A single routine usually does not work for all children. If the child is very ill, examination is limited. Also, points in the examination assume varying importance depending on age (for neonates,it may be different). But it is helpful to have some sort of standard:
Here we Take an example of a a boy of 3 years who is being seen because of vomiting.
Not everything mentioned in this summarized article will need to be done. The more experienced you are, the better you will be able to judge when and how to take short cuts. Don’t mistake taking short cuts for being lazy. Use the time saved to be available to answer questions, and to address the fears and hopes of the parents and child.
Important to Note: there is no correct order: be opportunistic, e.g with younger children on a lap listen to heart when there are gaps in crying.
1 Wash and warm your hands. Encourage both parents to be present.
2 Regard the child (e.g while feeding).
- Is he ill or well?
- Restless, still, or playing?
- If crying, is it high pitched or normal?
- Is he behaving normally?
- Any jaundice, cyanosis, rashes, anaemia, or dehydration?
- Is he moving normally?
- Does anything hurt, e.g neck, abdomen, limbs?
3 Talk to the child. Explain what you are doing. This helps you both relax, and enjoy the occasion (not a trivial point: a happy doctor is an engaged doctor; an engaged doctor is more open to subtle signs). If he seems anxious, examine his teddy in a playful way, to allow him to build up trust. Asking
about pets or siblings often helps.
4 If quiet or asleep, now is the time to get any listening done, so examine his heart, lungs, and abdomen. Use a warm stethoscope. Undress in stages.
5 Examine finger nails, then the hands, radial pulse, BP, axillary and neck nodes, neck lumps. Is there neck stiffness? (a ‘useless’ sign in infants)
6 Size and shape of head . Facial symmetry. In a baby, does the anterior fontanelle (between the parietal and frontal bones) feel tense (intracranial pressure incressed) or sunken (dehydration)?
7 Is there mucus in the nose? Leave ears and throat alone at this stage.
8 Count the respirations. Is there intercostal recession (inspiratory indrawing of the lower costal area, signifying increased work of breathing)?
9 Percuss the chest if >2yrs old (not very reliable even then), and palpate the abdomen. Is it distended, e.g by spleen, liver, fluid, flatus, faeces?
10 Undo the nappy, if worn. Have an MSU pot to hand. If urine is passed, make a clean catch . Inspect the nappy’s contents. Examine the genitalia/ anus. Find the testes. Rectal examination is very rarely needed.
11 Note large inguinal nodes. Feel femoral pulses.
Neurological examination After completing the above, much will have been learned about the nervous system; if in doubt, check:
- Tone: Passively flex and extend the limbs (provided this will not hurt).
- Power and co-ordination: Watch him walk, run, and pick up a small toy and play with it, with each hand in turn.
- Reflexes: Look for symmetry. Sensation:
- Light touch and pain testing are rarely rewarding.
- Fundi.
Ears/throat Leave to the end, as there may be a struggle. Mother holds the child on her lap laterally, one hand on the forehead, holding his head against her chest, and the other round his arms.
- Examine ear drums first (less invasive).
- Then, hold the child facing outwards, one arm around his arms, one on his forehead. You can then introduce a spatula and get one good look at mouth and tonsils.
- Inspect the teeth.
Growth Chart height, weight, and head circumference are all important to make a note of.
TPR charts Pulse and respiratory rate; T° (rectal T°: normally <37.8°C).
Finally ask child and parents if there is anything else you should look at.
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