in his hands and contents of his drawings. The eyes see what the mind knows! Develop a keen sense of obvservation during your day to day activities and by comparing different individuals to identify subtle differences in their facial features, phenotype, posture, gait, speech etc. It is a unique quirk of nature that among millions of people no two human beings look alike!
Sequence of Examination
The approach to examination should be unstructured to elicit best cooperation for the most relevant component of examination. The unpleasant examination should be postponed to the end. Auscultation may be done at the beginning in an infant suspected to have a cardiac problem because conventional sequence of examination would lead to crying by the time auscultation is done. This should be followed by inspection, palpation, percussion, recording of blood pressure, elicitation of deep tendon jerks, ENT examination, rectal examination and examination of the painful site or limb should be conducted in that order.
Scheme of Recording and Presentation
Presentation of physical findings should be standardised and according to a set pattern though the sequence of examination of children is unstructured.
Build and Nutrition
Skeletal size, body frame, subcutaneous fat, and muscle mass should be assessed. Is the child tall, short, fat, thin, muscular, asthenic or cahectic? Look for clinical evidences of marasmus, marasmic kwashiorkor and kwashiorkor.
Detailed anthropometry to record weight, height (or recumbent length with the help of an infantometer), surface area, midarm circumference, stem length (crown rump or sitting height), span, upper segment (vertex to pubic symphysis) to lower segment ratio, chest circumference and head circumference is essential for evaluation of children. Refer to details regarding anthropometry.
Objective assessment of development is required in selected cases.
Temperature, pulse, blood pressure (Hess capillary test, Trousseau’s sign should also be looked for, if indicated), and respiration rate should be recorded. The breathing is mostly abdominal or abdomino-thoracic in infants and it bccomes predominantly thoracic after the age of 5 years. In critically sick children capillary filling should be checked. Press the pulp of the finger and if it takes more than 3 seconds to refill or flush, it is suggestive of impending shock or poor circulation. Skin temperature (groin and axilla) is recorded in infants and preschool children and is quite reliable. It is 0.5°C lower than the oral temperature, while rectal or eardrum temperature is 0.5°C higher than oral temperature. Rectal temperature may be recorded in critically sick children but should be avoided as a routine procedure. Temperature can also be recorded over the skin of forehead and eardrum by using thermo-crystal strips and infrared technology respectively. These methods are quick and convenient but unreliable at times. In severely malnourished children and neonates, low reading thermometer (30-40°C) should be used to assess the severity of hypothermia. Heads of most infants feel warm to touch and it should not be mistaken for fever. It should be remembered that many normal children have diurnal variations in their body temperature, being lowest early morning and highest in the evening around 4 p.m. Mild elevation of temperature (oral temperature upto 37.7°C or 99.9°F) in some children especially during the afternoons in summer months is not indicative of any disease process. Avoid unnecessary work up if child is otherwise well, active, feeding and growing normally.
Tourniquet test (Hess capillary resistance test, Rumpel-Leed test). Sphygmomanometer cuff is wrapped around upper arm and inflated midway between systolic and diastolic blood pressure for 5 minutes. The skin of the forearm is examined 5 minutes later. The development of > 10 petechiae over an area of one square inch on the flexor surface of forearm is positive and suggestive of increased capillary fragility or thrombocytopenia. If the test is negative on one side it may be repeated on the other arm.
Trousseau’s sign. The blood pressure cuff is inflated above the systolic blood pressure for 3 minutes. The increase in muscle tone over thenar eminence and adduction of thumb are suggestive of positive Trousseau’s sign and is indicative of hypocalcemia. Peroneal sign can be elicited by applying the blood pressure cuff over the thigh.
Anemia, lymphadenopathy, cyanosis, jaundice, edema, are looked for during general physical examination. The peripheral lymphnodes are looked for in the neck, axillae, epitrochlear region, groins and popliteal fossae. The examination of lymphnodes should include their location or site, size, consistency, tenderness, warmth, whether discrete or matted, mobile or fixed to the overlying skin etc. Matted lymphnodes are characteristically seen in chronic inflammation due to tuberculosis. Discrete rubbery or firm lymphnodes are suggestive of malignancy or Hodgkin’s disease. There is physiological hyperplasia of lymphoid tissue in children. Cervical lymphadenopathy upto 1.0-1.5 cm diameter, when lymphnodes are discrete, mobile and non-tender is not significant. Cervical lymphnodes readily enlarge in children having pediculosis, pyoderma and recurrent upper respiratory infections.
