The pediatric physical examination: Chest and abdomen

INTRODUCTION — Examination of the chest and abdomen in children will be reviewed here. Other aspects of the pediatric physical examination are discussed separately.

●(See "The pediatric physical examination: General principles and standard measurements".)

●(See "The pediatric physical examination: HEENT".)

●(See "The pediatric physical examination: Back, extremities, nervous system, skin, and lymph nodes".)

●(See "The pediatric physical examination: The perineum".)

CHEST

Chest wall — The chest examination begins with careful observation and inspection of the chest wall.

●Symmetry and shape – The normal chest is symmetric and, in the infant or young child, almost round. The transverse diameter increases with age. When a persistently round, barrel-shaped chest is seen in a child older than 12 to 24 months, the examiner should consider the possibility of an underlying chronic pulmonary disease, such as cystic fibrosis or chronic asthma. (See "Asthma in children younger than 12 years: Initial evaluation and diagnosis", section on 'Physical examination' and "Cystic fibrosis: Clinical manifestations of pulmonary disease", section on 'Respiratory symptoms and signs'.)

Causes of an asymmetric chest wall include:

•Scoliosis (see "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on 'Terminology')

•Underlying cardiac disease that creates a precordial bulge (eg, atrial septal defect, partial anomalous pulmonary venous connection) (see "Isolated atrial septal defects (ASDs) in children: Classification, clinical features, and diagnosis", section on 'Physical examination' and "Partial anomalous pulmonary venous return", section on 'Physical examination')

•Poland syndrome (OMIM %173800) – Syndactyly associated with ipsilateral absence or hypoplasia of the pectoralis major muscle, which results in an inferiorly placed nipple [1] (see "Chest wall diseases and restrictive physiology", section on 'Poland syndrome')

●Rib cage and sternum – The width of the ribs and length of the sternum should be noted. A mild degree of pectus excavatum (funnel chest) or pectus carinatum (pigeon breast) is a common finding in an otherwise normal patient. Pectus excavatum frequently becomes accentuated with even mild degrees of airway obstruction. (See "Pectus excavatum: Etiology and evaluation", section on 'Clinical features' and "Pectus carinatum and arcuatum", section on 'Clinical features'.)

●Shoulder and clavicles – The shoulders should be examined, especially in the newborn, for clavicular fractures and foreshortened or absent clavicles. Clavicular fractures in the newborn may be undetected in the immediate neonatal period; on subsequent examination, the clavicles may have swelling (callous formation) and tenderness. (See "Neonatal birth injuries", section on 'Clavicle'.)

Shoulder alignment and level of the shoulder and scapulae in preadolescent and adolescent patients should also be evaluated because asymmetry of any of these may be a sign of scoliosis. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on 'Terminology'.)

●Nipple alignment and distance – Nipple alignment and the distance between nipples should be noted. Accessory nipples along the milk line are a normal variant (picture 1). A shield-like chest with widely spaced nipples can be found in patients with Turner syndrome (picture 2). Widely spaced nipples also may occur in a number of other syndromes, including 9p deletion, fetal hydantoin syndrome, trisomy 8, and trisomy 18, among others [2]. (See "Breast disorders in children and adolescents", section on 'Accessory breast tissue' and "Clinical manifestations and diagnosis of Turner syndrome".)

●Chest movement – Inspiration normally results in expansion of the chest wall and depression of the diaphragm. Unilateral paradoxical movement (ie, contraction of the chest wall and elevation of the diaphragm with inspiration) may occur in patients with unilateral pneumonia, pneumothorax, atelectasis, or a foreign body lodged in one of the main stem bronchi. Bilateral paradoxical movement can be seen in patients with neuromuscular disease [3].

Breasts — Assessment of breast tissue development and size is best determined with the patient in the supine position. While the breast area is being examined, the patient's head should be in the midline resting on the palm of the ipsilateral hand. The pattern for examination should be in concentric circles proceeding peripherally from the infraclavicular and axillary areas toward the areola. (See "Breast disorders in children and adolescents", section on 'Breast examination'.)

