Physical Assessment of the Child And Adolescent: An Overview of Normal vs. Abnormal Physical Examination Findings
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Physical Assessment of the Child
And Adolescent: An Overview
of Normal vs. Abnormal Physical
Examination Findings
WENDY L. WRIGHT, MS, RN, ARNP, FNP, FAANP, FAAN
ADULT/FAMILY NURSE PRACTITIONER
OWNER – WRIGHT & ASSOCIATES FAMILY HEALTHCARE @ AMHERST AND @ CONCORD
OWNER – PARTNERS IN HEALTHCARE EDUCATION
1
Disclosures
Speaker Bureau: Sanofi-Pasteur, Merck, Pfizer, AbbVie,
Biohaven
Consultant: Sanofi-Pasteur,, Pfizer, Merck, GSK
2
Wright, 2021 1Objectives
Upon completion of this lecture, the participant will be able to:
Describe the essential components of a comprehensive physical
examination on a child and adolescent
Identify normal vs abnormal physical examination findings
Identify special maneuvers which can identify pathology in children
and adolscent
3
Let’s Talk
About Some
Common
Problems
4
Wright, 2021 2Eye Complaint: History
Chief complaint
HPI, including the following associated symptoms:
Pain, itching, discharge, tearing, blurring, visual acuity changes, foreign
body sensation, photophobia, halo vision
5
History (continued)
Present status of visual function
Corrective lens, glasses and use
Last eye examination
Medications
Systemic
Ocular
Allergies
Past history
Ocular disease
Systemic disease
6
Wright, 2021 3History (continued)
Surgeries (if pertinent)
Family History
Ocular diseases
Systemic diseases
7
Physical Examination
Eyebrows
Note quantity and distribution of hair
Note any scaling or lesions
**Eyebrows are symmetrical and evenly distributed; No
dryness, scaling, or thinning of the lateral 1/3.
**Thinning of the lateral 1/3 of the eyebrow-
hypothyroidism
**Scaling-seborrheic dermatitis
8
Wright, 2021 4Eyelids
Lids should close in unison to cover the entire eye
Upper lid margin rests on the superior border of the iris
Lower lid margin rests on the inferior border of the iris
Palpebral fissure: Space between the upper and lower
lid
** Lids close in unison to cover entire eye. The
upper lid margin is at the superior border of the iris
and the lower lid is at the inferior border of the iris.
9
Abnormalities of Eyelids
Widening of the palpebral fissure
Hyperthyroidism (Exophthalmos)
Decrease in palpebral fissure size
Dehydration (Enophthalmos)
Ptosis
Cranial Nerve III Dysfunction
Muscular Dystrophy
10
Wright, 2021 5Exophthalmos
11
Ptosis
12
Wright, 2021 6Lid Margins
Lid Margins
Skin tone
Inversion or Eversion
Lesions
** The lid margins are appropriately colored; No lesions, edema, inversion
or eversion.
13
Abnormalities of the Lid Margins
Lesions: Hordeolum, Chalazion
Edema: Allergic Conjunctivitis, Crying, Infection
Entropion: Inversion of Lid Margin
Spasm or scarring of the lid
Eyelashes often invert and irritate the conjunctiva and
cornea
Ectropion: Eversion of Lid Margin
Aging
Exposes the conjunctiva to bacteria
Eye does not drain properly-tearing
14
Wright, 2021 7Entropion
15
Ectropion
16
Wright, 2021 8Eyelashes
Note
Color
Distribution
Direction in which they point
Discharge
**Eyelashes are ____ in color, evenly distributed, outward pointing; No
discharge or thinning.
17
Abnormalities of Eyelashes
Thinning
Make-up
Trichotillomania
Alopecia
Discharge
Conjunctivitis
Blepharitis
Dacryocystitis
18
Wright, 2021 9Blepharitis
19
Dacryocystitis
20
Wright, 2021 10Conjunctiva
Conjunctiva
Clear covering over the visible parts of the eye (except the
cornea)
Protective covering for the eye
Bulbar
Clear covering and the blood vessels that cover the sclera
Palpebral Conjunctiva
Thin covering above and below the eyeball
Forms deep recesses that fold forward to join the eyelid
21
Normal Conjunctiva
22
Wright, 2021 11Conjunctiva
Bulbar and Palpebral Conjunctiva
Color
Injection
Lesions
Foreign bodies
**Conjunctiva is clear and appropriately colored; No
injection, pallor, lesions, or foreign bodies.
23
Abnormalities of the Conjunctiva
Injection
Conjunctivitis, Irritation from Contact Lens, Iritis, Glaucoma
Pallor
Anemia
Lesions
Pterygium: An opaque, triangular shaped conjunctival lesion
usually seen nasally and able to extend over the cornea. May
interfere with vision.
Pinguecula: Yellow nodules usually seen at 3 and 9 o’clock on the
conjunctiva. No visual changes.
