The pediatric physical examination: General principles and standard measurements Author Jan E Drutz, MD Section Editor Teresa

K Duryea, MD Deputy Editor Mary M Torchia, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2013. | This topic last updated: jun 20, 2012. INTRODUCTION Sophisticated technological advances in medicine have proved to be remarkably beneficial in the diagnostic process, yet the well-performed history and the physical examination remain the clinician's most important tools. They are venerated elements of the art of medicine, the best series of diagnostic tests we have [1]. A relatively complete physical examination should be performed on each patient, regardless of the reason for the visit. Numerous medical anecdotes relate instances in which the examination revealed findings unrelated to and unexpected from the patient's chief complaint and major concerns. On occasion, a limited or inadequate examination may miss a significant condition, mass lesion, or potentially life-threatening condition. The general principles, standard measurements, and overall approach to the pediatric patient are discussed here. Examination of specific organ systems is discussed separately. (See "The pediatric physical examination: HEENT" and "The pediatric physical examination: Chest and abdomen" and "The pediatric physical examination: Back, extremities, nervous system, skin, and lymph nodes" and "The pediatric physical examination: The perineum".) GENERAL PRINCIPLES The approach After years of experience, seasoned examiners become aware of potential avoidable pitfalls often encountered upon entering a patient's room. Before entering the room, the clinician should review the patient's chart and confirm the identity of the patient and others in the room. Most clinicians have experienced the discomfort of walking into a room and greeting the patient, parent, or caregiver by the wrong name or of having the correct name but the wrong chart in hand. To avoid a potentially embarrassing situation, the examiner should always knock on the door and await a response before entering. Small children standing on the other side can be injured easily by the door handle or by the door's impact as it is being opened. Regardless of whether the clinician and caregiver have met previously, it is appropriate to greet everyone in a cordial manner, maintaining a professional yet friendly demeanor. Infants older than six months and anxious toddlers who are leery of strangers often are more comfortable when held by their caregiver. To gain the child's confidence and to avoid an early adversarial relationship, the clinician should try using a calm approach, a reassuring smile, and a toy or bright object as a diversion. An appropriate distance should be maintained during the historytaking portion. The clinician's approach should be cautious and nonthreatening once the physical examination is about to begin. Infants younger than six months who have no stranger anxiety and children older than 30 to 36 months who are familiar with the examining clinician and/or who possess a trusting demeanor generally cooperate during the examination without being held. Physical examination of 5- to 12-year-old children usually is easy to perform because these children are not typically apprehensive and tend to be cooperative.

General appearance The examiner may gain significant insight into important social and family dynamics by observation alone when entering the patient's room. Terms used to describe a patient's general appearance include degree of comfort (calm, nervous, shy), state of wellbeing (normal, ill appearing, distressed), activity level (sedate, alert, active, fidgety), physical appearance (neat, disheveled, unkempt), behavior and attitude (happy, sad, irritable, combative), body habitus (overweight, underweight, short, tall), and nutritional status (malnourished, normal, corpulent). The possibility of neglect should be considered if the child and caregiver make no eye contact or the patient lacks animation and has no social smile. Psychosocial intervention may be warranted in these circumstances. (See"Child neglect and emotional abuse".) If a child appears ill, particular attention should be paid to the way the patient has positioned himself or herself. A child who lies completely still on the examination table, is verbally responsive, but noticeably winces when an attempt is made to change position may have an acute abdomen. (See "Emergent evaluation of the child with acute abdominal pain".) A dyspneic patient who is sitting upright and slightly forward with the arms extended and hands resting on the knees might be experiencing an exacerbation of asthma. If an infant who is about to be examined is crying when the clinician enters the examination room, the pitch and intensity of the cry should be noted. A boisterous hardy cry is somewhat reassuring, whereas a weak and listless cry may indicate a seriously ill infant. A high-pitched, screeching cry could indicate increased intracranial pressure, reaction to a painful injury, toxic reaction, strangulated inguinal hernia, or other serious disorders. Note the patient's breathing pattern and skin color. If the patient has rapid, shallow respiration yet appears to be in no acute distress, the underlying cause could be primary pulmonary disease or respiratory compensation for metabolic acidosis. (See "Approach to the child with metabolic acidosis".) The examiner should evaluate the developmental status before touching the child. The patient's motor function, interaction with surrounding objects and people, response to sounds, and speech pattern give clues about whether the patient is normal or is in need of extensive developmental assessment. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Monitoring milestones'.) History Historical information depends almost completely upon the caregiver for patients in the neonatal age range through early childhood. To obtain pertinent information regarding a 5to 12-year-old child, the clinician must still rely primarily on the caregiver, although attention should be given to the relevant, and often honest, comments made by the patient. Interview the adolescent patient in the absence of caregivers when appropriate so that pertinent historical information, anticipatory guidance, and preventive health care issues can be more openly discussed. (See "Guidelines for adolescent preventive services".) Key elements in the history-taking process include establishing a warm, caring atmosphere and asking questions in a nonconfrontational, unhurried manner. The terminology and language used by the examiner should be appropriate for the educational level of the caregiver and the patient. Good eye contact and a sense of undivided attention should be maintained. The clinician should sit opposite the caregiver and/or patient at a comfortable distance, unencumbered by large objects, such as desks or tables. Outside interruption by the medical staff and by telephone calls should be kept to a minimum. An effort should be made to maintain an uninterrupted dialogue, to write few notes, and to refer to written data as little as possible. Physical examination The examiner should wash his or her hands thoroughly before beginning and after completing the examination. Protective gloves should be worn when

