PAEDIATRIC CLINICAL EXAMINATION

A SYSTEMATIC APPROACH

Professor Alf Nicholson 2016

Short case examinations are demanding and stressful for candidates and they require a
systematic approach, good technique and plenty of practice.

I would urge you to practice a pattern of examination in front of your peers and registrars,
consultants and tutors until your technique and tempo of examination is beyond reproach.

Observation from the end of the bed is very important in Paediatrics and is a learned skill that will
score you many marks if done well in the examination.

You should allow yourself 6-7 minutes to complete the examination of a system.

As a general rule, having washed your hands, introduce yourself to the patient and his/her parent
and then proceed immediately to observation.

You should then get on with the remainder of the examination and summarize your findings at the
end.

I am going to go through a proforma for the examination of various systems including:

a) Cardiovascular examination
b) Respiratory examination
c) Abdominal examination
d) Cranial nerves examination
e) Neurological examination of the upper and lower limbs
f) Joint examination
g) Neurodevelopmental examination

.
A: CARDIOVASCULAR EXAMINATION

For many students (and some postgraduate students) examination of the cardiovascular system
and, in particular listening for murmurs, is daunting. It would be very unfair for a medical student
with little paediatric exposure to accurately interpret various murmurs. Therefore a different
approach is required and is based on three essential questions:

1. General condition of the child and look for dysmorphic features

2. Assess for evidence of central cyanosis
3. Assess for evidence of congestive heart failure (hepatomegaly , tachypnoea and
tachycardia)

1|P age
Background :

GUILTY or INNOCENT ?
Many children (up to 50%) will have innocent murmurs (no underlying cardiac anomaly) most
often related to intercurrent fever or anaemia but these murmurs when noted can cause great
concern to parents. Innocent murmurs have the following characteristics:

a) soft
b) systolic
c) no associated symptoms
d) may vary with posture and respiration
e) localized (usually to left sternal border)

Types of innocent murmurs include :

1) Increased flow across branch pulmonary artery – seen especially in preterm infants , is a
physiological finding and disappears after a few weeks
2) Stills murmur – This is a vibratory murmur found at mid LSB and is caused by turbulence
around a myocardial muscle band in the left ventricle
3) Venous hum – it may be easy to hear the venous blood flow returning to the heart
especially at the upper LSB or aortic area . This is heart in both systole and diastole and
will disappear on lying the child flat

These are innocent murmurs and no endocarditis prophylaxis is required

Congenital heart disease :

8 per 1,000 children have congenital heart disease (just under 1%) with a VSD (ventricular septal
defect) accounting for 30% of the total. PDA is the next most common accounting for 12% of all
congenital heart disease.

The incidence of congenital heart disease (CHD) is increased if a positive family history :

Risk of recurrence

Previous sibling with CHD 2%

2 siblings with CHD 4%
Father with CHD 5%
Mother with CHD 6%

CHD is also associated with chromosomal disorders (especially Down’s syndrome, Turner’s
syndrome and Edward’s syndrome).

2|P age
CLINICAL EXAMINATION:

If 5 years or older, the child should be examined with pillows behind them so that they are at an
angle of 45 degrees. This is not possible for a younger child or baby where an opportunistic
examination will take place, perhaps lying in a cot or on mother’s lap.

OBSERVE from the end of the bed for:

- evidence of central cyanosis

- evidence of dysmorphic features
- signs of respiratory distress
- intravenous lines
- saturation monitor
- nasogastric tube placement
- sterniotomy or thoracotomy scars

HANDS - look for :

- peripheral cyanosis
- nail changes associated with subacute bacterial endocarditis
- evidence of clubbing (loss of nail angle, increased fluctuance and positive
Shamroth’s sign)
- pulse (rate, rhythm and character of the pulse) and assess to see if pulse volume
is equal left and right and then assess for any radio-femoral delay
- measure the BP with an age-appropriate BP cuff.

