Whenever possible a physical exam of a child between 6 months and 1 year should be performed quizlet

begin the examination with the child sitting on the parent's lap, moving the child to the exam table for the components that require him to lie down. Let the parent undress the child. try to be at the child's eye level. Engage the parents - calming the child or assisting.
assess temperament and bonding.
Engage children in age appropriate conversation, using a playful, reassuring voice.
Make a game out of the examination.
Let the child see and touch the tools you will use during the examination.

Avoid asking the child's permission to examine a body part.
complete the examination expeditiously. Or give the child a short break.

perform non-distressing maneuvers early, and potentially distressing maneuvers near the end.

general survey: Behavioral problems, such as poor parent-child interactions, sibling rivalry, inappropriate parental discipline, and an overall intense temperament.
look for signs of developmental delay in areas such as cognitive abilities, language, social and emotional tasks, as well as gross and fine
motor skills. developmental assessment - key part of the neurological exam.
Observe for signs of social or environmental problems, including parental difficulties such as
stress or depression, and risk for abuse or neglect.

Measure standing height (or stature).accurate, wallmounted stadiometer. Have the child stand with the heels back and the head against the wall or the back of the stadiometer.
If using a wall with a marked ruler, make sure to place a board or other flat surface across the
top of the child's head at a right angle to the ruler. Please note that stand-up weight scales with
height attachments are relatively inaccurate.

Weigh children in their underpants or gown on a stand-up scale. Use the same scales across
successive visits to optimize comparability.

head circumference is measured until the child reaches 24 months. may be helpful if you suspect a genetic or central nervous system disorder.

assess Body Mass Index for age. early detection of obesity in children older than two years old.
give parents their child's BMI results, together with information about the impact of healthy eating and physical activity.

Vital Signs
measure the blood pressure in children older than two years. blood pressure cuff - wide enough to cover two-thirds of the upper arm or leg.

Obtain pulse rate. Measure the heart rate over a 60-second interval.

The respiratory rate ranges from 20 to 40 per minute during early childhood and 15 to 25 during
late childhood, reaching adult levels around age 15.
You can observe for 60 seconds as the child sits quietly with shirt removed.

In children, auditory canal temperature recordings are preferred over other methods because
they can be obtained quickly with essentially no discomfort. Body temperature in children is less
constant than in adults.

The Skin
inspecting and palpating the fingernails, looking especially for any clubbing or cyanosis.
inspect the skin of the child's face and upper torso, noting color, pigmentation, texture, hair distribution and thickness, and any lesions.
Common skin conditions in preschool children include birthmarks, nevi, and scars.

Head and Face
observe the shape of the head, its symmetry and the presence of abnormal facies, which may not become apparent until later in childhood.
Some of the diagnostic facies include:
Down syndrome, fetal alcohol syndrome, perennial allergic rhinitis, and hyperthyroidism.

The Eyes
Inspect each cornea, iris, and lens. Check
the color of the conjunctiva and sclera.
test visual acuity in each eye and to determine whether the gaze is conjugate and symmetric.
Visual acuity may be difficult to measure in children younger than approximately 3 years of age
who cannot identify pictures on an eye chart. For children older than 3 years, however, formal
visual acuity testing is both feasible and preferred.
The examiner may assess visual acuity in broad terms by having the child read letters, numbers,
or symbols, or by using an "E" chart, in which the child is asked to point out which direction the
letter "E" is facing.

To test for conjugate gaze or to look for strabismus, —the corneal light reflex test—consists of simply observing the reflection of a light from the child's corneas. If you shine a light in front of the child's face and stand about 2 to 3 feet away, the reflections should be symmetrical and visible, very slightly nasal to the center of each pupil.

The cover-uncover test may assume the form of a game. Have the child look at your smiling
face. Cover one of the child's eyes. Then move your covering hand to the child's other eye and
see if the first eye moves. Movement of the eye just uncovered may indicate an abnormality.

When testing the visual fields in young children, test one eye at a time.
Hold the child's head in the midline while bringing an object such as a toy into the field of vision
from behind the child.

Ears and Nose
leave it for the end.
child lying down and restrained by the parent,
or in younger children, sitting on the parent's lap, with the child's legs restrained by the parent's
legs.
To view the tympanic membrane in young children, the auricle must be pulled upward, outward
and backward to afford the best observation with the otoscope.
hold the child's head with one hand and with that same hand, pull on the auricle.
With the other hand, position the otoscope with the handle pointing downward.

A pneumatic otoscope allows you to assess the mobility of the tympanic membrane as you
increase or decrease the pressure in the external auditory canal by squeezing the rubber bulb.

formal hearing testing is necessary for accurate detection of hearing deficits in young
children you can grossly test for hearing standing behind the child, and have them repeat your
whispered words while you cover one of the child's ear canals and rub the tragus using a circular
motion.

