General Differences

1. History is often imprecise because child cannot express his problems. The accuracy of history depends upon the intelligence, education, observational ability and concern of the mother, father or attendant.

2. Dietary and immunization history is of special significance among children. Perinatal events, growth and developmental history should be enquired and recorded.

SALIENT DIFFERENCES BETWEEN PHYSICAL EXAMINATION OF CHILDREN AND ADULTS3. There is general lack of cooperation by the child during examination. Observation is most contributory or informative in children and accorded maximum importance.

4. The approach during examination does not follow any set sequence but is unstructured. The unpleasant examination is postponed to the end.

5. Childhood period is characterised by rapid growth and development. A pediatrician, therefore, deals with subjects varying in weight from 1.0 kg to 40 kg and in different stages of maturation. The examination tools of different sizes are needed depending upon the age of the child e.g. size of stethoscope, ear specula, cuff of blood pressure apparatus, little finger for rectal examination etc.

General Physical Examination

1. Anthropometry is of particular importance and of special significance in children.

2. Developmental assessment is peculiar to children.

3. Disorders of head size and shape are limited to children because of open sutures.

4. Peculiar and diagnostic facies are by and large limited to children (dysmorphism).

5. Deficiency states are far more common among children. Some deficiency states produce different manifestations among children as compared to adults e.g. rickets vs osteomalacia.

6. Signs of meningeal irritation may be minimal or absent during first 3 months of life and in malnourished children.

7. Lymphoid hyperplasia is marked during preschool period.

8. Koilonychia is rare among children.

9. Vital signs: The norms of vital signs are different in children of different ages.

Vital signs in children
Age Temperature(oC) Pulse rate (per minute) Respiration rate (per minute) Blood pressure (mm Hg)
Newborn 36-37 140* 40* 60/40**
1 year 36.5-37.5 120 30 70/50
5 year 37±0.2 100 20 90/50
10 year 37±0.2 90 18 100/70
>10 year 37±0.2 80 18 110/80

* Double of adult, ** One-half of adult

Systemic Examination

Cardiovascular System

1. Pulse is rapid and difficult to feel among infants due to decreased vagal tone. Sinus arrhythmia is common.

2. Jugular venous pressure is difficult to evaluate in infants due to short and obese neck.

3. It is preferable to auscultate the heart of an infant first before he starts crying following palpation and percussion.

4. Precordial bulge may occur as a sign of long standing cardiac enlargement due to soft rib cage.

5. Apex beat is located in the 4th intercostal space at or slightly outside the midclavicular line.

6. Splitting of second heart sound is common. P2 is louder than Ain infants upto 6 months of age. Heart sounds are better audible due to thin chest.

7. Functional systolic murmurs and venous hum are common in children.

8. Right ventricular hypertrophy is seen in newborn babies while left ventricular preponderance occurs in adults.

9. Blood pressure is lower in children and proper cuff size (to cover two-third of upper arm) is essential for recording it. Flush method or Doppler system may have to be used to record blood pressure in infants.

10. Most congenital cardiac defects produce their clinical manifestations during early childhood while rheumatic heart disease is unlikely below the age of 3 years.

Respiratory System

1. The breathing is rapid and abdomino-thoracic among infants. The normal rhythm is inspiration – expiration – pause. It gets reversed to expiratory grunt – inspiration – pause in pneumonia. Intercostal and suprasternal recessions are common due to soft ribs.

2. Narrow air passages predispose to frequent occurrence of stridor, rhonchi and atelectasis.

3. Percussion may be impaired over the manubrium sterni due to enlarged thymus. The chest is more resonant in children as compared to adults.

4. The normal breath sounds are hollow and peurile or harsh vesicular in children. Due to small thorax the adventitious sounds from one side may be conducted to the opposite side.

Alimentary System

1. Abdomen is protuberant (pot-belly) and soft in infants. Divarication of recti and umbilical hernia are common.

2. Palpation of abdomen in infants is best achieved during feeding.

3. Palpable liver upto 2 cm and soft in consistency is normal throughout childhood while spleen tip may be normally felt during first 3 months of life.

Central Nervous System

1. Cooperation for proper CNS examination of children is exceedingly difficult. Several tricks or play attitude may have to be used for thorough CNS assessment. Sensations are most difficult to assess.

2. Several primitive automatic reflexes (Moro reflex, palmar grasp, neck tonic reflex) are present at birth and they disappear by the age of 5-6 months. Their persistence is indicative of brain damage.

3. Developmental screening is a part of CNS evaluation in children. Delay in appearance of social smile, persistence of automatic reflexes, neck tonic posture, clenched fists, increase in muscle tone, inability to follow light/red ball and approach objects are useful early markers of cerebral palsy.

4. Deep tendon jerks are normally brisk during infancy. When knee jerk is elicited on one side, crossed adductor response may be seen in normal infants. Cremasteric response is also exaggerated in infants and may be preserved even when there are other evidences of pyramidal involvement.

5. Plantars may be normally extensor on both sides in infants upto 2 years of age. The presence of unilateral extensor plantar reflex is more significant at this age.

6. Fundus examination reveals that disc is normally pale in infants. Papilledema appears only after 3 years of age when sutures have closed.

7. The likelihood of neurological symptoms being due to a disease outside the CNS is more common in children than adults.