Review of Systems and Examination of the Young Child

A child 1 to 5 years of age is becoming verbal and, if in pain, can tell you where it hurts. They may start to report nausea, sore throat, chest pain, fatigue, or headache. Note that headache in a preschool child is unusual and probably indicates a serious intracranial pathologic process. Other questions to add to the infants' review of systems include questions about snoring and loss of bowel or bladder control in a child who has been toilet trained. Most children have achieved daytime control by 4 years of age, although only about half of children are dry at night by then. Restless sleep, including nightmares, night terrors, and sleep walking are not uncommon at this age.

For an adequate examination, the child needs to be relaxed. With children in this age group, it is important that you speak softly and demonstrate the parts of the examination on dolls or toy animals, on yourself, or on the parent. Allowing the child to hold the stethoscope or penlight often distracts him or her enough so that other parts of the examination can be performed. The child soon learns that the light and stethoscope need not be feared. Play with the child. Have the child ''blow out'' the light. Let the child use the stethoscope as a telephone. Above all, talk to the child. It is amazing how easily an examination can be performed while telling a young child a simple fantasy about imaginary animals. Ask the child questions about these characters. A reassuring voice goes a long way in making the child comfortable. As you proceed with the examination, describe to the child what is being done, such as ''Now I'm going to listen to your heart beating.'' Children also seem to be reassured by conversations with their parents during the examination. Children younger than 3 years of age are best examined on the parent's lap;do your best to stay at the child's level.

The child should be completely undressed for the examination. If the child is modest, provide a gown or remove only the clothing that is necessary for each part of the examination. Re-cover that area before moving on. Modesty varies greatly among children in this age group. Respect the child's modesty.

Start the examination by washing your hands in warm water. Warm hands are more comfortable for the child. If the child is on an examination table, have the parent stand at the child's feet. Any child in respiratory distress is easiest to examine in the position of most comfort, usually sitting.

Gently tell the child what to do. It is better to say, ''Please turn on your back'' instead of ''Would you please turn on your back?'' Frame requests in the positive (''Hold still like a statue'') instead of in the negative (''Don't move''). The child may not hear the negation of ''move.''

In a child who appears to be apprehensive, auscultation of the heart and lungs should be performed first because this requires the child's cooperation and should be performed early when the child may be more cooperative. Because the sight of medical instruments is likely to frighten a child, use them last. Proceed with the examination in the following order for a cooperative older child (past the second birthday):

Take measurements and vital signs (this is often done by a nurse or assistant before the clinician begins his or her encounter with the child) • Observe the child's behavior (this is your most important source of information about his or her neurologic and musculoskeletal systems) Inspect the skin Examine the head and neck Examine the chest

BLOOD PRESSURE mm Hg 150

90 80 70 60 50

Systolic

PERCENTILE

95 90 75 50

10 5

Systolic

8 10 12 14 16 18 AGE

BLOOD PRESSURE mm Hg 150

90 80 70 60 50

Systolic

Systolic

95 90

75 50 25

10 5

Diastolic

PERCENTILE

95 90

75 50 25

10 5

8 10 12 14 16 18 AGE

Diastolic

25 10 5

8 10 12 14 16 18 AGE

25 10 5

8 10 12 14 16 18 AGE

Figure 24-38 National Heart, Lung, and Blood Institute blood pressure measurements. A, Percentiles for boys. B, Percentiles for girls.

Figure 24-38 National Heart, Lung, and Blood Institute blood pressure measurements. A, Percentiles for boys. B, Percentiles for girls.

Examine

the

heart

Examine

the

abdomen

Examine

the

genitalia

Examine

the

extremities

Examine

the

deep tendon reflexes if indicated

Examine

the

eyes

Examine

the

nose

Examine

the

ears

Examine

the

mouth and pharynx

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