Physical and Developmental Assessment of the Child

1
Physical and Developmental Assessment of the Child

• Chapter 7
• Children are not just little adults!

2
Pediatrics Critical Principles

• Goal is to maintain rapport and trust while
  gathering data
• Be flexible!
• Caregiver knows child bestbelieve it if a
  concern about childs health is expressed
• The child is imbedded in the family system
  (relationships, culture, issues)
• Start with a sincere compliment to parent about
  the child (builds rapport)

3
Pediatrics Critical Principles

• Consider the developmental level of the child
• Social, emotional, cognitive, physical
• Sometimes the child has no choice
• Consider altering order of exam as needed (heart
  exam when baby is quiet)
• Toe-to-head order, particularly in younger
  children
• If hungry, tired or needs new diaperharder to do!

4
Pediatrics History

• Significant Data
• Name and nickname
• Age
• Gender
• Grade in school
• Who is the primary caregiver
• Health status of family members
• Immunization and health maintenance history

5
Pediatrics Developmental Levels

• Infancy
• Early Childhood 1-4 yrs
• Middle (late) Childhood 5-10 yrs
• Adolescent
• Early 11-14 yrs
• Mid 15-16 yrs
• Late 17-20 yrs

6
PediatricsHistory

• Infancy caregiver for baby, age of mom, family
  resources (WIC, insurance, clothes), family
  composition
• Prenatal history
• Neonatal 1st 28 days
• Infant month 1 to month 12

7
Pediatrics Classification by birth weight and
gestational age

• Weight
• VLBW (
• Gestational age at birth
• Preterm
• Term 38-41 wk
• Post-term 41 wk

• Wt and GA are considered together
• SGA 5.5 lb or 2500 gm at term
• AGA
• LGA 9 lb or 4000 gm at term

8
Pediatrics Exam at Birth

• Apgar Scoring
• Possible scores 0-10
• 2 points max each for heart rate, respiratory
  effort, muscle tone, reflex irritability and
  color
• Scoring at 1 min
• 7-10 good score 7-10
• 3-6 moderately depressed
• 0-2 needs resuscitation, ventilation
  assistance, NICU follow up
• Scoring at 5 min (hard to assess if vented)

9
Pediatrics Infant examination

• Try to observe the child when undisturbed
• Distraction is key
• Naked is no problem
• Test developmental milestones before exam
• Explore feeding, sleeping, elimination, crying
• Examine while in caregivers lap
• How is mom and family adjusting to child
• Note caregiver interaction with child

10
Pediatrics Early childhood examination

• Gain confidence talk to child (builds trust)
• Examine dressed as much as possible
• Under 3 years of age, may be best to begin exam
  while child in parents arm or lap.
• Stranger anxiety age 9-15 months
• Do less distressing parts first and most
  distressing parts last
• Last lying down (abdomen), then throat, ears,
  genitalia
• Note parental interaction while holding child

11
PediatricsLate childhood assessment

• Objective Building trust and cooperation
  usually no problem
• Emotional disturbance, hx of illness
• Practice pointers
• Respect modesty
• Comfort with or without parents or siblings in
  room
• Start using order of adult exam

12
Pediatrics Adolescent assessment

• Objective Maintain rapport and trust, while
  gaining needed information
• Developmental considerations
• Need for privacy and developing autonomy vs. need
  for parental guidance and involvement
• Spend time with teen alone, with parent alone, as
  well as both together
• Avoid promising secrecy

13
Pediatrics Adolescent assessment

• HEADSSS
• Home / family relationships
• Education / employment
• Activities / social
• Drugs / alcohol
• Suicide/ depression
• Safety / risky behaviors
• Sexuality

14
Pediatrics Vital Signs

• Rectal temp is gold standard
• 100.4 rectal is a fever
• Infants have poor thermoregulation
• May drop in temp if septic
• May not spike a fever when really ill
• May have high temps for minor concerns

