Physical Assessment Across the Lifespan (Cephalocaudal Approach)
| Assessment Area | Normal Finding or Minor Variation* | Possible Abnormalities |
|---|---|---|
| Mental Status | ||
| Level of consciousness | Conscious, awake, alert; aware of self and environment; responds to external stimuli | Drowsy, confused, lethargic, delirious, stuporous, comatose |
| Orientation | Oriented × 3:
| Disoriented |
| Mood/behavior | Attentive, cooperative, pleasant | Hostile, uncooperative, restless |
| Speech (dysphonia) | Articulate, fluent, readily answers questions | Aphasic, hoarse, stutters, hesitates, repeats, slow/fast, slurred, or monotonous speech |
| Grooming/apparel | Neat, clean; clothes appropriate to occasion, season, and sex | Body odor, one-sided neglect, nail biting, fastidious |
| Concentration/attention span | Attentive, demonstrates continuity of ideas | Inattentive, unable to follow commands |
| Memory | Responds appropriately to questions:
| Inappropriate responses to questions |
| Cognitive skills | Responds appropriately:
| Concrete explanations of symbolic phrases, inappropriate responses to questions (Young children are normally concrete thinkers.) |
| General knowledge/ intellectual level | Responds appropriately:
| Inappropriate responses to questions |
| Skin | ||
| Color | Appropriate for race and genetic norm | Jaundice, cyanosis, pallor, redness, pigment changes (vitiligo), increased vascularity |
| Moisture | Appropriate to temperature, environment, activity Drier skin, especially over bony prominences and extremities. | Excessively dry/oily, moist, clammy, hot, cold |
| Temperature | Evenly warm over body (bilateral coolness of hands and feet may be normal) | Unilateral coolness of body parts, excessive warmth or coolness of skin |
| Texture | Smooth, even Increased wrinkling, thinner | Rough, dry, scaly |
| Mobility | Moves easily over underlying structures | Skin immovable |
| Turgor | After skin fold is pinched and released (dorsal surface of hand or inner forearm), skin returns to original place almost immediately Loss of elasticity results in tenting when turgor is assessed | Skin fold remains "tented" (Note number of seconds) |
| Edema | No edema (Particularly assess dependent areas.) Document as "0" or "none" | Edema present:
Scale:1+ Trace; disappears rapidly 2+ Moderate; disappears in 10–15 sec 3+ Deep; disappears in 1–2 min 4+ Very deep; remains after 5 min |
| Lesions | No lesions Cherry angiomas, seborrheic keratosis, sebaceous hyperplasia, cutaneous tags, cutaneous horns, senile lentigines | Describe according to: size, elevation, color, distribution, grouping, sensation. Measure with ruler to detect changes. See Table 2–1 for description of skin lesions. |
| Hair (Body and Cephalic) | ||
| Texture | Great variation normal Texture coarsens | Extreme changes noted: fine, silky, brittle, coarse, dry |
| Quantity | Great variation normal Thinning hair | Sparse, dense |
| Distribution | Well distributed; appropriate for age, sex, body area Symmetric balding common in men | Alopecia, excessive hair growth (especially face or chest hair on females) |
| Hygiene | Clean, well kept | Lice, nits, dandruff, dirty, strong body odor, unkempt appearance |
| Nails | ||
| Color (nail beds) | Pink, CFT <3 sec May take on yellowish color | Cyanosis, pallor |
| Consistency | Smooth, flexible Become more brittle | Brittle, pitting, transverse ridges |
| Contour | Convex | Concave ("spoon nails"), splitting, clubbing |
| Thickness | Single thickness Nails thicken | Increased thickness (usually indicates fungal infection) |
| Head | ||
| Size/contour | Normocephalic | Hydrocephalic, microcephalic, asymmetric |
| Scalp | Smooth, nontender | Scaling, masses, tenderness |
| Head circumference (measured at largest point above eyebrow and behind occiput) | Between 5th and 95th percentile on standardized growth chart. Exceeds chest circumference by 1–2 cm until 18 mo. | Below 5th or above 95th percentile. |
| Anterior fontanel | 3–4 cm in length and 2–3 cm in width until 9–12 mo of age. Soft, flat; bulges while crying. Closes between 9 and 18 mo. | Unusually large fontanel may indicate hydrocephaly (faulty circulation or absorption of CSF). Unusually small fontanel may indicate craniosynostosis (premature closure of sutures). Sunken or bulges while at rest. Early or delayed closure. |
| Posterior fontanel | 0.5–1 cm across. May be closed at birth or by 3 mo of age. | Delayed closure may indicate hydrocephaly. |
| Face | ||