24
Wright, 2021 12Pinguecula
25
Pterygium
26
Wright, 2021 13Sclera
Sclera
White portion of the eye
May look buff-colored or pale yellow in the periphery
Note
Color
Texture
Lesions
**Sclera are white, smooth; No lesions or icterus.
27
Sclera
28
Wright, 2021 14Abnormalities of Sclera
Yellow sclera
Physiologic or pathologic jaundice
Resolving subconjunctival hemorrhage
Red appearing sclera
Subconjunctival Hemorrhages
Note: It is actually the bulbar
conjunctiva not the sclera that
becomes jaundiced or red.
29
Excessive Vomitting Causing
Subconjunctival Hemorrhages
30
Wright, 2021 15 Cornea
Cornea
Portion of the anterior aspect of the eye which when
viewed from the side, protrudes forward
Transparent covering that protects the eye
Avascular covering over the iris and pupil
Note (Use a penlight and view from the side)
Appearance
Shiny
Lesions
Corneal Light Reflex
31
Cornea
32
Wright, 2021 16Cornea
**Cornea are smooth, transparent,
and shiny; No lesions or opacities.
Corneal light reflex is symmetric
bilaterally.
33
Abnormalities of the Cornea
Arc
Corneal arcus or arcus senilis
Thin
gray-white arc or circle that lies close to the
edge of the cornea or edge of the iris
Causes: aging, african americans, hyperlipidemia
Abrasion
Mild
injury to the cornea
Causes include foreign body, trauma, contact lens
Symptoms: pain, photophobia, discharge
34
Wright, 2021 17Corneal Abrasion
35
Herpes Simplex
36
Wright, 2021 18Abnormalities of the Cornea
Corneal Ulceration
Opacities
Cataracts
Scarring
Asymmetric Corneal Light Reflex
Strabismus (esotropia or exotropia)
37
Corneal Ulcer
38
Wright, 2021 19Asymmetric Corneal Light Reflex
39
Exodeviation
40
Wright, 2021 20 Iris
Iris
Colored portion of the eye
Contains muscle that surround the pupil and control pupillary size
These muscles are innervated by CN III
Note
Appearance
Shape
41
Note
Iris
Color
Detail
Anterior Chamber
** Iris is round, symmetric, ____ in color, and with clear detail. The anterior
chamber is without blood or pus.
42
Wright, 2021 21Iris
43
Abnormalities of the Iris
Hyphema: Blood in the anterior chamber
Trauma
Hypopion: Pus in the anterior chamber
Infection
Anterior uveitis (formerly, iritis):
Moderate pain, decreased vision, pupil is small and will
become irregular over time
Becomes irregular because the swelling distorts the pupil
Associated with many systemic disorders
Rheumatoid arthritis, SLE, Ankylosing spondylitis
44
Wright, 2021 22Abnormalities of the Iris
Iris Color Is Not Identical
Heterochromia Iridis
If this is seen, suspect Horner’s syndrome
Horner’s syndrome: Sympathetic nerve disruption, most often in the neck.
Iris is lighter in color, ptosis of eyelid, loss of sweating on forehead, and
pupil is smaller (all on the affected side)
Brushfield Spots
Down’s Syndrome
45
Pupils
Pupils
Normally round
Range in size from 3-7 mm
Allow images and light to enter
They change in size to adjust for light and to focus on an image
Note
Size
Shape
Regularity
46
Wright, 2021 23Pupils
Note
Symmetry
Newborn
Response to direct light
Older child
Response to direct and consensual light
** Pupils are ____mm, round, regular and equal bilaterally and respond
briskly to direct and consensual light.
