VITAL SIGNS, APPEARANCE, AND BEHAVIOR

Review vital signs and compare them with age-specific reference data (Table 5-2). “Normal” vital signs are age (and often sex and size) specific. “Normal” blood pressure (BP) is below the 90th percentile for age, sex, and height. Hypertension is defined as persistent BP readings above the 95th percentile for age, sex, and height. BP is discussed in Chapter 46. Use growth charts to assess height, weight, body mass index (BMI), and head circumference. Pay attention to symmetry of growth, morphologic features, development, behavior, and the patient’s interaction with parents and the examiner. Observe mental status in older children and adolescents. When evaluating an acute illness, look for disease-specific signs plus evidence of shock or toxicity, such as skin color, respiratory effort, hydration status (capillary refill), mental status, cry, and interactions. Chronic illness may result in growth abnormalities, system/organ-specific dysfunction, or other characteristic findings. A patient’s appearance and physical findings may reflect a pattern of malformation that is characteristic of a syndrome or other identifiable cause of structural defects (see Chapter 62).

HEAD, EYES, EARS, NOSE, AND THROAT (HEENT)

HEAD

Measure head size and plot the data on the growth chart. Head circumference increases steadily from an average of 34 cm at birth to 48 cm (girls) and 49 cm (boys) by age 2; it then increases more slowly until the mean adult value of 55 cm (female) and 56 cm (male) is reached. Look at head shape and symmetry, facial features, and hair whorls. Identify the sutures and fontanels in an infant (Figure 5-1 and Chapter 14); these are usually not palpable after 15 to 18 months, occasionally earlier. The anterior fontanel is diamond shaped and at birth is approximately 2 × 2 cm (range 1 × 1 to 3 × 4 cm). The posterior fontanel is usually not palpable, even at birth, but when open it is the size of a small fingertip (< 1 × 1 cm). The superior surface of the anterior fontanel is generally level with the surface of the skull. Marked ridging or bony prominence of sutures in young infants may reflect premature fusion (synostosis). Widely separated sutures may reflect increased intracranial pressure and may be accompanied by a bulging and enlarged anterior fontanel. To determine whether the fontanel is bulging, move the infant to a sitting position, inspect the fontanel, then run your fingers across the fontanel surface. If the fontanel protrudes convexly beyond the skull’s surface, it is bulging. Dehydrated infants often display a sunken fontanel, concave with respect to the skull surface.

Figure 5-1 Cranial sutures and fontanels.

From Seidel HM et al: Mosby’s guide to physical diagnosis, ed 6, Philadelphia, 2003, Mosby, p 258.

EYES

Identify the red reflex: Absence of the red reflex or presence of a white reflex always demands further evaluation. Assess extraocular motions and the corneal light reflection (see Eye Simulator, http://cim.ucdavis.edu/EyeRelease). Asymmetrical corneal light reflection is seen with strabismus. Young infants, especially Asian infants, commonly demonstrate pseudostrabismus, an artifact associated with prominent epicanthal folds (Figure 5-2). The corneal light reflection is symmetrical in pseudostrabismus.

Figure 5-2 Child with pseudostrabismus. Note the wide nasal bridge and prominent epicanthal folds.

From Berkowitz CD: Pediatrics: a primary care approach, ed 2, Philadelphia, 2000, WB Saunders, p 240.

NECK

Cervical lymph nodes can be palpated in healthy children, but they are not large, immobile, tender, fluctuant, or inflamed. Figure 5-3 shows the anatomic areas drained by the cervical nodes. The thyroid gland should be small and smooth and have no nodules or tenderness. Examine the range of motion (flexion, extension, lateral bending, rotation) of the neck, and, when appropriate, test for nuchal rigidity.

Figure 5-3 The lymphatic drainage and lymph nodes involved in infants and children with cervical lymphadenitis.

From Feigin RD, Cherry JD, editors: Textbook of pediatric infectious diseases, ed 4, Philadelphia, 1998, WB Saunders, p 171.

CHEST

Observe the rate, pattern, and effort of breathing. Diaphragmatic breathing may be exaggerated during respiratory illness in infants and toddlers, manifested by prominent abdominal protrusion during respiration; the cartilaginous ribs allow “collapse” of the chest during inspiration. Respiratory distress is signaled by expiratory grunting, nasal flaring, intercostal space retractions, and stridor. Wheezing, crackles, and asymmetrical breath sounds are concerning findings on auscultation. Transmitted upper airway sounds often cause confusion.

