Examination+of+the+pediatric+patient

= Examination Overview = toc **History/Systems Review** ê **Appropriate Tests and Measures to implement** ê **__Rule In/Out:__**
 * Causes of body structure and function impairments
 * Activity limitations
 * Participation barriers

ê **Help establish diagnosis, prognosis, and POC for child based on current level of function** (2)

**Examination Approaches** (2, 3) o __Top-Down Approach:__ family centered, typically used for children with known diagnoses, severe activity limitations, and already in early intervention programs

1)Determine desired outcomes (goals or objectives) using input from family/care-givers

2)Complete examination and evaluation process

3)Determine strengths and barriers to achieving goals through tests and measures

4)Implement plan of care o __Bottom-Up Approach:__ common in medical model and acute care

1)Perform tests to determine child’s strengths and weaknesses

2)Professionals determine goals and objectives

3)Process influenced by severity and complexity of case, functional status, family/home/school situation, and participation in the community = History = =Interview=


 * Read complete history from referring physician
 * Obtain more information through interview of child/ family/ caregivers/ other healthcare professionals (6)
 * Include:
 * chief complaint
 * history of present illness
 * past medical history (ex: illnesses, surgeries, traumas, immunizations)
 * birth ad pregnancy history (ex: maternal health, labor/ delivery complications, due date)
 * developmental history (ex: ages achieved milestones, school issues, behavior issues)
 * feeding history (ex: breast/ bottle, allergies)
 * review of systems (ex: see systems review below)
 * family history
 * additional social components (ex: living situation, daycare situation, parents occupations)
 * *examples taken from Pedicatric Hisory and Physical Exam Document, link provided below with additional details
 * 
 * Dunn Pediatric Background Information/ Medical History: []
 * Pediatric History and Physical Exam Document: []
 * Child history example: []

Vital Signs/ Growth Indicators (6)

 * Vital signs are the baseline indicators of health
 * Pulse
 * Brachial
 * 120-200 in newborn, slows with age
 * Take for full minute
 * Respiration
 * Observe abdominal movements during sleep or when calm
 * 40-60 breaths/ minute in newborn (smaller airway diameter, fewer alveoli, thicker alveolar walls, fewer fatigue resistant fibers in diaphragm, more horizontal alignment of rib cage which all contribute to higher rate and make them more prone to respiratory dysfunction
 * By 6 RR similar to adult
 * Blood pressure
 * Chart for norms based on age, gender, height (can misclassify tall and short kids)
 * Blood Pressure Levels Based on Age and Height: []
 * Temperature
 * Gold standard in kids especially under 3 months is rectal
 * 3 months to 3 years rectal or axillary
 * 4-5 years oral or axillary
 * 5+ years orally
 * Oral is approx. 0.5 degrees lower than rectal, axillary is typically less accurate and 1 degree lower than rectal
 * Fever= 100.4 F in rectal, above 103 is serious bacterial infection
 * 20-25% of chief complaints are fever related; additional 10-15% are associated signs
 * Growth Indicators
 * Head circumference
 * Increases .6 inches/ month in first 6 months (avg. at 6 months= 17 inches
 * 2 inches/ month 6 months-1 year (avg. at 1 year= 18 inches
 * 1 inch/ year in 2nd year; .5 inches/ year over up to age 5
 * Weight
 * Double birth weight by 6 months
 * 4-6 lb gain/ year in toddlers, by 2.5 weight increased x4
 * 5 lb gain/ year between 3-5 years (due to bone and muscle development)
 * Height
 * Increases 1 inch/ month -6 months then slows
 * Increases by 50% - 1 year(mostly in trunk)
 * Toddlers gain 3 inches/ year (mostly in legs)
 * 2 years= ½ of adult height
 * 5 years= more adult proportioned appearance
 * Changes in spurts
 * <3 years measured in supine; >3 years measured standing
 * Growth issues
 * Rapid growth in first year is slowed by physiologic anorexia (typical decrease in appetite usually starting at 18 months; begin to have specific preferences for foods and consume various amounts on different days)
 * Special needs kids growth will not follow typical parameters
 * World Health Organization Child Growth Standards: []

= Systems Review = The systems review is typically considered a part of the history taking portion of the exam. It is meant to be comprehensive and is intended to uncover any signs and symptoms that may have been missed during the physical exam completed by the physician or during the initial subjective history taking (6).