15
Pediatrics Physical Examination

• Pulse will be labile sensitive to illness,
  emotion, activity
• Use stethoscope on chest to check pulse
• Bradycardia

16
Pediatrics Growth Measures

• Measures of somatic growth Height, weight, head
  circumference
• Important indicator of health in very young
  children!
• Head circumference (HC) from prominences at
  forehead and occiput
• HC greater than chest circumference (CC) at birth
• HC equals CC at age 2
• 90 of final size by age 6 yrs.
• Measure each visit to age 2 then annually to age 6

17
Pediatrics Growth Measures

• NOT normal to lose weight in childhood
• By end of first year 3x birth weight, 50
  increase in height
• After age 2
• Gain 2-3 kg/year
• Expect 5 cm/year in spurts (measure standing)
• Failure to thrive poor weight gain for age
• Drop 2 percentiles in 6 months
• Weight-for-height

18
Pediatrics Growth Measures

• Adolescent growth spurt follows Tanner staging
  for males and females
• Height influenced by genetics as well as
  nutrition and overall health
• See CDC web site for growth chart updates
• http//www.cdc.gov/nchs/about/major/nhanes/growthc
  harts/clinical_charts.htm

19
Reviewing general principles and goals
20
General Approaches Toward Examining the Child

• Head-to-toe sequence for assessing adult clients
  usually helpful in older child or adolescents
• Toe-to-head order, particularly in younger
  children
• Consider altering order of exam as needed (heart
  exam when baby is quiet)
• Sequence for pediatric assessments generally
  altered to accommodate childs developmental
  needs
• Least invasive assessment first, always complete
  invasive assessment or skills to last (i.e.
  rectal temperature, checking the ears, etc.)

21
Goals of Pediatric Assessment

• Minimize stress and anxiety associated with
  assessment of various body parts
• Foster trusting nurse-child-parent relationships
• Allow for maximum preparation of the child
• Preserve the security of parent-child
  relationship
• Maximize accuracy of assessment findings

22
Preparation of the Child

• Childs perception of painful procedures
• Cooperation usually enhanced with parents
  presence
• Age-appropriate techniques

23
Physical Examination

• Growth measurements
• Recumbent length for infants up to age 36 months
  weight and head circumference
• Standing height weight after age 37 months
• Plot on growth chart
• By gender and prematurity if appropriate
• Less than 5th or greater than 95th percentile
  considered outside expected parameters for
  height, weight, head circumference

24
Growth

• Ethnic differences
• Expected growth rates at various ages
• Use of skin fold thickness and arm circumference
  for evaluation of body composition of muscle and
  adipose tissue
• Significance of head circumference measurements

25
Physiologic Measurements

• Importance of physiologic measurements in overall
  pediatric assessment
• Comparison with normal values for each age group

26
Pain Assessment with physiologic measurements

• Pain scales
• Facial Expression Scale (newborn and infancy)
• Objective Pain Scale (OPS) ( 4 months to 18
  years, nonverbal child)
• FACES Pain rating scale (children as young as 3
  years)
• FLACC Post-op pain tool (ages 2 mo to 7 years)
• Numeric scales (older children adolescents)

27
Suggested Infant and Toddler Vital Sign
Measurement

• Count respirations FIRST (before disturbing the
  child)
• Count apical heart rate SECOND
• Measure blood pressure (if applicable) THIRD
• Measure temperature LAST

28
Pediatric Blood Pressures

• Measurement devices
• Cuff selection
• Cuff placement
• Interpretation of BP measurement

29
Physical Assessment

• General appearance
• Face
• Posture, position, body movement
• Hygiene
• Nutrition
• Behavior

30
Physical Assessment

• Skin color, temp., turgor, rashes, birth marks
• Page 146, Table 7-8 Differences in Color Changes
  of Racial Groups

