1. Examining a Moving Target: Pediatric Physical Exam Pearls Tricia Groff, MD CHaD, General Pediatrics

2. Basics ➢ Listen to parental concerns – Parents are the best observers of their children ➢ Focus your exam this way ➢ Examples ➢ Always wash your hands before and after every exam ➢ Take time to establish rapport

3. What makes kids hard to examine? ➢ They move CONSTANTLY ➢ They cry and fuss ➢ They may have trouble answering your questions ➢ They may not be able to follow directions ➢ They can be intimidated/intimidating

4. What is your approach to overcoming these barriers? ➢ Explain what you are going to do before you do it: ● Show the child on a parent or stuffed animal first ● Let him/her play with the instruments -- make it a game! ➢ Engaging the child is more important than the sequence of the exam: ● Start with things that require them to be calm or quiet ● Save the most uncomfortable, scary, or intrusive parts for last ➢ Be gentle, but firm: ● Move slowly, pause when necessary, but... ● If your tactics are not working consider quickly finishing the necessary parts of the exam

5. Some other tactics... ➢ Kids love to play games – take advantage! ● Homemade toys: light, tongue depressor, water, stethoscope, reflex hammer, etc ➢ Be patient and observant: ● Children are very expressive! ● They will often do on their own what you can’t get them to do by asking ➢ Follow the child’s lead: ● If getting fussy or wild, stop talking and just move on

6. Challenges

7. FIRST THINGS FIRST: Stop, Look and Listen ➢ Stop: Do the ABC’s ➢ Look: sick or well?—most important ● Breathing (work, sound) ● General appearance (color, face) ● Activity (lethargic, irritable) ➢ Listen: to parent’s concerns

8. Observation

9. General Appearance ➢ Is there obvious distress? ➢ Facial expression ➢ Body habitus ➢ Hygiene, interaction with caregiver ➢ Activity and modifiers PRN ● Consolable, arousable ➢ Hydration status (or CV) ➢ Breathing – work, sound, position (or Resp) ➢ Color of skin and mucosa (or skin)

10. Vital Signs ➢ Compare to normal values for age and sex ● Tables in Harriet Lane ➢ Always plot growth and report percentiles ➢ Head circumference under age 3 ● Use BMI Underweight <5%ile Healthy weight 5-85%ile Overweight 85-95%ile Obese >95%ile Look at growth over time

11. Specific Areas: CV Exam Auscultation – technique similar to adults Remember to listen to axilla and back Listen laying and standing Timing of exam Early for infants (before you make them cry) Later for older children who may be timid To find a pulse: Experiment with different pressures, places

12. Pulmonary Exam Work of breathing – what do you look for? Retractions, accessory muscle use, nasal flaring Pay attention to what “normal” looks like!!! Positioning? Have child hug parent to expose back Note aeration and I:E ratio Increase tidal volume by asking child to: Blow on something – tissue, light, etc Hold breath (like going under water) Gently squeeze chest in infants

13. To differentiate upper airway sounds from lung sounds, listen at the mouth and compare character of sound to the lungs.

14. Abdominal Exam Liver or spleen tip may be palpable Tap or scratch Start low, ask for an exhale Surgilube on fingertips Abdominal mass? OR... Kidneys may be palpable in newborns Stool is often palpable Ticklish? Unable to relax? Positioning – knees bent and head back Firm touch, use whole hand Place their hand over your hand and have them press while you palpate (you can’t tickle yourself) Even crying babies must breathe! Hold your hand on baby’s abdomen, when they take a breath in  Palpate!

15. Specific Areas: Head Assess shape and position from all sides Proportion and symmetry Fontanelles – palpate upright Posterior closes at 2-3 mo Anterior closes at 6-18 mo Sutures: splayed, approximated overriding vs. fused

17. MicrognathiaFrontal Bossing

18. Abnormal helps you learn normal

19. Eyes Shape and position Strabismus Only intermittent after 2mo Resolved by 6mo Corneal light reflex Cover-uncover test Red reflex → fundoscopic exam

23. Ears, Nose and MOUTH Ears: make noise, look for something Effective restraint essential! Don’t forget to look at the outside of the ear and the canal Mouth: not just throat! Dentition, gums, mucosa, palate, oropharynx Stabilize head and gag PRN Traditional positioning: Face-to-face

25. How many deciduous teeth do children have?

27. Mouth

28. Palate and Oropharynx

29. Neck ➢ Range of motion ● Torticollis ➢ Lymphatic chains ● Also remember axillary and inguinal ➢ Thyroid may not be palpable

30. Neurological Exam ➢ Much of the toddler exam is observational ● Mental status ● Development ● Cerebellar function ● Basal ganglia ➢ Gait – developmental changes ● Specific tests: tandem, heel, toe, Gower ➢ Sensation – usually just gross assessment ➢ DTR, babinski

31. Cranial Nerves ➢ By observation or other parts of the exam: ● II – when doing HEENT ● III, IV, VI – tracking with toy ● VII – observation ● VIII – turns to voice ● IX/X – speech, gag ● XII – tongue movement ➢ That just leaves: I, V, XI ➢ Can try Simon says

32. Tone

33. Neurological Exam ➢ Not every patient needs a comprehensive neurologic exam ➢ No specific testing? ● Describe relevant observations ● Still include in note

34. Musculoskeletal exam ➢ Neonatal hip exam for DDH (developmental displasia of the hip) ● Hip external rotation and leg symmetry ● Barlow and Ortolani most reliable before 2mo

35. Barlow Ortolani

36. Genu VarumGenu Valgum

37. Scoliosis

38. Skin Describe what you see! ➢ Pink, ruddy, pale, cyanotic ➢ Jaundice ➢ Birthmarks ➢ Concerning nevi ➢ Rashes ➢ Bruises, abrasions, or lacerations

39. Genitalia How do you address patient comfort for teens? Consider having a chaperone Teach breast/testes self-exam as tool Sexual maturing (Tanner staging I-V) Male exam Hydrocele vs. hernia Foreskin usually retractable by 2-5y Never leave retracted! Hypo/epispadias—consider Stanford newborn, Zitelli

40. HymenLabial Adhesion

41. Rectal Exam ➢ Decubitis or when doing genital exam ➢ External Exam usually sufficient ➢ Look for Fissure, Skin Tag, Fistula ➢ What are the indications for an internal exam? ● To assess tone, stool (sometimes), hemorrhoid ● NOT to look for blood in and of itself

42. How to get good feedback on your pediatric physical exam... ➢ Ask for it! ➢ Set goals ● And share them with your preceptor ➢ Verbalize what you are doing and noticing as you perform the exam

43. Have Fun!