NB – Clubbing is first visible from 6 months onwards in those with cyanotic congenital heart
disease and is first apparent in the thumbs or toes. Clubbing takes a few years to disappear after
corrective surgery for cyanotic congenital heart disease

HEAD/NECK – look for :

- conjunctival pallor due to anaemia

- tongue for central cyanosis
- JVP (only if over 4 yo) with the child at 45 degrees and the head turned towards
the candidate so that the left side of the neck can be seen with the JVP visible.
- Palpate for a suprasternal thrill – in the suprasternal notch and, if present,
indicates valvular aortic stenosis

PRECORDIUM

a) inspection - inspect the chest thoroughly looking for evidence of use of accessory
muscles of respiration with tracheal tug, intercostal and subcostal recession, midline
sternotomy scars and lateral thoracotomy scars
b) Palpation - palpate for the apex beat (the most downward and lateral position where the
index finger is lifted by the impulse of the heart). Do not forget to place one hand on each
side of the chest to ensure that the apex beat is on the left side and to exclude
dextrocardia. Palpate also for heaves and thrills at the apex, the left sternal border and
the aortic and pulmonary areas.

3|P age
 c) Auscultation – it is important during auscultation to try to determine the following
features :

- heart sounds and their character

- any additional sounds (30% of children have a third heart sound)
- murmurs (their character and where they are best heard )

Heart sounds – the first heart sound (HS 1) is due to closure of the mitral and tricuspid valves.
The second heart sound (HS 2) is due to closure of first the aortic and then the pulmonary valves.
What you want to know is whether the HS 2 is loud (if so suggests pulmonary hypertension) or
split. Usually with inspiration the sounds of HS 2 separate and come together on expiration and
this is termed physiological splitting. In atrial septal defect (ASD) or RBBB you will hear fixed
splitting of HS 2. To hear a split HS 2, ask the child to sit up and listen to the mid LSB with the
bell during expiration. If the HS 2 is found to be split at that time then it can be said to be fixed and
split.

Murmurs – As mentioned above most murmurs are innocent so it is vital to know the
characteristics of innocent murmurs.

Ejection systolic murmurs are typically found at the upper LSB and imply outflow tract obstruction.
Try to determine whether an ejection click is present or not – this is recognised as a very crisp
start to the ejection murmur.

Pansystolic murmurs are typically found at the lower LSB or apex. The most common significant
murmur is a pansystolic murmur at the lower LSB and apex associated with a VSD.

Continuous murmurs are characteristically heard in the left infraclavicular area and represent flow
across a PDA.

Diastolic murmurs are unusual in children. A diastolic murmur best heard at the LSB with a
diaphragm and on expiration is typical of aortic regurgitation and it may be associated with a
collapsing pulse. This murmur is heard immediately after the HS 2.

Scars –

If a right lateral thoracotomy scar is found after lifting the arms and inspecting the back, this
implies placement of a Blalock-Taussig Shunt (artificial tubing between the subclavian and
pulmonary arteries) – any child with a BT shunt who is cyanosed is likely to have a diagnosis of
Fallot’s Tetralogy

A left lateral thoracotomy scar can be due to:

 left BT shunt
 repair of coarctation of aorta
 pulmonary artery banding
 PDA ligation

A median sternotomy scar implies a repair of intracardiac pathology with open cardiac surgery.

4|P age
If there is a median sternotomy scar and lateral thoracotomy scar – think of Fallot’s with a BT
shunt and then complete repair.

If a child has Downs Syndrome with a sternotomy scar – think AV canal defect with residual VSD.

Summarize your findings and try to come up with a most likely diagnosis.

In summary you should assess:

a) the general condition of the child

b) whether pink or blue
c) the character of the pulses – both upper and lower limb
d) for signs of congestive cardiac failure
e) for presence of scars
f) for presence of heaves or thrills

And only then to fine tune:

g) auscultation of the heart

 VSD - pansytolic murmur at lower LSB
 ASD - ejection systolic murmur at upper LSB + fixed split HS2
 PDA – Continuous murmur + collapsing pulses
 Fallot –Blue + harsh long systolic murmur at upper LSB +/- scars
 AS - Ejection systolic murmur URSE + carotid + suprasternal thrill
 PS - Ejection systolic murmur ULSE +/- thrill
 CoA - Ejection systolic murmur + weak or absent femoral pulses

B: RESPIRATORY EXAMINATION

INTRODUCE SELF

OBSERVATION:

