Unique character of the pediatric clinical evaluation

This evaluation involves the physician, the parent(s), and the child. Historical information is often taken from the parents, and it is not until the child reaches later development stages that he or she can contribute information about symptoms more actively. These considerations change the manner in which the pediatricians gathers data about symptoms. Rather than asking, for example, if the child has abdominal pain, the physician asks questions that focus on the manner in which abdominal pain would present to an observer. Thus, questions about loss of appetite, sudden episodes of crying and drawing the legs up in a fetal position, or the child’s crying when the parent has placed pressure on the abdomen are appropriate. The 24-mo-old child with a sore throat often does not complain of this but rather is observed by the parents to have more difficulty handling oral secretions, refuses solids, and has a foul breath odor. Questions are tailored to elicit this information.

As the child becomes older, he or she may begin to add historical information that expresses symptoms in unique ways. At times the information provided by the child suggests the diagnosis precisely, but at other times the child’s information may reflect a less developed sense of cause-and-effect relationships and be at variance with the data provided by the parents.

Guidelines for evaluation

The history is best taken with the child in a comfortable position. If the child is quiet and comfortable, the parent can focus better on specific questions.

The portions of the physical examination that require optimal cooperation are completed initially-the blood pressure measurement, pulmonary and cardiac examinations, and evaluations of the eyes and central nervous system. The younger child may be held by the parent or seated on the parent’s lap for these parts of the examination. The older child can be seated on the examination table. The pattern and rate of respirations are evaluated initially. Is there tachypnea? Is there increased work of breathing, as manifested by subcostal, intercostal, and/or supraclavicular retractions? Is there an expiratory grunt indicating that the child is expiring against a closed glottis to keep the small airways open longer? What are the colors of the skin, nails, and mucous membranes? After these assessments have been made, the physician may proceed to palpation, percussion (in indicated), and auscultation. It is not uncommon for the younger child to cry as the stethoscope is placed on he chest, but this can usually be overcome by patience and by increasing the child’s comfort, such as offering the infant a bottle. The same sequence may be followed for the cardiac examination.

After these portions of the examination the examiner proceeds to the parts of the examination that are usually more bothersome to the child. The abdominal examination requires that the child be on the examination table. It is helpful to have the parent hold a younger patient’s hand and speak reassuringly. Thus, the child does not tense the abdominal musculature unnecessarily, as might occur during crying. After the abdominal examination, the pulses may be palpated, the genitalia examined, and the hips and extremities evaluated clinical abnormalities.

The sequence of performing those portions of the physical examination that require inspection, palpation, percussion, and auscultation (pulmonary, cardiac, and abdominal) varies according to organ system. The most bothersome maneuvers are performed last. For example, during the cardiac examination, inspection can be followed by palpation and percussion and then by auscultation. For the abdominal examination, inspection should be followed by auscultation before percussion and palpation are completed.

With appropriate sensitivity to the child and the parent, an appreciation of the child’s developmental stage, and concern for minimizing the discomfort of an examination, the pediatrician can almost always obtain accurate clinical information and not cause undue upset to the child.