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General Pediatric Exams
Nov 25, 2010
•
Mark Morgan
categories:
Objective/Exam
Pediatrics
Newborn Male
Newborn Female
Male less than 1 Year
Female less than 1 Year
Male 1 to 4 Years
Female 1 to 4 Years
Male over 4 Years
Female over 4 Years
Sports Physical
Skin: Normal turgor and without lesions.
speech input
Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light
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Head: Normocephalic with age appropriate fontanelles.
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Peripheral Vessels: Normal pulses and perfusion.
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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.
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Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention.
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Genitalia: Normal male external genitalia. Testes descended bilaterally. No hernia present.
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Spine: Straight with no lesions.
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Joints: Hips with full range-of-motion; negative Barlow and Ortolani.
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Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities.
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Mental Status: Alert, oriented, in no distress. Appropriate for age.
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Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
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Skin: Normal turgor and without lesions.
speech input
Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light
speech input
Head: Normocephalic with age appropriate fontanelles.
speech input
Peripheral Vessels: Normal pulses and perfusion.
speech input
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs.
speech input
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds.
speech input
Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention.
speech input
Genitalia: Normal female external genitalia. No hernia present.
speech input
Spine: Straight with no lesions.
speech input
Joints: Hips with full range-of-motion; negative Barlow and Ortolani.
speech input
Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities.
speech input
Mental Status: Alert, oriented, in no distress. Appropriate for age.
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Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
speech input
General: Child appears age appropriate. Vitals noted and stable.
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Skin: Normal turgor and without lesions.
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Head: Normocephalic with age appropriate fontanelles.
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Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally.
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ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
speech input
Lymph Nodes: No significant lymphadenopathy.
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Thyroid: No thyromegaly; trachea midline without masses.
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Breasts: Without lesions or drainage.
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Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
speech input
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
speech input
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
speech input
Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia.
speech input
Spine: Straight with no lesions.
speech input
Joints: Full range of motion about all joints.
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Extremities: Digits and nails are normal
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Gait: Normal and appropriate gait for age.
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Mental Status: Alert, oriented, in no distress. Appropriate for age.
speech input
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
speech input
speech input
General: Child appears age appropriate. Vitals noted and stable.
speech input
Skin: Normal turgor and without lesions.
speech input
Head: Normocephalic with age appropriate fontanelles.
speech input
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally.
speech input
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
speech input
Lymph Nodes: No significant lymphadenopathy.
speech input
Thyroid: No thyromegaly; trachea midline without masses.
speech input
Breasts: Without lesions or drainage.
speech input
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
speech input
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
speech input
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
speech input
Genitalia: Normal female external genitalia.
speech input
Spine: Straight with no lesions.
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Joints: Full range of motion about all joints.
speech input
Extremities: Digits and nails are normal
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Gait: Normal and appropriate gait for age.
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Mental Status: Alert, oriented, in no distress. Appropriate for age.
speech input
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
speech input
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General: Child appears age appropriate. Vitals noted and stable.
speech input
Skin: Normal turgor and without lesions.
speech input
Head: Normocephalic.
speech input
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. Symmetric light reflex.
speech input
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
speech input
Lymph Nodes: No significant lymphadenopathy.
speech input
Thyroid: No thyromegaly; trachea midline without masses.
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Breasts: Without lesions or drainage.
speech input
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
speech input
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
speech input
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
speech input
Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia.
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Spine: Straight with no lesions.
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Joints: Full range of motion about all joints.
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Extremities: Digits and nails are normal
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Gait: Normal and appropriate gait for age.
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Mental Status: Alert, oriented, in no distress. Appropriate for age.
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Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
speech input
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General: Child appears age appropriate. Vitals noted and stable.
speech input
Skin: Normal turgor and without lesions.
speech input
Head: Normocephalic.
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Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. Symmetric light reflex.
speech input
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
speech input
Lymph Nodes: No significant lymphadenopathy.
speech input
Thyroid: No thyromegaly; trachea midline without masses.
speech input
Breasts: Without lesions or drainage.
speech input
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
speech input
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
speech input
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
speech input
Genitalia: Normal female external genitalia.
speech input
Spine: Straight with no lesions.
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Joints: Full range of motion about all joints.
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Extremities: Digits and nails are normal
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Gait: Normal and appropriate gait for age.
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Mental Status: Alert, oriented, in no distress. Appropriate for age.
speech input
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
speech input
General: Child appears age appropriate. Vitals noted and stable.
speech input
Skin: Normal turgor and without lesions.
speech input
Head: Normocephalic.
speech input
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Symmetric light reflex, normal fundi.
speech input
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
speech input
Lymph Nodes: No significant lymphadenopathy.
speech input
Thyroid: No thyromegaly; trachea midline without masses.
speech input
Breasts: Without lesions or drainage.
speech input
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
speech input
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
speech input
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
speech input
Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia.
speech input
Spine: Straight with no lesions.
speech input
Joints: Full range of motion about all joints.
speech input
Extremities: Digits and nails are normal
speech input
Gait: Normal and appropriate gait for age.
speech input
Mental Status: Alert, oriented, in no distress. Appropriate for age.
speech input
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
speech input
General: Child appears age appropriate. Vitals noted and stable.
speech input
Skin: Normal turgor and without lesions.
speech input
Head: Normocephalic.
speech input
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Symmetric light reflex, normal fundi.
speech input
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
speech input
Lymph Nodes: No significant lymphadenopathy.
speech input
Thyroid: No thyromegaly; trachea midline without masses.
speech input
Breasts: Without lesions or drainage.
speech input
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
speech input
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
speech input
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
speech input
Genitalia: Normal female external genitalia.
speech input
Spine: Straight with no lesions.
speech input
Joints: Full range of motion about all joints.
speech input
Extremities: Digits and nails are normal
speech input
Gait: Normal and appropriate gait for age.
speech input
Mental Status: Alert, oriented, in no distress. Appropriate for age.
speech input
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
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GENERAL: The patient is well developed, well nourished, alert and cooperative and appears to be in no acute distress. Vital signs as noted.
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EYES: Normal eye and funduscopic exam.
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VISION SCREEN: right eye 20/20, left eye 20/20
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EAR, NOSE, AND THROAT: Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose revels no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate, or lesion. Lips, teeth, and gums are in good general condition.
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NECK: No thyromegaly.
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LYMPH: No adenopathy.
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RESPIRATORY: Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub diminished breath sounds, or labored breathing.
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HEART: Regular rhythm with no significant murmurs, rubs, gallops, or clicks.
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ABDOMEN: Abdomen is soft, nontender without masses, hepatosplenomegaly, or abnormal pulsation. There is no guarding or tenderness.
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GENITALIA: Normal and age appropriate.
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MUSCULOSKELETAL: Examination shows no significant weakness or deformity of the musculoskeletal system. Can perform duck walk and heel-toe walk.
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SKIN: Normal, without rash or lesion.
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