Inspect the nose, using a large speculum on your otoscope. Check for nasal deviation and
polyps, and note the color and condition of the nasal mucous membranes.
Pale, boggy nasal mucous membranes are found in children with chronic, perennial allergic rhinitis.

Mouth and Pharynx
wear gloves.
Turn the examination into a game.
Don't show the tongue blade unless absolutely necessary. The child who can say "ahhh" usually
offers a sufficient, albeit brief, view of the posterior pharynx, rendering a tongue blade unnecessary.
With the child's mouth open, examine the upper and lower lips.
Examine the tongue, including the underside.
Note the size, position, symmetry and appearance
of the tonsils. The peak growth of tonsillar tissue is between 8 and 16 years.
Then lift the upper lip to examine the upper teeth. Look for staining or signs of erosion, which
often first appear here, and which may signify the need for a dental referral.

note the quality of the child's voice. Certain abnormalities can change the pitch and
quality of the voice.

Examination of a child's neck, including the sternomastoid muscles, is the same as that for
adults.
The vast majority of enlarged lymph nodes in children are due to infections and not malignant
disease. Lymphadenopathy is common in childhood.

Check the neck for mobility. Ensure that the neck is supple and easily mobile in all directions.
This is particularly important when the child is holding the head asymmetrically, and when
central nervous system disease such as meningitis is suspected. Normally, children should be
able to sit upright and touch their chins to their chests.
In children, nuchal rigidity is a more reliable indicator of meningeal irritation than is Brudzinski's
sign or Kernig's sign. Nearly all children with nuchal rigidity are extremely sick, irritable, and difficult to examine.

Thorax and Lungs
Carefully assess respirations and the pattern of breathing. first observe the child carefully. Assess the relative proportion of time spent on inspiration versus expiration. The normal ratio is one to one.
Prolonged inspirations or expirations are a clue to disease location. prolonged expiration is a frequent sign of asthma or lower airway obstruction.
Note any effort or "work of breathing," including nasal flaring and grunting.
Palpation, percussion, and auscultation achieve greater importance in a careful examination of
the thorax and lungs.

Let children move the stethoscope themselves, going back to listen properly.

Measure the blood pressure in the right arm. If the child is three to four years old, measure it in
both arms and one leg at a time to check for possible coarctation of the aorta

most school-aged children have a benign heart murmur at some point in their lives. The most common, Still's murmur, is a grade I-II/VI, musical, vibratory, early and midsystolic murmur with multiple overtones, located over the mid or lower sternal border but also frequently heard over the carotid arteries.

Compression of the carotid artery usually causes the precordial murmur to disappear. The
murmur will also diminish as the child goes from supine to sitting to standing.

Also in preschool or school-aged children, you may detect a venous hum. This is a soft, hollow,
continuous sound, louder in diastole, heard just below the right clavicle. It can be completely
eliminated by maneuvers that affect venous return, such as lying supine, changing head
position, or performing jugular venous compression. A venous hum has the same quality as breath sounds and therefore is frequently overlooked.

The murmur heard in the carotid area or just above the clavicles, is known as the carotid bruit. It
is early and midsystolic, with a slightly harsh quality. It is usually louder on the left and may be
heard alone or in combination with Still's murmur.
It may also be completely eradicated by carotid artery compression.

Breasts and Abdomen
breasts - inspection, because in both sexes
there is little breast tissue.

patient lie supine with knees flexed. placing your whole hand flush on the abdominal surface for a few moments without probing.
For particularly sensitive children, try placing the child's hand under yours.
Palpate lightly in all areas, then deeply, leaving the site of potential pathology to the end.
Begin palpating low on the abdomen, moving your hand upward so that you do not miss the edge of
the liver or spleen.
to determine the lower border of the liver - the scratch test. Place the diaphragm of your stethoscope just above the right costal margin at the midclavicular line.
With your fingernail, lightly scratch the skin of the abdomen along the midclavicular line, moving
from below the umbilicus toward the costal margin. When your scratching finger reaches the
liver's edge, you will hear a change in the scratching sound as it passes through the liver to your stethoscope.

The spleen felt easily in most children. It too, is soft with a sharp edge and projects downward like a tongue from under the left costal margin. The spleen is moveable and rarely extends more than one-to-two centimeters below the costal margin.

Palpate the other abdominal structures. You will commonly note pulsations in the epigastrium
caused by the aorta. left of the midline, on deep palpation.

