General Observations

Clinical Approach:

Smile - enter the room with a warm smile with proper body language.
Examiner -

Greet the examiner and tell him that you already wash your hands outside.
Pay utmost attention to examiners opening statement - confirm name/age/sex of the child.

Now ignore the examiner completely and turns toward the child and the caregiver.
Now greet the child and the caregiver.
Introduce to them with a smile. Make a repo with them.
Ask permission from the caregiver to examine the child and explain to the child that what you are going to do. Do not take permission from the child.
Expose the child from nipples to the knees. However, keep the underwear on.
Maintain the child's dignity especially of adolescent girls.
We can use a bedsheet/towel/blanket.
The child should be as flat on the bed as possible.

Play and chat with the child throughout the exam. Always do a gentle examination.

Warm your hands and stethoscope.

General examination:

Observe from the end of the bed: Look at the surrounding and things connected with the patients,. find any clue - line, oxygen, any device attached, iv access.

Now comments on :

Is the child comfortable or in pain?
Child look well or unwell
Note the child's nutritional status - thin/well nourished/obese/short/tall
Colour- cyanosis/pallor
See the unusual facial features -head size

Please note the following points in addition to the above:

Race- SCD/Spherocytosis

Things attached- O2, feeding tube, gastrostomy, cannula, nappies in older children,
Medications, urinary catheter, Perinatal dialysis catheter, Ileostomy or colostomy, nephrostomy, vesicostomy,
Growth and nutrition- muscle wasting, loss of subcutaneous tissue

GENERAL EXAMINATION:

Hands:

Nails- look for koilonychia, cyanosis, clubbing- IBD, CF
Scar from cannula, flapping tremor, palmer erythema,

The pallor of palmar crease

Pulse: radial
BP- you have to say that you would like to do BP, high BP due to renal artery stenosis, NF, pheochromocytoma
Head size and shape- See also behind the ear for VP shunt as this might be cause for abdominal scar
Face - haemolytic facies- Thalassemia (frontal bossing, malar prominence)
Conjunctiva- look for pallor, jaundice, KF rings
Mouth- ulcer in Crohn’s disease; Pigmentation- Peutz Zegher syndrome; stomatitis
Large tongue— hypothyroidism, BWS, GSD, Down’s syndrome,
Teeth-

look for caries. Caries in the back of mouth might indicate gastroesophageal reflux disease. Front teeth caries due to poor diet. gum hypertrophy in neutropenia,

Skin-

look for Scratch mark, bruises, Petechiae, Cafe-au-leit, skin nodules, scar

Chest- spider naevi and gynecomastia in liver disease, or scar, central line or Port a cath

The candidate should be able to identify stigmata of liver disease and should note other features associated with abnormal abdominal findings (bruising, hemodialysis, shunts)

SYSTEMIC ABDOMINAL EXAMINATION:

Anterior aspect and posterior aspect. I would ideally like to expose the patient from nipple to iliac crest

1. INSPECTION-

Supine position- Distension - 5 F

a. Symmetry- Asymmetry might be due to viscroptosis , Divarication of recti is due to hypotonia or after prolong abdominal distension

b. Skin- Scar- linear due to surgery, multiple due to needle in diabetes or deferoxamine; Striae in obesity; Stoma; Rashes (Abdominal Scars click here)

c. Umbilicus- normal umbilicus is flat .....; umbilical discharge in patent urachus, umbilical granuloma

d. Movement- in thin and malnourished children, Gastric peristalsis in pyloric stenosis, intestinal peristalsis, movement with respiration and pulsations.

e. Distended vein-

f. Hernia- better feel than to look for it during cough or crying. (inguinal/umbilical/femoral. A hernia is more common in African descent, ex-premature and in hypothyroidism.

g. Inspect genitalia - Tell the examiner that it is necessary to complete the abdominal exam.

2. PALPATION - The candidate should be able to differentiate normal from abnormal findings, and correctly identify the following organs: Liver, Spleen, Kidney, Bladder, Female genitalia, Male genitalia including the descent of testes.

a. Superficial b. Deep c. Bimanual

Always ask about pain with the child and the parent.