| Symmetric, with relaxed facial expressions | Asymmetric, weak; involuntary movements; tense or expressionless facies | |
| Cranial nerve (CN) VII: facial, motor | Able to smile, puff cheeks, frown, raise eyebrows, with symmetry noted | Unable to purposely and symmetrically use facial muscles |
| CN V: trigeminal: motor | Bilateral contractions of temporal and masseter muscles when teeth are clenched | Weak or asymmetric contraction of muscles |
| CN V: trigeminal: sensory | Able to distinguish touch on both sides of face | Unable to distinguish type and location of touch |
| Sinuses | Frontal and maxillary sinuses nontender | Tenderness |
| Nose (See Fig. 2–2.) | ||
| External | Symmetric alignment, patent nares | Asymmetric, nonpatent nares |
| CN I: olfactory | With eyes closed, identifies common odors bilaterally (e.g., tobacco, coffee, spices) | Unable to detect and identify odors |
| Septum | Straight, intact | Deviation, perforation |
| Mucosa | Moist, pink | Red (infection or irritation); pale (allergies or anemia); crusting; lesions; swelling |
| Mucus | No obvious mucus drainage | Yellow or green (may indicate bacterial infection), large amount clear (viral infection or allergy) |
| Eyes (See Fig. 1–9 [a].) | ||
| Brows/lashes | Arched along bony prominences, above orbits; vary from dense to scant; lashes present on upper and lower lids | Absent pigmentation, seborrheic dermatitis, redness/crusting at lash follicles |
| Lids | Lids are flush against eyeball. Upper lid covers 2–3 mm of iris. Upper lid completely covers sclera when eyes are closed | Edema, inflammation, stye, hard tumor (chalazion), inflammation (blepharitis), drooping (ptosis), eversion (ectropion), inversion (entropion), yellowish tumor on lids near inner canthus (xanthelasma), sclera visible when eyes are closed |
| Lacrimal apparatus | No edema, tenderness, or swelling of lacrimal gland, duct, or puncta Production of excess tears | Excessive tearing or dryness of eyes, swollen gland/duct, inflamed puncta |
| Eyeball (globe) | Symmetric (equal amounts of medial and lateral sclera, and symmetric corneal light reflection) | Eyes do not focus in same direction (strabismus), protrusion (exophthalmos), recession (enophthalmos) |
| Conjunctiva | Inner lid (palpebral) conjunctiva is pink, moist. Eyeball (bulbar) is clear, smooth, shiny, moist. | Pale, red, dull, wrinkled, dry |
| Sclera | Color varies somewhat according to race (white to light brown), but sclera is clear. | Marked vascularity, jaundice |
| Iris | Symmetric, clearly defined markings | Absence or dulling of color |
| Cornea | Opaque, smoothly rounded, Arcus senilis (thin, grayish white circle at edge of cornea) | In young persons, corneal arcus may suggest abnormal lipid metabolism |
| Lens | Clear | Clouding (cataract) |
| CN V: trigeminal | Corneal reflex: Blinking occurs when sclera is lightly touched with a wisp of cotton. (Contact lenses should be removed.) | Absence of corneal reflex |
| Pupils | Equal size (3–6 mm in average room light); round (See Fig. 2–3.) | Significant inequality, constriction (miosis), dilation (mydriasis) to light |
| CN III: oculomotor | Light reflex: Pupil constricts as light is shone directly into it (direct pupillary response); at the same time, the opposite pupil constricts (consensual response). | Absent or sluggish reaction to light |
| Accommodation: Patient focuses eye on examiner’s finger; eyes converge and pupils constrict as finger is moved toward nose. | Lack of accommodation | |
| Visual fields | Wide visual fields as tested by confrontation test with examiner | Diminished fields of vision (glaucoma) |
| Extraocular movements, CN III, IV, and VI: oculomotor, trochlear, abducens | Ocular alignment; smooth, parallel movement through 6 cardinal fields of gaze (See Fig. 2–4.) | Strabismus; jerky, involuntary movements (nystagmus); lid lag |
| Funduscopic Exam: Internal Eye (See Fig. 1–9 [b].) | ||
| Retina (innermost membrane of eye) | Yellowish, pink | Dark color or irregular markings |
| Optic disk (surrounds convergence point of blood vessels: optic nerve entrance) | Color may be yellowish or pinkish. Rings appear around disk. Medial side may be blurred. | White |
| Physiologic cup (inside optic disk) | Occupies less than half of optic disk; yellowish white with sharp margins; small vessels visible | White or pink; margins blurred; vessels absent; cup not visible; cup larger than half of disk diameter |
| Vessels | Arterioles: light red and about 3/5 size of veins Veins: dark red | Nicking or constriction of vessels, blurred "cottonlike" markings |