Male Child Genitalia
inspecting the penis.
extremely active cremasteric reflex that may cause the testis to retract upwards into the inguinal canal, and thereby appear to be undescended.
With warm hands, palpate the lower abdomen, working your way downward toward the scrotum along the inguinal canal.
increase intra-abdominal pressure by asking the child to do a sit-up. If you can detect the testis in the scrotum, it is descended even if it spends much time in the inguinal canal.
noting any swelling that may reflect an inguinal hernia. increase abdominal pressure and note whether a bulge in the inguinal canal increases.

Female Child Genitalia
A bright light source is essential.
Most children can be examined in the supine,
frog-leg position.
If the child seems reluctant, it may be helpful to have the parent sit on the examination table
with the child. Or, the examination may be performed while the child sits in the parent's lap
Inspect the external genitalia for pubic hair, the size of the clitoris, the color and size of the labia majora, and any rashes, bruises, or other lesions.
Next, visualize the structures by separating the labia with your fingers
gentle traction by grasping the labia between your thumb and index finger of each hand and separating the labia majora laterally and posteriorly to examine the inner structures.
Note the condition of the labia minora, urethra, hymen, and proximal vagina. If you are unable
to visualize the edges of the hymen, ask the child to take a deep breath to relax the abdominal
muscles.
Another useful technique is to position the patient in a knee-chest position.
Avoid touching the hymenal edges because the hymen is very tender without the protective
effects of hormones.
Examine for discharge, labial adhesions, estrogenization, hymenal variations, and hygiene.
The physical examination may reveal signs of sexual abuse, and may require more complete
evaluation by an expert in the field.

The rectal examination is not routine, but should be done whenever intra-abdominal, pelvic or
perirectal disease is suspected.

Musculoskeletal System
The normal young child has increased lumbar concavity, decreased thoracic convexity, and often a protuberant abdomen.
watching carefully from both the front and behind as the child stands and walks barefoot, touches his toes and runs a short distance.

To check for scoliosis, perform the Adam's Bend Test if the child is at least six years old. Have
the child stand with his bare feet together and bend forward with the knees straight and the
arms hanging straight down.
Look for any asymmetry in positioning.
If you detect scoliosis, use a scoliometer to test for the degree of scoliosis.

Finally, check for leg length discrepancy by having the child stand straight as you observe from
behind. Place your hands on his iliac crests. Your hands should be perfectly parallel to the floor.

Test for severe hip disease by observing from behind as the child shifts weight from one leg to
the other. A pelvis that remains level when weight is borne on the unaffected side is a negative
Trendelenberg's sign.
But with an abnormal positive sign in severe hip disease, the pelvis tilts toward the unaffected
hip during weight bearing on the affected side.

For children age eight or older, perform a sports pre-participation screening musculoskeletal
examination. Organized sports often require this medical clearance in order for the child to
participate.

Nervous System
The sensory examination can be performed by slightly tickling the child's skin using a cotton ball
or soft object and asking the child to indicate when he feels it. Make sure the child's eyes are
closed, and don't use a pin, because it will scare the child.

Observe the child's gait and coordination while the child is walking and running. Note any
asymmetries, weakness, undue tripping or clumsiness.

To check for gross motor development and balance, ask the child to balance on one foot and to hop. You might try asking him to walk on his heels, if he is old enough to perform this maneuver.

If you are concerned about the child's strength, have the child lie on the floor and then stand up
and closely observe the stages. Most normal children will first sit up, then flex the knees and
extend the arms to the side to push off from the floor and stand up.
Hand preference is demonstrated by most children by age two. Check for weakness in the nonpreferred upper extremity.

show the child the reflex hammer, treating it
like a toy so he is not frightened. Distract the child or ask him to close his eyes so he does not
see the impact of the hammer and provide a false reaction.

fine motor development, ask the child to copy an "X" or a square, or draw a person (which should display several body parts). Then, discuss their pictures to test for cognition and language as well.

The cerebellar examination can be performed by asking the child to touch your finger and then
his nose, and by having him perform rapid hand movements. Children older than five years old
should be able to tell right from left, so you can assign them right-left discrimination tasks as
well.

Cranial Nerve I, generally not tested at this age.

Cranial Nerve II, visual acuity. Snellen chart or "E" chart for those children ages three years and older.

Cranial Nerve II, along with Cranial Nerve III, child's eye assessment.

Cranial Nerves III, IV, and VI, track light, or an object,

Cranial Nerve V - having the child smile.
Cranial Nerve VII - asking the child to make faces.
Cranial Nerve VIII - formal hearing testing session.
Cranial Nerves IX and X - asking the child to stick out his whole tongue and move it back and forth.
Cranial Nerve XI - having the child push your hand away with his head.
Cranial Nerve XII - observe the child's speaking ability.

At what age would you think of performing a child's physical exam when they are in their parent's lap?

What approach is the most appropriate when performing a physical assessment on a toddler?

What is the best position for examination of a child of age 3 months to 1 year old?

What is physical examination of a child?