Some general symptoms to look for during the review include (6)
 * Fatigue
 * Weight loss/gain
 * Change in Appetite
 * Sweating
 * Itching
 * Disruption of sleep pattern

Listed below are the systems to be checked. The diagnosis of the child will help determine the extent of the system review needed. For example, if a child is being seen for a simple musculoskeletal condition in their leg, it is unlikely that they will need genitourinary and gastrointestinal system checks. However, it is important not to disregard any system. If a physician has done a recent physical screening on that child and the physical therapist can get access to that screening, the therapist may not need to repeat all system screens. Otherwise, the physical therapist needs to consider which aspects of the systems review are most important for that child, and perform those screenings (6).

System Screenings

 * Musculoskeletal (3)**
 * Record height, weight, head circumference
 * Observe size and shape of head, face, and skull
 * Observe abnormalities of eyes, ears, nose, mouth, palate, teeth
 * Observe and measure bruising, swelling
 * Record refusal to bear weight, walk, or move; note night pain
 * Cardiovascular-Pulmonary (3)**
 * Record vitals: heart rate, blood pressure, respiratory rate, pain, and temperature
 * Palpate brachial, femoral, radial, and pedal pulses
 * Auscultate heart and lung sounds
 * Percuss over lung fields, listening for areas of dullness
 * Observe patient, looking for cyanosis, nasal flaring, cough, SOB or excessive crying, fatigue, unexplained weight fluctuations, response to activity/change in position
 * Neuromuscular (3)**
 * Observe ability to make eye contact and track objects
 * Observe genereal resistance to passive movements and determine whether or not it is velocity-dependent
 * NEWBORNS: APGAR score, child’s gestational age and birth weight, ability to suck and swallow, irritability/consolability
 * APGAR: A score of 7-10 is an indicator of a newborn in good health. A score <7 indicates a newborn who needs medical attention. A low score does not mean the child will have serious long-term health problems (16). Table below adapted from (16).
 * __Areas for testing:__ || **Score: 2** || **Score: 1** || **Score: 0** ||
 * **Breathing Effort** || Infant cries well || respiration's are slow and irregular. || Infant is not breathing ||
 * **Heart Rate** || Heart rate is greater than 100 bpm || Heart rate is less than 100 bpm || Infant has no heart beat ||
 * **Muscle Tone** || Active muscle motion || "Some muscle tone" || Muscles are loose and floppy ||
 * **Reflexes** || Grimacing along with couch, sneeze or vigorous cry || Grimacing is present in response to stimulation || No grimace response or reflex irritability in response to mild pinch ||
 * **Skin Color** || Entire body is pink || Body is pink but extremities are blue || Skin color is pale blue ||
 * Gastrointestinal (3)**
 * Observe excessive mucus in mouth and nose, signs of dehydration, unexplained weight loss/gain, posturing neck extension or head movements during feeding
 * Note reports of fever, nausea, vomiting, abdominal pain, colic, reflux, chronic hunger or refusal to eat, diarrhea, or change in urine/output
 * Genitourinary (3)**
 * Record vitals: increased blood pressure
 * Note changes in bowel/bladder function, frequent UTI’s, abdominal pain, pain with urination, pain referral to low back, flank, inner thigh, leg, or ipsilateral shoulder, or altered menstrual cycle
 * Observe fever, vomiting, chills, fluid retention/edema, dehydration, unexplained weight gain/loss, irritability, unusual odor, discharge, or signs of abuse
 * Integumentary (3)**
 * Observe color and pigmentation, scarring, presence of hair, turgor/hydration, swelling, presence of skin lesions, rash, skin infection, change in mole
 * Palpate skin texture, temperature
 * Endocrine (3)**
 * Note increased thirst, frequent urination, persistent constipation or diarrhea, increased sweating, hunger or decreased appetite, headache, dizziness, lightheadedness, emotional lability, alterations in menstruation
 * Observe swollen gums, delayed healing of typical sores/abrasions, precocious puberty, short stature, unexplained weight loss/gain
 * Lymphatic/Immune (3)**
 * Palpate lymph nodes, spleen, and liver noting any enlargements; joints for swelling
 * Note fever, sore throat, rash, general malaise, night sweats, joint pain, weight loss