Head and Face
Look for size, shape, symmetry, bossing or prominences, anterior fontanel (size and tension), sutures, Macewen’s sign, auscultation, and transillumination of skull. Macewen’s sign or cracked-pot sound is elicited by percussion of skull. The amplified sound may be listened with the help of a stethoscope. The sign is positive when sutures are separated due to raised intracranial tension. It is physiologically present during infancy as long as the anterior fontanel is open. Transillumination of skull is indicated in all infants below one year of age. Flash light equipped with a rubber foam cuff is snugly applied over the frontal and occipital areas in a dark room and rim of translucency is looked for. When translucency extends beyond 2.0-2.5 cm in the frontal area and over 1.0 cm in the occipital region it is abnormal and is indicative of subdural effusion, subdural hematoma, hydrocephalus, hydranencephaly, and porencephaly. Intracranial bruit should be looked for in infants with raised intracranial tension and intractable congestive heart failure. It may be heard in 10 to 15 percent of normal children. The odd shaped skull may occur due to premature fusion of skull sutures because skull bones grow at right angle to the direction of sutures. The antero-posterior diameter may be increased (dolichocephaly) or decreased (brachycephaly). The skull may appear grossly asymmetrical (plagiocephaly), may grow vertically like a tower (oxycephaly, acrocephaly) or appear like a boat (scaphocephaly). In clover leaf skull all the cranial sutures are prematurely fused and brain grows through the anterior and temporal fontanels producing projections or bulges at vertex and temporal areas. Characteristic facies e.g. Down syndrome, cretin, Gorgoyle, chromosomal disorders etc, and evidences of facial dysmorphism like asymmetry of face, size and position of ears, distance between eyes, alignment of eyes, nasal bridge, lips and chin etc. should be looked for. Develop a keen sense of observation. Eyebrows, eye lashes and eyes should be examined for evidences of vitamin A deficiency, cataract, coloboma (partial absence of a part of eye), pupils, ptosis, exophthalmos and setting-sun sign. Look for aniridia (absence of iris) which is known to be associated with Wilm’s tumor and heterochromia irides (the color of the irisis of two eyes is different). Due to unexplained reason, infants with PEM and tuberculosis may have relatively long eye lashes. Long and curly eyelashes is a characteristic feature of Cornelia de Lange’s syndrome. Look for hirsutism, bushy eyebrows which may extend to nasion over the middle of forehead (synophrys). Examine the profile of the face for parotid swelling. It is seen in front of the angle of the jaw and lifts the lower lobe of the ear laterally which is best seen when child is viewed from behind.
Mouth and Throat
Evidences of vitamin B complex deficiency, angular stomatitis, and cheilosis should be looked for. Tongue should be examined whether it is dry or wet, coating, color, papillae, tremors, symmetry, aphthous ulcers, Assuring etc. Teeth and gums, should be examined for oro-dental hygiene and bleeding manifestations. Note how many deciduous or permanent teeth have erupted. The timing or onset of primary dentition is variable (due to genetic or constitutional factors) and is unreliable for assessment of nutritional status. Primary dentition may be delayed upto one year due to constitutional factors. Milk teeth are white in color and have a smooth edge in contrast to permanent teeth, which have an ivory-white or off-white color and have a finely serrated edge. Look for Kopliks spots in all children presenting with upper respiratory tract infection to diagnose measles during the prodromal stage. They are pinhead sized white spots (like sago) with a red margin and are distributed over the buccal mucosa opposite the molar teeth. Examine throat in all children for size of tonsils, evidences of inflammation, follicles, membrane, petechiae etc. Tonsils are physiologically large in most children. Small and atrophic tonsils may be seen in children with immunodeficiency disorder or may be absent following tonsillectomy.
Ears must be examined in all children with unexplained fever, upper respiratory tract infection, car ache or discharging ear. The child should be positioned properly and restrained for ease of examination. In newborns and infants the direction of ear canal is upwards while in older children it runs downwards and forward. To visualize the tympanic membrane pull the pinna of the ear with thumb and index finger of one hand up and back in older children and downwards or laterally in infants and newborns. Use the largest speculum that will fit the ear canal. The hand holding the otoscope should rest against the cheek or head of the child so that, if child moves, the otoscope moves accordingly without imposing any risk to the child. Look for secretions, wax, foreign body and inflammation in the ear canal. Examine the tympanic membrane for its color, clarity, bulging or retraction, cone of light and perforation. Absence of cone of light indicates loss of lustre due to inflammation. The common type of perforations are antero-inferior, subtotal (rather large in size) and attic over the par flaccida.