●Infants and prepubertal children – Infants often have transient breast tissue enlargement secondary to perinatal maternal estrogen stimulation; this enlargement may remain for several months before spontaneous regression occurs. In a prospective study in predominantly White European children <27 months of age, palpable breast enlargement was greater and persisted longer in females than males; at >10 months of age, 62 percent of females and 45 percent of males continued to have palpable breast tissue [4]. (See "Normal puberty", section on 'Sexual maturity rating (Tanner stages)' and "Breast masses in children and adolescents", section on 'Neonates and infants'.)

After spontaneous regression of neonatal breast tissue, there is generally no discernable difference in the size and shape of the breasts between male and female prepubertal children. Premature thelarche may occur bilaterally or unilaterally during the first two years of life and then again at six to eight years and should be monitored to ensure it is not the start of true precocious puberty. (See "Definition, etiology, and evaluation of precocious puberty", section on 'Premature thelarche'.)

In normal breast development, the areola is large, the nipple is raised, and the surrounding tissue is firm. Children with obesity may have pseudoprecocious breast area enlargement, in which the areola is small, the nipple is flat, and the surrounding breast tissue is soft.

●Pubertal development

•Females – Breast development staging in females is based upon standards established by Marshall and Tanner (sexual maturity rating) (table 1) [5,6]. The range is from no evident breast tissue (stage 1) to complete adult development (stage 5) (picture 3). Early in pubertal development, females may experience the development of a firm, tender-to-touch unilateral or bilateral subareolar nodule, termed the breast bud.

The timing of pubertal onset varies widely. In the United States, there has been a trend toward earlier onset of pubertal development. Typical pubertal breast development and the etiology and evaluation of early and delayed breast development are discussed separately. (See "Normal puberty" and "Definition, etiology, and evaluation of precocious puberty" and "Approach to the patient with delayed puberty".)

•Males – Early in pubertal development, males may experience the development of a firm, tender-to-touch unilateral or bilateral subareolar nodule. In approximately two-thirds of individuals, these nodules occur as part of the developmental pattern of physiologic pubertal gynecomastia. They develop as a result of direct testicular secretion of estrogen and the peripheral conversion of prohormones to estrogen. These nodules decrease in size over one to two years, although residual nontender remnants may remain [7]. (See "Gynecomastia in children and adolescents", section on 'Pubertal gynecomastia'.)

Males can also have nonphysiologic gynecomastia; the cause is undetermined in most cases. Possible causes include drugs or herbal products (table 2), hypogonadism (eg, Klinefelter syndrome), tumors (eg, testicular, adrenal), malnutrition, renal disease, and severe liver disease. Whereas physiologic gynecomastia is common in infancy and adolescence, prepubertal gynecomastia is extremely unusual and should be considered pathologic. (See "Gynecomastia in children and adolescents", section on 'Pathologic gynecomastia'.)

Lungs

●Breathing assessment – Observation of the breathing pattern is foremost in the examination of the lung. The rate, rhythm, and depth of breathing should be noted.

•A periodic sigh is normal in everyone.

•Shallow, rapid breathing can be seen with anatomic defects, pulmonary infection, pleuritic disease, and metabolic disorders.

•Slow breathing may occur as a result of central nervous system pathology, metabolic disease, and drug effect.

•Deep rapid breathing may be caused by vigorous exercise, anxiety, and metabolic acidosis.

•A prolonged expiratory phase occurs in patients with an acute exacerbation of reactive airway disease or asthma.

•Rapid breathing alternating with respiratory pauses may occur in sleeping infants [8].

●Auscultation and breath sounds

•Approach – An organized symmetric approach to auscultation of the lung fields should be used. Sequential auscultatory examination proceeds from one side of the chest to the other, comparing breath sounds in anatomically similar areas. Either the bell or the diaphragm of the stethoscope may be used, depending upon the size of the child; the diaphragm is more appropriate for listening to the lungs of larger patients.