Videos: media type="youtube" key="ZN7tMDSOBog" height="315" width="420" > = Tests & Measures =
 * Head to Toe Pediatric physical assessment: (Temp, HR, BP, RR, head circumference with norm values)
 * Children's Hospital of Pittsburgh Systems Review Form : []


 * “**Tests and measures help confirm or reject hypothesis regarding what factors are contributing to the child’s current level of performance” (3) and “support the physical therapist’s clinical judgments about appropriate interventions, anticipated goals, and expected outcomes” (3, from APTA)



Assessments for Routine Based Interviews
Scale for Assessment of Family Enjoyment of Routines (SAFER) Routines Based Interview (RBI) Scale for Assessment of Teachers' Impressions of Routines and Engagement (SATIRE) Scale for Teachers' Assessment of Routines Engagement (STARE)


 * ==**Play-based assessment:**(3)==
 * Naturalistic observation
 * Focus on __spontaneity__ and __ease__ of movement during __functional skills, movement activities,__ and __transitions__ between play positions
 * __Advantages:__Functional and activity base
 * __Disadvantages:__ Limited info on body structures/function (ROM, strength)
 * **ICF-CY Framework (International Classification of Functioning, Disability and Health-Children and Youth Version** (3)
 * Neuromusculoskeletal and movement-related functions =most critical to physical therapy tests and measures
 * ==Range of Motion (3)==
 * Must be compared to age-matched normative values
 * There is wide range of normal
 * **__Goniometry__**may be difficult to assess or unreliable if the child is:
 * Of very young age
 * Apprehensive
 * Active
 * Unable to tolerate demands of an exam


 * **Tools for Cooperation**
 * Distract the child with songs, games, small toys, or caregivers and evaluate ROM by observation
 * Structure ROM exam to cover all tests in each position before moving to different position
 * Perform in consistent order


 * **Special Tests**
 * Galeazzi Sign/Allis Test: quick leg length screen
 * Supine, knees best, stabilize at ASIS
 * Adam’s forward bend test: trunk ROM, scoliosis screen
 * Prone Hip Extension Test: assess hip flexion contractures (Thomas test difficult)
 * Prone, legs off end of table, stabilize PSIS, pull leg into hip extension
 * Measure angle between femur and table surface
 * Hamstring Length
 * Varus/Valgus in Supine


 * ==**Strength (3)**==
 * Needed to assess ability of child to perform age-appropriate gross motor activities
 * All activities have strength component

media type="youtube" key="OriTPGFPRaM?feature=player_detailpage" height="288" width="512"
 * **Infants:**
 * Kicking in air
 * Pull-to-sit maneuver


 * Head lift in prone


 * **Toddler/Preschool**:
 * Getting up from floor using half kneeling
 * Jumping
 * SLS
 * Stairs
 * Heel raise
 * Use demonstration or games (Simon Says)


 * **MMT**
 * School aged (ages 3-4)
 * Cognition dependent
 * Grades 0-3 same as adult
 * Grades 4-5: dependent upon force adjustment for age
 * **Hand held dynamometry is preferred**
 * Reliable as long as child performs at best effort
 * Use praise/encouragement
 * Proven reliable for numerous diagnoses
 * Allow practice
 * ==Gait Analysis (3)==
 * Bare feet
 * With and without orthotic or assistive device