 General and nutritional status

 Signs of respiratory distress – tachypnoea, grunting, use of accessory muscles of
respiration, cyanosis
 Obvious chest deformity
 Pectus excavatum or carinatum
 Scars
 Evidence of chest hyperinflation

HANDS:
 Presence of clubbing
 Anaemia
 Peripheral cyanosis
 Signs of CO2 retention rarely seen

5|P age
Check pulse rate
Pulsus paradoxus (always ask for BP)

Head and Neck:

 Central cyanosis
 Trachea central +/- tracheal tug
 Nasal polyposis

Chest:
 Localisation of apex beat
 Chest expansion – is it equal and is there evidence of reduced overall chest expansion
 Tactile +/- vocal fremitus
 Chest percussion
 Upper border of the liver and cardiac dullness

THREE ESSENTIAL QUESTIONS

 Are there signs of acute respiratory distress?

 Is there clubbing present?

 Are there signs of chronic chest hyperinflation?

C: ABDOMINAL EXAMINATION

INTRODUCE SELF

INSPECTION:

 General observation and nutritional status

 Look for obvious wasting or loss of subcutaneous fat
 Look for pallor or bruising, evidence of jaundice or oedema
 Bedside locker clues
 Obvious PEG tube or NG tube
 Ask for centile chart and chart height and weight

HANDS:
 Clubbing,
 Anaemia,
 Koilonychia,
 Palmar erythema

Always assess vital signs

Head and Neck

6|P age
  Jaundice or anaemia
 Mouth aphthous ulcers
 Dentition
 Spider naevi
 Cervical lymphadenopthy

ABDOMEN:
Inspect for:
 Distension
 Scars
 Abdominal wall veins
 Obvious herniae
 Stoma sites
 PEG tube

Palpation:
 Gentle quadrant palpation
 Palpation for hepatomegaly and splenomegaly (start in RIF)
 Palpation for renal masses

Percussion
 Liver and spleen
 Check for shifting dullness

Auscultation:
 Bowel sounds
 Renal artery bruits

Always offer to inspect groin if feasible (look for UDT, inguinal herniae)

Check femoral pulses

7|P age
D: NEUROLOGICAL EXMAINATION OF UPPER LIMBS

INTRODUCE SELF

INSPECTION

Look for resting posture of upper limbs, muscle wasting or fasciculations, involuntary movements,
trophic changes and neurocutaneous stigmata (eg café au lait spots)

Look for neck or spinal scars

Look for “claw hand” (Klumpke lesion C8, T1) or “waiter’s tip” (Erb’s C5, C6)

TONE ASSESSMENT
Assess tone at the wrist and elbow and by passive pronation/supination of the forearm

POWER ASSESSMENT
Grade power from 1 to 5 (normal power)

a. shoulder abduction (C5,C6) – abduction at shoulders with elbows flexed “stop me pushing
them down”
b. should abduction (C5,C6,C7) – “push down against me”
c. elbow flexion (C5,C6) – “pull my hands towards you”
d. elbow extension (C7,C8) – “push me away”
e. wrist flexion (C6,C7) – wrists flexed “don’t let me straighten them”
f. wrist extension (C6,C7) – wrists extended “don’t let me straighten them”
g. hand grip (C8,Y1) – “squeeze my finger as tight as you can and don’t let go”
h. finger abduction (C8,T1) – “spread your fingers apart and stop me pushing them together”

REFLEXES:
 Biceps and brachioradialis (C5,C6)
 Triceps (C7,C8)

COORDINATION:
 Finger nose test
 Put a pen into a pen top
 Thread a bead
 Check for dysdiadochokinesis

8|P age
SENSATION:

Light touch +/- sharp/blunt differentiation in dermatomes

 Shoulder (C4)
 Radial aspect of upper limb (C5 arms, C6 forearm)
 Tips of fingers (C7)
 Ulnar aspect of upper limb (C8 forearm, T1 elbow)
 Axilla (T2)