CARDIOVASCULAR

Palpate pulses in the carotid, brachial, radial, femoral, and dorsalis pedis areas. Hydration status and peripheral perfusion is best tested with capillary refill, which should be < 2 seconds. Observe and palpate precordial activity. Auscultate the heart for rhythm, rate, quality of the heart sounds, and murmurs. Young children often have prominent “sinus arrhythmia,” a physiologic variation of heart rate associated with the respiratory cycle: rate increases with inspiration and decreases with expiration. You should be able to hear the physiologic splitting of the second heart sound at the second or third left intercostal space even in infants with a rapid heart rate (the splitting will be a “blurring” of the second heart sound during inspiration with return to a “crisp” sound during expiration). A venous hum is often heard when a young child is sitting and turns the head to one side; this is a continuous to-and-fro sound that disappears when supine or with head movement. Physiologic murmurs change with position, often being more prominent when supine and diminishing when sitting. Pathologic heart murmurs are loud, often occur in diastole, and do not change with position (discussed in Chapter 48).

ABDOMEN

Examine the umbilical cord in newborns and identify the vein and the two arteries. Note the presence of granulation tissue, umbilical hernias, or a patent urachus. Observe, auscultate, and palpate the abdomen for distention, local or rebound tenderness, and masses. Palpate the liver, spleen, and kidneys. Expect the liver edge and kidneys to be palpable in a healthy newborn and young infant. Many constipated preschool children have stool in the descending colon and sigmoid that is palpable as a tubular mass in the left lower quadrant and is associated with stool in the rectal vault. If a rectal examination is necessary, you will be shown the age-appropriate technique.

GENITALIA

Before inspecting the genitalia, ask permission. This alerts parent and child or adolescent to what is coming next and also shows respect for privacy and the parent’s responsibility. Explain to the child that only a doctor or a parent should look at the “private parts,” “under their underwear,” or “where their bathing suit covers.” To observe the age-appropriate appearance of male and female genitalia, you must understand the genital changes that occur as the child grows from infancy to adolescence.

MUSCULOSKELETAL AND EXTREMITIES

The musculoskeletal examination is important at all ages. Examine the newborn’s hips with Ortolani and Barlow maneuvers (Figure 5-4) to identify developmental dysplasia. The Ortolani maneuver identifies the dislocated hip, which will be felt to move anteriorly (reduce) into the acetabulum, with a palpable or audible “clunk.” The Barlow maneuver identifies the dislocatable hip, which will be felt to move posteriorly (dislocate) out of the acetabulum, with a palpable or audible clunk. Use the musculoskeletal evaluation of older children and adolescents to identify restricted or excessive joint mobility, joint effusions, signs of trauma, and gait abnormalities.(Figure 68-1shows age-related variations of the legs and feet: genu varus and valgus, flexible flat feet, metarsus varus, tibial torsion, and femoral anteversion. The “2-minute musculoskeletal examination” assesses strength, symmetry, flexibility, muscle bulk, and range of motion (Figure 68-2). Common pediatric orthopedic problems are discussed inChapter 68

Figure 5-4 Ortolani (reduction) (A) and Barlow (dislocation) (B) tests.

From Berkowitz CD: Pediatrics: a primary care approach, ed 2, Philadelphia, 2000, WB Saunders, p 358.

BACK

The scapulae and iliac crests should be symmetrical in appearance, prominence, and placement. Inspect and palpate the spine along its entire length to identify curves, hair tufts, pits, dimples, or masses. Dimples over the lower spine are common and do not need further investigation if the underlying skin is intact. If not, investigate to identify a sinus tract or underlying abnormality. A dimple in the coccygeal or gluteal cleft area is usually benign, whereas a sacral dimple may represent an occult spinal dysraphism (spina bifida occulta). Examine school-age children and adolescents for scoliosis, kyphosis, and lordosis. Figure 5-5 demonstrates the technique to identify scoliosis.

Figure 5-5 Examination for scoliosis: The back and spine are inspected when the patient is upright and bending forward from the waist.

From Berkowitz CD: Pediatrics: a primary care approach, ed 2, Philadelphia, 2000, WB Saunders, p 386.

NEUROLOGIC

Observation is a key tool for the neurologic examination. Assess developmental milestones, symmetry, tone, strength, and reflexes. Primitive reflexes, including rooting, sucking, obligate grasp, Moro reflex, and tonic neck reflex, are found in healthy newborns and young infants. Persistence of primitive reflexes beyond 4 to 6 months should raise concern (Chapter 58). You should be able to demonstrate the findings that reflect the disappearance of primitive reflexes (e.g., the voluntary grasp of an infant older than 2 months indicates that the reflexive grasp of the newborn has disappeared).

SKIN

Observe and palpate the skin to assess color, perfusion, turgor, pigmented lesions, and rashes. Identify jaundice, petechiae, purpura, vesicles, and urticaria (Chapter 49). Examine the skin for common birthmarks and skin conditions unique to children (Chapter 57). Recognize bruises and other characteristic findings of child abuse (Chapter 24).

KEY POINTS