 * ==Balance Assessment==
 * Assess ability to change and maintain body positions during play and functional activities (3)
 * **Pediatric Balance Scale**, adapted from Berg Balance Test (4)
 * Reordering of tests
 * Decreased time measure for holding static postures
 * Demonstration and clearer instruction
 * Pediatric sized bench/equipment


 * **Additional Qualitative Test Ideas**
 * **FOPQ:** measures fear in children/adolescents with chronic pain (12) [[file:FOPQ.article.pdf]]
 * **PedsQL:** quality of life measure for several complex pediatric diagnoses (cancer, fatigue, chronic pain, etc.) [[file:PedsQL.cancer.pdf]]
 * **Parent Resources**
 * **[]**
 * **[|Preparing for Pediatric PT Evaluation]**

= Standardized Assessments =

Norm-Referenced vs. Criterion Referenced tests (2): http://ptjournal.apta.org/content/67/12/1873.full.pdf
 * Norm-referenced: have reference points that are determined by the average performance of a group, compares the performance of the child to the average performance of a group of children. This type of test is also termed //discriminative.//
 * Aim of test is to determine __//eligibility//__ for services, diagnosis, or placement
 * Should NOT be used to track progress over time
 * Criterion-referenced: reference points are determined by specific cutoff points, essentially the child competes against themself, and the child's mastery of the skill is measured. This type of test is also termed //evaluative//.
 * Aim of test is program planning or evaluation (11, 13)‍
 * Measure of child's progress

Tests administered to children should be both reliable and valid (2):
 * Reliability: consistency in measures with repetition, often recorded as a percent agreement or as a correlational value
 * Interrater reliability: looks at difference in scores given by two different testers who are giving the same test to the same child
 * Test-retest reliability: looks at difference between score given on test the first time, to the test given a second time, practice and memory both can have an effect on this
 * Validity: answers the question, “Does the test truly measure what it was intended to measure?”
 * Sensitivity: ability of test to determine those who demonstrate dysfunction
 * Specificity: ability of test to determine those who are “normal”

spasticity, vestibular function, head and trunk control, French angles, and legs (2) || Criterion-referenced (2) ||
 * TEST || Purpose || Ages || Time to administer || Materials needed || Description of Assessment || Type of test ||
 * AIMS || Identifies children who are delayed in motor development and evaluates development over time || Birth-18 mo || 20-30 min || age-appropriate toys, carpeted area/exam mat, stable wooden chair/bench || 58 gross motor skills assessed in prone, supine, sitting, standing (7) || Norm-referenced (2,7) ||
 * Bayley (BSID) || Identifies young children with developmental delay || 1-42 mo || 15-20 min || test kit, tissue, 5 small coins, Cheerios, 3x5 blank index cards (no lines), safety scissors for children, stairs, stopwatch, several sheets of blank paper || cognition, receptive language, expressive language, fine motor and gross motor ability (8) || Norm-referenced (2) ||
 * GMFM || Measures change in gross motor function over time in children with cerebral palsy, GMFM-88 also can be used on children with Down Syndrome || Any child whose motor skills are at or below that of a 5 year old level || 45-60 min || floor, 2 straight lines 3/4 in wide, 8 in apart and 20 ft long, 24 in diameter circle marked on floor, firm exercise mat, small toy >4 in high, small bench, large bench (for standing/cruising), stopwatch, 12-24 in stick, large toy that child must carry with 2 hands, 5 steps, stool on castors || 88 items assessed with following positions/movements: lying and rolling; sitting; crawling and kneeling; standing; walking; running and jumping (9) || Criterion-referenced (2) ||
 * INFANIB || Examines neurological function in infants || Birth-18 mo || Minimal time || None || 5 areas assesssed:
 * PDMS-2 || Extimates a child's motor abilities || Birth-72 mo || 45-60 minutes (or 20-30 minutes for gross motor component) || test kit, rattle, soft toy, small toy on strink, empty soft drink can, 8-in ball, tennis ball, cup, spoon, washcloth, several sheets of blank paper, pencils/crayons/markers, blunt scissors, large pull toy, book with think cover pages, food pellets (Cheerios), 4-5 feet of heavy string/rope, stairs, stopwatch, mat, sturdy object 16-21 in high || Gross motor component: reflexes, stationary, locomotion, object manipulation (10) || Norm-referenced(2) ||
 * PEDI || Evaluates functional capabilities and performance || 6 mo-7.5 yrs || 45-60 minutes || None || Self-care, mobility, social function (2) || Norm-referenced (2) and Criterion-referenced ||


