Fig. 15.18 Timing of puberty in males and females.
The physical examination • 313
signs, they should ideally be reassessed in 1–2 hours if there
is a high level of parental or clinical anxiety that the signs are
out of keeping with a simple viral illness in a child of that age.
Use a stadiometer (Fig. 15.20).
and turning round; if so, comment warmly on this cooperation
and provide positive feedback on helpful behaviour. Children’s
social skills regress when they are unwell and some are very
The child may comply with a full adult-style examination. Although
children under 11 years are often not able to express themselves
well, those over 5 years are able to understand and comply with
requests such as finger-to-nose pointing, heel-to-toe walking, and
being asked to ‘sit forward’ and ‘take a deep breath in and hold it’.
There are many non-specific signs that are common to a range
of conditions from a simple cold to meningitis. These include
a runny nose, fever, lethargy, vomiting, blanching rash and
irritability. However, some signs are serious, requiring immediate
investigation and management (Box 15.10).
Children become ill quickly. If a child has been unwell for less
15.10 Serious signs requiring urgent attention
• Poor perfusion with reduced capillary refill and cool peripheries
• Listless, poorly responsive, whimpering child (suggesting sepsis)
• Petechial rash over the trunk (suggesting meningococcal sepsis)
• Headache with photophobia or neck stiffness (suggesting meningitis)
• Respiratory distress at rest (rapid rate and increased respiratory
effort, indicating loss of respiratory reserve due to pneumonia or
Head straight, eyes and ears level
Gentle upward traction on mastoid process
Barefoot with feet flat on floor
Fig. 15.20 Stadiometer for measuring height accurately in children.
Healthy tonsils and pharynx look pink; when inflamed, they are
Inspecting the throat reveals the presence, but not the cause, of
the infection; pus on the tonsils and pharynx does not differentiate
a bacterial from a viral infection (p. 185).
• Sit the child across their knees with the child’s ear
• Place one arm around the child’s shoulder and upper
arm that are facing you (to stop them pushing you
• Place their other hand over the parietal area above
the child’s ear that is facing you (to keep the child’s
• Use an otoscope with the largest speculum that will
comfortably fit the child’s external auditory meatus.
• To straighten the ear canal and visualise the canal and
tympanic membrane, hold the pinna gently and pull it out
and down in a baby or toddler with no mastoid
development, or up and back in a child whose mastoid
Palpable neck and groin nodes are extremely common in children
under 5 years old. They are typically bilateral, less than 1 cm in
diameter, hard and mobile with no overlying redness, and can
persist for many weeks. In the absence of systemic symptoms
such as weight loss, fevers or night sweats, these are typically
a normal, healthy immune response to infection. Only rarely are
they due to malignancy (Box 15.12).
Normal ranges for vital signs vary according to age (Box 15.11).
• Sit the child on their knees, both facing you.
• Give an older child the opportunity to open their mouth
spontaneously (‘Roar like a lion!’). If this is not
successful, proceed as described here.
• Place one arm over the child’s upper arms and chest
(to stop the child pushing you away, Fig. 15.21).
• Hold the child’s forehead with their other hand (to stop
the child pulling their chin down to their chest).
• Hold the torch in your non-dominant hand to illuminate the
• Slide a tongue depressor inside the child’s cheek with
your dominant hand. The child should open their clenched
teeth (perhaps with a shout), showing their tonsils and
Fig. 15.21 How to hold a child to examine the mouth and throat.
Fig. 15.22 How to hold a child to examine the ear.
15.11 Physiological measurements in
want to move, and if they are forced to do so, the neck remains
aligned with the trunk. With a young child, move a toy to catch
their attention and see if they move their head.
It can be difficult to identify a child with severe illness. With
experience you will learn to identify whether a child is just miserable
or really ill. Early-warning scores (such as PEWS or COAST, Fig.
15.23) can help. Certain features correlate with severe illness
Children who experience neglect or physical and/or emotional
abuse are at increased risk of health problems. At-risk children
are often already known to other agencies but this information
may not be available to you in the acute setting. Injuries from
physical abuse can be detected visually. Consider non-accidental
injury if the history is not consistent with the injury, or the injury
is present in unusual places such as over the back. It may be
difficult to detect neglect during a brief encounter but consider
it if the child appears dirty or is wearing dirty or torn clothes
that are too small or large. The parent–child relationship gives
insight into neglect; the child is apparently scared of the parent
(‘frozen watchfulness’) or the parent is apparently oblivious to
the child’s attention (Box 15.14).
Feel the brachial pulse in the antecubital fossa in children below
2–3 years. Do not palpate the carotid or radial pulses in young
children. Measure blood pressure using a cuff sized two-thirds
the distance from elbow to shoulder tip. Repeat with a larger
cuff if the reading is elevated. If in doubt, use a larger cuff, as
smaller cuffs yield falsely high values.
The child under 3 years has a soft chest wall and relatively
small, stiff lungs. When the lungs are made stiffer (by infection
or fluid), the diaphragm must contract vigorously to draw air into
the lungs. This produces recession (ribs ‘sucking in’ – tracheal,
intercostal and subcostal) and paradoxical outward movement
of the abdomen (wrongly called ‘abdominal breathing’). These
important signs of increased work of breathing are often
noticed by parents. Older children may be able to articulate
the accompanying symptom of dyspnoea.
Children’s small, thin chests transmit noises readily, and
their smaller airways are more prone to turbulence and added
sounds. Auscultation may reveal a variety of sounds, including
expiratory polyphonic wheeze (occasionally inspiratory too), fine
end-expiratory crackles, coarse louder crackles transmitted from
the larger airways, and other sounds described as pops and
squeaks (typically in the chest of recovering patients with asthma).
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