Do

Assess Tanner staging for both male and female patients. You should assess and report pubic hair development separately from breast or genitalia development.

Girls	Hair (Pubic/Axillary)	Breasts
Stage I	No coarse/pigmented hair	Papilla elevated only
Stage II	Scant course pigmented hair on labia	Breast buds palpable, areola enlarge
Stage III	Course, curly hair over mons pubi, sAxillary hair develops	Elevation on contour, areola enlarge
Stage IV	Hair of adult quality, not on lateral thigh	Areola forms a secondary mound on the breast
Stage V	Spread of hair to lateral thigh	Adult breast contour

See: Bickley, LS and PG Szylagyi. Bates’ Guide to Physical Examination and History Taking, 8th edition. 2003. Lippincott Williams & Wilkins, Philadelphia pp: 700,714

Boys	Hair (Pubic/Axillary)	Testes	Length Penis
Stage I	No coarse/pigmented hair	<2.5 cm	No growth
Stage II	Scant course pigmented hair at base of penis	2.5-3.2 cm	Earliest increase length/width
Stage III	Course, curly hair over pubis	3.6cm	Increased growth
Stage IV	Hair of adult quality, not on lateral thigh Axillary hair develops	4.1-4.5	Continued growth
Stage V	Spread of hair to lateral thigh	>4.5 cm	Mature genital size

See: Bickley, LS and PG Szylagyi. Bates’ Guide to Physical Examination and History Taking, 8th edition. 2003. Lippincott Williams & Wilkins, Philadelphia pp: 707

Know

Pubertal changes typically occur between the ages of 8 and 14 in girls and 9 and 16 in boys. Occurrence of pubertal changes outside these ranges should be evaluated.

Precocious puberty:

Benign precocious adrenarche: may occur in boys before age 9 and girls before age 8; absence of penile enlargement in boys or of clitoral enlargement in girls distinguishes this from pathologic virilization. Precocious thelarche: isolated premature breast development in girls
Other causes include: CNS tumors, Ovarian cysts, Gondal tumors, Congenital adrenal hyperplasia, exogenous sources

Delayed puberty:

Constitutional (physiologic): most common, occurs in boys more often and is associated with delayed growth and bone age; ask about family history
Other causes: Malnutrition (including anorexia nervosa), chronic disease, Central causes (hypothalamic/pituitary abnormality, tumors, drugs, other endocrine problems like hypothyroidism), gonadal causes (chromosomal—XXY, XO, anatomic abnormalities, immunologic).

An excellent demonstration of the 2 minute orthopedic examination in an older child can be found: www.clippcases.org case # 6 (Mike pre-sports physical); also Chapter 17 in Goldbloom’s Pediatric Clinical Skills (p 311).

Do

Be able to perform a basic musculoskeletal examination (see ICMII benchmarks)
Additional techniques:

Assess the strength major muscle groups of the upper and lower extremities

Be able to test pelvic girdle strength: Ask the patient to sit on the floor and then stand up.
Lower extremity strength/joint function: Ask the child to squat and walk like a duck across the room.

Back examination

Inspect the back for spinal dimples & midline abnormalities such as a tuft of hair, midline nevi or central dimple (this should be done beginning in infancy)
Assess whether the spinal dimples are level

Inspect the patient back from behind when the stand. If the spinal dimples are at the same level, there is not significant leg length discrepancy. (example page 273 Goldbloom)

Assess symmetry/ screening for scoliosis:

Shoulders should be at the same level, as should posterior superior iliac crest.
Inspect the patient’s back when they are facing away from you.
Have the child bend forward at the waist keeping knees straight and allowing arms to hang freely; ribs/thorax should be symmetric

Know

Gower’s sign occurs when a child is unable to rise from a sitting to standing position without assistance. This sign indicates proximal muscle weakness

Midline abnormalities may indicate an underlying spinal cord or vertebral abnormality

Scoliosis occurs is common in children and screening is a part of the adolescent examination

Excessive thorasic kyphosis that persists when the child lies down is pathologic

References:

Goldbloom, R B. Pediatric Clinical Skills, 3rd edition. 2003 Elsevier Science (USA) Philadelphia. This is a gold mine of tips and techniques for the pediatric history and physical. Excellent pictures and explanations are included in each chapter.

Bickley, LS and PG Szylagyi. Bates’ Guide to Physical Examination and History Taking, 8th edition. 2003. Lippincott Williams & Wilkins, Philadelphia.
This textbook provides an excellent basic introduction to the pediatric history and physical.

Zitelli, BJ and H. W. Davis. Atlas of Pediatric Physical Diagnosis, 4th Edition. 2002 Elsevier Science, Philadelphia.
This book is an outstanding reference for physical diagnosticians in pediatrics. It provides both normal and abnormal findings and is subdivided by subspecialty with an emphasis on diagnoses that have significant findings on physical exam.

Other references:

1. Eye examination in infants, children and young adults by pediatricians. Pediatrics 2003 111:902-907. [AAP committee recommendations]

2. US Preventive Services Task Force. Screening for visual impairment in children younger than age 5 years:recommendation statement. Ann Fam Med May 1, 2004; 2(3):263-266.

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