Physical Exam Key Points

1. General appearance. This is critically important in gauging illness severity. Is a young child running around the room playing or lying quietly, allowing strangers to examine him or her without protest?

2. Vital signs. Fever (or hypothermia) can accompany infection, neoplasia, or rheumatologic disorder. Tachycardia may suggest more severe illness, and with hypotension and fever suggests septic shock.

3. Lymph nodes. Enlarged lymph nodes can accompany infection, inflammation, or infiltrative disorders. Tender, mobile nodes are more likely to be reactive; firm, fixed, or matted nodes, malignant. Nodes up to 1 cm are usually not pathologic in children. Fluctuance suggests abscess. Location is important. Look for a source of infection in an area draining into the nodal region. Enlarged supraclavicular nodes suggest malignancy and should prompt immediate investigation.

4. Lungs. Look for signs of pulmonary infection (eg, rales, rhonchi, egophony, or decreased breath sounds). Pleural rub may accompany an infectious, malignant, or rheumatologic disorder.

5. Skin and mucosa. Petechiae, bruising, or mucosal bleeding suggests concurrent thrombocytopenia or coagulopathy, which might accompany a malignant hematologic disorder or disseminated intravascular coagulation from severe infection. Also look for rashes, which may help identify an infection or rheumatologic diagnosis.

6. Heart. New murmur in a patient with a high WBC count and fever can indicate bacterial endocarditis or rheumatic fever.

7. Abdomen. Tenderness, guarding, or rebound with leukocytosis suggests an acute abdominal process (eg, appendicitis) and would necessitate emergency surgical consultation. Hepatosplenomegaly may suggest an infiltrative disorder.

8. GU system. Pelvic pain or vaginal discharge in a sexually active girl can indicate pelvic inflammatory disease.

9. Neurologic exam. Irritability or lethargy, seizures, or cranial nerve palsies can indicate CNS infection such as meningitis or encephalitis or CNS infiltration with leukemic cells.

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