47
Abnormalities of the Pupils
Aniscoria: Inequality of the pupils
Normal Variation: Respond normally to light
Increase in Intracranial Pressure
Acute Angle Closure Glaucoma
Severe pain
Decreased vision
Pupil is dilated
Cornea is cloudy
Increase in intraocular pressure
48
Wright, 2021 24Abnormalities of the Pupils
Miosis
Equally constricted pupils
Drugs, morphine, bright light
Mydriasis
Equally dilated pupils
Anticholinergic agents, mushrooms, increased intracranial pressure
Inability to accommodate
Cranial nerve defect (III, IV, VI)
49
Visual Acuity
Visual Acuity
Test of central vision
Controlled by cranial nerve II (Optic)
Use a Snellen Chart (wall or hand-held)
Stand 20 feet from wall chart
Place hand held Snellen 13 inches from face
50
Wright, 2021 25Visual Acuity
Infants
Central vision is present, may just see light
Optimum distance for visualization: 8-12 inches
Assess by checking direct and consensual response
to light, blinking, extending the head in response to a
bright light (Optical blink reflex) and blinking in
response to a quick movement of an object toward
the eye
2-4 weeks, should be able to fixate on objects
5-6 weeks, coordinated eye movements
51
Visual Acuity
Child
Vision:20/200 at 1 year old, 20/40 at 3, 20/30 at 4-5
years of age
No test that accurately measures acuity in child < 3
Can test using a hand-held Snellen chart or a wall
chart
Letters and Lazy E are the best tests
Older Child and Adult
Adult visual acuity is reached at approximately 6
years of age
52
Wright, 2021 26Visual Acuity
Visual Acuity is ____OD, ____OS, and ____OU (corrected or
uncorrected)
53
Abnormalities of Visual Acuity
Absence of a direct or consensual
response to light, absence of blinking,
negative optical blink reflex, or failure
to blink when an object is moved
quickly toward the eye: Blindness
Asymmetric Visual Acuity: Amblyopia
54
Wright, 2021 27Red Eye
Differential falls into the following categories
Infections with or without trauma (conjunctivitis)
Inflammation with or without trauma (uveitis)
Vascular (subconjunctival hemorrhage)
Systemic diseases
Allergies
Chemical
Acute glaucoma
55
Non-vision Threatening Causes of Red Eye
Subconjunctival hemorrhage
Hordeolum
Chalazion
Blepharitis
Conjunctivitis
Dry eyes
Corneal abrasions
56
Wright, 2021 28Hordeolum
Etiology
Obstruction of the glands of Zeiss
Staphylococcal aureus is the most common causative organism
History
Swollen, red, painful lesion on the lid margin
Itchiness of the eyelid
57
Hordeolum
Physical examination
Erythematous, tender nodule on the margin of the eyelid
Surrounding edema
Treatment
Warm compresses-20 minutes qid
Antimicrobial ointment or drops
Good eye hygiene and handwashing
58
Wright, 2021 29Hordeola
59
Hordeola
60
Wright, 2021 30Internal Hordeola
61
Chalazion
Etiology
Obstructed meibomian glands
Chronic inflammatory lesion that grows inward as it enlarges
May become infected
History
Lesion on the outside of the eye
May become slightly inflamed
Usually non-tender
62
Wright, 2021 31Chalazion
Physical examination
May or may not visualize a nodule on the outside of the
eyelid
Visible on the inside of the lid
May become erythematous, tender and edematous
Treatment
None
Antimicrobialagent if infected
Surgical management
63
Chalazion
64
Wright, 2021 32Chalazion
65
Case Study 1: TM
TM is a 19 y.o.w.m student with a 2 day history of
yellow discharge & redness in both eyes.
Began approximately 2 weeks after developing a cold
Associated with a mild blurring of the vision and itching
Denies
pain, photophobia, other visual changes,
headache
Has done nothing to treat
Meds: none; Allergies: NKDA, NKEA
PMH: Noncontributory
PE:Visual acuity 20/20 OD, OS, OU; 4 mm preauricular
node
66
Wright, 2021 33Viral Conjunctivitis
Etiology
Adenovirus is the most common cause
40 strains available
Recent studies have shown that they can remain
viable on plastic and metal surfaces for up to 1 month
Symptoms
Watery discharge, foreign body sensation, redness
URI symptoms are common including sore throat and
fever
Often bilateral
67
Viral Conjunctivitis
Signs
Normal visual acuity, PERRLA, EOMI, Fund nl
Mucoid-slightly watery discharge
Mild, diffuse injection
Preauricular lymphadenopathy
Treatment
Symptomatic only
Cool compresses
Strict eye hygiene
68
Wright, 2021 34Viral Conjunctivitis
69
Viral Conjunctivitis
70
Wright, 2021 35Viral Conjunctivitis
71
Bacterial Conjunctivitis
Etiology
Staphylococcal
Streptococcus pneumoniae/pyogenes
Haemophilus influenzae
Neisseria
Symptoms
Redness, swelling, purulent discharge, itching
No symptoms until eye complaints began
72
Wright, 2021 36Bacterial Conjunctivitis
Signs
Normal visual acuity, PERRLA, EOMI, Fund nl
Diffuse injection
No ciliary injection
Unilateral at onset
Treatment
Topical antimicrobials x 5-7 days
Warm compresses qid x 10-20 minutes
Strict eye hygiene given contagion
73
Bacterial Conjunctivitis
74
Wright, 2021 37Bacterial Conjunctivitis
75
Vision Threatening Red Eye
Disorders
Corneal Infections or Ulcerations
Hyphema
Hypopion
Iritis/Uveitis
Acute Angle Closure Glaucoma
Orbital Cellulitis
Chemical injury (particularly-alkali)
76
Wright, 2021 38Case Study 3: TY
TY is a 6 yowm who presents with his mom
for an evaluation of (R) pink eye.
Began this am. Denies discharge,
itching, recent URI. Mom denies trauma
but does report strange occurrence
yesterday. He failed to respond to her
calling. When he finally came, he
reported being asleep outside.
