EXAMPLES OF ABNORMALITIES

842 B AT E S G U I D E T O P H Y S I C A L E X A MI N AT I ON A N D H I S T ORY TA K I N G
ASSESSI NG YOUNG AND SCHOOL- AGED CHI LDREN
In children, the presence of nu-
chal rigidity is a more reliable indi-
cator of meningeal irritation than
Brudzinskis sign or Kernigs sign.
To detect nuchal rigidity in older
children, ask the child to sit with
legs extended on the examining
table. Normally, children should
be able to sit upright and touch
their chins to their chests. Younger
children can be persuaded to ex
their necks by having them follow
a small toy or light beam. You also
can test for nuchal rigidity with
the child lying on the examining
table, as shown here. Nearly all
children with nuchal rigidity will
be extremely sick, irritable, and
difcult to examine. In many
countries, the incidence of bacte-
rial meningitis has plummeted be-
cause of vaccinations.
The Thorax and Lungs
As children age, the lung examination becomes similar to that for adults.
Cooperation is critical. Auscultation usually is easiest when a child barely
notices (as when in a parents lap). Let a toddler who seems fearful of the
stethoscope play with it before it touches the childs chest.
Assess the relative proportion of time spent on inspiration versus expiration.
The normal ratio is about 1:1. Prolonged inspirations or expirations are a
clue to disease location. Degree of prolongation and effort or work of
breathing are related to disease severity.
Young children asked to take deep breaths often hold their breath, further
complicating auscultation. It is easier to let preschoolers breathe normally.
Demonstrate to older children how to take nice, quiet, deep breaths. Make
it a game. To accomplish a forced expiratory maneuver, ask the child to blow
out candles on an imaginary birthday cake or use pinwheels.
Nuchal rigidity is marked resistance
to movement of the head in any
direction. It suggests meningeal
irritation due to meningitis, bleed-
ing, tumor, or other causes. These
children are extremely irritable and
difcult to console and may have
paradoxical irritabilityincreased
irritability when being held.
When meningeal irritation is pres-
ent, the child assumes the tripod
position and is unable to assume a
full upright position to perform the
chin-to-chest maneuver.
With upper airway obstruction such
as croup, inspiration is prolonged
and accompanied by other signs
such as stridor, cough, or rhonchi.
With lower airway obstruction such
as asthma, expiration is prolonged
and often accompanied by wheezing.
Pneumonia in young children gener-
ally is manifested by fever, tachy-
pnea, dyspnea, and increased work
of breathing.
Although upper respiratory infec-
tions due to viruses can cause young
infants to appear quite ill, upper
respiratory infections in children
present with the same signs as in
adults, and children generally appear
well, without lower respiratory signs.
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EXAMPLES OF ABNORMALITIES ASSESSI NG YOUNG AND SCHOOL- AGED CHI LDREN
Older children will be cooperative for the respiratory examina-
tion and can even go through the maneuvers of assessing frem-
itus or listening to E to A changes (see pp. 314315). As
children grow, the evaluation by observation discussed on the
previous page, such as assessing the work of breathing, nasal
aring, and grunting, becomes less helpful in assessing for re-
spiratory pathology. Palpation, percussion, and auscultation
achieve greater importance in a careful examination of the tho-
rax and lungs.
Children in respiratory distress may assume a tripod position
in which they lean forward to optimize airway potency. This
same position can also be caused by pharyngeal obstruction (see
p. 841).
The Heart
The examination of the heart and vas-
cular systems in infants and children is
similar to that in adults, but recogni-
tion of their fear, their inability to co-
operate, and in many instances, their
desire to play, will make the examina-
tion easier and more productive. Use
your knowledge of the developmental
stage of each child. A 2-year-old may
be easiest to examine while standing
or sitting on the mothers lap, facing
her shoulder, or being held. Give
young children something to hold in
each hand. They cannot gure out
Childhood asthma is an extremely
common condition throughout the
world. Children with acute asthma
present with varying severity and
often have increased work of breath-
ing. Expiratory wheezing and a
prolonged expiratory phase, caused
by reversible bronchospasm, can
be heard without the stethoscope
and are apparent on auscultation.
Wheezes are often accompanied
by inspiratory rhonchi caused by
viruses that triggered the asthma.
39
Tripod position
Retractions
Nasal flaring
General abnormalities may suggest
increased likelihood of congenital
cardiac disease, as exemplifed
by Down syndrome or Turners
syndrome.
A CHILD IN RESPIRATORY DISTRESS
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EXAMPLES OF ABNORMALITIES
844 B AT E S G U I D E T O P H Y S I C A L E X A MI N AT I ON A N D H I S T ORY TA K I N G
ASSESSI NG YOUNG AND SCHOOL- AGED CHI LDREN
how to drop the object and, therefore, have no hand free to push you away.
Endless chatter to small children will hold their attention and they may for-
get you are examining them. Let children move the stethoscope themselves,
going back to listen properly.
Blood Pressure. Measure the blood pressure in both arms and one leg at
one time around age 3 to 4 years to check for possible coarctation of the
aorta. Thereafter, only the right arm blood pressure needs to be measured.
Benign Murmurs. Preschool and school-aged children often have benign
murmurs (see gure on p. 845). The most common (Stills murmur) is a
grade III/VI, musical, vibratory, early and midsystolic murmur with mul-
tiple overtones, located over the mid or lower left sternal border, but also
frequently heard over the carotid arteries. Carotid artery compression will
usually cause the precordial murmur to disappear. This murmur may be
extremely variable and may be accentuated when cardiac output is increased,
as occurs with fever or exercise. The murmur will diminish as the child goes
from supine to sitting to standing.
In preschool or school-
aged children, you may
detect a venous hum.
This is a soft, hollow,
continuous sound,
louder in diastole, heard
just below the right
clavicle. It can be com-
pletely eliminated by
maneuvers that affect
venous return, such as
lying supine, changing
head position, or jugu-
lar venous compression.
It has the same quality
as breath sounds and,
therefore, is frequently
overlooked.
The murmur heard in
the carotid area or just
above the clavicles is
known as a carotid
bruit. It is early and
midsystolic, with a
slightly harsh quality. It
is usually louder on the
left and may be heard
alone or in combination with the Stills murmur. It may be completely
eradicated by carotid artery compression.
In coarctation of the aorta, the blood
pressure is lower in the legs than in
the arms.
Among young children, murmurs
without the recognizable features of
the three common benign murmurs
may signify underlying heart dis-
ease and should be evaluated thor-
oughly by a pediatric cardiologist.
Pathologic murmurs that signify
cardiac disease can frst appear
after infancy and during childhood.
Examples include aortic stenosis
and mitral valve disease.
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