| Macula | Located about 2 disk diameters lateral to disk; no vessels in immediate area | |
| Fovea | Bright center of macula | |
| Visual Acuity | ||
| CN II: optic (See Fig. 2–3.) | "20/20" as tested by the Snellen Eye Chart (The larger the denominator, the worse the vision.) | Squinting; tearing; diminished acuity: nearsighted (myopia), farsighted (hyperopia), loss of accommodation (presbyopia), double vision (diplopia) |
| Infant follows objects with eyes or smiles in response to parent’s smile. Young child reaches for objects of interest. Child who does not know alphabet but can follow directions can make appropriate responses to Blackbird or Snellen E Eye Chart. Acuity is normally less than 20/20 until age 5 yr. | Does not follow objects or smile. | |
| Ears | ||
| Auricle | Smooth, clear skin; top of pinna in line with inner canthus of eye; no tenderness when manipulated | Unusually small, low-set ears; solid lesions (tophi); tenderness upon movement |
| Canal | Clear ear canal without redness; small, moderate amount of wax (cerumen); no pain or foul odor | Canal red or white coated (otitis externa), blood or serous fluid present, occluded by wax or foreign body, swelling, pain, foul odor |
| Tympanic membrane (TM) (See Fig. 2–5.) (For 3 yr old and under, hold auricle down and back, for others, hold auricle up and back to inspect TM) | Pearly gray and intact; landmarks visible: umbo, malleus, intact anterior cone of light Tympanic membrane red when child is crying. | Red (infection), dull (fluid), perforations, white markings (old scars), landmarks not visible (bulging membrane), landmarks pronounced (retracted membrane), prominent blood vessels over malleus (may indicate the early stage of an infection: otitis media), interrupted cone of light (serous otitis media) Redness, bulging, and immobility are the 3 characteristics of acute otitis media. |
| CN VIII: acoustic (auditory acuity) | Hears whispered or spoken voice from about 2 ft away (Have client repeat what was said.) Infant startles to loud or unexpected noise. Child 6 mo or older turns head toward noise (localization of sound). Older child follows simple directions. Weber test: test for lateralization (Normally, sound heard in midline and equally in both ears.) Rinne test: compares air and bone conduction (Normally, sound heard longer through air than through bone: AC >BC.) | Diminished hearing. To distinguish between conductive and sensorineural loss, use a tuning fork to perform: No response to noise. Does not turn toward noise |
| Mouth | ||
| Lips | Symmetric, moist, intact, pink | Excessively dry, cyanosis, pallor, lesions (herpes simplex), chancre, irritation of outer corners (angular cheilosis), cleft lip |
| Buccal mucosa | Pink, smooth, moist (Patchy brown pigmentation is normal in African-Americans.) Oral hyperpigmentation and leukoedema (grayish white benign lesion of buccal mucosa) increase with age. | Bright cherry red mucosa (associated with carbon monoxide poisoning), lesions, ulcers, white patches (thrush), inflamed parotid ducts |
| Gums | Pink, moist | Inflammation, swelling, bleeding, retraction from teeth, discoloration |
| Teeth | White, tight fitting | Discolored, loose, or missing teeth; cavities (caries); cracks; chips |
| Hard palate | Intact, pink, smooth, moist | Cleft palate, lesions |
| Soft palate/pharynx | Pink, moist, uvula at midline Pharyngeal tonsils are normally large in toddler. (Mouth of child usually inspected at end of the exam.) Cleft uvula | Redness, inflammation, exudate, enlarged tonsils |
| CN IX and X: glossopharyngeal and vagus | Symmetric movement of soft palate and uvula as patient says "Ah," swallows without difficulty, gag reflex intact | Absent gag reflex, asymmetry of uvula, difficulty swallowing |
| Tongue | Pink, rough (dorsal surface), moist, fits easily into mouth | Inflamed, smooth, lesions, ulcerations, white areas, enlarged tongue, twitching (fasciculation) |
| CN XII: hypoglossal | Tongue protrudes with symmetry | Lateral deviation of protruded tongue |
| CN VII and IX: facial sensory, glossopharyngeal sensory | Distinguishes tastes of familiar substances | Diminished ability to distinguish tastes |
| Floor of mouth | Intact frenulum that does not restrict tongue movement | Tight frenulum (restricts tongue movement), white patches, inflamed submaxillary ducts |
| NECK | Supple, and head flexes easily toward chest. | Neck stiff. Shows signs of pain when head flexed onto chest (nuchal rigidity). May indicate meningitis. |
