Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Shakun Gupta and I am an Associate Professor of Pediatrics at University of Virginia.
Today, we will be reviewing what you need to know to examine your pediatric patients.
Examining children is a bit of an art form and is often unfamiliar to clerkship students who may have a varied degree of experience being around children, may never have worked with children and may not have been exposed to pediatric patients in the pre-clinical years. Don’t worry these nerves are normal and even though children can’t necessarily cooperate with the exam, you can still do it.
I am going to give you my best tips and tricks to get the exam you need on your pediatric patient with as little crying as possible. And hint here – it is not always possible that you can examine a child thoroughly without any degree of distress or discomfort for the child however if that exam is going to affect your plan and management, it is important for the care of the child that you do a good and detailed job.
Since pediatric patients range in age from newborns to young adults, your exam techniques will have to vary quite a bit. Also depending on whether you are seeing a well child visit or a focused complaint you may be doing the full exam or a more focused physical exam for example on the knee for knee pain. I am not going to cover special exam maneuvers in detail in this episode.
Lets start with newborns and infants. Remove all the clothing including hats and socks and diapers and make sure you are looking at the entire baby undressed. This can clue you in to alertness and their general appearance, any abnormal or normal skin findings, breathing changes, range of movement of extremities and overall tone of the muscles. You can also observe many developmental milestones by simply carefully observing the baby with their parent and what they do – for example – do they turn to noise when you enter the room, do they smile, do they make sounds or words, do they reach out and so forth.
Even though you look at everything from top of head to tips of toes, you may not be able to examine in that order so get comfortable with being flexible and moving around to different body parts.
Do as much of the exam as you can in the parent or caregiver’s arms. This is where babies and really young children of all ages are most comfortable. You may have a parent hold the baby and then listen to their heart and lungs while they are on their shoulder or even while they rock them or feed them. For checking red reflexes, wait until the end of your exam or at the very beginning when a baby is calm and turn off the room lights – babies will naturally open their eyes and position yourself so you are ready with your ophthalmoscope to look. I much prefer this to trying to pry the eyes open. You can use a pacifier or let a baby suck on a clean gloved finger if a parent okays it or a parent’s clean finger if they are crying.
When you need to check the rest of the exam including abdomen, GU and in a non-walking child – the hip exam which you should always do – you will need to lay them on their back on an exam table or bed, they may cry so ask the parent to come over and talk to them and be near their face for comfort. You can reassure the parent that nothing you are doing hurts their child but that in general babies and young children don’t like being held in place by strange hands and that you will be done very soon. You can also talk the parent through the exam that you are doing so they are reassured by saying things like “her heart sounds so healthy and her belly feels so normal and soft.” Parents are often as nervous as you are and this can really help them partner with you during the visit to help soothe their child.
As we move into the toddler and preschool child range, I recommend continuing to have the child sit in their parent’s lap or at least next to their parent for as much of the exam as possible. Even if a child is comfortable on the exam table, let them sit up for as much of the exam as you can before you have them lay down. It is helpful to not jump right in and get close to the child but rather walk into the room, sit a little bit away from the child and calmly talk to the parent first. I always say hello to the child but I focus most of my attention and gaze toward the parent for a while. Often as I am speaking to the parent over a few minutes, the child will start to feel at ease, come out from behind their parent’s back or wherever they are hiding as they realize I am not as scary as I first seemed. Then as you move from history taking to physical exam try to sit on a low chair or stool so you are not hovering over the child as you examine them. As you move closer to the child, always talk to the child as well as the parents. Try to notice something cool about them (i.e. light-up shoes, a character on a T-shirt or a toy they brought with them) or ask them their favorite anything like color, book, friend, etc. This gets children to open up and once they’re chatting with you, you can be doing your exam without much attention to what you’re actually doing but they’re listening to you instead. To distract and calm them, consider telling them a story throughout the exam or try to make the physical exam a game like play with the instruments, show them how they work, how they have a light, etc. Finally, consider having something fun in your pocket such as a sticker or a fun pen to make the experience more enjoyable to distract them. Start with the heart and lung exam while the child is most cooperative and calm. Save the worst parts of the exam for last for example the mouth exam or the ears. But if a child is already crying, take the opportunity to look at their teeth and in their mouth.
If you want them to take a deep breath for your lung exam, ask them to pretend to blow out the birthday candles and hold your finger up like a candle flame.
Other tips if your patient is particularly nervous are:
You can examine the parent first for example look in mom’s mouth or listen to the mom’s heart before the child’s to demonstrate that it won’t hurt. You can let them listen to your heart before they listen to yours. You can listen to their arm or leg with your stethoscope a few times before you put it on their chest or stomach to demonstrate that it’s not painful. If you are not sure if a child has true abdominal tenderness or is scared, you can tell them you are listening to their belly and use the stethoscope to push down on their abdomen as you watch their face for grimacing or you can have them put their hands under yours on their belly as you push down. Always try to warm up your stethoscope also with your hands before touching the child.
