Physical Examination

The goal of the physical examination is to identify the current surgical issues and to
ensure that the organ systems other than the one being treated are healthy. Unlike
the adult physical examination, in which one can often follow the same routine
every time, the pediatric examination must be modified for each patient. Interacting
with children of different ages and temperaments in different settings can be
challenging.

Hand washing before and after performing the physical examination is essential.
Hand washing serves purposes beyond infection control. On a psychological level, it
conveys a reassuring message to the parent that hygiene is important to the
surgeon. On a practical level, it warms the surgeons hands before he or she
touches the child.

In an older and cooperative child, physical examination can be performed according

to a standard routine. However, this routine may have to be modified in young
children or infants who do not cooperate.

Infants should be positioned on the examination table for the entire examination.
Toddlers and small children may sit in their parents lap for the initial part of the
examination, and they may be moved to the examination table and positioned for
the abdominal, inguinal, genital, and rectal examinations when necessary. Having
the parent by the examination table reduces the childs anxiety and should be
encouraged.

Skin and integument

Always ask the patient to undress completely. The pediatric surgeon is often
consulted for evaluation of lesions or lumps and bumps. The lesion in question
should be inspected for its size, shape, consistency, circumscription, and mobility.
Thoroughly search for other, similar lesions on the body. Also inspect the skin for
rashes, which may indicate an infectious process or vasculitis. Scars indicating
previous surgery should be noted.

Cellulitis may arise after any trauma that interrupts the skin barrier (eg, scratch,
laceration, foreign body, surgical wound). Erythema and warmth with induration and
fluctuance indicates an abscess. Inspect the skin for birthmarks, noting any changes

in their character. Bruises and burn scars, especially those resembling cigarette
burns or burns that have a well-defined shape, should be suspected as signs of child
abuse.

Lymph nodes
Lymphadenopathy can occur in many locations and often involves the cervical,
axillary, epitrochlear, or inguinal chains. In children, lymphadenopathy most
commonly has an infectious etiology, and a source of infection should be sought
throughout the examination. The infection may be bacterial, viral, fungal, or
protozoal. Enlarged lymph nodes may represent metastatic disease, or they may be
the presenting sign of malignancies, such as acute lymphoblastic leukemia (ALL),
Hodgkin disease, and non-Hodgkin lymphoma.

Head, ears, eyes, nose, and throat

On head, ears, eyes, nose, and throat (HEENT) examination, note the size and
shape of the patients head. Children with abnormal fusion of the coronal sutures
are not normocephalic. Microcephaly or macrocephaly may indicate a neurologic or
intracranial process. An icteric sclera suggests hepatic or biliary dysfunction.

Otitis media can be excluded if tympanic membranes that are clear and if visible
landmarks are found. Finding an erythematous oropharynx or inflamed nasal
turbinates with associated rhinorrhea is common in upper respiratory tract
infections. A quick dental examination to identify loose teeth is important in children
scheduled to undergo surgery.

Chest wall
Breast tissue is commonly observed in infant boys and girls. This is normal and due
to a slow decline in maternal hormones in the infants bloodstream. On a similar
note, the pediatric surgeon may be asked to evaluate a male adolescent for
gynecomastia, which is often due to the changing hormonal environment associated
with puberty.

Evaluation of breast masses in girls requires particular attention. In preadolescent

girls, one must distinguish a mass from a breast bud, keeping in mind that breast

development does not occur at the same rate in both breasts. Normal breast tissue
must be differentiated from a breast mass in female adolescents.

The pediatric surgeon may also encounter deformities in the chest wall, such as
pectus excavatum and pectus carinatum. Apart from discerning the degree of
deformity, performing cardiac and pulmonary examinations is important in children
with these deformities.

Cardiovascular system
Heart rate and rhythm should be noted on the cardiovascular examination. Many
children have an audible murmur at some point between infancy and adolescence.
Most murmurs fortunately occur in normal hearts and are benign. Murmurs that
have a structural cause may indicate a need for preoperative antibiotic prophylaxis.
Consult a cardiologist if a new-onset murmur is in question.

Check proximal and distal pulses. Expect strong pulses throughout. Suspect
coarctation of the aorta if pulses in the upper extremity are strong but pulses in the
lower extremity are weak or absent.[7]

Lungs
Good respiratory effort in a cooperative child is critical in the pulmonary
examination. No layers of clothing should be present between the stethoscope and
skin. Breath sounds should be clear on both sides. Abnormal breath sounds, such as
rhonchi, wheezes, and crackles, indicate an underlying pulmonary process.

Abdomen
The abdominal examination should be performed systematically and gently.

First, observe the patients abdomen. If scars are present, their length and location
can give the surgeon an idea of the previous surgeries performed. The shape of the
abdomen may also be a clue to guide diagnosis. A scaphoid abdomen in a neonate
or infant may suggest a diaphragmatic hernia but may be normal in a thin child.
Intestinal obstruction, an abdominal mass, or ascitic fluid may cause abdominal
distention.

