Behavioral Problems* Poor parent-child interactions Sibling rivalry
Inappropriate parental discipline "Difficult temperament" Developmental Delay (see DDST) Gross motor delay Fine motor delay
Language delay (expressive, receptive) Delay in social or emotional tasks Social or Environmental Problems Parental problem, e.g., stress, depression Risk for abuse or neglect Neurologic Problems Weakness Abnormal posture Spasticity Clumsiness
Attentional problems and hyperactivity Autistic features Specific Systems
The initial paragraphs of each section in this chapter describe components of the examination that can be accomplished by observation alone.
*Note: The child's behavior during the visit may not represent typical behavior, but your observations may serve as a springboard for discussion with parents.
quickly. Make sure they remain solidly in their parent's lap throughout much of the examination.
Engage children in conversation appropriate to their ages, and then ask simple questions about themselves, their illness, or their toys. It is helpful to compliment them about their appearance or behavior, tell a story, or play a simple game or trick to "break the ice." If a child is shy and reticent, turn your attention to the parent to allow the child to warm up to you gradually.
You can observe a lot just by watching.
The physical examination, with certain exceptions, does not need to take place on the examining table; it can occur on the floor or with the child sitting on the parent's lap. The key is to engage the child's cooperation. For the few young children who resist undressing, expose only the part of the body being examined. When examining two or more siblings, it is wise to begin with the older one, who is more likely to cooperate and set a good example.
Your approach to the child should be pleasant. Explain each step of the examination as you are performing it. Keep up a running conversation with the parent or the child during the examination to provide distraction.
Plan the order of the examination so that you do the least distressing procedures first and the most distressing (which tend to involve the throat and ears) last. Start with the parts that can be accomplished while the child is sitting—for example, examination of the eyes, palpation of the neck, percussion, and auscultation.
Lying down may make the child feel more vulnerable and more likely to resist further examination, so make this change with care. Once the child is supine, examine the abdomen first, saving either the throat and ears or genitalia for last.
Remember that the physical examination is designed to gather essential information, and an incomplete examination is frustrating for both you and the parents. Thus, patience, distraction, play, flexibility in the order of the examination, and a caring but firm and gentle approach are all keys to successfully examining the young child.
Usually, resistance to the examination is developmentally appropriate. Many toddlers will strive to stay upright and seek the comfort of their parents. In these cases, avoid conveying frustration and reassure the parents that this behavior is normal. Some parents become embarrassed and scold the child, compounding the problem. Involve the parent in the examination (by removing diapers or palpating the abdomen) and play with the child. If needed, pause to allow the child to recover. Learn which techniques work best for you and which approach you find most comfortable. It is not unusual to require a parent's help to restrain the child for examination of the ears or throat. However, use of formal restraints is not appropriate.
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