Medical Centric

GENERAL EXAMINATION

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GENERAL EXAMINATION

It is important to establish rapport with the parent and the child.

The doctor should:

  • Note the behavior of the child and level of awareness and take these into account with the parent’s report
  • Note if the child’s appearance is unusual at all and in what way
  • Note any major or minor abnormalities
  • Record the nature and distribution of skin lesion and rashes, if any
  • Note the color, shape, and positions of bruises, if any. If they have a suspicious appearance, consider the possibility of non-accidental injury
  • Consider any pieces of equipment such as feeding pump or portable devices that the child may have come with
  • Consider any obvious device to be seen such as a central nervous catheter or gastrostomy tube

LIMBS

The doctor should start examining from the hand and feet, as this is less threatening.

  • The feet should be examined for variety of problems such as an overriding toe where one toe lies on top of an adjacent toe, flat feet, rocker-bottom feet or minor varus deformity.
  • Using the back of the hand, the doctor should feel for the skin temperature of the joint line.
  • Note any knee and other bony abnormalities including any muscle wasting, tenderness and the full range of movements of the knee and ankle
  • Look specifically for skin changes (whether the skin is dry or moist) and swelling in and around of the joints.
  • The hand should also be examined. Note if the child has a single palmar crease. This may be associated with various conditions that affect a person’s physical and mental growth as seen in children with Down’s syndrome.
  • Note any limb abnormalities such as complete absence of the limb, syndactyly or polydactyly.
  • Note if there is an increased curvature of the nail plate also known as clubbing. This may indicate the presence of an underlying medical condition such as cyanotic congenital heart disease or, chronic inflammatory bowel disease
  • Move all the limbs and check if the movement is normal. Watch the child’s face when you move the limbs.

HEAD, FACE, AND NECK

The child’s face should be examined, and the following should be noted.

  • Is it normal in appearance? If this is not so, features that seem abnormal should be identified.
  • Does the baby have dysmorphic features? If yes, these features should be checked for in the parents. This may be nothing more than a family trait.
  • Is the tongue large or protruding?
  • Does the ear appear normal in position, or are they low set and abnormal in any way?
  • Are the eyes abnormally small with anatomic malfunctions (microphthalmos) or is there an abnormally increased distance between them (hypertelorism).
The head
  • The shape and circumference of the head should be noted. If the head appear smaller than a normal head, the baby may be microcephalic, it may be flattened if the baby is brachycephalic, or globular if the baby is hydrocephalic.
  • Examine the anterior fontanelle. This should be done by palpation in babies and infants. The fontanelle should be close by the middle of the second year (18 months). It should be flat or full. A delayed closure may be seen in rickets, hydrocephalus, and hypothyroidism.
  • A sunken fontanelle may be indicative of dehydration
  • If the fontanelle is tense and bulging, it may indicate raised intracranial pressure
  • Note if the child can move the head, eyes well in all directions and if this movement is normal and full

CHEST

Examining the chest may include both the cardiovascular and respiratory system. This is done systematically by first looking then feeling then listening with the stethoscope

CARDIOVASCULAR SYSTEM

  • Begin by recording pulse rate, rhythm, strength, and character
  • The anterior chest wall should be palpated and percussed for heart size and the site and nature of the apex beat.
  • Determine the presence of any thrill
  • Listen to the first and second heart sound, then the sounds between them and any murmurs between the heart sounds.
  • The timing, character, loudness, site, and distribution of any murmur should be noted
  • Check if this is transmitted to the neck
  • Record blood pressure if heart or kidney disease is suspected.

RESPIRATORY SYSTEM

  • Assess the work of breathing. Is there any intercostal or subcostal recession, or use of accessory muscles?
  • The upper edge of the liver is percussed to determine if the lung is over-inflated.

It is added to interpret breath sounds and noises in the very young. Noises can be high-pitched, low and coarse depending on the site and nature of the obstruction.

  • Wheezing occurs when the mid-airways are narrowed and may be bilateral in asthma and unilateral in airway obstruction. It is usually expiratory
  • Persistent and bilateral fine crackling noises on inspiration may indicate bronchiolitis or rarely left heart failure
  • Intermittent noises during inspiration and expiration may indicate liquid debris
  • Stridor is a harsh noise that originates in the upper airways such as in the case of croup.