appropriate. Patients and caregivers are well aware when the examiner fails to carry out this seemingly routine practice. Skilled clinicians employ different techniques to gain pediatric patient cooperation. The use of toys, distracting objects, and pictures helps in the examination of young children, infants, and toddlers. Engaging the two- to four-year-old in stories or a discussion of imaginary animals frequently creates an effective diversion. Food, in the form of chewable snacks or liquid refreshments, can be used as a means of pacification, depending upon the stage of the examination. When an otherwise normal-acting child older than four years fails to cooperate for an examination, even in the presence of a familiar caregiver, it may be an indication of either an earlier traumatic encounter between the patient and another examiner or a failure on the part of the current examining clinician to use the correct approach. An underlying psychosocial problem or personality defect should be suspected when a child who is older than four years is totally combative or extremely uncooperative. For patients old enough to understand but who appear apprehensive, the examiner should explain what is going to be done during the examination and allow them to look at and touch any of the instruments to be used. Older patients should be warned in advance of potential pain or discomfort. The examination of an infant, toddler, or child should be performed in the presence of a parent or guardian; if the parents presence may interfere with the examination (eg, suspected child abuse), a chaperone should be present [2]. The use of a chaperone for the examination of the anorectal and genital areas and/or breasts of female adolescent patients should be a shared decision between the patient and the clinician after the clinician has explained the reason for the examination and described how the examination will proceed. The sex of the chaperone should be determined by the patients wishes and comfort (if possible). If a patient is offered the use of a chaperone and declines, this should be documented in the chart. If the patient has a complaint, sign, or symptom that appears to involve a particular part of the anatomy, that part of the examination should be performed last. As an example, consider a patient complaining of right-lower-quadrant abdominal pain thought to be attributable to appendicitis; by not examining that part of the body first, the clinician may be able to divert the patient's attention away from the involved area and rule out other possible causes for the pain. Patient privacy should be respected. If a patient objects to being unclothed or to wearing an examination gown, allow him or her to remain clothed until a specific part of the anatomy must be checked. When an area needs to be examined, the patient should be asked to remove or pull free the garments that are hindering visualization, palpation, or auscultation. The order in which the physical examination is conducted often is age-specific and depends upon examiner preference. For an infant and younger child, the clinician may prefer to begin by examining the eyes, noting the red-light reflex, extraocular eye muscle movements, and visual tracking and then move to other parts of the body or organ systems before finally examining the ears, which are sensitive. For the older, more cooperative child, the examination might begin at the head and progress down the body, with the neurologic examination last. In general, the portions of the pediatric examination that require the most patient cooperation, such as blood pressure measurement, lung and heart auscultation, and eye and neurologic examinations, are performed initially. These examinations are followed by the more bothersome portions, including abdominal and ear examinations and measurement of head circumference. STANDARD MEASUREMENTS