Examine-in supine position. Partially flex the legs.

Hands and forearm should be at the same plane as that of the abdomen, get down to the level of the child

Warm hands

Be gentle

Start with the least painful area.

Always look at the child's face.

In obese children - two hand exam can be done.

source- rcemlearning

a. Superficial palpation- to calm down the child. look for guarding and tenderness.

b. Deep palpation- Ask the child to take a deep breath. Inform the child that you are going to press deep

Liver- move the finger in expiration. Flex The fingers at the metacarpophalangeal joint, using the forefingers in parallel to the costal margin. begin in the right iliac fossa and move towards the costal margin.

Border- below costal margin In midclavicular line, which may be the enlargement or maybe push down effect. for that, we have to measure liver span by tape measure.

Surface- smooth / nodular

Consistency- firm/ hard

Tenderness

Spleen - If not palpable then turn the child.

Kidney- palpate both kidneys

Bladder

Mass - size, shape, surface, edge, consistency, tenderness, movement with respiration, bruits

Palpate hernial sites with or without cough

Fluid thrill- you can take the help of the examiner

See the direction of blood flow in a distended abdominal vein -- in portal hypertension, it is away from the umbilicus, and in enterohepatic inferior vena cava obstruction, blood flow towards the umbilicus.

3. PERCUSSION

For the upper border of the liver

For mild splenomegaly

Ascites - to elicit fluid thrill and shifting dullness. you can take the help of the examiner. (perform if abdomen distended)

4. AUSCULTATION

Bowel sounds- in every 5-10 seconds up to a minute. say it is increased/absent/ normal

Rubs- over the liver, spleen, or other abdominal mass

Bruits- on renal artery - bell at a renal angle or at flanks

Venous hum- on the right upper quadrant in pulmonary artery hypertension.

EXAMINE POSTERIOR ASPECT OF THE ABDOMEN-

INSPECTION-

Spine- kyphosis, scoliosis,

Skin- tuft of hair, swelling, lipoma, purpura and petechie

Scar- repair of spina bifida, resection of spinal tumor, scar at loin - nephrectomy

Perianal fissure and fistula - IBD

Patulous anus - spina bifida

PALPATION-

For tenderness. at a renal angle for nephritis, Bony prominence of the spine for tumor and infection, and paravertebral muscle for spasm

AUSCULTAION- at renal angle for buite

Indicate that you will examine genitalia and rectal examination if indicated.

OTHER SYSTEMS- Neck and axilla for lymphadenopathy

CVS- Pulmonary stenosis in algillae syndrome, PDA in rubella, Dextrocardia in polysplenia, and asplenia syndrome

Respiratory- in CF

CNS - in hypotonia

	Liver	Spleen	Kidney
Location	Right iliac fossa	Left iliac fossa	Flanks
Decent during inspiration	Descend	Descends	Descends
Can get above it?	No	No	Yes
Special features	None	Notch	Ballotable

Candidates must not perform rectal or vaginal examinations. (Additional Points: from RCPCH)

Candidates are not expected to examine the external genitalia or perianal region if this is likely to upset a child. In other circumstances, if this is required the candidate will be specifically asked to do this.

The candidate is expected to recognize the following:

• Nasogastric tube

• Gastrostomy

• Continuous ambulatory peritoneal dialysis or another dialysis catheter

• Ileostomy or colostomy

• Nephrostomy/vesicostomy

• Indwelling central venous access device for parenteral nutrition

Patterns of Abnormalities

The candidate is expected to recognize normal and abnormal clinical signs and to discuss the pattern of signs which suggests a diagnosis.

• Liver disease e.g. portal hypertension, cirrhosis, storage disorder, chronic liver disease

• Splenomegaly e.g. spherocytosis, thalassemia, portal hypertension

• Infection 20 e.g. viral hepatitis, ascites, glandular fever