1. Chapter 25
The Pediatric Patient

2. Competencies
Differentiate the structural and physiological variations between pediatric patients and adults.
Identify personal-social, language, and fine and gross motor findings when using the Denver II.
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3. Competencies
Elicit a complete health history from a patient or caregiver using standard components of a pediatric health history.
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4. Competencies
Identify various techniques of approaching patients at different developmental levels before initiating the physical examination.
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5. Competencies
Perform inspection, palpation, percussion, and auscultation in a head-to-toe examination of a pediatric patient.

6. Physical Growth
Weight
Length or height
Head circumference
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7. Physical Growth Average weight gain Rapid growth periods Infancy
Adolescence

8. Allaying Childhood Fears During Physical Exam
Infant
Toddler
Preschooler
School age
Adolescent

9. Anatomy and Physiology
Vital signs
Temperature regulation
Variations by age
Pulse
Respirations
Blood pressure
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10. Anatomy and Physiology
Skin and hair
Lanugo
Vernix caseosa
Head
Closure of fontanels
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11. Anatomy and Physiology
Eyes, ears, nose, mouth, and throat
Visual acuity
Variations in eustachian tube
Development of sinuses
Eruption of teeth
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12. Anatomy and Physiology
Breasts
Breast tissue begins to develop at 8 to 10 years of age
Thorax and lungs
Infant
Chest development
Nose breathing
Abdominal breathing
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13. Anatomy and Physiology
Heart and peripheral vasculature
Placement
Cardiac output
Abdomen
Musculoskeletal system
Bone growth ends at 20 years of age
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14. Anatomy and Physiology
Neurological system
Incomplete at birth
Neurons become myelinated
Urinary system
Bladder location
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15. Anatomy and Physiology
Female genitalia
Development of pubic hair
Male genitalia
Descent of the testes
Onset of puberty

16. Health History Biographical data Name
Contact information
Source of data
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17. Health History Chief complaint
Infants, toddlers, young preschoolers are unable to describe their health concerns; caregiver will describe
Older preschoolers, school-age children, and adolescents are able to describe their health concerns

18. Past Health History Birth history Medical history Prenatal
Labor and delivery
Postnatal
Medical history
Hospitalizations
Emergency department visits
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19. Past Health History Injuries and accidents Childhood illnesses
Document exposure to measles, mumps, rubella, pertussis, chickenpox, RSV
Immunizations
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20. Past Health History Family health history SIDS ADHD
Congenital disorders
Mental retardation

21. Social History School or day care environment Home environment
Academic performance (if applicable)
Home environment
Potential exposure to lead
Gun safety
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22. Social History Child’s personal habits
Activities child enjoys
How does child cope with stress?
Domestic and intimate partner violence
Adolescents may be at risk

23. Health Maintenance Activities
Sleep
Diet
Safety
Critical to assess childproofing the environment

24. Developmental Examination
Denver II
Personal-social
Fine motor-adaptive
Language
Gross motor

25. Physical Examination Equipment Appropriate child-sized equipment
Developmental examination tools
Ophthalmoscope, otoscope
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26. Physical Examination General approach Warm environment
Methods to reduce anxiety and promote security
Respect patient’s modesty
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27. Physical Examination General approach (cont’d)
Interview older children and adolescents separate from caregiver
Perform uncomfortable procedures last

28. Examination Vital signs Blood pressure Heart rate Temperature
Respiratory rate
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29. Examination Physical growth Weight Height or length Head circumference
Chest circumference
Apgar score
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30. Examination Skin Hair Inspect color, lesions Palpate texture
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31. Examination Head Inspect for symmetry, shape, head control
Palpate fontanels, suture lines, surface characteristics
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32. Examination
Eyes
Assess eyes toward the end of the exam in children up to 10 years old
Vision screening
Tumbling E chart
Allen test
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33. Examination Eyes (cont’d) Strabismus screening Hirschberg test
Cover-uncover test
Color vision
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34. Examination Eyes (cont’d) Inspect Eyelids Lacrimal apparatus Sclera
Iris
Pupils
Lens
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35. Examination Eyes (cont’d) Inspect Red reflex Retina Optic disc
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36. Examination Ears Nose Auditory testing External ear Internal ear
Inspect mucosa, nasal septum, presence of drainage
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37. Examination Mouth and throat
Inspect lips, buccal mucosa, teeth, hard palate, soft palate, oropharynx
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38. Examination Neck Breasts Palpate thyroid and lymph nodes Inspection
Assess sexual maturity rating
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39. Examination Thorax and lungs
Inspect shape of thorax, presence of retractions
Palpate for tactile fremitus
Percuss diaphragmatic excursion
Auscultate breath sounds
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40. Examination Heart and peripheral vasculature
Usually performed at beginning of exam
Inspect
Apical impulse, precordium
Palpate
Thrill
Peripheral pulses
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41. Examination Heart and peripheral vasculature (cont’d) Auscultate
Heart sounds
Innocent murmurs
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42. Examination Abdomen Calm child before proceeding Inspect Auscultate
Contour
Peristaltic wave
Auscultate
Bowel sounds
Palpate
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43. Examination Musculoskeletal system General approach Inspection
Use of games to facilitate evaluation
Inspection
Muscles, joints, tibiofemoral bones
Palpation
Joints, feet, hip, femur

44. Neurological Examination
General approach
Infant
Toddler
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45. Neurological Examination
Reflex mechanisms of the infant
Rooting
Sucking
Palmar grasp
Tonic neck
Stepping
Plantar grasp
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46. Neurological Examination
Reflex mechanisms of the infant (cont’d)
Babinski
Moro
Galant
Placing
Landau
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47. Neurological Examination
Cranial nerve testing
Infant
Toddler
School age
Adolescent

48. Genitalia Examination
Tanner sexual maturity rating
Female
Age-specific guidelines
Inspect perineal area
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49. Genitalia Examination
Male
Age-specific guidelines
Inspect penis, scrotum
Palpate scrotum
Hernia

50. Anus Examination Performed if problem detected or abuse suspected
Inspect for bleeding, fissures, prolapse, skin tags

51. Signs of Sexual Abuse in Children
Strong fear of examination
Presence of STD
Absent or delayed anal reflex
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52. Signs of Sexual Abuse in Children
Anorectal tears, ecchymosis, pruritus, scarring, or bleeding
Broken hymen, vaginal tears