6.3 Complete vs Focused Physical Examination

Domain II.B.3 asks you to perform an appropriate physical examination — complete or focused. The CPNP-PC decision is not whether you can list every organ. It is whether you chose the right exam for this visit, sequenced it so an infant stays assessable, and did not skip the high-risk pediatric maneuvers that miss retinoblastoma, coarctation, developmental dysplasia of the hip, and scoliosis.

Complete well exam versus focused sick exam

A complete (comprehensive) examination belongs at health-supervision visits, new-patient visits, and whenever the history is undifferentiated. It is age-appropriate and includes the growth measurements you have already plotted, general appearance, skin, HEENT (including red reflex in infancy), dentition, neck, chest, cardiovascular exam with femoral pulses, abdomen, spine and hips, genitalia, Tanner staging when relevant, and a neurologic/developmental observation. Anticipatory guidance does not replace laying on hands.

A focused (problem-oriented) examination belongs at most sick visits: the organ systems that explain the chief concern plus the systems that hide emergencies. A child with fever still needs hydration status, meningismus when age-appropriate, perfusion, and a lung exam — not only a throat culture. A child with limp still needs hip, knee, and abdomen. Focused does not mean eyes and ears only because that is what the parent mentioned.

A sports preparticipation physical evaluation (PPE) is a focused clearance exam (cardiovascular risk, musculoskeletal screening, concussion history, vision). It is not a substitute for a Bright Futures well visit. Immunizations, developmental or mental-health screening, confidential adolescent care, and anticipatory guidance still need a health-supervision encounter. If the athlete is already in the office, convert the slot to a complete well visit when time and consent allow, or schedule the well visit — do not check only the PPE boxes and close the chart.

Sequence for infants: least invasive first

A screaming infant has an uninterpretable heart murmur and an uncountable respiratory rate. Observe first, invade last.

1. Watch before you touch: color, work of breathing, dysmorphic features, interaction with the caregiver, spontaneous movement, and tone.
2. Count respiratory rate and inspect the chest while the infant is quiet or feeding.
3. Auscultate heart and lungs next — still quiet. Listen for murmur, gallop, and equal breath sounds.
4. Palpate the abdomen, femoral pulses, and fontanelle.
5. Hip maneuvers, then ears, mouth, and other invasive steps last. Warm the stethoscope; keep the infant in the caregiver's lap as long as you can.

Leave the most aversive steps (otoscopy, oropharynx, a blood-pressure cuff on a toddler) until you already have the quiet-exam data.

Hips: Ortolani and Barlow early, Galeazzi later

Barlow (adduct and posterior pressure) tests whether a reduced hip can be dislocated. Ortolani (abduct and lift the greater trochanter) tests whether a dislocated hip can be reduced — a clunk, not a click. These maneuvers are most useful in the first 2–3 months, when the capsule is still lax. After that, muscle tightness makes them insensitive.

Later infancy and walking-age children: Galeazzi (Allis) sign (unequal knee heights with hips and knees flexed, feet on the table), limited or asymmetric abduction, asymmetric thigh or gluteal folds (supportive, not diagnostic), and a limp or Trendelenburg gait once walking. A positive Ortolani, limited abduction, or Galeazzi inequality is a referral to pediatric orthopedics, not a recheck next visit plan. Imaging choice (ultrasound versus pelvis radiograph) is age-dependent and belongs with the DDH chapter; the exam-level rule is do the age-right maneuver and do not ignore an abnormal hip.

Tanner staging

Sexual maturity rating (Tanner) is part of the complete exam in later childhood and adolescence, not an optional extra for gynecology.

• Girls: breast (B1–B5) and pubic hair (PH1–PH5). Breast budding (Tanner 2) is the usual first sign of puberty. Menarche typically follows about 2–2.5 years later, often at Tanner 4.
• Boys: genital (G1–G5) and pubic hair. Testicular enlargement (volume ≥4 mL, Tanner 2) is the first sign — inspect and palpate; looking only at pubic hair misses delayed or precocious puberty.

Precocious or delayed puberty is an endocrine problem (later chapter). This section's job is: stage it, document it, and do not skip the genital exam because it is awkward.

Blood pressure, vision, and hearing

Blood pressure is measured annually beginning at 3 years. Measure earlier — including in infancy — if there is prematurity or NICU history, congenital heart disease, renal disease or recurrent UTI, solid-organ transplant, treatment with drugs that raise BP, or other AAP-risk conditions. Use an appropriately sized cuff (bladder width about 40% of mid-arm circumference; length 80–100% of circumference) on the right arm, child seated, feet on the floor when age allows. Interpret with age-, sex-, and height-percentile tables, not adult 120/80. Elevated readings are repeated; one hurried nursing-station number is not a hypertension diagnosis.

