Pediatric Primary Care (9 page)

J.  Neck.

1.  Palpate trachea for deviation.

2.  Palpate thyroid, noting size, shape, symmetry, tenderness, or nodules.

3.  Palpate carotid arteries.

4.  Palpate neck structure.

a.  Pain or tenderness.

b.  Enlargement of parotid gland.

c.  Web like tissue.

K.  Eyes.

1.  Check peripheral vision.

2.  Check visual acuity.

a.  Snellen E chart.

b.  Allen test.

3.  Note whether eyelashes curl away from eye.

4.  Note whether eyebrows are above eye and do not meet at midline.

5.  Test for any strabismus.

a.  Hirschberg test.

b.  Cover-uncover test.

6.  Observe for nystagmus or ptosis.

7.  Inspect conjunctiva for drainage, redness, swelling, pain.

8.  Inspect sclera, cornea, iris.

9.  Check: pupils equal, round, react to light.

10.  Examine with ophthalmoscope.

a.  Optic disk, macula, arteriole/vein, fovea centralis, red reflex.

11.  Inspect lachrymal ducts: tears, drainage.

12.  Inspect placement, alignment of outer eye: palpebral slant, epicanthus, lids.

L.  Ears.

1.  Inspect placement and alignment of pinna.

2.  Inspect auditory canal: color, cerumen, patency.

3.  Observe for skin tags and hygiene.

4.  Examine middle ear with otoscope.

a.  Color of tympanic membrane, light reflex, bony landmarks.

5.  Check hearing.

a.  Rinne test.

b.  Weber test.

M.  Nose.

1.  Observe mucosal lining for color, discharge, patency.

2.  Observe color of the turbinates and meatus.

3.  Note if septum is midline.

N.  Mouth and throat.

1.  Observe internal structures.

a.  Hard and soft palate, palatoglossal arch, palatine tonsil, tongue, oropharynx, palatopharyngeal arch, uvula.

2.  Palpate ethmoid, frontal, and maxillary sinuses.

3.  Observe lip edges.

4.  Observe eruption of teeth.

a.  Number appropriate for age.

b.  Color and hygiene.

c.  Occlusion of upper and lower jaw.

5.  Check salivation.

6.  Check drooling.

7.  Check swallowing reflex.

8.  Note color, texture, or any lesions of the lips.

9.  Observe gingiva and mucous membranes for color, texture, moistness.

O.  Tongue.

1.  Observe for smoothness, fissuring, coating, or redness.

2.  Tongue able to extend forward to lips?

3.  Tongue interfere with speech?

P.  Chest.

1.  Observe shape of thorax.

2.  Check costal angles; should be between 45 and 50°.

3.  Check that points of attachments between ribs and costal cartilage are smooth.

4.  Check movement.

a.  Inspiration: chest expands, costal angle increases, diaphragm descends.

b.  Expiration: reverse occurs.

Q.  Lungs.

1.  Evaluate respiratory movement: rate, rhythm, depth, quality, character.

2.  Auscultate breath sounds.

a.  Vesicular breath sounds.

b.  Bronchovesicular breath sounds.

c.  Bronchial breath sounds.

3.  Note adventitious breath sounds.

a.  Crackles, wheezes, stridor, pleural friction rub.

4.  Check for cough.

a.  Productive/nonproductive.

b.  Color of secretions.

5.  Check retractions.

6.  Check abdominal breathing.

7.  Check thoracic expansion.

8.  Palpate tactile fremitus.

R.  Heart.

1.  Auscultate heart sounds.

a.  Aortic area, pulmonic area, Erb's point, tricuspid area, mitral or apical area.

2.  Check S1-S2.

3.  Palpate for thrill.

4.  Record murmurs.

a.  Area best heard.

b.  Timing within S1-S2 cycle.

c.  Change with position.

d.  Loudness and quality.

e.  Grade intensity of murmur.

S.  Vascular.

1.  Assess capillary refill; should occur in 1-2 seconds.

2.  Assess circulation.

a.  Color and texture of skin.

b.  Nail and hair distribution.

3.  Assess perfusion.

a.  Edema.

b.  Pulses (4–0).

4.  Assess collateral circulation.

T.  Abdomen.

1.  Inspect contour and size of abdomen.

2.  Note condition of skin.

3.  Inspect umbilicus for hernias, fistula, discharge.

4.  Auscultate bowel sounds.

5.  Auscultate for any aortic pulsations.

6.  Percuss abdomen.

7.  Palpate outer edge of liver.

8.  Palpate spleen.

9.  Elicit abdominal reflux.

10.  Palpate femoral pulses.

U.  Neurologic.

1.  Observe behavior, mood, affect, interaction with environment, level of activity, positioning, level of consciousness, orientation to surroundings.

2.  Check reflexes of the infant.

a.  Rooting (present birth to 6 months of age).

b.  Sucking (present birth to 10 months of age).

c.  Palmer grasp (present birth to 4 months of age).

d.  Tonic neck (present at 6–8 weeks of age and lasts until 6 months).

e.  Stepping (present birth to 3 months of age).

f.  Plantar grasp (present birth to 8 months of age).

g.  Moro (present birth to 4–6 months of age).

h.  Babinski (child 15-18 months of age normally fans toes outward and dorsiflexes greater toe).

i.  Galant (present birth to 1–2 months of age).

j.  Placing (lack of response is abnormal).