Auscultation of the lungs of young children can be difficult. They may be fearful of the examiner or uncomfortable due to illness. Being held by the caregiver may alleviate some of their anxiety. It also may be best to focus on the inspiratory phase, as little may be heard during exhalation.

•Abnormal findings – Auscultation may help localize a particular area of involvement or specific pathologic condition. Ordinarily, deep mouth breathing produces clear, soft breath sounds over the lungs. Atypical breath sounds in the form of crackles, rhonchi, or wheezes are heard most often in patients with underlying pulmonary disease. Upper airway congestion in small children often produces coarse sounds that, when transmitted through the larger airways, may give the impression of an underlying lung abnormality. Frequently, coughing and/or vigorous crying will clear a congested upper airway, helping the clinician distinguish between upper and lower airway sounds.

In small children, an inspiratory high-pitched stridulous sound with or without significant respiratory distress may be the result of narrowing at or near the larynx or anywhere along the trachea. This condition can be caused by a croup-like illness, anatomical defect, mass lesion, foreign body, or external obstruction. Patients in severe respiratory distress with stridor may have epiglottitis or croup. (See "Croup: Clinical features, evaluation, and diagnosis", section on 'Clinical presentation' and "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Clinical presentation'.)

When absent or decreased breath sounds are heard over a particular lung area, spoken words may sound muffled or the letter E may sound more like an A (egophony), especially in a child with a segmental or lobar consolidation. Fairly well-localized squeaky crackles during respiration may be caused by a pleural friction rub. Decreased breath sounds can also be heard with acute severe reactive airway disease and are usually accompanied by wheezing. (See "Asthma in adolescents and adults: Evaluation and diagnosis", section on 'Physical findings'.)

Heart — In older cooperative patients, the clinician may evaluate the heart at any time during the examination. In infants and younger children, it is best to evaluate the heart early in the examination.

General appearance — The examining clinician should assess general appearance before auscultation of the heart or palpation of the cardiovascular system. Cyanosis, poor nutritional status, increased respiratory rate and effort, sweating during feeds, or precordial bulge may be signs of cardiac disease or heart failure. Jugular venous distention, peripheral edema, and evidence of hepatic engorgement suggest right ventricular dysfunction [9].

Palpation

●Peripheral pulses – Palpation of the cardiovascular system should begin with the peripheral pulses. The pulse rate, regularity, and degree of fullness should be noted [9].

•A rapid pulse may indicate heart failure, arrhythmia, an underlying respiratory problem, anxiety, or agitation. (See "Heart failure in children: Etiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

•Bounding pulses suggest aortic insufficiency, patent ductus arteriosus, truncus arteriosus, or an arteriovenous malformation. (See "Aortic regurgitation in children", section on 'Physical examination' and "Clinical manifestations and diagnosis of patent ductus arteriosus (PDA) in term infants, children, and adults", section on 'Clinical manifestations' and "Truncus arteriosus".)

•An extremely slow pulse rate could mean heart block, a central nervous system problem, or a metabolic abnormality. (See "Bradycardia in children".)

•When femoral and upper extremity pulses are palpated simultaneously, delayed or diminished femoral pulses suggest obstruction of blood flow in the aorta (eg, coarctation of the aorta). (See "Clinical manifestations and diagnosis of coarctation of the aorta", section on 'Clinical manifestations'.)

•When upper extremity pulses are palpated simultaneously, a delayed or diminished pulse may indicate a filling defect in a peripheral artery.

●Chest wall – Palpation of the chest wall can be useful in the assessment of ventricular function and hemodynamic status and detection of valvar lesions. Palpation of the heart through the chest wall determines the apical impulse and the presence of a heave, tap, or thrill.

•Apical impulse

-Newborns – In newborns, the right ventricle remains dominant, and the apical impulse (a palpable lift) is best felt in the area of the left lower sternal border; it is better appreciated with the heel of the hand.