 * **Carey et al.** (1)
 * Review with aim to evaluate 3 current pediatric participation measures administered by physical therapists
 * **__CAPE:__**Children’s Assessment of Participation and Enjoyment
 * Children/youth age 6-21 years old
 * Measures participation in very day activities with interview-assisted questionnaire
 * 5 activities: recreational, active physical, social, skill-based, and self-improvement
 * Limitations: difficult to interpret results, not used for younger children or severe disabilities
 * **__SFA:__**School Function Assessment
 * Assess performance of school-aged children (K-6) with disabilities
 * Collaboration of professionals to provide best care
 * Participation in roles like peers in classroom, playground, during transportation, toileting, and at meal time
 * Limitations: restricted age range, lengthy assessment, in general education setting only
 * **__M-FUN:__**Miller Function and Participation Skills
 * Developmental assessment tool ages 30 months-7 years old
 * Norm-based performance assessment and criterion based participation assessment (home and classroom)
 * Performance assessment (visual motor, fine motor, and gross motor skills) reliable/valid; Participation assessment not
 * **Key points:**
 * Tests and measures should be selected carefully for each individual child based on strengths and limitations of tests
 * PT’s role to select tests that will provide information to guide plan of care and outcomes in child, family, and environmental categories of ICF model[[file:Carey et al. .pdf]]

Description of Assessments
> http://agesandstages.com/pdfs/questionnaire_diagram.pdf
 * ASQ** (15)
 * The Ages and Stages Questionnaire is a developmental screening tool that evaluates children ages 1-66 months in areas of:
 * Communication, gross motor, fine motor, problem solving and personal/social skills
 * Scores interpreted as:
 * On schedule development, close to cut off for age category or below cut off for age category
 * Follow up action recommended based on scores
 * The normative referenced sample consisted of 15,138 U.S. children considering geography, ethnicity and socioeconomic status.

PDMS
http://journals.lww.com/pedpt/Fulltext/2005/01710/Factors_That_Influence_Standardized_Test_Selection.62.aspx

**How to choose which assessment is right for your child:**




= Case summary - Adriana =

Adriana is a 5 year old girl who was diagnosed with mild cerebral palsy. In the video, we see Adriana in her gym class with her fellow kindergartners, performing multiple gross motor tasks. During the video, we see Adriana attempt to complete similar motor tasks as her peers including running, skipping, galloping, jumping jacks, cup stacking, and two-legged jumping. Adriana falls twice while running during the video, and it is reported that she falls at least 1-2 times a day. It is indicated that typically when she falls, she gets back up right away without indication of injury. The child appears very resilient, although there is concern for potential injury with repeated falls. The child's PE teacher and physical therapist are present in the video. Due to the child's difficulty with skipping, we see the therapist attempt to assist the child by demonstrating the task and giving handheld assist. Adriana is still unable to coordinate the movement. Adriana appears to be motivated to keep up with her peers, however she is unable to do so in most activities due to factors listed in the table below.