| Trachea | Midline position | Deviation |
| Carotid arteries/jugular veins | Lack of audible blood flow with bell of stethoscope; full, regular, equal carotid pulses (palpated bilaterally, one at a time, after auscultation); no distention of jugular veins with head of bed elevated 45 to 60 degrees. | Blowing sound over artery with auscultation; distended, pulsating jugular veins when head of bed elevated >60 degrees (unilateral distention also significant) |
| CN XI: spinal accessory | Note strength of trapezius muscles while patient shrugs shoulders against examiner’s hand. Also, note forceful movement and contraction of opposite sternomastoid muscles as patient turns head to each side against examiner’s hand. | Atrophy, fasciculations or weakness of trapezius or sternomastoid muscle, droop of shoulders, downward and lateral displacement of scapula |
| Lymph nodes (use circular finger motions to examine nodes) | Nonpalpable, or small, nontender, movable (shotty) nodes may be found in normal persons (indicate past infection). | Enlarged, tender, hard, fixed nodes. Tender nodes over 1 cm in size may indicate active infection. |
| Thyroid gland | Stand behind patient and gently push trachea to one side. Palpate extended side as patient swallows. Repeat on opposite side. There should be no enlargement, masses, or tenderness. (Gland is normally slightly enlarged during pregnancy and puberty. Right lobe may be slightly larger.) Auscultate over gland; lack of audible blood flow with bell of stethoscope. Thyroid becomes more fibrotic. | Enlargement (goiter), nodules, tenderness Blowing sound over gland on auscultation (bruit) |
| Thorax and Lungs (Anterior and Posterior Thorax) | ||
| Inspection | ||
Quiet respirations | Gasping, wheezing, stridor | |
Erect posture | Thoracic lateral curve in spine (scoliosis), or "hump back" (kyphosis), may affect breathing | |
Slightly convex contour of thorax | Pigeon chest, funnel chest, barrel chest | |
AP diameter (in proportion to lateral diameter) 1:2 | Increased AP diameter seen in barrel chest (more in elderly) | |
Infant’s thorax is round and develops usual adult shape after age 6 yr. | ||
Symmetrical upward and outward movement of thorax with inspiration | Unilateral impairment or lagging of respiratory movement | |
Minimal effort used for breathing | Retractions of intercostal space, supraclavicular or sternomastoid contractions, nasal flaring | |
Rate of respirations between 12 and 20 per minute; smooth, even rhythm | Tachypnea (fast), bradypnea (slow) rate, hypoventilation (shallow), hyperventilation (deep); Cheyne-Stokes, Biot’s, apneustic, cluster breathing | |
Respirations are abdominal until age 6. | Retractions (sinking in of soft tissue of chest) during inspiration. | |
| Palpation | ||
Trachea midline | May be displaced laterally because of collapsed lung (atelectasis), air in pleural cavity (pneumothorax), fluid in thoracic cavity (pleural effusion) | |
Thoracic expansion: Examiner stands behind patient and places thumbs on either side of spine with fingers extending around lower rib cage. During inspiration, examiner’s thumbs move upward, outward, and equidistant from midspinal line. | Unilateral lag in chest expansion, no expansion | |
Thorax nontender, no masses palpated | Tenderness of intercostal spaces (may indicate inflamed pleura), tenderness of ribs (may indicate fracture or arthritis) | |
Tactile fremitus: As patient voices "99," mild purrlike vibrations are palpated symmetrically over thorax down to diaphragm. (Fremitus is normally slightly increased on right side.) | Decreased fremitus (pleural effusion, pneumothorax, emphysema, very thick chest wall) Increased fremitus (pneumonia, secretions, tumor) | |
| Percussion | ||
Resonance (loud intensity, low pitch, long duration) | Dullness is heard when fluid or solid tissue replaces air (lobar pneumonia, pleural effusion, hemothorax, emphysema, fibrous tissue, tumor). Hyperresonance is heard over hyperinflated lungs (emphysema, asthma, pneumothorax). | |
Measurement of diaphragmatic excursion: Note distance between levels of dullness on full inhalation and exhalation (assessed on posterior thorax only, normally 5–6 cm). | High level of dullness may suggest pleural effusion or a paralyzed diaphragm. | |
| Auscultation | ||
Instruct patient to hold head in midline and to breathe deeply, quietly, and with mouth open. | Sounds may be decreased in obstructive lung disease, muscular weakness, pleural effusion, pneumothorax, emphysema. | |