Test proprioception and vibration sense

E: NEUROLOGICAL EXAMINATION OF THE LOWER LIMBS

INTRODUCE SELF

ASSESS GAIT

a. Normal walking and note characteristic patterns (eg hemiplegic gait, widebased cerebellar
gait or waddling gait with proximal myopathies
b. Heel-toe walking – tests for cerebellar lesions
c. Walking on toes
d. Walking on heels
e. Fog test (walking on the outsides of the feet) will bring out signs of a subtle hemiplegia
f. Hop on one foot and then the other
g. Stand with both feet together (with eyes open this tests for truncal ataxia and with eyes
closed (Romberg’s) tests posterior columns.
Gower’s manoeuvre

INSPECTION

Note resting posture, muscle wasting, fasciculations, involuntary movements, trophic canges and
neurocutaneous stigmata

Always examine the lower back

Inspect feet for evidence of pes cavus

TONE ASSESSMENT

Check at the ankle, knee and hip

Check for ankle clonus

9|P age
POWER ASSESSMENT

Grade from 1 to 5 (normal)

a. hip flexion (L1,L2,L3) – “lift your leg straight up and don’t let me push it down”
b. hip extension (L5,SI,S2) – “keep your leg on the bed, stop me lifting it up”
c. knee flexion (L5,SI) – “bend your knee, pull your foot in towards your bottom and stop me
straightening it”
d. knee extension (L3,L4) – “straighten your leg, stop me bending it”
e. ankle plantarflexion (SI) – “push down, push my hand away”
f. ankle dorsiflexion (L4,L5) – “stop me pushing it down”.

REFLEXES

Knee Jerk (L3,L4) and Ankle Jerk (SI,S2)

Reinforcement if necessary

Plantar response (may be upgoing up until 18 months old)

SENSATION

Test light touch +/- sharp/blunt differentiation

 L1 – groin
 L2 – upper thigh
 L3 – knee
 L4 – medial aspect of leg below knee
 L5 – lateral aspect of leg below knee and continues down onto the medial aspect of the
foot
 S1 – sole of the foot
 S2 – central posterior aspect of the leg and thigh

Test for proprioception and vibration

F: EXAMINATION OF THE JOINTS:

 General assessment
 Active (+/- passive) movements of the joints.
 Examination for extra-articular manifestations

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INTRODUCE SELF
Ask for temperature chart.

Inspect overall for:

 rashes
 Raynauds
 centiles
 anaemia
 alopecia
 parotid swelling
 hepatosplenomegaly
 urinalysis
 stool analysis

JOINT INSPECTION:
Note:
 swelling
 redness of overlying skin
 angulation
 deformity
 evidence of muscle wasting

JOINT PALPATION:
Check for:
 tenderness
 increased temperature
 swelling
 contractures

JOINT MOVEMENT:
Always check active movements first and only check passive movements if active movements are
incomplete

Fingers – flexion and extension only

Wrist:
 Flexion (80 degrees) and extension (70 degrees)
 Radial (20 degrees) and ulnar deviation (30 degrees)
 Pronation (90 degrees) and supination (90 degrees)

Elbow:
 Flexion (135 degrees) and extension (0-10 degrees)

Shoulder:
 Abduction (180 degrees) and adduction
 Flexion (90 degrees) and extension (45 degrees)
 Internal (55 degrees) and external rotation (45 degrees)

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Cervical spine:
 Flexion (45 degrees) and extension (55 degrees)
 Lateral flexion (ear to shoulder – 40 degrees)
 Rotation (chin in line with shoulder – 80 degrees)

Hip:
 Flexion (120 degrees) + Thomas Test for fixed flexion deformity
 Extension (15 degrees)
 Abduction (50 degrees) and adduction (30 degrees)
 Internal (35 degrees) and external (45 degrees) rotation

NB: When checking all hip movements, the pelvis should be stabilised.