Ear exams can cause particular anxiety for medical students so lets talk about this.
It is all about the hold, the actual ear exam is quick but it is worth taking the time to get the child and you in a comfortable and yet firm hold before you try to look – this will make it worthwhile.
One example is to have the child in the parent’s lap facing you or away from you, the parent wraps their arm around both the child’s arms. If a child is kicking you can tuck the legs around the parent’s body or in between the parents legs. You then hold the child’s head against the parent’s chest or neck as you look and that will also help you stabilize the child.
You should always watch a child walk in the exam room even if there are no complaints, children will not want to walk toward you so I recommend having the parent move to the other side of the room and call out to their child while they hold out their arms – you can watch the gait from behind as the child walks away from you. If there are complaints, have the child walk or even run longer distances in the hallway.
For school age children you can generally plan to do your exam head to toe on the exam table and that is how you should present your exam in your oral presentation. I will give some tips on oral presentations in a minute. Back to examining school age children, since they are much more cooperative the exam is pretty much what you have standardly learned in medical school done sitting up as much as possible until they have to lay down. I still always try to engage them first in a little chat about something they are into or like to do or might be wearing, carrying, looking at so that we develop rapport. You could simply ask “so jonny what do you like to do after school or on weekends?” then you can say “oh wow I’ve never done that tell me about it” or “oh I used to do that too when I was a kid.” Pediatrics is a great rotation to remember and use your own childhood memories to relate to children. I also tell school age children every part of the exam and what I will be doing before I do it – for example “open your mouth and say ahh – im going to use a light to see your throat” Even school age children get very nervous at the doctor’s office so this helps everyone know what to expect in the room, it is also teaching them about their body.
For pre-teens and older, the exam may not be the hardest part of your visit in terms of cooperation but engaging the patient is very important. I always address them directly by name and speak to them as I enter the room even before I introduce myself to their parent. Try again to find something about them that you can relate on – sometimes they may be on a phone or other device when you come in and it can be tempting to speak to the parent present who is often more chatty. Politely ask the teen to put away their phone and tell them you want them to feel involved in their health and you want to answer any questions they have about their body or health. This helps set the stage immediately for the parent so they don’t feel ignored. At this age you will probably speak to them alone at some point in the visit and the HEADS exam is covered in our adolescent episode so check it out! But even with the parent, keep in mind the child is your patient and giving them eye contact, using their name, having them answer questions first always really helps them feel confident and engaged. They tend to open up once they know you really are their doctor. If you are discussing something that the child doesn’t know or can’t answer, then turn to the parent and explicitly say that you are going to get the parent’s opinion also.
One particular part of the physical exam I want to address is the external genital exam. This may not be something you as a medical student want to do in any child over the infant/toddler stage without a chaperone present and that is completely acceptable. In babies and toddlers, I often do the genital exam to note “normal or abnormal findings and in boys presence of descended bilateral testes” just after I do the abdominal exam. I do tell the parents why I am looking in that area. I also check their bottom for any rash, sacral anomaly or asymmetric creases. As young as toddlers, I start talking about that area as private and explain that to me that means something we don’t show in public and something no one looks at except in a doctor’s office or if it’s a parent with your permission. That might not be exactly what the parent is teaching them at home but it is modeling early the discussion of consent and body autonomy which I think is important. I continue to say a developmentally appropriate version of this every single time I do a genital exam from then on. I do not use other words for genitalia besides the correct anatomic terms even if a parent does in the room. Again that may not the parent’s preference but it is mine so you find what feels comfortable to you. As kids get older, you need to perform the genital exam again to look for an anatomic abnormality, dermatologic changes or lesions, sexual maturity rating which is also known as tanner staging, noting hernias or testicular abnormalities in males. If you acknowledge to kids that yes it is uncomfortable and they are allowed to feel nervous but why you need to check from head to toe they usually are okay with it.
Now some tips on presenting your physical exam. Start with vitals – you can give the numbers but better to interpret them rather than simply report. An example of that would be saying “temperature is 101.6 versus our patient is febrile today with a temperature of 101.6”. Remember in pediatrics growth is like another vital sign – we care a lot about growth and development of our patients so we want to hear their growth parameters and also your interpretation of those parameters. An example of this is saying “sally is at the 59th percentile for weight and 75th percentile for height versus Sally is growing very steadily along her weight and height percentiles with stable weight and height parameters and a normal BMI”
Another tip is to always start with a general appearance – this could be something like well appearing, well nourished, ill appearing, tired, toxic, sick, well hydrated, smiling, crying, or any combination of the above. It is a great way to give everyone listening some context to frame the remainder of the physical exam and assessment. Some people like to present general appearance and then vitals and growth parameters; others present vitals and growth parameters and then general appearance. Then, even if you did not do the exam in a head-to-toe fashion, you do want to present it head to toe. If you just did a focused exam, then you want to give the vitals and general appearance, and then go to the parts that you examined.