Weight, height, head, and chest circumference Measurement of the standard growth parameters throughout childhood and adolescence is essential for assessing normal development [3]. Data obtained should be plotted on standard growth curves to determine progress. Weight is measured at each periodic well-child visit (figure 1A-B and figure 2A-B) (calculator 1). Height (length) is measured at each periodic well-child visit. In the child younger than two years, measuring body length when the child is in the supine position is preferable to trying to obtain an accurate measurement while the child is standing (figure 3A-B) (calculator 2). In older children, the height measurement should always be done with the patient standing (figure 4 and figure 5A-B) (calculator 3 and calculator 4). Frontal-occipital head circumference is recorded routinely until the patient is two or three years old. Measurement should be attempted only at the conclusion of the physical examination, as infants generally dislike this portion of the examination. The measuring tape should encircle the head and include an area 1 to 2 cm above the glabella anteriorly and the most prominent portion of the occiput posteriorly (picture 1). Frontal-occipital head circumference should be plotted on a standardized head circumference chart. A number head circumference charts are available. They are discussed separately. (See "Etiology and evaluation of microcephaly in infants and children", section on 'Head circumference charts'.) A disproportionately large head may be indicative of hydrocephalus or macrocephaly. A head circumference that is smaller than normal may constitute microcephaly and suggest potential underlying neurologic deficits. In some children, however, small head size may be normal. (See "Etiology and evaluation of microcephaly in infants and children", section on 'Definitions' and "Etiology and evaluation of macrocephaly in infants and children", section on 'Etiology'.) Chest circumference is measured at the time of the newborn examination, but it is not a part of the routine examination for well-child visits. The chest circumference is measured at the nipple line. Head circumference is 1 to 2 cm larger than chest circumference in most newborns and in children 12 to 18 months old; an exception is the normal rapidly growing head of the premature infant.

Vital signs Temperature Routine measurement of the patient's temperature is not always necessary. When a temperature measurement is needed, the technique and appropriate site for measurement are age dependent. Rectal temperature recordings in infants and young children are preferred, although axillary recordings are acceptable; axillary measurements are consistently lower than rectal measurements, but the absolute difference varies too widely for a standard conversion [4]. Oral temperature readings (about 1F [0.6C] below rectal temperatures) should not be obtained until the child is old enough to understand how to hold and retain an oral thermometer under the tongue. (See "Pathophysiology and management of fever in infants and children", section on 'Temperature measurement'.) Rectal temperature measurements should be taken with the patient in the prone position with the legs slightly flexed at the hips and knees; the thermometer is directed anteriorly at an angle of approximately 20 to the surface of the examination table [5,6]. Battery-operated and electronic thermometers for recording oral or rectal temperatures generally are reliable and fast. The use of infrared tympanic membrane and temporal artery thermometers is discussed