Normal Sounds:Over lung fields: "Vesicular": inspiration > expiration. | Adventitious sounds: rales (crackles), wheezes, coarse sounds (rhonchi) | |
Vocal fremitus or resonance: As patient voices "99," muffled sounds are auscultated down to level of diaphragm. | Decreased fremitus may suggest pleural effusion, pneumothorax, emphysema, very thick chest wall. Increased fremitus (bronchophony) may suggest pneumonia, secretions, tumor. | |
| Heart and Pulses | ||
| Inspection | ||
Apical impulse seen in 4th, 5th, or 6th intercostal space, at or medial to the midclavicular line. (May be more easily seen with patient turned slightly on left side.) | Left ventricular enlargement may displace the apical impulse laterally. Impulse may be undetectable in obesity, muscular chest wall, or increased AP diameter. | |
No lifts/heaves of sternum or ribs | Right-sided heart failure may cause sternum or ribs to lift with each heart beat | |
| Palpation | ||
Apical impulse usually occupies only 1 interspace. | Apical impulse diameter increased in left ventricular enlargement | |
No lifts/heaves or thrills ("vibrations") | Thrills may suggest aortic or pulmonic stenosis. | |
| Percussion | ||
When apical impulse is nonpalpable, percussion may assist examiner in locating left cardiac border. When percussing from lung resonance toward cardiac border, dullness should be elicited at or medial to the midclavicular line. | An enlarged heart may displace the cardiac border laterally. | |
| Ausculation | ||
Identify the 4 major auscultatory areas: | ||
| Listen Carefully To | ||
First heart sound (S1): Duller, lower pitched, slightly longer duration than S2, and louder at the apex (5th LICS just medial to the midclavicular line). Splitting may be detected along the lower left sternal border. | Accentuated in tachycardia, hyperthyroidism, exercise, anemia, mitral stenosis; diminished in first-degree heart block, mitral regurgitation, congestive heart failure, coronary heart disease | |
Systole: Quiet interval between S1 and S2 when ventricles contract and empty | Mitral valve prolapse may cause a systolic click. Systolic murmurs (swishing sound) may indicate heart disease; however, many occur in a normal heart when there is fever or large fluid volume (grading of murmurs described in child health section). | |
Second heart sound (S2): Snappier, higher pitched, shorter duration, and louder at the base (upper left chest area). Splitting may be detected bilaterally in the 2nd or 3rd intercostal spaces and is accentuated by inspiration and usually disappears on expiration. | Increase in normal splitting that continues throughout respiratory cycle may suggest pulmonic stenosis, right bundle branch block, or mitral regurgitation | |
S2 in aortic area is usually louder than in pulmonic area. | S2 loud in pulmonary hypertension | |
Diastole: Quiet interval between S2 and S1 when ventricles relax and fill. Most conditioned athletes have an audible S3, and many have an S4. An S3 may normally be heard in children, young adults to the age of 35–40, and during the last trimester of pregnancy. | An opening snap (very early in diastole) usually suggests a stenotic mitral valve. An S3 in persons over 40 is almost always pathologic, indicating early ventricular resistance to filling. An S4 results from increased resistance to ventricular filling after atrial contraction. An S3 in persons over 40 is almost always pathologic, indicating early ventricular resistance to filling. An S4 results from increased resistance to ventricular filling after atrial contraction. Diastolic murmurs always indicate heart disease. | |
Apical heart rate: regular rhythm (may vary with change in respiratory rate) | Irregular heart rate | |
| PULSES (See Fig. 2–7). | "Splitting" of sounds (4 distinct sounds) PMI visible in thin child | |
| Grade 1 or 2 innocent (no pathology) murmur in up to 30% of children | Grade 3 or greater murmur. | |
| See Cardiac Murmurs in pediatric section. | Diastolic murmur | |
| Innocent murmur is always systolic, usually heard in pulmonic area, and may disappear with position change. | Thrill (vibratory sensation accompanying murmur and palpable in upper left chest) | |
| Full (volume), regular rhythm; symmetry noted. Pulse is somewhat irregular and varies markedly with respiratory rate. | Bounding or weak, thready pulse; pulses absent in acute arterial occlusion and arteriosclerosis obliterans | |
| Carotid (See neck exam.) | ||
Abdominal aorta (See abdominal exam.)