Head and Face
Look for any swelling , hair line, webbing, jugular venous pressure (JVP), pulsations, thyroid gland, lymphnodes, mass, fistula and position of trachea.
Skin and Appendages
Examine nails of hands and feet for clubbing, koilonychia or flattening, splinter hemorrhages, Osier nodes, brittleness and transluscent bands. Koilonychia or spooning of nails as a sign of iron deficiency is relatively uncommon in children.
Skin should be examined for color, texture, elasticity/turgor, pigmentation, hemorrhagic spots, rash (blanches on pressure as opposed to petechiae and ecchymoses), pyoderma, subcutaneous nodules, neuroectodermal dysplasia, nevi, xanthoma, spider nevi, palmar erythema etc. Follicular hyperkeratosis is characteristically seen over extensor surfaces of forearms and buttocks. It occurs due to nutritional deficiency of vitamin A and essential fatty acids. The nature and distribution of skin lesions, whether isolated or generalized, symmetrical or asymmetrical, centrifugal or centripetal, present on flexor or extensor surfaces or areas exposed to sunlight should be looked for. The morphology of skin lesions is described as macules (areas of discoloration, neither raised nor depressed), papules (elevations upto 5 mm diameter), nodules (larger than papules), vesicles (blisters upto 10 mm diameter), bullae, wheals (pale, flat papules with surrounding erythematous flare as seen in urticaria), scales, burrows (dark brown straight or sinuous elevations in interdigital areas produced by female scabies mite), comedones (black heads of acne), plaques (circumscribed flat areas of skin felt either raised, depressed or thickened), ulcerations, erosions or scar formation etc. Look for distribution, color, texture, brittleness and pediculosis in scalp hair. Rarely hair may show alternate bands of depigmentation producing typical flag-sign in children due to chronic malnutrition.
Dermatoglyphics. The pattern of creases and ridges over the palms may provide useful information of clinical significance in children. Single horizontal palmar crease or Simian crease (due to merging of head and heart lines) is classically seen in children with Down syndrome or as an isolated minor anomaly or in association with other chromosomal disorders. Distal triradii are seen over the bases of index (a), middle (b), ring (c) and little (d) fingers while proximal triradius (t) is located on the palm close to the wrist. The atd angle in normal subjects measure 40°. The atd angle is obtuse (between 75°-80° due to distal location of proximal triradius) in children with Down syndrome, Turner syndrome and congenital rubella syndrome. There may be abnormalities in the pattern of ridges over finger tips in children with Down syndrome (ulnar loops in all fingers), congenital rubella syndrome (more whorls), trisomy-18 (increase in arches) and Klinefelter syndrome (marked reduction in ridge count).
|Degree||Acute weight loss||Signs|
|Mild||Upto 5%||Irritability, excessive thirst.|
|Moderate||5-10%||Depressed anterior fontanel, sunken eyes, reduced tears and sweat, loss of skin turgor, dry mucosa, reduced urine Output.|
|Severe||> 10%||Extreme loss of skin turgor and absence of tears, marked oliguria or anuria, tachycardia, cold and clammy skin, shock, acidosis, alteration in consciousness.|
In hypernatremic dehydration, mucosa is parchment like, with marked thirst, skin is doughy, shock and renal shut down are delayed. Seizures may occur during rapid correction of hypernatremic dehydration.
Evidences Deficiency States
The clinical evidences and severity of dehydration should be looked. In a marasmic child, evalution of dehydration is difficult because skin turgor is impaired due to loss of subcutaneous fat. Look for evidences of excessive water loss (vomiting, diarrhea) or poor intake, thirst, dry buccal mucosa, oliguria/ anuria, acidosis and shock for making the diagnosis of dehydration in malnourished children. Look for evidences of protein-calorie deficiency (undernutrition, marasmus, marasmic-kwashiorkor, kwashiorkor) deficiency Of vitamin A, C, D & B complex and mineral deficiencies (iron, calcium, magnesium, copper, and zinc).