PE: Absent red reflex-OD; Visual acuity
20/100 (OD); 20/30 (OS); Pupil-slightly
constricted (OD). Unable to view the
fundus (OD)
77
Hyphema
Definition
Bleeding into the anterior chamber of the iris
Causes include trauma or surgery
Symptoms
Pain, red eye, blood in anterior chamber
Blurred or Absent vision
Signs
Absence of the red reflex
Blood in the anterior chamber
Increased IOP
78
Wright, 2021 39Hyphema
Signs
Decreased visual acuity
Injected conjunctiva (mild-severe)
79
Hyphema
80
Wright, 2021 40Complication of
Hyphema
81
Hyphema
Treatment
Always assume that the globe is ruptured as 25% have other serious
ocular injuries
Shield the eye and refer immediately
Can lead to devastating visual complications including blood staining
of the cornea, glaucoma, atrophy of the optic nerve
82
Wright, 2021 41Reasons to Refer Immediately
Sudden unilateral loss of vision
Lacerations that involve the lid margin or tear duct apparatus
Ocular pain, photophobia, ciliary injection
Corneal ulceration
Hyphema or Hypopion
Pupillary distortion
Central or deep foreign body
Iritis or scleritis
83
Blowout Fracture
84
Wright, 2021 42Ears
85
John...
John is a 19 year old male who is new to the
practice. Presents with a 3-day history of right ear
pain, nasal discharge and fever of 102.
Decreased sleep and appetite. Last urine-2 hours
ago.
PE:Ears: Canals pale white. Right TM erythem, edem
and without movement. Left TM-slightly retracted.
Nasal mucosa pink. Tonsils pink: no exudate. Nodes:
nonpalpable, nontender; Lungs: clear bilaterally
86
Wright, 2021 43Ear Canal
Anatomy Overview :
The external canal is an S-shaped pathway leading to the
middle ear
Itis approximately 2.5 cm long, covered with a thin layer of
very sensitive skin.
The canal is protected and lubricated with cerumen,
secreted by the sebaceous glands in the distal 1/3 of the
canal.
87
Otitis Media
Symptoms
Fever
Pain
Discharge from ear
Tugging or batting at the ear
Irritability, crying, lethargy
Decreased appetite
Decreased sleep
Recent URI
88
Wright, 2021 44Otitis Media
Signs
Red, bulging tympanic membrane
Retracted with pus, fluid or air bubbles
No movement with insufflation
Inability to see normal landmarks
Occasionally-hole in the tympanic membrane
89
Ears
Auricles
Position
Size
Lesions
**Auricles are level with the outer canthus of the eye
and symmetric. They are proportionate in size to the
body without lesions or deformities
90
Wright, 2021 45Abnormalities of the
Auricle
Small or Low-Set Ears: Congenital Defects
Accutane exposure in utero
Large Protruding Ears: Fragile X Syndrome
Protruding Ears: Mastoiditis
91
EARS
Ear Canal
Before age 6, pull auricle down, back, and out
Color
Lesions
Discharge
Foreign body
**Ear canals are pale white with a _____amount of
hair present. There are no lesions, discharge or
foreign bodies
92
Wright, 2021 46Abnormalities of the Ear Canal
Erythema and discharge: Otitis externa
Foreign body
Cerumen
Cholesteatoma
93
EARS
Tympanic Membrane
Color
Appearance
Bony Landmarks
Cone of Light
Insufflation
**Tympanic membrane is pearly gray, moveable, and
intact AU. The bony landmarks are clearly visible. The
cone of light is at 5 o’clock on the right and 7 o’clock
on the left. There is no erythema, perforations, or
retractions.
94
Wright, 2021 47Variations of Tympanic
Membrane
Normal TM
Acute OM
Otitis Media
with Effusion
95
Abnormalities of the Tympanic
Membrane
Erythematous, Bulging TM: Otitis Media
Retracted TM: Eustachian Tube Dysfunction, Serous OM
Bullae on TM: Bullous Myringitis
Perforation: Trauma, OM, Flying
96
Wright, 2021 48AOM
S. pneumoniae
Gram-positive
diplococci
=> 25% PCN-
resistant via altered
protein- binding
sites
Veryunlikely to
resolve on own
Usually the sickest
97
Acute OM
H. influenzae
Gram-negative bacilli
=>40% amoxicillin-
resistant via beta-
lactamase production
M. Catarrhalis
90-95% beta-lactamase
producing
Likely to resolve on own
98
Wright, 2021 49Bullous Myringitis
Intensely painful
Often presents
with TM
performation
99
Duration of Treatment for
AOM
Regimens evaluated
Numerous treatment options were evaluated
Treatment success evaluated at 12–14 days
Results
Similar response in all patients between short-
course (eg, 5 days) and standard-course (eg, 10
days) therapy
PatientsTreatment for Otitis
Media
Plan
Therapeutic
Decongestants/antihistamines: not shown to
be effective
Auralgam: analgesic for the ear
Warm compresses
NSAIDs/Tylenol
101
Otitis Media
Plan
Educational
No smoke exposure
Finish all medication
Consider ventilation tubes
102
Wright, 2021 51Nose and Sinuses
103
NOSE AND SINUSES
Skeleton
Structure
Midline
**Skeleton is straight and midline without deformities
or deviations.
