Physical Exam Key Points

1. Vital signs and growth parameters. Fever should be confirmed and weight loss or growth failure recorded. Hypertension may be a clue to renal involvement. Respiratory rate may be elevated in patients with chest disorders.

2. Skin. Examination should be meticulous, evaluating for skin breaks, nodules, and rashes, which may be clues to the diagnosis. Petechiae may be another clue.

3. EENT. Conjunctivae may demonstrate injection or even splinter hemorrhages in endocarditis. Fundi and disk margins should be examined. EENT exam should include pneumatic otoscopy (otitis media is overdiagnosed) and clinical exam of the sinuses.

4. Lymph nodes, organomegaly. Generalized disorders often include generalized adenopathy and enlargement of liver spleen, or both. Regional lymph node enlargement may be a clue to disorders such as cat-scratch disease.

5. Chest and lungs. Changes in breath sounds or adventitious sounds may confirm a localized process.

6. Heart. A new murmur may be a result of infection or a disorder such as rheumatic fever.

7. Abdomen and perianal area. Assess for pain, masses, and bowel sounds. Patients with a previously ruptured, walled-off appendix may present with prolonged fever and diarrhea. Regional enteritis commonly involves the anus; skin tags and fissures may be clues.

8. Extremities, bones, back. A search for localized tenderness may be critical to making a correct diagnosis. Be certain to examine the spine for flexibility and paraspinous muscle spasm.

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