Bones and Joints
Look for chest deformity, localized swelling, ends of long bones, sternal tenderness, joint inflammation, swelling, mobility etc., size and symmetry of limbs. Arthralgia (joint pain alone) and arthritis (joint pain with swelling) should be differentiated. Migratory or fleeting joint pain is suggestive of acute rheumatic fever and gonococcemia. Examine hands and feet for their size, shape and length of fingers and toes, dermatoglyphics, syndactyly and polydactyly; whether preaxial (towards the side of thumb) or postaxial (towards the side of little finger). Examine fingers for clinodactyly (deflection of finger) and camptodactyly (fixed flexion of inter-phalangeal joints producing claw-like appearance). Look for deformities like club foot (plantar flexion, inversion and adduction of foot) and calcaneo-valgus deformity (dorsiflexion and eversion of foot). Bowed legs are normally seen during first two years of life while slight knock knees are common between the ages of 2 to 5 years. The severity of bowed legs is assessed by measuring the distance between the knees when medial malleoli are closely aligned in a supine infant. For assessment of severity of knock knees, the child is asked to stand with knees
|Deficiency state||Symptoms and signs|
|1.||Vitamin A||Night blindness, bitot spots (chalky-grey spots on the temporal side of corneo-scleral junction), xerophthalmia, keratomalacia and toad like skin due to follicular hyperkeratosis (phrynoderma), mucosal alterations leading to frequent respiratory and GI infections and formation of renal and vesical calculi.|
|2.||Vitamin B complex||Thiamine (BI): Dry beri-beri (polyneuritis, ptosis, hoarseness of voice, tenderness of calf muscles, sluggish deep tendon jerks) and wet beri-beri (palpitation, tachycardia, dyspnea, cardiomegaly and edema with low voltage, prologned QT interval and inversion of T waves on BKG).Riboflavin (B2): Glossitis (sore, red and glazed tongue), cheilosis (cracking of the angles of the mouth), scaly dermatitis at nasolabial folds, circum-corneal vascularization and keratitis.
Niacin (PP factor): Pellagra characterized by diarrhea, dermatitis (over parts of skin exposed to sun light), dementia (muscle weakness, loss of memory, depression and lethargy.
Pyridoxine (B6): Failure to thrive, hypochromic anemia, peripheral neuropathy and seizures.
Folk acid (keto-glutaric acid): Megaloblastic anemia.
Cobalamin (B12): Megaloblastic anemia, thrombocytopenia.
|3.||Vitamin C (ascorbic acid)||Scurvy characterized by marked irritability, hemorrhages under the periosteum of long bones (pseudoparalysis with frog-like posture), gums, mucous membranes and skin, and scorbutic rosary (posterior dislocation of sternum) with angulation of “scorbutic beads”.|
|4.||Vitamin D(cholecalciferol)||Rickets characterized by bossing of skull, craniotabes, delayed closure of anterior fontanel, costochondral beading (rachitic rosary), pigeon-shaped chest, Harrison’s sulcus (retractions at lower borders of chest corresponding to the insertion of diaphragm), spinal deformities, widening and enlargement of ends of long bones, bowing of legs, knock knees, coxa vara, pot-belly etc.|
|5.||Vitamin E (tocopherol)||Hemolytic anemia in preterm babies, progressive neuromyopathy manifesting as ataxia, and paralysis of extrinsic ocular muscles.|
|6.||Vitamin K||Early and late-onset hemorrhagic disease of the newborn with bleeding manifestations from different sites.|
Vitamins A,D,E and K are fat soluble while vitamins B complex and C are water soluble vitamins.
barely touching each other and distance between medial malleoli at ankles is measured. The physiological severity of bowed legs and knock knees is limited to 5 cm. The arch of feet is obliterated by pad of fat during first 2 years of life producing physiological flat feet. In children with history of arthralgia or arthritis, mobility of joints should be tested in all directions. Limitation of internal rotation is an early sign in many diseases of hip particularly slipped epiphysis and Legg-Perthe’s disease. Excessive external rotation of hips is a common finding in infants upto 18 months. Pretzel test is useful to elicit tenderness of sacroiliac joints.
Curvature (kyphosis, scoliosis), swelling, tenderness, and range of movements should be looked for. Spinal deformity may account for displacement of apex beat.