104
Wright, 2021 52Nose and Sinuses
External
Vestibule
Ala Nasi
Bridge
Tip
Columnella
105
NOSE AND SINUSES
Nares
Patency
Foreign Body
**Nares are patent. No foreign bodies
**Discharge from one nare: Foreign body
106
Wright, 2021 53Anatomy and Physiology
Internal
Air enters the nasal cavity through the nares bilaterally
Airthen passes into a widened area known as the
vestibule and then on to the nasopharynx
Septum
Medial wall of the nasal cavity
Supported by bone and cartilage
Covered with mucous membranes
Well supplied with blood
107
NOSE AND SINUSES
Septum
Position
Perforation
**Septum is midline and intact without
deviations, ulcerations, or perforations.
**Deviation may be present in some
children, particularly after a nasal fracture or
birth process, and may interfere with nasal
breathing.
108
Wright, 2021 54NOSE AND SINUSES
Mucosa
Color
Discharge
Edema
Polyps
**Mucosa is pink and without discharge, edema, erythema, or
lesions.
**Erythematous Mucosa: Viral or Bacterial Infection:
**Pale, Boggy Mucosa or Polyps: Allergic Rhinitis
109
Anatomy and Physiology
Turbinates
3 sets: Inferior, middle and superior
Located laterally
Bony structures
Protrude into the nasal cavity
Functions
Increases surface area of the nose & mucosa
Cleans the air
Warms the air
Humidification
110
Wright, 2021 55NOSE AND SINUSES
Turbinates
Color
Edema
Discharge
**Lowerand middle turbinates are darker in color than
the mucosa and without edema or discharge.
**Erythematous, Edematous Turbinates: Sinusitis
**Pale, Boggy Turbinates: Allergic Rhinitis
111
Sinuses
4 sets of sinuses
Maxillary
Ethmoid
Sphenoid
Frontal
**All are present at birth, except the frontal,
which develops at 1 year of age
112
Wright, 2021 56Anatomy Slide
Accessed at AAAAI Patient Resource Center.
113
NOSE AND SINUSES
Sinuses
Maxillary
Frontal
Tenderness
Erythema
**Frontal and Maxillary sinuses are nontender
and without erythema or edema
**Tenderness: Sinusitis
**Erythema: Abscess
114
Wright, 2021 57Allergic Rhinitis
115
Physical Examination Findings
in the Individual With Allergic
Rhinitis
Pale, boggy mucosa and Watery discharge in nose and eyes
turbinates Ulcerations on nasal mucosa
Allergic shiners Pharyngeal edema
Allergic salute Lymphoid tissue
Conjunctival injection Nasal polyps
Cobblestoning Long eye lashes
Allergic facies High arched palate
Dennie’s lines
116
Wright, 2021 58117
118
Wright, 2021 59119
120
Wright, 2021 60121
122
Wright, 2021 61123
PHARYNGITIS
124
Wright, 2021 62Pharyngitis
Epidemiology
30 million patients seen yearly in US for pharyngitis
Most often seen in colder months
Peak age: 5-8 years; however with increase in # of children in daycare at
younger age, it is occurring in younger children
Tonsils serve as our 1st line of defense against respiratory pathogens
125
Pharyngitis
Epidemiology
Tonsils are small in infancy
Increase in size until approximately 10 years of age and then they regress
Pathogens for pharyngitis spread via person to person
Pathogen
Group A Beta hemolytic strep
1/3-1/2 of cases in children aged 2 - 14
Non-group A strep
Viral pharyngitis: 1/2 of cases in infants < 2
126
Wright, 2021 63Pharyngitis
Epidemiology
Group A Beta Hemolytic Strep
Most interest because of its association with severe complications
Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis -
complications
Rheumatic fever: 20/100,000 people in early 1900’s, now 1:100,000
Recent increase in cases
Many cases in individuals without sore throat
127
Pharyngitis
Symptoms
Group A Beta Hemolytic Strep
Rapid onset of sore throat
Fever 103-104
Swollen glands
Children often complain of abdominal pain
Usually-no URI symptoms
Headache
Decreased appetite
Dysphagia
Irritability
128
Wright, 2021 64Pharyngitis
Symptoms
Viral Pharyngitis
Usually not a severe sore throat
Low grade temp
Mild swollen glands
Associated with URI symptoms
129
MOUTH
Anatomy and Physiology
Lips
Tongue
Mucosa
Uvula
Tonsils
Posterior Pharynx
Dentition
Gingiva
130
Wright, 2021 65MOUTH
Anatomy and Physiology
Lips
Tongue
Mucosa
Uvula
Tonsils
Posterior Pharynx
Dentition
Gingiva
131
MOUTH
Lips
Color
Moisture
Lesions
Abnormalities
**Lips are appropriately colored and moist; No
lesions or abnormalities
132
Wright, 2021 66Abnormalities of the Lips
Blue: Cyanosis
Abnormal Development: Cleft Lip
Vesicles: Herpes Simplex, Impetigo
Thin Upper Lip: Fetal Alcohol Syndrome
133
Mouth
134
Wright, 2021 67MOUTH
Tongue
Position
Size
Deviation
Lesions
Coating
Frenulum
**Tongue is straight, appropriate size and midline. It is lightly
papillated without lesions or coating. Frenulum is intact.
