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Pediatric Physical Exams
Mar 31, 2010
•
Mark Morgan
categories:
Objective/Exam
Pediatrics
Short Version
General: Appears age appropriate. Skin: Normal turgor and without lesions. Head: ***<1 yr - Normocephalic with age appropriate fontanelles./>1 yr - Normocephalic.*** Eyes: Conjunctivae non-injected; sclerae anicteric; extraocular movements intact; pupils equal, round, and reactive to light. ***<1yr - Red reflex present bilaterally./1-4 yr - Red reflex present bilaterally. Symmetric light reflex./>5 yr - Symmetric light reflex, normal fundi. ENT: Tympanic membranes gray, sharp landmarks. Nose clear. Palate is complete. Tonsils non-inflamed bilaterally. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Peripheral Vessels: Normal pulses and perfusion. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds. Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention. Genitalia: ***Normal male external genitalia; testes descended bilaterally; no hernia./Normal female external genitalia.*** Tanner: Tanner stage ***I/II/III/IV/V*** Spine: Straight with no lesions. Joints: <4 months - Hips with full range-of-motion; negative Barlow and Ortolani./>4 months - Full range-of-motion about all joints. Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities. ***Gait: Normal and appropriate gait for age.*** Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
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Long Version
General: Appears age appropriate. Alert, oriented, in no distress.
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Skin: Normal turgor and without lesions.
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Head: ***Normocephalic with age appropriate fontanelles.(96% ant font close by 2 years)/Normocephalic.***
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Eyes: Conjunctivae non-injected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. ***Red reflex present bilaterally. (newborn)/Red reflex present bilaterally. Cover-uncover test shows symmetric light reflex. (1-4 years)/Cover-uncover test shows symmetric light reflex, Normal fundi. (>5 years)
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ENT: TMs normal Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
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Neck and axillae: No significant lymphadenopathy. No thyromegaly; trachea midline without masses.
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Breasts: Without lumps or drainage.
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Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs.
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Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
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Abdomen: Soft, nontender, without organomegaly or masses palpable. Bowel sounds normal. No distention. ***No hernia defects./Small umbilical hernia present.***
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Genitalia: ***Normal male external genitalia; testes descended bilaterally; no hernia./Normal female external genitalia.***
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Tanner: Tanner stage ***I/II/III/IV/V***
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Spine: Straight with no lesions.
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reference: This is an online version of a template by Stephen P. Merry, MD, MPH, Consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
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