-Older children – In older children, the apical impulse is palpated using the tips of the middle and index fingers and is usually located in the fourth or fifth intercostal space in the left midclavicular line.

•Heave – In a patient with left ventricular hypertrophy, a heave can be detected best with the palm and proximal surfaces of the fingers of the right hand [9].

•Tap – A tap caused by pressure overload is felt near the apex as a well-localized sharp impulse.

•Thrill – A thrill is a palpable loud murmur of grade IV to VI. Thrills associated with specific cardiac defects often are well localized. (See "Approach to the infant or child with a cardiac murmur", section on 'Palpation of the chest'.)

Auscultation — Auscultation of the heart can be achieved using either the bell or diaphragm of the stethoscope. The bell is designed for listening to low-frequency sounds and the diaphragm for high-frequency sounds. Thorough evaluation necessitates auscultation of all areas of the precordium, as well as the back, neck, and axillary areas. The process includes noting the rate and rhythm and listening for the normal first and second heart sounds. Close attention should be given to detecting ejection clicks, systolic and diastolic murmurs, pericardial friction rubs, extra heart sounds, and diastolic rumbles. Cardiac auscultation and cardiac murmurs in infants and children are discussed separately. (See "Approach to the infant or child with a cardiac murmur", section on 'Auscultation of heart sounds and murmurs' and "Common causes of cardiac murmurs in infants and children".)

ABDOMEN

Appearance — Visualization of a child's abdomen is performed best in good light with the patient supine and the examiner positioned at the patient's right side. Findings may include:

●Abdominal distention – Although often seen after a patient has eaten, abdominal distention noted at other times may indicate abnormal gas-filled loops of bowel, a ruptured viscus, fecal retention, mass lesion, or ascites.

●Scaphoid abdomen – A scaphoid abdomen can occur in a patient with upper gastrointestinal obstruction or as a result of starvation.

●Abdominal wall protrusions – Abdominal wall protrusions are common. Umbilical hernias frequently are present in the infant, toddler, and younger child, particularly in Black children. Most umbilical hernias are uncomplicated, require no surgery, and resolve spontaneously. (See "Care of the umbilicus and management of umbilical disorders", section on 'Umbilical hernia'.)

Diastasis recti and small epigastric hernias, if not readily visible, can be elicited by having the patient raise their head off the examining table while lying supine or by having the child tense the abdominal muscles; these hernias do not require surgical correction.

●Other findings – Peristaltic waves may be seen occasionally. Vascular pulsation and vascular lesions other than hemangiomas usually are not seen on the abdomen of children. Hyperpigmented and hypopigmented skin lesions are discussed separately. (See "The pediatric physical examination: Back, extremities, nervous system, skin, and lymph nodes", section on 'Skin'.)

Auscultation — Abdominal auscultation often is difficult and unrewarding in the active, uncooperative child but may be of significant benefit in the child experiencing abdominal discomfort. Active bowel sounds often are heard in patients with gastroenteritis and usually are decreased or absent in patients with appendicitis or intestinal obstruction. Stenosis involving the aorta or iliac, femoral, or renal arteries may give rise to an audible abdominal bruit.

Some examiners have employed an auscultatory technique to determine the inferior margin(s) of the liver and/or spleen by listening with a stethoscope over the patient's abdomen while gently scratching the abdominal skin surface with a blunt instrument. Starting in the ipsilateral lower abdominal quadrant of the organ being examined and advancing superiorly, the examiner is able to identify the lower border of the liver or spleen when a change in sound from tympany to dullness is heard.

Percussion — Percussion helps detect mass lesions and organ size and often can identify local areas of pain. Solid or fluid-filled structures, such as a urine-filled bladder, produce a dull sound to percussion; gas-filled loops of bowel produce tympany.