| ||
Pulse volume described as:
Dorsalis pedis and posterior tibial pulses may be more difficult to find | ||
| Breasts and Axillae | ||
| Female breasts | Symmetric (Common for dominant side to be slightly larger.) | |
| Skin: intact, no edema, color consistent with rest of body, smooth, convex contour | Redness, inflammation | |
| Consistency: varies widely (Firm, transverse inframammary ridge along lower breast edge should not be mistaken as abnormal mass.) Inframammary ridge thickens | Any lump or mass that is larger or that significantly differs from other breast tissue should be described according to location, size, shape, mobility, consistency, and tenderness. (Tenderness may be due to premenstrual fullness, inflammation, fibrocystic condition, or sometimes carcinoma.) Signs of breast cancer: peau d’orange skin (edema/thickened skin with enlarged pores), retractions, dimpling. Hard, irregular, fixed, noncircumscribed masses | |
| Areola | Small elevations around the nipple (Montgomery’s glands) are normal. | Rashes or ulcerations may suggest cancer of mammary ducts (Paget’s disease). |
| Nipple | Usually elastic, everted Nipples become smaller and flatter | Recent changes in size or shape (retraction, flattening, broadening, thickening, loss of elasticity) or the directions in which the nipples point suggest cancer. |
| Intact skin, no discharge | Rashes, ulcerations, or discharge may suggest | |
| Occasional hair around nipple | Paget’s disease. Describe any discharge according to color, odor, consistency, quantity, and exact location. A nonmilky discharge may suggest breast disease and should be further evaluated. | |
| Male breasts | Flat or muscular appearance without masses | Gynecomastia: a firm disk-shaped glandular enlargement on one or both sides resulting from imbalance in estrogen/androgen ratio, sometimes drug-related (spironolactone, cimetidine, digitalis preparations, estrogens, phenothiazines, methyldopa, reserpine, marijuana, or tricyclic antidepressants) A hard, irregular, eccentric, or ulcerating nodule suggests breast cancer, not gynecomastia. |
| Axillae | Smooth, intact skin | Rash (may be caused by deodorant). Velvety, smooth deeply pigmented skin should be further evaluated. |
| Small, soft, movable, nontender lymph nodes may be palpated. | Enlarged, tender, hard nodes may be due to hand or arm infection but may also be a sign of breast cancer. | |
| Abdomen | ||
| Note: Inspect first, as always, but auscultate prior to percussing or palpating | ||
| Inspection | ||
| Umbilicus | Usually positioned at midline and slightly below center of abdomen, may be normally everted or inverted | A recent change in contour or location may suggest an abnormality such as a hernia or tumor. (Having the patient cough will cause a hernia to bulge farther out. Check for reducibility. Report if hernia cannot be gently reduced or "pushed back" when patient relaxes.) Bluish discoloration of periumbilical skin (Cullen’s sign) may indicate intraperitoneal hemorrhage, which may be caused by a ruptured ectopic pregnancy or acute pancreatitis. |
Soft (reducible) bulge of umbilicus (hernia) until 4 yr old | Hernia persists after 4 yr of age or is nonreducible. (Hernia cannot be pushed back into abdominal cavity when child is at rest.) NOTE: Nonreducible hernia may indicate strangulation of tissue and is an emergency situation. | |
| Contour | Symmetric, slightly rounded or convex, no visible masses or organs | Enlarged organs or masses cause asymmetry. A distended abdomen may be caused by: fat, flatus, feces, fetus, fluid, or fibroids. Ascites (serous fluid in peritoneal cavity) causes bulging flanks. |
| Skin | Old, silver striae (stretch marks) and a few small visible veins are normal. Describe location and characteristics of scars. | Ascites may cause skin to be tense and to glisten. Bluish discoloration may indicate trauma or intra-abdominal bleeding. Turner’s sign is ecchymosis of one or both flanks. |
| Pulsations | Aortic pulse is a normal finding. | Increased pulsation may be seen with an abdominal aortic aneurysm or in patients with thin-walled, hollow-shaped (scaphoid) abdomens. |
| Peristalsis | May be visible in very thin patients. | Visible waves may suggest intestinal obstruction. |
| Ausculation | ||