31
Skin Examination

• Infant vasomotor instabilitybluish mottling as
  a normal response to cold (acrocyanosis-peripheral
  instability)
• 1/3 have physiologic jaundice occurs by 2nd -3rd
  day and gone by day 7 (I O ok, feeds ok,
  responds ok)
• Pathological jaundice occurs in 1st 24 hrs after
  birth

32
Skin Examination

• Milia blocked sebum glands on face
• Distended capillaries stork bites (nape of
  neck), angel kisses (face)
• Vascular malformations port wine stain,
  hemangioma
• Skin tenting or poor turgor means significant
  dehydration

33
Skin Examination

• Pigmentation variations
• Mongolian spot (blue-black LS patch) Native
  American, Hispanic, African, Asian, Mediterranean
• Café-au-lait spots
• Abnormal skin lesions Diaper rash, rashes with
  fever, open sores, generalized rashes, petechiae,
  viral symptoms, symptoms of abuse a sick child
  looks sick

34
Lymphoid tissue

• Easily palpable and enlarged slightly until
  puberty
• Cervical nodes 1cm are enlarged
• Supraclavicular enlargement suspect Hodgkins
  disease
• Larger or tender nodes occur with local or
  systemic infection, hematological disorders,
  malignancies.
• If abnormal in size or texture record location,
  consistency, tenderness, size in centimeters.

35
Lymph Nodes
36
Head Neck

• Head shape Symmetry
• Head lag after 6 months strongly indicates
  cerebral injury and referred for further
  evaluation
• Note Head control in infants
• Head posture in older child
• Evaluate ROM

37
Face

• Initial inspection of facial appearance
• Note symmetry of facial expression, indicator of
  mood, alertness, neurologic function
• Sunken eyes malnutrition, dehydration, severe
  illness

38
Skull examPalpate the skull for patent
structures, fontanels, fractures, swelling

• Fontanels (soft spots) at intersection of skull
  suture sites
• anterior, posterior, mastoid, sphenoid
• Posterior fontanels may be closed at birth
  closes by 2 months of age
• 90 anterior fontanels closed by 7-19 months

39
Image 104 B Palpating the anterior fontanel.
40
Skull exam

• Head shape variations due to birth trauma
• Caput succedaneum (scalp edema)
• Scalp swelling crosses the midline
• Cephalhematoma
• Scalp swelling does not cross the midline (vacuum
  extracted birth subperiosteal bleeding)

41
Neck

• The thyroid may not be palpable.
• Flexible neck is normal
• Painless limitation of motion (torticollis)
• Resistance to flexion (nuchal rigidity) from
  meningeal irritation (meningitis, hemorrhage)
• Child will be irritable and hard to console

42
Eye Examination

• Behavior suggests visual deficit straining,
  squinting, reading difficulty, blurry vision or
  eye fatigue, run into things (clumsy), tilts
  head to use better eye
• Hx. eye infections, birth exposure to infection
  (Chlamydia, gonorrhea, herpes)
• Family hx glasses as child, strabismus,
  amblyopia, cataracts
• PERRLA

43
Eye Examination

• Inspect external eye structures
• Assess for conjunctivitis at birth
• Vestibular function (dolls eyes reflex)
• normal in infant up to 2 months old eyes will
  move in the same direction as the body, while
  body is being turned
• When turning stops, eyes will shift to opposite
  direction

44
Eyes
45
Eye Examination- pathologic

• Teary eyes assess for lacrimal blockage,
  photophobia
• Setting sun sign eyes appear to deviate down
  see sclera over top of iris
• Hydrocephalus
• Visual loss a concern
• Sunken eyes malnutrition, dehydration, severe
  illness

46
Eye Examination

• Corneal Light Reflex

• Test visual reflexes
• Neonate Blink response to bright light
• Pupillary response to light should be present
  after 3 weeks
• Hirschberg test asymmetry in corneal light
  reflex (should be symmetrical after age 6 months)
• Test EOMs after age 2 years