Percussion can be used to help make the diagnosis when a distended abdomen is thought to be the result of ascites. The patient should be supine, and percussion should begin peripherally. At first dullness will be noted. As percussion advances centrally, the air-filled loops of intestine, forced to the midline by ascitic fluid, will emit a tympanitic sound. When the patient turns to one side or the other, the locations of tympany and dullness shift as the fluid moves into dependent areas. A fluid wave can be produced when the examiner strikes one flank area with the tips of the fingers of one hand and detects gentle pressure with the other hand on the opposite flank [10]. This finding is better demonstrated by employing the aid of an assistant who at the same time has placed the ulnar surfaces of both fully extended hands pointing toward one another along the midline of the abdomen.

The overall accuracy of the physical examination for the detection of clinically nonobvious ascites was only 58 percent in one series [11]. The most useful physical finding was flank dullness; if this was not evident (in the hands of an experienced examiner) the probability of ascites being present was less than 10 percent.

Palpation — Palpation is extremely beneficial for determining liver, kidney, and spleen size and for detecting abdominal masses. An examiner's warm hands and initial gentle, soft touch may go a long way in gaining the cooperation of the patient for deeper, more thorough palpation. The often-ticklish younger child may require a calm, reassuring touch, and no initial hand movement by the examiner. After a few moments, these children are instructed to take a deep breath and then exhale slowly while the examiner applies firm steady pressure to the abdomen. A fairly complete examination can be achieved by repeating the procedure in all four quadrants.

The softer and less tense the abdominal musculature, the more easily organs and mass lesions can be felt. For the child who is obese, a two-hand technique with the fingers of one hand applying pressure on top of the fingers of the other hand may be required. When peritonitis is suspected, rebound tenderness may be elicited by pressing firmly and slowly on the abdomen and then quickly releasing pressure. Subsequent wincing by the patient or other audible or visual signs of pain confirms the examiner's impression.

Abdominal organs are relatively easy to palpate in children because in general the abdominal wall is thin. The examiner should stand on the patient's right side when attempting to feel the liver, placing the fingers of the right hand over the right middle to lower quadrant in a somewhat oblique position. Palpation should progress in a superior direction until the lower edge of the liver is detected. Alternatively, with the left hand under the right flank applying minimal pressure, the examiner can place gentle, cephalad-directed pressure on the liver until the edge of the liver is felt with the right hand. A similar maneuver in the left upper quadrant and posterior flank helps determine the inferior margin of the spleen.

The kidneys can be palpated in much the same way as the liver and spleen. Renal tenderness is determined easily in a cooperative child with pyelonephritis through percussion of the flank areas. A firm striking blow with the ulnar surface of the closed fist to the flank area will elicit discomfort in the patient with renal infection.

SUMMARY

●Chest wall – Examination of the chest wall includes observation of the shape, symmetry, alignment and distance between the nipples, and movement with inspiration and exhalation. Chest wall abnormalities may provide clues to underlying pulmonary, genetic, cardiac, or neuromuscular disease. (See 'Chest wall' above.)

●Breasts – Examination of the breasts includes assessment of pubertal stage (picture 3) in females and assessment for gynecomastia in males. (See 'Breasts' above and "Gynecomastia in children and adolescents", section on 'Physical examination'.)

●Lungs – Examination of the lungs includes observation of breathing pattern and auscultation of the lung fields. Abnormalities detected during the lung examination may provide clues to anatomic defects, upper airway obstruction, pulmonary disease, and metabolic disorders. (See 'Lungs' above.)

●Heart – Examination of the heart includes observation (general appearance; central and peripheral color; nutritional status; respiratory rate and effort; sweating; chest contour; venous distention; edema), palpation (of the pulses and of the heart through the chest wall), and auscultation. (See 'Heart' above.)

●Abdomen – Examination of the abdomen includes inspection (contour, symmetry, peristalsis, skin markings), auscultation (bowel sounds, bruits), and percussion and palpation (to detect mass lesions and assess organ size and localized pain). (See 'Abdomen' above.)