| Bowel sounds | Vary in frequency, pitch, and loudness but usually consist of clicks and gurgles from 5–35 per min | Increased sounds with gastroenteritis, early intestinal obstruction Decreased, then absent sounds, with paralytic ileus, peritonitis Loud, prolonged gurgles (borborygmi) or unusually loud, rushing, high-pitched tinkling sounds, associated with cramping, may indicate intestinal obstruction. |
Listen to the upper abdomen, over the aorta, and to the renal, iliac, and femoral arteries. No vascular sounds should be heard. | An abdominal aortic bruit (swishing noise) associated with decreased pulses in the legs may indicate a dissecting aneurysm. | |
| Percussion | ||
Tympany in all 4 quadrants. The gastric air bubble produces a loud, tympanic sound in upper left quadrant at rib cage. Normal fluid, feces, or distended bladder produces dullness. | Dullness in both flanks (body part between ribs and iliac crest) may indicate ascites. Positive fluid wave and/or shifting dullness indicate ascites. | |
Liver dullness percussed at the right midclavicular line (6–12 cm from top to bottom of liver). | Increased liver measurement may suggest hepatomegaly. | |
Splenic dullness percussed posterior to the left midaxillary line (usually about 4–6 cm). | A large area of dullness may suggest splenomegaly. | |
| Palpation | ||
Lightly palpate to identify skin temperature, areas of tenderness, masses, or muscular resistance. | "Guarding" (increased resistance) may indicate inflammation. | |
Deeply palpate to identify masses. The abdominal aortic pulse is also palpated in the upper abdomen, slightly to left of midline. | Describe any mass according to location, size, shape, consistency, tenderness, and mobility. | |
Adult aorta is not more than 2.5 cm wide. | Increased width of abdominal aorta with expansile pulsation may suggest an aneurysm. Pain in this area may suggest rupture of the aorta. (Caution: Do not prolong palpation of an enlarged aorta.) "Rebound" tenderness (pain induced or increased by quick withdrawal of examiner’s palpating hand) suggests peritoneal inflammation, such as occurs with appendicitis. | |
Palpate liver below right costal margin as patient inhales deeply. Palpable up to 2 cm below RCM. | Increased liver size, tenderness, firmness, or irregularity of shape may suggest an abnormality. Liver palpable more than 2 cm below RCM may indicate CHF. | |
Palpate for spleen below left costal margin; adult spleen is usually nonpalpable. Palpable up to 2 cm below LCM. | A palpable, tender spleen may indicate abnormality. Spleen palpable more than 2 cm below LCM may indicate mononucleosis or sickle cell crisis | |
As patient inhales deeply, palpate left and right flank to "capture" the kidneys. (A normal right kidney may be palpable. A normal left kidney is rarely palpable.) | Enlargement of kidney may suggest tumors, cysts, hydronephrosis, polycystic disease. Pain on palpation or first percussion may suggest pyelonephritis (kidney infection). | |
| Musculoskeletal | ||
| Firm muscles palpable; demonstrates ability to resist passive motion | Atrophy, naccidity, weakness, or paralysis may suggest a neurologic abnormality. | |
| All joints show full range of smooth, coordinated, symmetrical movement without swelling, tenderness, increased heat, redness, crepitus, or deformities. (See Figure 1–25.) Loss of one or more inches in height common. Joint and muscle agility vary greatly. | Spastic movements may suggest neurologic abnormality. Tenderness may suggest arthritis, synovitis, tendinitis, or bursitis. Tenderness at the costovertebral angles may suggest a kidney infection rather than a musculoskeletal problem. | |
| Spine | Posture is erect. Spinal column is in alignment. Shoulders and iliac crests are level. Spine shows cervical concavity, thoracic convexity, lumbar concavity. Lordosis ("swayback") may be noted during pregnancy or with marked obesity. | Kyphosis ("hunchback") often seen in the elderly. Scoliosis (lateral curvature) may be associated with vertebral and rib cage deformity or unequal leg length. Often becomes evident during adolescence. |
| Lateral spinal curve that disappears when child bends forward (postural or functional scoliosis) Functional scoliosis may be due simply to poor posture or may be related to an underlying defect such as unequal leg length. | Lateral spine curve that does not correct itself when child bends forward (structural scoliosis) | |