Second, listen for bowel sounds. Be patient because up to 2 minutes may pass
before bowel sounds are heard. The absence of bowel sounds may suggest
peritonitis. The character of the bowel sounds is also important; high-pitched
sounds are consistent with bowel obstruction.

While listening for bowel sounds in a young child, the clinician may use a
stethoscope to palpate the abdomen, systematically covering the entire abdomen.
Begin the palpation in an area away from the area of reported pain, leaving that
area for last. Diffuse tenderness may suggest peritonitis or a generalized process.
Focal points of tenderness often reflect the underlying pathology. Discern if the pain
is superficial, musculoskeletal, or visceral.

Gently evaluate the patient for peritoneal signs, such as rebound and guarding.
Overly aggressive examination creates unnecessary pain and fear in the child. In
young children, facial expressions and behavior are often more reliable indicators of
pain than verbal reports are. Palpation can also give the surgeon an idea of the size,
shape, and consistency of an abdominal mass. The size of the liver and spleen can
be determined by percussion and palpation of their edges.

Inguinal region
The inguinal region is most commonly examined in the evaluation of a hernia or
hydrocele. If an inguinal hernia is not visible on examination, the child should be
coaxed to perform a Valsalva maneuver (eg, coughing or straining as during a bowel
movement). Intra-abdominal pressure is increased in crying infants. Hernias should
be easily reducible and not incarcerated or strangulated, which are surgical
emergencies.

Genitalia
Children as young as 2 years understand the concept of modesty, and special
attention must be given to modesty during the genital examination. In addition,
always ensure that a staff person of the same sex as the patient is present in the
room during the examination.

Genital examination in boys is necessary in the evaluation of a number of

conditions, including hydroceles and undescended testes. The genital examination
is one of the least comfortable parts of the physical examination; boys can assume
the position most comfortable for themlying down, sitting frog-legged, or
standing.

Transillumination may be a useful technique to visualize the contents of an enlarged

scrotum but cannot be relied on for a diagnosis, especially in infants. Note the size
and shape of the testicle in the scrotal sac and the character of any fluid. Part of the
male genital examination includes checking for the presence of both testes in the
scrotal sac.

The testis, epididymis, and spermatic cord should be appreciated as separate

structures. Retractile testes can masquerade as undescended testes; always check
to determine whether a testicle that is not in the scrotum can be brought down into
the scrotum.

Performing a female genital examination to evaluate for fused labia, imperforate

hymen, vaginal or perineal bleeding, and an assortment of other issues is not
uncommon. Note that a pelvic examination performed by the surgeon is likely to be
the first for a girl and has lasting psychological consequences. Always suspect
sexual abuse when vaginal tears are present. Vaginal discharge can be a sign of a
sexually transmitted disease and should raise the surgeons index of suspicion for
abuse.

Rectum
The rectal examination may be traumatic to the child and their parents and should
be performed quickly but thoroughly. Explaining the process to the child is useful to
assure them that nothing will be done to them without first letting them know.

First, inspect the anus. Fissures, fistulas, skin tags, and other lesions can be seen by
gently separating the anal opening.

Next, inform the child that he or she will feel a finger on the outside. Gentle external
pressure often causes the anal sphincter to relax and facilitates passage into the

anal canal. Condylomata acuminata, caused by human papillomavirus, are

consistent with sexual abuse. Always use water-soluble lubricant on a gloved finger
and obtain a stool sample for a guaiac test whenever feasible. The little finger may
be used in infants and toddlers, and the index finger may be used in larger children.

Sphincter tone may be decreased in patients who have previously undergone

anoplasty or have sustained traumatic injury to the sphincter muscle. Decreased
sphincter tone is more alarming in the trauma setting because it indicates spinal
cord injury.

Palpate the entire circumferences of the anal canal and rectum. Note the location,
size, and texture of a palpated mass. Presacral tumors may be the cause of a child
presenting with constipation. The examiner must differentiate discomfort due to the
examination itself from tenderness due to an underlying process. Many children can
make this differentiation if asked.

Pain on examination may be caused by anal fissures externally, appendicitis in a

low-lying appendix, or pelvic inflammatory disease. The surgeon may also detect a
fecal impaction during the rectal examination of a child with constipation.

Back and spine

Scoliosis and other spinal deformities are obvious during examinations of the back.
Vertebral tenderness to palpation may be a sign of trauma. Costovertebral angle
tenderness may be indicative of pyelonephritis or appendicitis in a patient with a
retrocecal appendix.

Extremities
Clubbing is observed in many patients with chronic illness, especially patients who
have pulmonary disease. Cyanosis is an indicator of poor oxygenation or perfusion,
and efforts should be made to determine whether the cyanosis is chronic or acute.
Edema may be a sign of impaired renal or cardiac function. Suspect abuse in
patients with extremity deformities secondary to long-bone fractures.

Nervous system

Much can be gained from observing a childs behavior. An interactive and playful
child is likely to have no focal neurologic findings on examination. However, a basic
neurologic examination, which only takes a minute with practice, should be
performed regardless. This comprises assessment of cranial nerve function, motor
and sensory examination, reflex evaluation, and cognitive assessment.