separately. (See "Pathophysiology and management of fever in infants and children", section on 'Temperature measurement'.) Respiratory rate Accurate determination of the respiratory rate should be attempted only when the patient is asleep or at rest. It can be obtained by auscultation, palpation, or direct observation. The normal range for the respiratory rate depends upon the age of the child. A systematic review of 20 studies provided respiratory rate percentiles for healthy children who were typically awake and at rest (table 1) [7]. A sustained breathing rate in excess of the upper limit of normal generally indicates primary respiratory tract disease; it may also occur secondary to a metabolic disorder, infectious disease, high fever, or underlying heart disease. Heart rate According to one author, "those who wish to know the inner body feel the pulse and thus have the fundamentals for diagnosis" [8]. The heart rate can be measured by direct auscultation or palpation of the heart or by palpation of peripheral arteries (carotids, femorals, brachials, or radials). Like the respiratory rate, the normal heart rate varies with age. A systematic review of 59 studies provided heart rate percentiles for healthy children who were typically awake and at rest (table 1) [7]. A heart rate above the upper limit of normal may indicate primary cardiac disease; it also can occur secondary to an underlying systemic or metabolic disorder, infectious disease, or high fever. Blood pressure Yearly blood pressure measurements are measured in children ages three years and older. Obtaining an accurate blood pressure reading in children under the age of three often is difficult. In most circumstances, routine blood pressure measurements should not be attempted in these children unless they have evidence of underlying renal disease, such as a tumor, nephrotic syndrome, glomerulonephritis, pyelonephritis, or renal artery stenosis. Another reason for measuring the blood pressure in children under the age of three is the finding or suspicion of underlying cardiovascular disease, such as coarctation of the aorta or patent ductus arteriosus (PDA). Blood pressure devices include the standard extremity cuff and mercury bulb sphygmomanometer, the hand-held aneroid manometer, and the Doppler and oscillometric devices. Patients old enough to understand should be shown the blood pressure device before the examiner attempts to take a measurement. The patient should be allowed to play with the device or feel the cuff inflate to gain his or her cooperation. The proper technique for blood pressure measurement is discussed separately. (See "Definition and diagnosis of hypertension in children and adolescents", section on 'Measurement of blood pressure'.) As with pulse and respiratory rates in children, blood pressure varies with age. Standard reference charts that give the ranges of normality should be consulted (calculator 5 and calculator 6) (table 1 and table 2 and table 3) [9]. The systolic pressure measured in the lower extremity generally is about 20 mmHg higher than that measured in the upper extremity. (See "Definition and diagnosis of hypertension in children and adolescents".) High blood pressure In addition to the disorders mentioned above, elevated blood pressures are associated with neuroblastomas, pheochromocytomas, thyroid disease, neurofibromatosis, Cushing disease, intoxication from or ingestion of various substances, increased intracranial pressure, and myriad other disorders. It is wise to keep in mind that elevated systolic pressures alone frequently are noted in patients after vigorous exercise, excessive agitation, or during febrile illnesses. (See "Epidemiology,

risk factors, and etiology of hypertension in children and adolescents", section on 'Secondary hypertension'.) Low blood pressure Abnormally low blood pressure recordings are noted in patients with heart failure from numerous causes and in patients in shock from causes such as sepsis or hypovolemia. A rapid change in the patient's position from supine to standing or sitting may result in orthostatic hypotension. (See "Initial evaluation of shock in children".) Wide pulse pressure Widened pulse pressures can occur in patients with aortic regurgitation, arteriovenous fistulas, patent ductus arteriosus, or hyperthyroidism. (See "Aortic regurgitation in children" and "Clinical manifestations and diagnosis of patent ductus arteriosus" and "Clinical manifestations and diagnosis of hyperthyroidism in children and adolescents".) Narrow pulse pressure Narrowed pulse pressures are found in patients with subaortic or aortic valve stenosis and occasionally in those with hypothyroidism. (See "Subvalvar aortic stenosis (subaortic stenosis)" and "Valvar aortic stenosis in children" and"Acquired hypothyroidism in childhood and adolescence".)

SUMMARY Assessment of the general appearance should include the child's state of well-being, activity level, physical appearance, behavior and attitude, body habitus, nutritional status, preferred position (particularly for ill-appearing children), pitch and intensity of the cry (in crying infants), breathing pattern, skin color, and developmental status. (See 'General appearance' above.) The history is generally obtained from the caregiver for infants and preschool children. Children aged 5 through 12 may contribute to the history if they are willing and able. Adolescent patients should be interviewed in the absence of caregivers when appropriate. (See 'History' above.) The order in which the physical examination is conducted often is age specific and depends upon examiner preference. The portions of the examination that require the most cooperation usually are performed first, and the more bothersome portions are performed last. If the patient has a localized complaint, sign, or symptom, that part of the examination should be performed last. (See 'Physical examination' above.) Measurement of the weight, length/height, and head circumference is essential for assessing normal development. Data obtained should be plotted on standard growth curves to determine progress. (See 'Weight, height, head, and chest circumference' above.) Routine measurement of the patient's temperature is not always necessary at health supervision visits. When a temperature measurement is needed, the technique and appropriate site for measurement are age dependent. (See 'Temperature' above.) The respiratory rate can be obtained by auscultation, palpation, or direct observation. (See 'Respiratory rate' above.) The heart rate can be measured by direct auscultation or palpation of the heart or peripheral arteries (carotids, femorals, brachials, or radials). (See 'Heart rate' above.) Yearly blood pressure measurements are routinely obtained in children ages three years and older. Blood pressure measurements also should be obtained in children younger than three years if there is evidence or suspicion of underlying renal or cardiovascular disease. (See 'Blood pressure' above.) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES