Pediatric Physical Examination An Illustrated Handbook EDITION THREE KAREN G. DUDERSTADT, PhD, RN, CPNP, FAAN Clinical Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California Children‚'s Health Center, San Francisco General Hospital, San Francisco, California 2 3 Table of Contents Unit I Pediatric General Assessment 1. Approach to care and assessment of children and adolescents, 1 Karen G. Duderstadt 2. Assessment parameters, 9 Karen G. Duderstadt 3. Developmental surveillance and screening, 22 Abbey Alkon 4. Comprehensive information gathering, 36 Karen G. Duderstadt; Naomi A. Shapiro 5. Environmental health history, 57 Karen G. Duderstadt 6. Newborn assessment, 67 Annette Carely; Karen G. Duderstadt Unit II System-Specific Assessment 7. Skin assessment, 89 Renee P. McLeod 8. Heart and vascular assessment, 110 Patricia O’Brien; Julianne Evangelista 9. Chest and respiratory assessment, 132 Concettina (Tina) Tolomeo 10. Head and neck assessment, 151 Karen G. Duderstadt 11. Lymphatic system assessment, 165 Karen G. Duderstadt 12. Eyes, 176 4 Karen G. Duderstadt 13. Ears, 195 Patricia Jackson Allen 14. Nose, mouth, and throat, 218 Patricia Jackson Allen 15. Abdomen and rectum, 239 Victoria F. Keeton 16. Male genitalia, 255 Angel K. Chen 17. Male and female breast, 273 Erica Bisgyer Monasterio; Naomi A. Schapiro 18. Female genitalia, 284 Erica Bisgyer Monasterio; Naomi A. Schapiro 19. Musculoskeletal assessment, 302 Karen G. Duderstadt; Naomi A. Schapiro 20. Neurologic assessment, 332 Karen G. Duderstadt 5 Copyright 3251 Riverport Lane St. Louis, Missouri 63043 PEDIATRIC PHYSICAL EXAMINATION: AN ILLUSTRATED HANDBOOK, THIRD EDITION ISBN: 978-0-323-47650-8 Copyright © 2019 by Elsevier, Inc. All rights reserved. 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To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2014 and 2006. International Standard Book Number: 978-0-323-47650-8 Executive Content Strategist: Lee Henderson Content Development Manager: Lisa Newton Content Development Specialist: Melissa Rawe Publishing Services Manager: Julie Eddy Senior Project Manager: Marquita Parker Designer: Brian Salisbury Printed in the China Last digit is the print number: 9 8 7 6 5 4 3 2 1 7 8 Dedication To all the students who have shaped my work as a teacher and a mentor; To the children and families whom I have had the privilege of caring for and who have enriched my life; and To Chris, my constantly patient husband, who has supported my life’s work. 9 Contributors Abbey Alkon, RN, PNP, MPH, PhD, Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California Developmental Surveillance and Screening Patricia Jackson Allen, RN, MS, PNP-BC, FAAN, Professor Emerita, School of Nursing, Yale University, New Haven, Connecticut Ears Nose, Mouth, and Throat Annette Carley, DNP, Clinical Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California Newborn Assessment Angel K. Chen, RN, MSN, CPNP, Associate Clinical Professor and Vice Chair, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California;, Pediatric Urology Nurse Practitioner, Children’s Health Center, San Francisco General Hospital, San Francisco, California Male Genitalia Karen G. Duderstadt, PhD, RN, CPNP, PCNS, Clinical Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California, Children’s Health Center, San Francisco General Hospital, San Francisco, California Approach to Care and Assessment of Children and Adolescents Assessment Parameters 10 Comprehensive Information Gathering Environmental Health History Head and Neck Assessment Lymphatic System Assessment Eyes Musculoskeletal Assessment Neurological Assessment Julianne Kristine Evangelista, DNP, MS, BSN, Pediatric Nurse Practitioner, Cardiology, Boston Children’s Hospital, Boston, Massachusetts Heart and Vascular Assessment Victoria F. Keeton, MS, RN, CPNP, CNS, Associate Clinical Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California Abdomen and Rectum Renee P. McLeod, PhD, APRN, CPNP, FAANP, Dean, Professor, College of Nursing, United States University, San Diego, California, Pediatric Nurse Practitioner, Mid-City Pediatrics, San Diego, California Skin Assessment Erica Monasterio, BSN, MN, FNP-BC, Clinical Professor, Director, Family Nurse Practitioner Program, Department of Family Health Care Nursing, School of Nursing, Clinical Professor, Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California Male and Female Breast Female Genitalia Patricia O’Brien, MSN, CPNP-AC, FAHA, Nurse Practitioner, Department of Nursing/Patient Services, Cardiovascular Program, Boston Children’s Hospital, Boston, Massachusetts Heart and Vascular Assessment Naomi A. Schapiro, PhD, RN, CPNP, Clinical Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California 11 Comprehensive Information Gathering Musculoskeletal Assessment Male and Female Breast Female Genitalia Concettina (Tina) Tolomeo, DNP, APRN, FNP-BC, AE- C, Nurse Practitioner, Director of Program Development and Operations, Yale School of Medicine, New Haven, Connecticut Chest and Respiratory Assessment 12 Reviewers Sameeya Ahmed-Winston, RN, MSN, CPNP, CPHON, Pediatric