E- EXAMINATION

A-ABNORMAL FINDINGS
N-NORMAL FINDINGS
P-PATHOPHYSIOLOGY

PALPATION
TEXTURE
E
1. Use the finger pads to palpate the skin.
2. The technique of palpating the skin of a younger child can be accomplished by
playing games. For examples, use the finger pads to walk up the abdomen and touch
the nose.
N
Skin of the pediatric patient normally is smooth and soft. Milia, plugged
sebaceous glands, present as small, whit papules in the newborn. Milia occur mainly on the
head, especially the cheeks and nose. Preterm infants have vernix caseosa.

HAIR
INSPECTION
Lesions
A
Yellow, greasy-appearing scales on the scalp of a light-skinned infant are abnormal infant
are abnormal. In dark-skinned infants, the scaling is light gray.
P
Seborrheic dermatitis (cradle cap) is possibly related to increased epidermal tissue growth.
HEAD
Inspection
Shape and Symmetry
E
With the patient sitting upright either in the caregiver’s arms or on the examination table,
observe the symmetry of the frontal, parietal, and occipital prominences.
N
The shape of a child’s head is symmetrical without depressions or protrutions. The anterior
fontanel normally may pulsate with every heartbeat. The Asian infant has a flattened
occiput, more so than infants of other races.

A
A flattened occipital bone with resultant hair loss over the same area is abnormal.
P
A prolonged supine position places pressure on the occipital bone.
Head Control
E
1. Assess head control while the patient is in the position used for assessing shape and
symmetry.
2. With the head unsupported, observe the patient’s ability to hold the head erect.
N
At 3 months of age, the infant is able to hold the head steady without lag.
A
Lack of head control is evidenced by the infant who is unable to hold the head steady while
in a sitting position and is abnormal. Head lag beyond 4 to 6 months of age should be
further investigated.
P
Documented prematurity, hydrocephalus, and illnesses causing developmental delays are
possible causes of head lag.
Palpation
Fontanel
E
1. Place the child in an upright position.
2. Using the second or third finger pad, palpate the anterior fontanel is the junction of
the sagittal, coronal, and frontal sutures.
3. Palpate the posterior fontanel at the junction of the sagittal and lambdoidal sutures.
4. Assess for bulging, pulsations, and size. To obtain accurate measurements, the
patient should not be crying. Crying will produce a distorted, full, bulging
appearance.

N
The anterior fontanel is soft and flat. Size ranges from 4-6 centimeters at birth. The fontanel
gradually closes between 9 and 19 months of age. The posterior fontanel is also soft and
flat. The size ranges from 0.5 to 1.5 centimeters at birth. The posterior fontanel gradually
closes between 1 and 3 months of age. It is normal to feel pulsations related to the
peripheral pulse.
A
Palpation reveals a bulging, tense fontanel, which is abnormal.
P
Signs of increased intracranial pressure are associated with meningitis and an increased
amount of CSF.
A
A sunken depressed fontanel is abnormal.
P
A sunken, depressed fontanel is a sign of dehydration.
A
A wide anterior fontanel in a child older than 2 ½ years is an abnormal finding.
P
An anterior fontanel that remains open after 2 ½ years of age may indicate disease such as
rickets. In rickets, there is a low level of vitamin D relative to decreased phosphate levels.
Other causes of enlarged fontanel include congenital hypothyroidism, Down syndrome, and
hydrocephalus.
Suture Lines
E
1. With the finger pads, palpate the sagittal suture line. This runs from the anterior to
the posterior portion of the skull in a midline position.
2. Palpate the coronal suture line. This runs along bith sides of the head, starting at the
anterior fontanel.
3. Palpate the lambdoidal suture. The lambdoidal suture runs along both sides of the
head, starting at the posterior fontanel.
4. Ascertain if these suture lines are open, united, or overlapping.

N
Grooves or ridges between sections of the skull are normally palpated up to 6 months of
age.
A
Suture lines that overlap or override one another, giving the head an unusual shape,
warrant further investigation.
P
Craniosynostosis is premature ossification of suture lines, whereby there is early formation
and fusion of skull bones. Craniosytostosis may be caused by metabolic disorders or may be
a secondary consequence of microcephaly.

Surface Characteristics
E
1. With the finger pads, palpate the skull in the same manner as the fontanels and
suture lines.
2. Note surface edema and contour of the craniu,.
N
The skin covering the cranium is flush against the skull and without edema.
A
A softening of the outer layer of the cranial bones behind and above the ears combined with
a ping pong ball sensation as the area is pressed in gently with the fingers is indicative of
craniotabes, an abnormal finding.
P
Craniotabes is associated with rickets, syphilis, hydrocephaly, or hypervitaminosis A.
A
A resonant or “cracked pot” sound is produced upon percussion of the skull in an older
infant.
P
This is Macewen’s sign. It is a normal finding in young infants hwen the cranial sutures are
open. After early infancy, hydrocephalus and other pathologies that cause increased
intracranial pressure cause cranial suture separation, this is when Macewen’s sign may be
elicited.

A
A localized, subcutaneous swelling over one of the cranial bones of a newborn is referred to
as a cephalhematoma and is abnormal. This abnormality differs from other surface
characteristics in that edema does not cross suture lines with this condition. Varying
degrees of swelling can persist up to 3 months.

P
Cephalhematomas acquired during forceps deliveries are due to subperiosteal bleeding and
usually resolve within a couple of weeks, but may persist longer.

A
Swelling over the occipitoparietal region of the skull is abnormal.

P
Caput succedaneum results from pressure over the occipitoparietal region during a
prolonged delivery. It usually resolves within 1 to 2 weeks after birth.

A
Molding can occur in conjunction with caput succedaneum.

P
The parietal bone overrides the frontal bone as a result of induced pressure during delivery.
It should resolve within 1 week of delivery.
Eyes
General Approach
1. The adult Snellen chart can be used on children as young as 6 years.
2. Test every 1 to 2 years through adolescence.
3. If the child resists wearing a cover patch over the eye, make a game out of wearing
patch.
4. The Allen Test can be used with children as young as 2 years of age.

Tumbling E Chart
Examination
1. Ask the child to point an arm in the direction the E is pointing
N
Vision is 20/40 from 2 to approximately 6 years of age, when it approaches the normal
20/20 acuity.

Allen Test
E
1. With the child’s eyes both open, show each card to the child and elicit a name for
each picture.
2. Place the 2-to-3-year-old child 4.5 m (15 feet) from where you will be standing. Place
the 3-to-4-year-old child 6 m (20 feet) from you.
3. Ask the caregiver to help cover one of the child’s eyes.
4. With the child’s eye covered and the child standing at the appropriate distance
listed, show the pictures one at a time, eliciting a response after each showing.
5. Show the same pictures in different sequence for the other eye.
6. To record findings, the denominator is always constant at 30, because a child with
normal vision should see the picture on the card (target) at 9m (30feet). To
document the numerator, determine the greatest distance at which three of the
pictures are recognized by each eye, for example, right eye= 20/30.

N
The child should correctly identify three of the cards in three trials. Two to three-year-
old children should have 15/30 vision. Three –to-four-year children should be able to
achieve a score of 15/30 to 20/30. Each eye should have the same score.
A/P
If the scores for the patient’s right and left eyes differ by 1.5 m (5feet) or more or either
or both eyes score less than 15/30, refer the patient to an ophthalmologist.

Strabismus Screening
The Hirschberg test and the cover-uncover test screen for strabismus. The latter is the
more definitive test.