Examining children is definitely a unique experience. Although they tend to be healthier than adults, they still tend to have a healthy fear of anyone trying to stick anything in any orifice. The pediatrics rotation can be a tough clerkship but if you're comfortable with performing the physical exam then you should make a great impression with your preceptors and maybe even find it to be a little fun.

Extra History

There's a few questions you should ask for children that you won't for adults.

• History of vaccinations is a must, to figure out whether the child is at risk of any unusual infections or will be putting other patients at risk
• Especially if the child is actively sick, ask about recent travel, exposure to other kids, and school attendance.
• As my pediatrician once said, "there are three things you must do: eat well, sleep well, and poop well." So ask about diet, sleep, and bowel habits (because it's important!).
• Along those lines, make sure the child is exercising!
• For younger patients, inquire about developmental milestones, to determine whether a child needs further workup for learning disabilities, autism, or neurologic disorders.
• If a child is school-age, ask them about their favorite class and who their best friend is.
• Find out how home life is. Do they get along with siblings, and any issues on the parents' end? Anyone smoking in the home, and are there guns?
• For teenagers, ask about sex, drugs, and mental health issues. Maybe let the patient fill out a questionnaire to have time to think about their answers.

Physical Exam

Normally you'd move head-to-toe for an adult exam. This will work for 8-9 year-olds and up, but younger kids will get more anxious and uncomfortable with time, so do the faster/quieter maneuvers early.

• Heart/Lungs: Do this first, because it's hard to listen to heart sounds when all you can hear are unearthly screams. In younger kids, I let them touch the stethoscope first. For older kids I'll ask them to point out where to listen. The head? The foot? Nope, the chest! Occasionally I'll let them listen with the earpieces, but always clean it after.
• Abdomen: Take a quick listen to bowel sounds, make sure there's no masses or tenderness. You can tickle them if they seem cool with it.
• Skin: If the kid is sick, keep an eye out for rashes and be able to describe them. Check for diaper rashes and lesions on the hands/feet (hand/foot/mouth disease!?!?!?!).
• MSK: Check primitive reflexes and muscle tone in infants. Depending on the circumstances, I might check reflexes or back symmetry (for scoliosis). For younger/hyperactive patients, just having them run around the room or grab for objects will give a great idea of any neurologic abnormalities or muscle weakness, plus it helps them burn off some energy.
• Lymph Nodes: Keep these in mind when you're poking and prodding everything, especially if the child is sick or a parent has felt a mass. Check the cervical nodes and inguinal too, especially if you're "in the neighborhood."
• Pupils: I think this starts getting a little more invasive. Sometimes the light freaks them out so I'll shine it on their hands or in my own eyes. In addition to the usual pupil exam, confirm the presence of a normal red reflex to rule out cataracts (cloudy view) or retinoblastoma (white instead of red). You'll want to examine the fontanelles while you're on the head, to check for proper closure or dehydration in an infant.
• Tympanic Membrane: Probably the most difficult maneuver, but being a pro at this will make you a god. I have the child sit on a parent's lap. The parent uses one arm to hold the child's arms against their torso, and the other arm wraps around the child's head and holds it to the parent's chest. If the parent does this correctly, the child should be relatively immobilized and one of their ears will be sticking out. At this point, the freakout level is probably pretty high (both for you and the patient). Take a deep breath, stabilize the otoscope (so it doesn't puncture the membrane if the kid twitches), and slowly look for that cone of light. Take your time, it's better to take a little longer to do it right the first time than have to torture the kid twice. Good job, you're almost done...
• Oropharnyx: At this point the child is probably screaming, but as soon as you try to look in their mouth they're going to grit their teeth and not open at all. If they'll open for you, great! If not, have the parent hold the head, stick a tongue depressor along the inside of the cheek, then pop the jaw open from the molars. If you go from the front or take too long, the kid might clamp down on the tongue depressor, so try to be quick. While they're gagging, scope out the posterior oropharynx to look for tonsillar enlargement or lesions. Don't forget to examine the teeth for poor hygiene. Some people (wiser than myself) examine the oropharynx before the ears but this is just how I roll.