Nurse Practitioner, Children’s National Medical Center, Washington, District of Columbia Margaret-Ann Carno, PhD, MBA, CPNP, DABSM, FAAN, Associate Professor of Clinical Nursing and Pediatrics, School of Nursing, University of Rochester, Rochester, New York Caroline Farless, RN, MS, CPNP, UCSF Benioff Children’s Hospital, Pediatric Neurosurgery, San Francisco, California Emily Graf, PA-C, MSHS, Physician Assistant, Blood and Marrow Transplant, Children’s National Medical Center, Washington, District of Columbia Kari Ksar, PNP, Pediatric Nurse Practitioner, Lucile Packard Children’s Hospital, Palo Alto, California Onica Kuch, RN, MSA, CPNP, CNRN, UCSF Benioff Children’s Hospital, Pediatric Neurosurgery, San Francisco, California Nancy McLoone, RN, MS, CPNP, Assistant Professor, Pediatric Nurse Practitioner, Mankato Clinic, Minnesota State University, Mankato, Minnesota Jessica Pech, APN, CPNP, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois 13 Preface Pediatric Physical Examination: An Illustrated Handbook, third edition, is written for students, educators, and pediatric health care providers dedicated to mastering the art and technique of the comprehensive physical examination of infants, children, and adolescents. Facing increasing pressures, primary health care providers need astute assessment skills combined with quick references to assist them in caring for children and families. This third edition of Pediatric Physical Examination: An Illustrated Handbook will provide the novice or experienced provider with pediatric content from experts in the field, useful examination techniques from birth to adolescence, and pediatric clinical pearls not covered in other texts on health assessment across the life span. In response to suggestions by students and experienced clinicians who have used the text as a resource across pediatric clinical settings, the third edition includes a red flag feature in many of the chapters to alert readers to key findings across systems. Also included in some chapters of the third edition is a note on interprofessional collaboration to highlight important collaborations with pediatric specialists, physicians, behavioral health, nutritionist, and therapists to provide comprehensive care to children and families. There are also many new photos and illustrations of important assessment findings. The initial chapters of this handbook begin with an overview of the developmental approach to information gathering and assessment of children from birth to adolescence. Chapter 3 focuses on development surveillance and presents evidence on reliable and valid developmental and behavioral screening tools. Chapter 4 presents comprehensive information on history taking in infants, 14 children, and adolescents, including expanded coverage of pediatric mental health assessment. Chapter 5 reviews the unique vulnerability of children to environmental hazards and focuses on the importance of the environmental health history in identifying and reducing environmental risk factors that have an impact on child health. The most exciting addition to the text is Chapter 6, Newborn Assessment. This chapter features a head-to-toe assessment of the term newborn and reviews pertinent health history and common newborn conditions. Chapter 7 presents assessment of the skin and common pediatric findings. The chapters that follow are organized in the pediatric-oriented “quiet-to-active” approach to physical examination. Pediatric experts consider this to be the most effective approach to assessing young children. This format begins with the quieter parts of the exam—cardiac and respiratory—which require astute listening skills and less active participation of the young child. Then, Chapters 10 through 14, which cover assessment of the head and neck, eyes, ears, nose, and throat, require more active participation from the child and are better performed after the quiet parts of the physical examination. Chapter 15 reviews abdominal assessment from birth to adolescence. A unique feature of the text remains the developmental approach to examination of the male and female genitalia and the developing breast in males and females, presented in Chapters 16 through 18. Chapter 19 includes a comprehensive assessment of the child and adolescent athlete for sports participation, as well as the recent guidelines on assessment for concussion. Finally, Chapter 20 presents neurological assessment from a pediatric developmental perspective. Working with children and families is a hopeful endeavor, and health in childhood builds the foundation for health promotion and health protection throughout life. Pediatric primary care providers have a key role in protecting and improving the health of the next generation. Through astute physical assessment, providers build trust with children and families and preserve the provider/patient relationship, ultimately improving health outcomes and decreasing health care costs. This handbook assists the pediatric health care provider with this most important undertaking: promoting the 15