Genitals and Sexual Maturity Stage
Assess-sexual maturity score in adolescent children and look for any genital abnormalities. Adolescence and sexual maturation is earlier by 2 years in girls compared to boys. Breast development is the first manifestation of sexual development in girls while testicular enlargement heralds the onset of sexual maturity in boys. In preadolescent obese boys, penis may be embedded in the pubic fat giving an erroneous impression of hypogonadism. Identify whether sexual maturation is advanced, normal or retarded.
Stages of sexual development
|Age (yr)||SMR*stage||Pubic hair||Breasts|
|10-13||2||Sparse, lightly pigmented over medial border of labia.||Breast and papilla elevated to form mound, areolar diameter is increased.|
|12-14||3||Darker, beginning to curl.||Breast and areola enlarged, no contour separation.|
|12-14||4||Coarse, curly, abundant.||Areola and papilla elevated to form secondary mound.|
|14-17||5||Adult feminine triangle, spread to thighs.||Nipple; projects, areola part of general breast contour.|
|Age (yr)||SMR*stage||Pubic hair||Testes||Penis|
|10.5-15||2||Scanty light colored||Enlarged scrotum, pink texture is altered||Slight increase|
|12-15.5||3||Darker beginning to curl||Larger||Longer|
|12-15.5||4||Adult type but less in quantity||Larger with dark scrotum||Larger with increase in glans and breadth|
|15-16||5||Spread to medial surface of thighs||Adult size||Adult size|
Assessment of severity of illness
It is important to assess whether an acutely sick child can be managed on an ambulatory basis or should be admitted to a hospital. The presence of following clinical features suggest that the child is critically sick:
• Anxious, dull and expressionless toxic look.
• Altered sensorium, moaning or groaning sounds, absence of cry, lack of any response to parental overtures, bulging anterior fontanel or neck rigidity
• Refusal to drink or eat.
• Seizures without any past history of epilepsy or febrile convulsions.
• Hyperpyrexia despite adequate antipyretic therapy and cold sponging.
• Marked respiratory distress with intercostal recessions, grunting and stridor or slow gasping breathing.
• Central cyanosis (in the absence of cyanotic heart disease), ashen-grey pallor, mottling of skin or extremities, ecchymoses, hypotension.
• Evidences of moderate to severe dehydration or acidosis (Kussmaul’s breathigh)
Scheme for Presentation
General: Attitude, posture, appearance, cry, comfortable, gravely sick, toxic, restless, dyspneic, orthopneic, level of consciousncss, evidences of meningeal irritation.
Build and nutrition: Skeletal size, body frame, muscle mass, subcutaneous fat, tall, short, fat, thin, cahectic.
Anthropometry: Weight, height (or length if < 2 years), mid-arm circumference (for children between 1-5 years), head circumference, chest circumference, upper segment to lower segment body ratio and span. State the weight age, height age, percentile placement of measurement on the standard growth charts, degree of malnutrition.
Vital signs: Temperature, pulse, respiration, blood pressure. Anemia, cyanosis, jaundice, edema, lymphadenopathy
Head and face: Head size, shape, bossing, fontanels, sutures, Macewen’s sign, characteristic facies, facial dysmorphism, abnormalities in the eyes, ears, nose, mouth, chin etc.
Mouth and throat: Orodental hygiene, teeth, gums, tongue, tonsils, buccal mucosa, evidences of water, vitamins, and mineral deficiencies, examination of ears, nose and throat.
Neck: Hair line, webbing, JVP, arterial and venous pulsations, thyroid gland, trachea, cysts, fistulae, lymph glands etc.
Skin and appendages: Nails: clubbing, flattening or koilonychia, color, translucent bands, splinter hemorrhages.
Skin: color, texture, turgor and elasticity, skin rash, nodules, purpura, ecchymoses, pigmentation, pyoderma, eczema, neuroectodermal dysplasia, nevi, xanthoma, spider angioma and palmar erythema etc.
Hair: Distribution, color, texture, brittleness, eye brows, eyelashes, hirsutism.
Scheme for Presentation (Contd.)
Evidences of deficiency states: Evidences of dehydration, protein-energy malnutrition, deficiencies of vitamins, minerals and trace elements.
Bones and joints: Deformities of long bones, thorax, spine, hands and feet, evidences of arthritis, bony tenderness, rickets etc.
Genitals and sexual maturity stage: Are genitals normal or ambiguous, sexual maturity stage: normal, retarded or advanced (precocious).
Developmental examination: Is development normal, globally retarded or retarded in a specific field, developmental age and developmental quotient.