pediatric physical examination

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:

Vital Signs	Normal value	Patient value	Remarks
Temperature
Pulse
Respiration
B.P.

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

·         Respiratory system

·         Cardiovascular system

·         Haematological system

·         Intugumentary system

·         Genitourinary system

·         Endocrine system

·         Immune system

·         Musculoskeletal system

·         Central nervous system 

6.      Assessment of Growth and development  (according to classification of age )

Book picture	Baby picture		Remarks
	Attained	Not  attained
Biological development
Gross motor development
Fine motor development
Sensory development
Moral development
Cognitive development
Psychosexual development
Psychosocial development
Spiritual development
Language development
Play needs of the child