Approach to the Problem
A patient’s general appearance is considered one of the most important elements of the physical examination. It represents a subjective impression of the patient’s state of being. First and foremost, this impression informs about the patient’s overall degree of wellness, distinguishing whether or not the patient is ill-appearing. In addition, one can assess specific aspects of the patient’s presentation ranging from the obvious to the more subtle. Specifically, one can examine such patient characteristics as alertness level, nutritional status, facial expression, consolability, developmental ability, respiratory effort, personal interaction, behavior, hygiene, coloring, movement, and gait.
Key Points in the History
• It is essential to ascertain whether the observed general appearance is consistent with that noted by the caregivers.
• Obtaining a patient’s baseline status is crucial.
• A changing story, or one inconsistent with physical findings or developmental ability, raises the suspicion of child abuse.
• In the case of a critically ill or injured patient, elicit a SAMPLE history—as described by Pediatric Advanced Life Support—Signs and symptoms, Allergies, Medications, Past medical history, Last meal, and Events leading to presentation.
• When pain is present, assess the patient’s subjective degree of pain, or preferably utilize a facial or numerical pain scale.
• When evaluating a febrile child, response to and timing of antipyretics, consolability, and willingness to feed help to determine the severity of illness. Reevaluation following defervescence is also helpful.
• When evaluating children of non-English-speaking families, all efforts should be made to communicate in their preferred language to avoid missing crucial elements in the history and physical examination.
Key Points in the Physical Examination
• A social smile is rarely present in a child with meningitis or other invasive serious bacterial infections. However, it may be present in occult bacteremia.
• Absent tears, dry mucous membranes, ill general appearance, and delayed capillary refill are reliable external clues of dehydration.
• Tachypnea, nasal flaring, grunting, and accessory muscle use are signs of respiratory distress. Depressed sensorium, apnea, bradycardia, and cyanosis are signs of respiratory failure.
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