| Small tuft of hair or dimple at lower end of spine with normal leg movement | Tuft of hair or dimple at lower spine without normal leg movement or abnormal urinary or bowel sphincter control may indicate underlying neurologic defect. | |
| Extremities | Equal leg lengths Hips symmetric | Unequal leg lengths |
| Gluteal folds symmetric | Asymmetric gluteal folds | |
| Knees same height when infant supine with knees and hips flexed at 90 degrees | One knee higher when infant supine with knees and hips flexed at 90 degrees (Galeazzi’s sign) Limited leg abduction | |
| Hips symmetric | One hip prominent.Findings listed above may indicate dislocated hipin young child or scoliosis in older child. | |
| Legs flexed at hips and knees when infant held upright with examiner’s hands under infant’s axillae | Legs adducted (brought toward midline) and extended (straightened) when infant held uprightmay indicate paraplegia. | |
| Knock-knees (genu valgum) are normal until age 7 yr and may be benign past age 7. | Knock-knees after age 7 should be investigated. | |
| Bowlegs (genu varum) are normal throughout toddler period and may be benign thereafter. | Bowlegs that persist past age 3 should be investigated. | |
| Feet in anatomic alignment | Foot turned outward (talipes or pes valgus) Foot turned inward (talipes or pes varus) | |
| Arch of foot commonly flat (pes planus) prior to 4 yr of age Broad-based gait in toddler | Persistent flat arch may be benign or problematic. | |
| Toe walking without heels touching floor (pes equinus) common until several months after walking begins | Prolonged toe walkingmay indicate cerebral palsy or tight heel cords. | |
| Pigeon toe (toeing in) usually benign | Severe toeing in that does not improve after walking begins | |
| Negative Homans’sign bilaterally (No pain in calf when foot is quickly dorsiflexed.) | Calf pain with upper foot dorsiflexion may suggest thrombophlebitis. | |
| Neurologic | ||
| Cranial nerves (See Head and Neck Assessment.) | Intact | Abnormalities in cranial nerve assessment may suggest neurologic disorders. |
| Cerebral functioning (See Mental Status Assessment.) | Intact | |
| Cerebellar functioning | Intact | |
| Negative Romberg test: maintains upright position with only minimal swaying when standing with feet together and eyes closed | Loss of balance is termed "positive Romberg test" (indicates sensory ataxia). | |
| Gait is coordinated and balanced, with erect posture, swinging of the arms, and movements of the legs. Tandem walking (heel-to-toe) is intact. | Uncoordinated gait may suggest cerebral palsy, parkinsonism, or drug side effect. | |
| Coordinated and steady movement while: sliding heel of one foot down opposite shin, rapidly touching thumb to each finger, rapidly touching own nose and then examiner’s finger | Inappropriate movements suggest cerebellar disease. | |
| Motor system | Intact No involuntary movements Muscle size, tone, and strength are assessed in musculoskeletal exam. | Tics, tremors, fasciculations may suggest neurologic involvement. |
| Sensory system | Intact Upon symmetric testing of the arms, legs, and trunk, identifies:
| Inappropriate response indicates neurologic disorder. |
| Sensory cortex | Discrimination (stereognosis): "Can you identify the object in your hand?" (e.g., key, paper clip, coin); "What number am I writing on your hand?" (graphesthesia) "Can you feel me touch both sides of your body?" | Inabilities suggest a lesion in the sensory cortex. |
| Reflexes | Symmetric and intact Biceps (inner elbow) Triceps (behind and above elbow) Brachioradialis (lower arm) Patellar (knee) Achilles (ankle) Plantar (sole of foot) Reflex Scale
| Diminished or absent reflexes may suggest upper or lower motor neuron disease; however, this may also be found in normal people. (Reinforcement by isometric contraction such as asking patient to push his or her hands together while knee reflex is checked may increase reflex activity.) A positive Babinski’s reflex (toes spread and dorsiflex when sole of foot is stroked) may be seen in pyramidal tract disease or in the unconscious patient. |
* A "minor variation," in this context, is one that usually does not require treatment.
Key: Text appearing in blue type refers to pediatric variations. Text appearing in gray type refers to geriatric variations.