Evaluation and Examination of the Pediatric Surgical Patient
Nicholas Cortolillo
Assessment of the pediatric surgical patient requires in-depth knowledge of surgical diseases in children as well as an understanding of the spectrum of pediatric physiology and its derangements across several ages from newborns to infants, children, and adolescents.
Surgeons and their trainees must also be aware of the unique challenges embedded into pediatric medicine.
The care plan must take into account the patient, the problem, the anticipated prognosis, and the child’s caretaker.1
Substantial anxiety is usually present with the surgical evaluation of a child.
Trust building with patients and their parent or guardian lays the foundation for an effective evaluation.
Establishing rapport begins at the initial encounter and continues into the postoperative stages.
Fears and knowledge gaps should be elicited and addressed by the pediatric surgeon through communication and education.
Reviewing images, explaining models, and freehand drawings may be helpful toward this goal.
Surgeons should be prepared to explain topics such as embryologic development, genetics, and oncology in layperson’s terms.
The size of the incision, the intervention, and the expected postoperative course should all be discussed.
HISTORICAL BACKGROUND
An adequate history involves input from both the child and parents and forms the foundation of the relationship to follow.
The chief complaint (CC) represents the reason why the patient presented for care.
A history of present illness (HPI) should be methodical and include symptom onset, acuity, progression, severity, associated symptoms, and aggravating or alleviating factors.
Pertinent positives and negatives should be documented in a thorough review of systems.2
Birth history, developmental milestones, medical conditions, and previous surgeries, or interventions should be listed separately.
Diligently note any unusual bleeding episodes or known bleeding disorders. Inquire about any previous exposure to anesthesia.3
Review scheduled medications, “as needed” medications, and supplements that the child takes.
Drug allergies, food allergies, and symptoms that occur with these reactions are important.
For children with genetic diseases, congenital malformations, or malignancies, the social and family histories are requisite for a complete pediatric presentation.
THE EXAMINATION
Every examination begins and ends with handwashing.
Not only does this form the foundation for infection control, the routine also nonverbally reassures the parent that the surgeon promotes hygiene.
It also helps to warm the surgeon’s hands before touching the child.
The physical examination may be performed according to a standard routine in older and more cooperative children.
Improvisation and flexibility are required in the approach to young children and infants who may not cooperate.4
Portions of the examination for young children and toddlers may occur within their parents’ laps.
It is advisable to perform the abdominal, rectal, and genital examinations on an examination table.
Having the parent close by will help to reduce the child’s anxiety (Figure 1.1). Infants should always be evaluated on the examination table.
 Figure 1.1 The child may feel more secure if the caregiver stays with the child during the physical examination. (Reprinted with permission from Hatfield NT, Kincheloe CA. Hatfield Introductory Maternity and Pediatric Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer; 2018.) |
Skin
The pediatric surgeon is frequently asked to evaluate lumps and bumps and skin lesions.
Complete description of any lesion includes size, shape, mobility, circumscription, and consistency.
The remaining skin must be assessed for similar lesions, surgical scars, or rashes, which can key into autoimmune disorders or vasculitides.
Bruises, redundant or irregular scars, and well-defined burns should raise concern for child abuse.5
Lymphatics
In children, lymphadenopathy is most commonly infectious; therefore, searching for a source of infection in the examination is prudent.6
Bacterial, viral, fungal, and protozoal culprits should be considered.
Enlarged lymph nodes may represent primary malignancy (acute lymphoblastic leukemia [ALL] and Hodgkin and non-Hodgkin lymphoma) or metastatic malignancy.
The axillary, cervical, inguinal, and epitrochlear basins are the most frequent locations for lymphadenopathy.
Head, Ear, Eyes, Nose, and Throat
Physical examination findings among these organ systems are high-yielding in the pediatric population.
Scleral icterus may suggest hepatic dysfunction, biliary obstruction, or hemolysis.
Micro- or macrocephaly may signify an intracranial process.
Abnormal fusion of coronal sutures is not considered normocephalic.
Otitis media may be excluded if the tympanic membranes are clear and landmarks are visible.
An inflamed oropharynx in the setting of rhinorrhea may signify an upper respiratory infection.
Loose teeth are important to acknowledge for children who are to receive anesthesia.7
Chest Wall
The evaluation of pectus excavatum (concave) and pectus carinatum (convex) is accompanied with heart and lung examinations.
Ascertaining the degree of deformity and assessing its psychosocial effects are required.8
Breast tissue is common in infants of both sexes because of a slow decline in maternal hormones in circulation.
Male adolescents may also experience gynecomastia because of high hormonal activity during puberty.9
In preadolescent girls, breast growth occurs at different rates, so one must be able to distinguish a breast mass from a breast bud.
Cardiovascular
Age-appropriate exercise activity and feeding provide functional clues to the child’s cardiac status.
Rate and rhythm should be compared against age-appropriate norms.
Color and respiratory effort should be assessed.
The neck should be examined for prominent vessels, abnormal pulsations, and bruits.
The lungs should be auscultated for crackles or wheezing, features which suggest cardiac asthma of congestive heart failure.
Likewise, the abdomen should be assessed for hepatomegaly or ascites.
Capillary refill should be under 3 seconds.
Pulses in all 4 extremities should be strong and equal; any discrepancy warrants vascular evaluation.
Many children will have a murmur between infancy and adolescence, most of which are innocent.
Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S2, maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands.10
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