47
Eye Examination

• Nystagmus (jiggly eyes)
• Amblyopia decreased vision in one or both eyes
  without other disorder or anomaly
• best resolution if treated by age 6
• Constant nystagmus, marked strabismus, slow
  lateral movements and setting sun sign all
  suggest vision loss in the infant

48
Strabismus(crossed eyes) Cover-uncover test
after age 3 yrs
49
Normal development of visual acuity

• Peripheral vision intact in newborn but poor
  coordinated vision until 4 months
• 2-4 weeks old can fixate on object
• 4 weeks can fixate and follow a light or bright
  toy
• 3-4 months can fixate, follow and reach for toy
  (depth perception)
• 6-10 months can follow toy in all directions
• Macula (keen vision) mature by 8 months

50
Visual Acuity Testing

• Allen test for vision in second year
• normal to name three out of seven objects within
  three to five trials
• Snellen visual acuity testing start age 3 yrs.
• Snellen E chart 3 to 6 yrs alphabet chart by
  age 7 or 8 years (cultural issue with images)
• Farsighted is normal at birth
• 20/50 or better by age 3
• 20/40 or better by age 4
• 20/20 by age 6 to 7
• Both eyes should be on same line for acuity

51
Fundoscopic exam

• Red reflex should be present in newborn
• to assess lens clarity, corneal clarity, retinal
  abnormality
• Ocular fundus
• at 2-6 months pale, few vessels developed,
  macula barely visible, no foveal light reflection
• Same procedures in young child as in adult exam

52
Cat's eye reflex. Whitish appearance of lens is
produced as light falls on tumor mass in left
eye.
53
Ear History

• History of ear infections more than three before
  age 2 years is significant
• Surgical history any ear tubes placed?
• Family history of hearing loss

54
Risk factors for hearing deficit

• Prenatal exposure to rubella
• Exposure to ototoxic drugs
• Meningitis, mumps, otitis media
• Illness with high fever

55
Ear History

• Infant should start to babble by age 6 months
• At what age did talking start?
• Was speech intelligible?
• Is child inattentive, confused or withdrawn?
• Crying, tugging on ears
• Associated symptoms fever
• Trauma to ears or objects placed inside ears?
• Any exposure to tobacco smoke (increased OM risk)

56
3-4 months blink reflex, stops and gets more
alert (listens) to sound
57
Auditory Acuity Tests

• Newborn to 3 months Moro (startles and blink
  reflex) with loud noise will turn towards voice
  and may get quiet
• 3-4 months blink reflex, stops and gets more
  alert (listens) to sound
• 6-8 months turns head toward sound responds to
  own name, initiates sounds
• 12-15 months first words, follows simple
  direction, points to familiar objects or sounds
• 18-24 months 50 speech intelligible to
  strangers
• Audiometry screening test neonates can test
  again as needed by age 4

58
Ear exam

• Examine external ear (neonate clue to other
  deformities)
• Pneumatic insufflation motion normal reduced TM
  motion in OM
• Fearful ages 1-4 internal ear exam best done
  last
• Caregiver to hold child on lap, holding limbs and
  stabilizing head
• Avoids trauma to TM or canal
• At birth canal should be patent

59
Ear Cross Section
60

• Infant eustachian tube shorter, wider, more
  horizontal (increased middle ear infection risk)

Image 314 Comparison of anatomic position of
eustachian tube in, A, child and, B, adult. The
eustachian tube is shorter, wider, straighter,
and more horizontal in the child than in the
adult.
61
Signs of Otitis Externa (OE)

• Hx. itching
• Hx. frequent swimming, Q tip use
• Erythema, edema of external canal
• Discharge white (yeast), yellow, greenish

62
Signs of Otitis Media (OM)

• Yellow-amber serous OM
• Red acute OM
• Air/fluid levels or air bubbles serous OM
• Bulging OM
• Drum hypo mobility with insufflation (or
  Valsalva)
• Best sign of OM TM shape and mobility more
  important than color of TM in infants