Knee:
 Flexion (135 degrees) and extension (up to 10 degrees)

Ankle:
 Dorsiflexion (20 degrees) and plantar flexion (50 degrees)
 Inversion (5 degrees) and eversion (5 degrees)

G: NEURODEVELOPMENTAL EXAMINATION

INTRODUCE SELF

OBSERVATION:
Observe:
 Posture
 Evidence of flexion deformity
 Muscle wasting
 Obvious dysmorphic features
 Evidence of NG tube or PEG tube
 Head circumference
 Ears – normal or low set
 Sutures and fontanelles
 Response to loud noises
 Visual responsiveness – test fixing and following
 Presence / absence of cataracts, colobomata or strabismus
 Other dysmorphic features

EXAMINATION:

 Trunkal tone in ventral and vertical suspension

 Presence/absence of head lag
 Peripheral tone assessment especially:
o hip adductors/knee flexion and extension/ankle plantar flexion in lower limbs
o pronation/supination, elbow flexion and extension in the upper limbs

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  Persistence of primitive reflexes especially Moro and ATNR
 Presence/absence of hepatosplenomegaly
 Neurocutaneous stigmata (café au lait, ashleaf macules etc)

DEVELOPMENTAL ASSESSMENT

An essential requirement for all students to know

What influences development?

Development used to be viewed too narrowly as a maturational process. Child development is

now seen as a process in which genetic and environmental influences continuously alter each
other in a dynamic manner. The family environment strongly influences cognitive and language
outcomes in toddlers.

In general terms , developmental skills can be grouped into four categories:

Gross motor including sitting , walking , running , climbing and kicking a ball

Fine motor and vision including hand skills including drawing shapes and puzzles
At 2 years of age a child should copy a line , at 3 years a circle , at 4years a cross , at 5 years a
square and a triangle

Speech and language skills including language and non-verbal communication

Social behaviour and play including feeding , toileting , dressing and social relationships

Addressing parental concerns

Questions to ask

 Do you have any concerns about how your child talks and makes speech sounds?

 Do you have any concerns about how your child understands what you say?

 Do you have any concerns about how your child uses his or her hands to do things?

 Do you have any concerns about how your child walks or runs?

 Do you have any concerns about how your child behaves?

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  Do you have any concerns about how your child gets along with others?

 Do you have any concerns about how your child does things for him or herself?

 Do you have any concerns about your child’s learning?

 Do you have any concerns about your child’s hearing or vision?

 Do you have any other concerns?

VISION AND HEARING

 Enquiry: do you have any concerns about your child’s vision?

 Does your child: notice you across the room and follow movements - see or pick crumbs
on the floor?
 Observing: developmentally expected visual behaviour
 Examination for abnormal eye movements, for example, nystagmus and a squint

HEARING

 Enquiry: do you have any concerns about your child’s hearing? Does your child seem to
hear quiet sounds: turn and locate a person talking?
 Eliciting a history of risk factors for hearing, for example, family history, meningitis,
Neonatal intensive care unit admission, abnormalities of the palate and cranio-facial
abnormalities.
 Early referral is made for hearing assessment for any concerns.

DEVELOPMENTAL EXAMINATION

Gross Motor development:

Motor abilities have a weak correlation with cognitive development. In effect this means that
being a late walker does not imply that a child will struggle at school . Many are just cautious or
may have hypermobile joints and these factors both delay walking . You would like to see a child
walking by 18 months of age unless a bottom shuffler

Questions to ask :

 Do you have any concerns about the way your baby moves his arms/legs or body? Have
you ever noticed any odd or unusual movements?
 Has your baby every been too floppy or too stiff?

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  Did your baby have a strong preference for one hand and ignore the other hand?

Worrying features :

 Fisting of hands beyond 3 months

 Poor head control at 4 months
 Not sitting independently with straight spine by 10 months
 Not walking by 18 months.

Fine motor development

Questions to ask :
 Do you have any concerns about: the way he uses hands to reach for, pick up, explore
and play? Any asymmetry or any unusual hands movements?

Normal developmental pattern:

 Achieving sharp visual focus and differentiation of movements – exploration with index
finger (8-9 months)
 Maturing grasp: improving apposition of tips of fingers with the tip of the thumb (palmar at
6 months of age , scissors (thumb-finger) at 9-10 months and fine pincer at12 months.
 Releasing with open hands or with pressure (10-11 months); controlled release – puts
one cube on top of another (13 months).

Worrying features

 No index finger exploration by 12 months

 Lack of purposeful exploration of objects and toys by 12 months.