135
Abnormalities of the Tongue
Deviation: Cranial Nerve XII
Dysfunction
White Coating: Thrush
Thick Frenulum: Tongue Tie
Protruding Tongue: Angelman
Syndrome
Ulcerations: Thrush, Apthous
Stomatitis, Coxsackie Virus
136
Wright, 2021 68MOUTH
Mucosa
Color
Lesions
Coating
Moisture
**Mucosa is appropriately colored,
smooth, and moist without lesions,
masses or coating.
137
Abnormalities of Buccal Mucosa
Coating: Thrush
Ulcerations: Chewing Tobacco; Apthous
Stomatitis; Hand, Foot, and Mouth Disease
138
Wright, 2021 69MOUTH
Hard and Soft Palate
Continuity
Lesions
**Hard and Soft Palate are continuous without lesions or
abnormalities.
**Incongruous Hard and Soft Palate: Cleft Palate
**Ulcerations: Thrush, Apthous Stomatitis, Coxsackie Virus
**Coating: Thrush
139
MOUTH
Uvula
Position
Color
Lesions
**Uvula is midline and smooth. It rises with phonation
and is without lesions, erythema, or deviation.
Asymmetry: CN X Dysfunction, Tonsillar Abscess
Erythema: Viral or Bacterial Pharyngitis
140
Wright, 2021 70MOUTH
Tonsils
Anterior and Posterior Pillars
Color
Edema
Exudate
**Tonsils are present bilaterally and
without edema, erythema, or
exudate.
141
Abnormalities of the Tonsils
Erythematous, Edematous: Viral or Bacterial Pharyngitis
Exudate: Bacterial Pharyngitis, Mononucleosis, Viral
pharyngitis
Asymmetric Enlargement: Tonsillar Abscess
142
Wright, 2021 71MOUTH
Posterior Pharynx
Color
Lesions
Edema
Exudate
**Posterior pharynx is pink without lesions, erythema,
exudate, or edema.
**Lymphoid tissue: Viral or Allergic Illness
**Exudate and Edema: Strep Pharyngitis
143
Pharyngitis
Signs
Group A Beta Hemolytic Strep
Erythematous, edematous tonsils, uvula
Exudate
Lymphadenopathy
Palatal petecchiae
Fever
Rash-scarletina
144
Wright, 2021 72Pharyngitis
Signs
Viral Pharyngitis
Slightly erythematous tonsils
Can have exudate
URI physical exam findings
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Exudative pharyngitis
Exudative pharyngitis
Differentials include:
Strep pharyngitis
Peritonsillar abscess
Mononucleosis
Viral pharyngitis
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Wright, 2021 73Scarletina
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Strawberry Tongue
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Wright, 2021 74Pharyngitis
Plan
Diagnostic
Throat culture: 24 hour is the gold standard
Quick strep: 85-100% specificity; 31-95%
sensitivity
Must swab both tonsils for best results
Consider mononucleosis
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Pharyngitis
Even with a best case
scenario, 1/3 - 1/2 of cases
of strep pharyngitis are
missed or overdiagnosed
using history and physical
examination only!!!