• Frank blood or clear drainage in canal
  (especially after head trauma)
• Look for ruptured TM
• Worry about basal skull fracture
• Assess for cerebrospinal fluid (CSF) glucose on
  Test tape exam

63
Nose

• Note deformity, deviation
• Note air movement through nares, mucosa, septum,
  turbinate appearance
• Unilateral foul discharge look for foreign body
• Infants are obligate nose breathers check
  patency in neonates

64
Paranasal sinus

• NOT developed in infants
• Enlarge and gets filled with air
• Maxillary by age 4
• Frontal and sphenoid by age 7 years
• Sinusitis rare until late childhood
• Unilateral nasal discharge, tooth pain a sign of
  maxillary sinusitis

65
Facial findings suggestive of allergy

• Allergic shiners
• Creased lower eyelids (Morgans lines)
• Facial pallor
• Open mouth breathing
• Allergic crease on nose
• Postnasal drip

66
Internal Structure of Mouth and Oropharynx

• The cry tells a lot about health (shrill or no
  cryworrisome)
• Inspection of buccal mucosa
• Color, dryness, fissures, lesions
• White exudate that does not displace thrush
• Observe breastfeeding in neonate

67
Internal Structure of Mouth and Oropharynx

• Quick look is only chance
• Make it a game Pant like a dog
• Most resistant to tongue bladeuse at end of the
  exam
• If seated, less likely for tongue to obstruct the
  pharynx
• Note motion with phonation / crying
• Note also the presence of the gag reflex

68
Dental Examination

• Dentition history
• Toothaches, bleeding gums
• Eating habits, dental care habits, thumb sucking,
  trauma
• Normal dentition 20 deciduous teeth
• Drooling starts, then 6-8 months first eruption
  (1 tooth per month)
• Permanent teeth start age 6 yr.
• Teeth condition pain, caries, malocclusion,
  missing
• Breath indicator of hygiene
• Gum inflammation, lesions, hypertrophy

69
Mouth and Throat

• Laryngitis can lead to airway obstruction.
• No drooling is normal after age 2 years
• Chronic drooling mental deficiency
• Acute onset of drooling grave sign of
  epiglottitis or poison ingestion.
• Epiglottis posterior to tongue
• Will look like red swollen thumb when infected

70
Physical Assessment (cont.)

• Chest
• Heart
• Lungs
• Abdomen
• Genitalia
• Back and extremities
• Neurologic assessment

71
Respiratory History

• Day care or home exposures (RSV, colds)
• Cough (dry, barks, whooping)
• Wheezes, stridor, whooping, noisy breathing,
  choking (asthma, foreign body)
• SOB or dyspnea
• SOB and cough with activity
• night SOB asthma

72
Respiratory History

• Distressed while supine (orthopneic)
• Sputum with coughserious in child
• Recent OM, sinusitis
• Pets or allergens exposures
• Smokers in home
• Tachypnea (pneumonia)
• Failure to thrive, weight changes, appetite
  changes, stooling changes (cystic fibrosis signs)

73
Respiratory History

• PMH
• More than 6-8 URI per year
• Allergies
• Asthma
• Pneumonia
• GERD

74
Respiratory examination

• Parent may hold infant or hold child upright in
  lap
• Normal nose breathing age birth to 3 months
• Normal abdominal muscle use to age 6

75
Respiratory rate

• Apnea if 20 sec pause between breaths
• Check abdominal motion under age 6 yrs.
• 1-5 yrs 20-40 breaths/min
• 6-14 yrs 15-25 breaths/min
• 15 yr and up 16 breaths/min

76
Lung Examination

• Observations
• Cry robust, weak, high pitched
• Clubbing in fingers occurs later in childhood
  (CV, respiratory, GI disorders cystic fibrosis)
• Rounded thorax normal until age 6 yr
• Persistent think chronic asthma, cystic fibrosis