Speech, language and communication

Questions (note the language spoken at home) to ask

 How does your baby respond to: your smile? – calling his name? – saying “no” to him? -
simple commands such as “come here”, give it to me?
 Does your baby say any clear words other than “Mama” or “Dad” (get examples)
 Does your baby look at family members or familiar objects when you ask for them or
name them?
 How does your baby ask for things? Does he point to ask?
 How does your baby show you anything? Does he draw your attention by pointing to it?

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Worrying features

 no babbling by 10 months

 not responding to name by 12 months

 not pointing or using other gestures by 12 months.

Social and Play Development:

Questions :

 Do you have any concerns about the way your toddler responds to you?
 How does your toddler respond to you: - when you smile at him: - play nursery games
such as pat-a-cake or peek-a-boo?

Typical developmental patters

 Social smiles (6-8 weeks)

 Uses finger and eye pointing to direct others’ attention to share interest (9-12 months)
 Becoming stranger aware – reacting by withdrawing or crying (6 months)
 Social referencing – checking back by looking towards the caregiver in new situations (12
months)

Worrying features

 Not responding to carer’s interactions such as smiles by 8 weeks

 no joyful engagement in fun activities by 5 months
 lack of interest in social games by 9 months
 no pointing or other gestures by 12 months.

Cognitive development

Questions:
 Do you have any worries about the way your child uses common objects or plays with
toys?
 Does your baby look for a toy that has fallen out of sight or is hidden from him?

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  How does your child play with toys and common objects?

Improving eye-hand coordination enables infants to look at which they hold in their hands by 4
months and reach out to grasp by 5 months. They relate objects together by banging or clicking
them at 6 months, placing things in and out of containers at 9-15 months and inserting pegs into
holes by 15 months.

These concepts emerge as simple acts such as shaking of a bell (7 months), using cause-and-
effect toys, for example pressing large buttons to activate a musical toy (9 months), intentional
means-end actions such as pulling a toy with a string (9 months) and moving a car (12 months).

H: CRANIAL NERVES EXAMINATION

General comments relating to conscious level of the patient.

Inspect for obvious strabismus/ptosis/facial palsy

I.
Not unless specifically requested
Test sense separately in each nostril, the other being occluded by finger pressure
(coffee/almonds/cocoa)
Anosmia mostly due to trauma (don’t forget Kallmann’s)

II.
 Visual acuity
o Snellen charts (distant vision)
o Jaeger chart (near vision)

 Visual Fields
o finger satisfactory but hat pin better
o distance from patient 1 meter
o equidistant from examiner and patient
o each eye in turn and both together

 Colour vision
o Ishihara plates
o fundoscopy

III, IV, VI:

 Inspect eyelids + pupils
 Direct + consensual response
 Eye movements in H – distribution

If diplopia – ask in what direction of gaze are the objects most widely separated and in this
position the most peripheral image is the false one.

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By covering the eyes alternately and enquiring when the outer image disappears it is possible to
establish which eye is at fault.

V:
 Sensory part – ophthalmic/maxillary/mandibular divisions
 Jaw jerk
 Corneal reflex – not if fully conscious
 Muscles of mastication

VII:
Inspection:
 Inspect for facial droop /- involvement of frontalis
 Examine voluntary contractions of facial muscles “burry eyelashes”
 Glabellar tap
 Sensation to ant, 2/3 of tongue

Test muscles of facial expression.

a. look up and raise your eyebrows (UMNL spares frontalis)

b. screw your eyes up tight and bury your eyelashes (look for Bell’s phenomenon)
c. keep them shut and don’t let me open them (tests orbicularis oculi)
d. show me your teeth (look for asymmetry of nasolabial folds)
e. puff out your cheeks and keep them like that.

Also examine:
BP and external auditory canal (look for herpetic vesicles)

VIII:

Whisper at 3 metres with eyes closed and opposite ear occluded by finger pressure on tragus

Rinne’s test: normally AC>BC but if conductive deafness BC>AC

Weber’s: held in midline – normally sound arises in midline if N. deafness –

appears to arise on healthy side if conductive loss – sound referred to
affected ear.

IX/X:
 Gag response
 Movement of uvula

XI:
 Sternomastoid and trapezius muscles

XII:
 Inspection of protruded tongue
 “tongue in cheek”

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