PEDIATRIC
PHYSICAL EXAMINATION FORMATE
1. General appearance:
Level of
conscious: conscious/oriented/confused/disoriented/coma
Grooming: well
groomed/unhygienic
Nourishment – Well
nourished / Mal nourished
Body build – Thin
/ Moderate / Obese
Health – healthy /
unhealthy
Activity – Active
/ dull
Posture:
straight/flexed
2.
Vital Signs:
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Vital Signs
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Normal value
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Patient value
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Remarks
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Temperature
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Pulse
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Respiration
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B.P.
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3.
3. Anthropometric measurement:
Height (cm):
Weight (kg):
Chest circumference:
Head circumference:
Mid arm circumference:
Calculate degree of malnutrition: actual weights X 100/expected weight
4.
Head to toe
examination
a)
Skin:
Color: pink/yellow/pale/blue (cyanosed)
Temperature:
cold/warmth/hot
Texture: moisture/dry
Turgor: good
elasticity/poor elasticity/no elasticity
Integrity:
normal/injury
Presence of
scar/rash/pruritis/echymosis/redness/edema etc
b)
Head:
Scalp: cephal
hematoma/caput succedaneum/eruption /
purities/scaling/brushing/bleeding/dryness/moles/scars/rashes/scalp
Trauma/lumps lesion/pressure ulcers
Shape:
symmetry/asymmetry
Hair distribution:
equal/alopecia
Hair texture:
soft/hard/brittle/ dryness
Hair colour:
black/brown/ white/salt and pepper
Posterior
fontanel: closed/open (0-6 weeks only)
Anterior Fontanels:
closed/open/buldged/depressed (0 to 18months)
Sutures:
widened/closed (up to infant only)
c)
Face: symmetry
asymmetry/puffiness/swelling (facial oedema)/flushed / pale/ cyanosed/ pink
d)
Eyes:
Visual acquit:
normal/myopia/hyperopia/blurred vision/double vision/color blindness
Eye lid:
normal/nystagmus/strabismus/ptosis/squint eyes
Eye ball:
normal/exopthalmus/sunken eyes
Presence of
orbital edema/black rings / tenderness /inflammation /redness /photophobia/
itching /eye injuries etc
e)
Nose:
Mucosa: pink/
red//pale
Septum:
medial/deviated
Nasal breath: Rt
nostril/Lt nostril/both nostril/absence
Presence of
crust/nasal discharge/ bleeding/ Sneezing/loops of smell/obstruction/breathing
problems etc.
f)
Mouth:
Lips:
normal/angular Stomatitis/crackled lip/ dry lips/wet lips/colour of the
lips/cleft lip/cleft palate
Teeth: number of
teeth/ dental carries/loss of teeth/
Gum:
normal/soft/red (gingivitis)/pale/bleeding/pus collection/swelling
Tongue:
normal/pale/yellow/cyanosed/red (glossitis)/white patches/tongue tie/sharp
tongue/blend tongue/sore/loss of taste bud
Uvula:
pink/pale/red/motile/immobile/
Larynx: voice
changes
g)
Ear:
Hearing acquit:
normal/conductive hearing loss/sensory hearing loss/mixed hearing loss
Discharge, pain,
tenderness behind the ears, any ears surgery.
h)
Neck:
Length: Short/long
Palpable thyroid
gland: yes/no
Palpable lymph
node/yes/no
ROM: yes/no
Stiffness/pain/swelling/taticolis
etc
i) Chest:
Inspect for Shape:
Normal/Funnel/Pigeon/Barrel shape and Presence of rash/injury/scar etc
Palpation: mass/nodules/tenderness etc
Percussion:
normal/dull sound
Auscultation: for Lung sounds: normal breath sounds/
crackles/wheezing/grunting etc
j) Abdomen:
Inspection: bowel movement, scar, rashes,
pulsations, umbilicus, contour & symmetry
Umbilical cord:
number of artery and vein. Cord size
Palpation: organ enlargement/mass
Percussion: fluid or gas collection
Auscultation: bowel sound in each quadrant for
5mins
Circumference of the abdomen
k)
Back:
Body curves –
Lordosis / Kyphosis / Scoliosis/lumphosis/spina bifida
Movement – Showing
ROM / inappropriate ROM
Ability to Carry out ADLs (Activity of daily
living)
Presence of lesions/lumps/scar/injury etc
l) Extremities:
Range of motion:
yes/no
Length: equal/unequal size
Number of digitals:
normal/polydactyl/syndactyl
Nail colour and
shape:
pale/blue/red/yellow/soft/clubbing/spoon shape/ pits and splinter
haemorrhages
Anomalies: locked
knee/bowed leg/club foot etc
Presence of
injury/wound/scar/amputation/discharges/reflexes of the extremities etc
m) Pelvic & Genitalia- external
genitalia, foul smelling discharge, inguinal hernia/ Phimosis,
epispadiasis/hypospadiasis
n)
Specific Findings:
5.
Systemic
examination
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Respiratory system
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Cardiovascular system
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Haematological system
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Intugumentary system
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Genitourinary system
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Endocrine system
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Immune system
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Musculoskeletal system
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Central nervous system
6.
Assessment
of Growth and development (according to
classification of age )
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Book picture
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Baby picture
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Remarks
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Attained
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Not attained
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Biological development
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Gross
motor development
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Fine
motor development
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Sensory
development
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Moral
development
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Cognitive
development
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Psychosexual
development
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Psychosocial
development
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Spiritual
development
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Language
development
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Play
needs of the child
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