<range type="comment" id="371535868_7">Comments on goals</range id="371535868_7"> = =

References

<span style="font-family: Tahoma,sans-serif;">1. Carey, H. and Long T. (2012). The Pediatric physical therapist’s role in promoting and measuring participation in children with disabilities. //Pediatric Physical Therapy//; 24(2):163-170. 2. Connolly, B. H., and Montgomery, P. C. (2005) Therapeutic Exercise In Developmental Disabilities. SLACK Incorporated; Thorofare, NJ. 3rd Ed: page 24-26. 3. Effgen, S. (2013). //Meeting the physical therapy needs of children//. (2nd ed., pp. 110-111). Philadelphia, PA: F.A. Davis Company. 4. Franjoine, MR. Pediatric balance scale: a modified version of the berg balance scale for the school-aged child with mild to moderate motor impairment. //Pediatric Physical Therapy//. (2003); 15(2): 114-128. <span style="font-family: Tahoma,sans-serif;">5. Heineman, K. R. and Hadders-Alga, M. (2008). Evaluation of neuromotor function in infancy-a systematic review of available methods. //J Dev Behav Pediatr//; 29:315-323. <span style="background-color: #ffffff; color: #333333; font-family: 'lucida grande',tahoma,verdana,arial,sans-serif;">6. Lovelace-Chandler, V., & McGee, M. (2012, 2006, 2000, 1994). Chapter e-5 screening for referral and differential diagnosis. (pp. 1-38). Saunders, an imprint of Elsevier Inc. Retrieved <span style="background-color: #ffffff; color: #333333; font-family: 'lucida grande',tahoma,verdana,arial,sans-serif;"> from <span style="background-color: #ffffff; color: #3b5998; font-family: 'lucida grande',tahoma,verdana,arial,sans-serif;">@https://elearning.kumc.edu/section/default.asp?id=412907231237 7. Mayson, T. (2007) Outcome Measures: The Alberta Infant Motor Scale (AIMS). Sunny Hill Health Centre for Children. Retrieved 27 September 2012, from <[|http://www.therapybc.ca/eLibrary/docs/Resources/AIMS%20Evidence%20Summary%20-%20October%203rd.pdf]> 8. Mayson, T. (2007) Outcome Measures: The Bayley Scales of Infant Development, 3rd Edition(BSID-III). Sunny Hill Health Centre for Children. Retrieved 26 September 2012, from < [] > 9. Mayson, T. (2007) Outcome Measures: The Gross Motor Function Measure (GMFM). Sunny Hill Health Centre for Children. Retrieved 26 September 2012, from < [] > 10. Mayson, T. (2007) Outcome Measures: The Peabody Developmental Motor Scales, 2 nd Ed. (PDMS-2) Sunny Hill Health Centre for Children. Retrieved 26 September 2012, from <[]> 11. Montgomery, P. C. and Connolly, B. H. (1987). Norm-Referenced and Criterion-Referenced Tests: Use in pediatrics and application to task analysis of motor skill. //J of the American Physical Therapy Assoc;// 67: 1873-1876. 12. <span style="font-family: Tahoma,sans-serif;">Simons, L. E., Sieberg, C. B., Carpino, E., Logan, D. and Berde, C. (2011). The fear of pain questionnaire (FOPQ): assessment of pain-related fear among children and adolescents <span style="font-family: Tahoma,sans-serif;"> with chronic pain. //<span style="font-family: Tahoma,sans-serif;">J Pain //<span style="font-family: Tahoma,sans-serif;">; 12(6): 677-686. <span style="font-family: Tahoma,sans-serif;">13. Tecklin, J. (2008). //Pediatric physical therapy//. (4th ed., p. 69-82). Baltimore, MD: Lippincott Williams & Wilkins. 14. Tieman, B. L., Palisano, R. J., and Sutlive, A. C. (2005) Assessment of Motor Development and Function in Preschool Children. //Mental// //Retardation and Developmental Disabilities// //Research Reviews;// 11: 189-196. //15. What is ASQ?// (2012). Retrieved 26 September 2012, from <http://agesandstages.com/what-is-asq/> 16. Zieve, D., & Kaneshiro, N. (2011, December 2). //Apgar//. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003402.htm