MUST DO A THROAT CULTURE
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Wright, 2021 75Remember…
Adolescents/Young
Adults with mono
have strep
pharyngitis 50% of
the time
151
Peritonsillar Abscess
Generally begins as an acute febrile URI or pharyngitis
Condition suddenly worsens
Increased fever
Anorexia
Drooling
Dyspnea
Trismus
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Wright, 2021 76Peritonsillar Abscess
Physical examination
May appear restless
Irritable
May lie with head hyperextended to facilitate respirations
Muffled or “hot potato voice”
Stridor may be present
Respiratory distress
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Peritonsillar Abscess
Physical examination findings
Fiery red asymmetric swelling of one tonsil
Uvula is often displaced contralaterally and often
forward
Large, tender lymphadenopathy
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Wright, 2021 77Peritonsillar Abscess
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Peritonsillar Abscess
Trismus
156
Wright, 2021 78Peritonsillar Abscess
157
Peritonsillar Abscess
158
Wright, 2021 79Cardiac
Examination
159
Heart Sounds
Auscultate for rate, rhythm and presence of extra heart
sounds with the athlete in a supine position
The heart should also be auscultated in a sitting and standing
position
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Wright, 2021 80Cardiac Physical
Auscultation Examination
Locations
Auscultate in 5 locations with the bell
and the diaphragm
Aortic - 2nd ics, right sternal border
Pulmonic - 2nd ics, left sternal border
Erb’s point - 4th ics, left sternal border
Tricuspid - 5th ics, left sternal border
Mitral - 5th ics, left midclavicular line
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Cardiac Physical
Heart Sounds Examination
S1: Mitral and Tricuspid closure
Abnormally loud: Mitral stenosis
S2: Aortic and Pulmonic closure
Physiologic split: common, widens with inspiration
Fixed split: ASD, pulmonary stenosis
S3: Early diastole
2 types: Physiologic and Pathologic
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Wright, 2021 81S3 Heart Sound
Physiologic
Heard in about 1/3 of children under 16
Rarely in adults over 30
Pathologic
To differentiate from physiologic, correlate with history and physical
examination findings
Sign of poor cardiac output
Seen with CHF
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S4 Heart Sound
Known as an atrial gallop
Late diastole
Physiologic and Pathologic
Physiologic
Virtually never seen except in exceptionally trained athletes (50% of
pro basketball players, runners)
Pathologic
Poor ventricular compliance
Long-standing hypertension, CHF, HCM
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Wright, 2021 82Click
Systolic in timing
Mid-late systolic click: MVP
Early systolic click: Mitral stenosis
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Murmur
Sound of turbulent blood flow
Blood flowing through the vessels and
chambers of the heart is normally silent
When blood flow becomes turbulent-a
murmur is produced
Murmurs are often described using 7
characteristics
These help the health care professional to
figure out possible causes of the murmur
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Wright, 2021 83QUALITIES OF A HEART MURMUR
1. Timing
When does it occur?
Systole, diastole or continuous
167
Heart Murmurs
Systolic
MR PASS MVP
Diastolic
MS ARD
Fitzgerald Health Education Associates, 2000
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Wright, 2021 84QUALITIES OF A HEART MURMUR
2. Shape
Is there a change in the intensity of the murmur
Crescendo, decrescendo, both
3. Location
Where do you hear it loudest?
4. Radiation
Does it radiate anywhere?
Aortic-neck; mitral-axilla
169
QUALITIES OF A HEART MURMUR
5. Intensity
How loud is the murmur?
Graded on a roman numeral scale or I through VI
170
Wright, 2021 85Intensity
Grade I: Very faint, barely audible
Grade II: Soft, quiet but easily heard
Grade III: Moderately loud; no thrill
Murmur is as loud as S1 and S2
Grade IV: Loud, thrill is present
Grade V: Very loud, thrill is present
Grade VI: Able to be heard with stethoscope off chest; thrill is
present
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Systolic Murmurs
Mitral
Regurgitation
Physiologic
Aortic
Stenosis
Systolic
Mitral
Valve
Prolapse
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Wright, 2021 86Additional Systolic
Murmurs
· Systolic Murmurs
ASD, VSD
Coarctation of the Aorta
Picked up at birth
Adult type: 2nd - 3rd I.sp, rad - back, thrill
Unequal femoral pulses
Tetralogy of Fallot
Picked up at birth; baby often in distress
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Physiologic Murmur
Physiologic Murmur
Caused by turbulence around the valves due to a
temporary increase in blood flow
Etiology
Fever, hyperthyroidism, pregnancy, no cause
50% will have a physiologic murmur at some point in life
Timing: Early-mid systole
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Wright, 2021 87Physiologic Murmur
Location: 2nd-4th interspaces of LSB
Radiation: Little
Intensity: Grade I - II/VI; Occasionally III/VI
Pitch: Medium
Quality: Soft, blowing; May occasionally be harsh
175
Physiologic Murmur
Aids to Diagnosis
Softens or disappears with sitting or standing
Softens or disappears with inspiration
Associated Findings
None unless person has anemia, pregnancy, fever, hyperthyroidism
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Wright, 2021 88Sudden Cardiac Death
From 1985 - 1995: 158 cases of sudden death
during competitive exercise in the US
This translates to 1:1,000,000 athletes
4 sports have been associated with more than 5
sudden deaths
Football, soccer, basketball, track
177
Mayo Clinic Study
