Abdomen

The examination of the abdomen is often one of the earlier parts of the examination of a young child because this requires no instruments other than the stethoscope and is usually painless. An anxious child 2 or 3 years of age can be examined in the parent's lap: By leaning back in the chair, the parent acts as the examining table, with the supine child semireclined against the parent's chest and abdomen. An adequate abdominal examination on a child may require repeated ''visits'' to that part of the examination, until the child is relaxed with the process.

Inspect the abdomen. As children grow older, the protuberant abdomen becomes more scaphoid, except in children who are obese.

Inspect the umbilicus. Tell the child to cough. Are there any bulging masses at the umbilicus?

Auscultate for peristaltic sounds. Are any bruits present? The presence of an abdominal bruit may be suggestive of coarctation, especially in the presence of upper extremity hypertension and reduced or delayed femoral pulses. Use the stethoscope to listen over the kidneys posteriorly. The presence of a bruit in this location is suggestive of renal artery stenosis.

Percuss the abdomen for abnormal dullness.

Light palpation is performed as described in the adult examination. Is tenderness noted? Observe the patient's face while palpating. Facial expressions are more useful than asking the child, ''Does this hurt?'' Children are often very ticklish;if you sandwich the child's hand between your two hands as you examine, the child's tendency to giggle diminishes. Alternatively, light palpation can be done with the stethoscope after listening to the bowel sounds.

Deep palpation is also performed as in adults.

Palpate the liver and spleen as described in Chapter 17, The Abdomen. The liver span of a 3-year-old is approximately 1.5 inches (4 cm). By 5 years of age, the span has increased to 2 inches (5 cm). Begin palpation for organomegaly well down in the lower abdomen, and work your way up. Otherwise, you risk missing the edge of a markedly enlarged liver or spleen.

The kidneys may be palpable by ballottement in children up to 5 to 6 years of age. Place your left hand under the right costal margin at the costovertebral angle. Your right hand is placed over the midposition of the right abdomen. Tap firmly on the abdomen to try to feel the size of the kidney. The hands should be reversed to feel the left kidney.

Palpate the femoral pulses. Place the tips of your fingers along the inguinal ligament, midway between the symphysis pubis and the iliac crest. Time the pulse with the radial pulse; they should peak at the same time.

Palpate the femoral lymph nodes. It is common to find several 0.2 to 0.4-inch (0.5- to 1-cm) nodes.

Inspect the anus. Is diaper rash present in a child who is not yet toilet trained? Is there evidence of excoriations? Pinworm infestation commonly causes pruritus and excoriations.

Rectal examination is usually not part of the standard examination in this age group. Only children with abdominal pain or symptoms referable to the lower gastrointestinal tract require a rectal examination. Instruct the child to lie on his or her side, knees drawn up, facing the parent at the side of the table. Tell the child that the examination will be like ''taking your temperature.'' You should use your fifth finger, gloved and well lubricated, for the examination. Tenderness and sphincter tone are determined, as well as the presence of a mass.

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