77
Inspect

• Is breathing audible?
• Note central cyanosis
• Inside of mouth, under tongue, conjunctiva
• Bluish or raspberry colornot pink nor
  strawberry color
• Note nasal flaring, accessory muscle use,
  retractions (works to breathe)

78
Normal breast development

• Slight enlargement at birth to day 7 (witches
  milk from maternal estrogen)
• Tanner staging in adolescence
• Normal transient male gynecomastia in teens
• Allaying parental and child concerns

79
History Suggesting CV Disease

• Poor weight gain / poor feeding
• Growth lag / failure to thrive
• Fatigues easily with normal activity
• Cyanosis during exercise or crying
• Squatting to rest during play (tetralogy of
  Fallot)
• Knee-chest position at rest
• SOB, chest pain with exertion
• Dizziness or fainting
• Frequent respiratory tract infections

80
Cardiovascular exam

• Infant heart is more horizontal, apex is at 4th
  ICS and more lateral to MCL
• Apex at 5th intercostal space by age 7
• Heart sounds louder thinner chest wall, smaller
  thoracic space
• Normal murmur in first 2-3 days as switch from
  fetal to neonatal circulation (normal color,
  feeding, alertness)
• Suspect all unknown extra heart sounds until
  proven innocent

81
Normal cardiovascular variations in children

• Sinus arrhythmia with respiration is common in
  infants and young children
• S2 split during inspiration is common
• Fixed S2 split suggests ASD
• Physiologic S3 common
• Functional murmurs
• Systolic murmur 2-3 days after birth (fetal shunt
  closure)

82
Innocent murmurs

• increased blood flow in the heart (no valvular or
  pathologic cause).
• History is negative and person is asymptomatic
• Murmur should be grade I-II / VI
• Heard best at 2nd to 3rd L- ICS
• Mid-systolic, no radiation of sound to apex, base
  or back
• Heard best at expiration
• Present while reclining but disappears while
  seated or with valsalva maneuver

83
High blood pressure

• Start BP check age 2-3 years
• Doppler BP best
• Cuff size critical 2/3 upper arm or leg
• Evaluate any systolic and/or diastolic BP if
• More than the 95th percentile or higher for age,
  gender and height
• Elevated on at least 3 occasions

84
Peripheral vascular findings

• Normal pulse force same in all extremities
• Full bounding pulses with PDA
• Absent or reduced femoral pulses with normal
  upper extremities pulses coarctation of aorta
• Weak pulses with vasoconstriction or reduced
  cardiac output
• Pulsus alternans varying force, regular rhythm
  (heart failure)

85
Abdominal History

• Appetite
• Dietary intake
• Stooling patterns
• GERD signs and symptoms
• N / V

86
Abdominal Exam

• Large liver (6-10 cm in MCL in children)
• Spleen usually palpable in LUQ in younger
  children
• soft, protuberant abdomen
• Assess for presence of anus in neonate
• Avoid rectal exams in child unless necessary
• Palpate kidneys in children
• Umbilical cord should fall off after 7-10
  daysshould NOT smell foul
• Not normal distension, flat areas (missing
  organs), tenderness, altered bowel sounds

87
Hernias

• Common (ventral, umbilical)
• Umbilical hernias most common in infants bulge
  at umbilicus most close by 2nd birthday

88
Constipation

• Functional disorder more common than organic
  causes (such as Irritable bowel syndrome,
  Crohns)
• As long as soft consistencynot a concern!
• Breastfed infant can go up to 7-10 days between
  stoolingif feeding well, wet diapers and gaining
  weight, no distension or vomiting--doing well!
• Behavioral issues feeding / fluid intake toilet
  training

89
Diarrhea

• Increase in daily fluid loss (or volume) of stool
• Normal infant in first month 10-12 stools daily
• Infectious causes most common sudden onset,
  fever, vomiting, flatus, with frequent stooling
• Watch for dehydration, weight loss, failure to
  thrive
• Dehydration reduced number of wet diapers
• Acute dehydration can be life threatening