Significant cardiac abnormalities were found in
0.39 percent of 2,739 athletes
95% of all sudden deaths in athletes under 30
years of age have been due to structural heart
problems
178
Wright, 2021 89Hypertrophic
Cardiomyopathy
Most common cause of sudden cardiac death in
the athlete
A few well-known sports figures have died from
this disease
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HCM
Hypertrophic Cardiomyopathy
Cardiomyopathy: disease of cardiac muscle
Presents in young adulthood
Septal thickening and abnormal movements of the mitral valve; Often is
accompanied by outlet obstruction
Etiology
Strong genetic component: Autosomal dominant
Often times, family history of individuals dying prematurely as early as in
the 20’s
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Wright, 2021 90Hypertrophic
Cardiomyopathy
Clinical Symptoms
DOE
Often asymptomatic and die spontaneously during exercise
Timing: Mid-systolic
Location: Left sternal border
Radiation: Down left sternal border; occas. carotids
Intensity: Grade II and louder/VI
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Hypertrophic
Cardiomyopathy
Quality: blowing, moderately harsh
Aids to Diagnosis
Decreases with squatting, hand grip or valsalva
Increases with standing
Associated Findings
Rapid upstroke of the carotid impulse
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Wright, 2021 91Abdominal
Examination
183
Abdominal Examination
Inspection
Contour of abdomen
Flat
Scaphoid
Malnourished
Protuberant
Obesity
Gas distention from obstruction
Tumor
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Wright, 2021 92Abdominal Examination
Inspection
Skin
Color and moisture
Scars and incision
Striae (Cushing’s syndrome)
Dilated veins
Rashes or lesions (Cherry angiomas, herpes zoster)
185
Abdominal Examination
Inspection
Symmetry
Visible Organ Enlargement/Masses
Hernia: defect in the wall of the abdomen through which a mass of tissue
and occasionally the intestine protrudes
Should be reducible
Lipoma: common, benign fatty tumors in the subcutaneous tissues
Pressing down on the edge of it will cause it to
slip out from under your finger
186
Wright, 2021 93Abdominal Examination
Auscultation
Bowel sounds
Very unreliable
Can be normal in the setting of serious pathology
Borborygmi: loud, prolonged gurgles that are indicative of hyperperistalsis
Intestinal obstruction
Gastroenteritis
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Abdominal Examination
Palpation
Essential when assessing the abdomen
Light palpation
Lightly palpate the entire abdomen
Purpose:
Identify abdominal tenderness
Superficial masses
Muscular rigidity or guarding
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Wright, 2021 94Costovertebral Angle Tenderness
Tap gently on the area above the 10-12th ribs
posteriorly
Continue tapping as you move downward
“What if anything do you feel?”
CVAT-pyelonephritis
189
Mark…
Mark is a 12 yowm who presents with an 8 hour history of worsening
abdominal pain. Woke him from sleep. Epigastric at onset. Now
seems lower in right side of abdomen. Associated with nausea and
vomiting for the past 2 hours and a temp of 100. Denies bowel
changes, urinary symptoms.
Meds: none; Allergies: NKDA
What is going on with Mark?
190
Wright, 2021 95Appendicitis
Inflammation/Infection of the Appendix
Can lead to ischemia and perforation of the appendix
Etiology
Most common age: 10-19 years
Incidence: 1.1/1000 Persons each year
Males>females
Whites>Nonwhites
Summer-most common time of year
Midwest-highest incidence
191
Appendicitis
Mortality and morbidity rates remain high
Perforation rates: 17-40%
Perforation has been known to occur within 1st 24-48 hours of the
infection
192
Wright, 2021 96History of a patient with
appendicitis
Careful history is the most important aspect
Individual is usually a teen or young adult
Classic presentation: awakens in the night with vague periumbilical
pain
Worsens over the period of 4 hours
Subsides as it migrates to the RLQ
Worsened with movement, deep respirations,
coughing
193
History of a patient with
Appendicitis
Pain precedes anorexia, nausea or vomiting
Nausea and anorexia are very common
Vomiting may or may not be present
Question the diagnosis if patient is
hungry
Low grade fever or none at all
Usually seek attention within 12-48 hours
Patient will often report feeling constipated
194
Wright, 2021 97Clinical Pearl
The presence of pain before
vomiting is highly suggestive
of appendicitis.
Diarrhea before pain is more
likely to be gastroenteritis.
195
Physical Examination
Abdominal Examination
Tenderness at McBurney’s point
1/3 the distance between the anterior iliac spine and the umbilicus
Guarding
Contraction of the abdominal walls
Frequently present
Can be faked or induced
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Wright, 2021 98Physical Examination
Rigidity
Important predictor of appendicitis
Involuntary spasm of the abdominal musculature
Caused by peritoneal inflammation
Markle’s sign
Heel-drop jarring test
197
Physical Examination
Rebound tenderness
Press on area above the pain
Suddenly withdraw fingers
Rovsing’s Sign
Pain felt in RLQ when examiner presses firmly in the LLQ and suddenly
withdraws
Psoas Sign
Patient is placed in a supine position
Ask patient to lift thigh against your hand that you have placed above
the knee
198
Wright, 2021 99Physical Examination
Obturator Sign
May be or may not be positive
Patient is positioned in supine position with the right
hip and knee flexed
Internally rotate the right leg
199
Wendy L. Wright, ARNP
Family Nurse Practitioner
Owner – Wright & Associates
Family Healthcare
Amherst, NH
email: WendyARNP@aol.com
200
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