Vision. A red reflex (Brückner) is part of every infant well exam and remains relevant whenever you examine young children. Leukocoria, an absent reflex, or marked asymmetry is same-week ophthalmology — retinoblastoma and congenital cataract are time-critical. Cover-uncover (and alternate cover) testing looks for strabismus once the child can fixate; a consistent tropia needs ophthalmology, not it will straighten. Instrument-based screening and later visual acuity follow current Bright Futures periodicity; the trap is skipping the red reflex because she tracks my light.

Hearing. Universal newborn hearing screening is already done; a failed screen needs diagnostic audiology, not endless rescreens while language windows close. Ongoing surveillance of language is your hearing screen between formal tests. Formal audiometry follows periodicity and any language concern. A whisper test is not a substitute.

Femoral pulses, spine, and the rest of the do-not-skip list

Palpate femoral pulses on infant and early-childhood well exams and compare with brachial pulses. Delayed, weak, or absent femorals, or a lower-extremity BP much lower than the arm, suggest coarctation of the aorta. A loud murmur is not required. Missing unequal femoral pulses is a classic CPNP-PC trap.

Spine: inspect for scoliosis (Adams forward bend in school-age children), sacral dimples, hair tufts, and hemangiomas over the midline. A simple shallow midline dimple without other markers is usually benign; a large, deep, off-midline pit, or a dimple with a tuft or mass, raises occult spinal dysraphism and needs imaging or referral rather than reassurance.

Heart: innocent versus pathologic murmurs are a later cardiology chapter; still listen in sitting and supine, and with standing if a hypertrophic-cardiomyopathy question is on the table (PPE). Lungs, abdomen (including hepatosplenomegaly), skin (birthmarks, bruising patterns), and a screening neurologic exam complete the well visit.

Genitourinary exam and chaperones

Inspect the external genitalia at well visits. In boys: hypospadias, chordee, descended testes, hydrocele versus hernia, and later testicular exam for adolescents (cancer counseling and torsion teaching). In girls: labial adhesions, discharge, signs of estrogenization, and Tanner stage. Sexual abuse findings are a maltreatment chapter; unexplained bruising, injury, or discharge still stops a routine exam and starts a safety process.

Offer a chaperone for genital and breast examinations, especially in older children and adolescents, and document. Explain what you will do before you do it. Assent from the child plus caregiver consent is the usual well-child model; adolescent confidential care adds a private interview.

Adolescents: confidential time

Examining an adolescent with a parent glued to the exam table for the entire visit is a trap. Offer time alone beginning in early adolescence (commonly around 12–13 years, earlier if the teen is sexually active or requests it). Explain confidentiality and its limits: suicidal or homicidal ideation, abuse, and other legally required reports cannot remain secret. HEADSSS-style history lives with screening tools and anticipatory guidance; the physical-exam point is that you cannot complete an appropriate adolescent exam — breast, genitalia, skin, sports cardiac questions — if you never create a private, chaperoned space.

Clinic vignettes

A 6-week-old is here for shots. You start with observation and auscultation in the parent's arms, palpate femorals, perform Ortolani and Barlow, check the red reflex, and finish with ears and mouth. You do not skip the red reflex because the infant is due for vaccines.

A 4-year-old presents with fever and ear pain. Focused exam is appropriate, but you still assess hydration, work of breathing, and neck. You do not perform a full Tanner-staged genital exam because every visit is complete if the history is straightforward otitis — unless another indication appears.

A 15-year-old brings a sports form. Blood pressure is 118/76, femorals are palpable, heart is regular without murmur, and the musculoskeletal screen is normal. You still offer confidential time, review immunizations and Bright Futures screening, and either complete a well visit or schedule one. Signing the PPE does not close health supervision.

Exam traps

1. Skipping the red reflex in infancy.
2. Missing unequal or delayed femoral pulses (coarctation).
3. Using Ortolani/Barlow on a 12-month-old as the only hip test, or ignoring Galeazzi and limited abduction later.
4. Deferring blood pressure until adolescence in a healthy 3-year-old, or never measuring BP in a former 26-week infant.
5. Treating a sports PPE as a well visit.
6. Examining an adolescent without offering confidential time (and a chaperone for GU/breast exams).
7. Doing the mouth and ears first in a newborn so you never hear a quiet heart.

Complete when the visit is health supervision. Focused when the visit is a problem, without dropping emergency systems. Sequence infants so the data are real. Do the pediatric-specific maneuvers — red reflex, femorals, age-right hips, Tanner, BP from 3, spine — every time they apply.