90
Colic

• Recurrent and inconsolable crying at least 3 hrs
  a day and at least 3 days a week
• Drawing up legs, appears in pain
• Look for any fever, diarrhea, vomiting
• Severe symptoms, sudden onsetneeds surgical
  assessment for intussusception
• Increased risk of child abuse

91
Pyloric stenosis

• closure of the gastric outlet
• Symptoms typically start by 4th week up to 3rd
  month
• Persistent vomiting, eventually projectile after
  eating
• Hungry baby
• Physical exam
• Distension of upper abdomen, peristaltic waves
  after eating, thickened muscle in RUQ felt
  (olive)

92
MSK Examination

• Gross and fine motor skills follow developmental
  patterns
• Walk by 15 mos, run by 24 mos, tricycle by 3
  years
• 2 yr old can copy lines, 4 yr old can draw
  circles
• Middle childhood increase strength and
  coordination, increasing competence in multiple
  tasks

93
Observe

• Posture newborn should lie symmetrically with
  limbs semi-flexed and legs partially abducted at
  hip
• Assess for level hips, scapulae and clavicles
• Reduced walking, running or playing activities
• Normal presentation
• Symmetry, no deformities in joints or bones
• Bilateral movements should be equivalent
• Gait with in-toeing or out-toeing

94
Image 444 Radiographs showing severe scoliosis
before surgical correction (A) and surgical
correction of scoliosis, including internal
fixation (B).
95
Genu Varum

• Norm 0-2 yr age
• Bow legs
• Obesity, rickets, growth plate disorder,
  metabolic bone disorder

96
Genu Valgus

• Norm age 2-6 years
• Knock knees (ext rotation of hips or external
  tibial torsion eversion of legs with toes out)

97
Neurological History

• Higher cortical function age-appropriate
  developmental achievement as markers for CNS
  functioning
• Language, cognition
• Emotional, social
• Motor

98
Neurological History

• Denver II tests for developmental delays in
  infancy (needs intact neuro to perform)
• School work art work and handwriting for fine
  motor coordination and age-appropriate development

99
Neurological exam

• Gait, facial appearance, use of language
• Cranial nerves
• Trunk and extremities
• Power, motor tone (spastic or flaccid),
  coordination, sensation, reflexes
• Impact of home and social environment on language
  skills (slowed language development if multiple
  languages in home)

100
Neurological exam

• Power (weakness with activity or game)
• Gross motor skills in first year
• Postural strength while infant develops seated
  after 6 mos, standing after 10 mos, walk by 12-14
  mos
• Duck walk, hopping, heel and toe walk
• Ability to get up off floor or reach for toy
  (balance and coordination)
• Strength in UE (like adults) wheelbarrow game
  push up trunk with arms

101
Neurological exam

• Coordination (with motion and activities)
• Gait with ambulation
• Running or walking
• Heel to shin, finger to nose
• Fine motor game (blocks, writing, nuts and bolts)

102
Neurological exam

• Assess primitive reflexes
• Anal reflex present at birth
• Rooting reflex CN V
• Moro startle reflex
• Palmar grasp to age 4 months
• Pinch nose and tongue sticks out CN XII
• Babinski normal at 9 mos should extinguish by
  age 2 yrs

103
Brachioradialis Reflex
104
Genitourinary Assessment

• Male
• Infant / young child
• Undescended testescheck bilaterally
• Fertility and cancer risks
• Tanner staging
• Testicular cancer risk
• Assess for STDs in adolescents
• HIV risks

105
Genitourinary Assessment

• Female
• Normal prominent labia majora, closed vaginal
  opening at birth
• Assess gynecologic causes when abdominal pain
  occurs (miscarriage, PID, ectopic pregnancy,
  ovarian cyst)
• Pre-adolescent GU exams ( It is better if you
  ask the parent to step out of the room)
• Adolescents
• Note LMP each visit
• Assess for STDs and HIV risk
• Stopped menses athletic, anorexia, pregnancy