Top Tips for Clinical Examination
Watch the child play, walk into the room and interact with parents / siblings. This often yields valuable information prior to the actual examination. Take time to build rapport with a nervous child. Examination will be easier if the child is relaxed.
Ask parents before trying to expose the child and explain to them why this is important. Expose only relevant body areas at a time and always keep family members aware of what you are examining. Consider a chaperone especially with an adolescent being seen without a parent/caregiver and where the examiner and patient are not the same gender. Be aware of cultural contexts and for female patients to be examined by a female. Exposure is important as comparison of limbs can be useful, and joint effusions, rashes and other clues can easily be missed.
Always look at the child’s face during the examination; many children and young people will deny pain but facial expression, withdrawal or crying may suggest discomfort.
pGALS is a validated simple assessment of the musculoskeletal system - it is easier and quicker to perform than you think! Check out the PMM and the pGALS app. Seek out opportunities to practice and be observed with feedback. The more practice you have the more likely you are to pick up abnormalities. pGALS can be performed in less than 2 minutes !
Abnormal findings in pGALS should be followed by detailed examination of the relevant region using a ‘look, feel, move, function, measure’ approach (pREMS).
Never forget to examine the joint above and below the problem site. Referred pain is common. A 'rule of thumb' for any regional joint examination is to also examine the joint above, below and opposite (to compare, which may be helpful especially if one side is not problematic).
Asymmetry of joint range of movement is usually significant but remember symmetrical loss of joint range can be easily missed.
For children with chronic conditions it is important to assess growth and pubertal development. Plot height and weight on growth charts and follow them over time. Also look for evidence of leg length discrepancy or muscle wasting.
The findings of pGALS and pREMS need to be interpreted in the clinical context. Remember that examination of other systems is often indicated e.g., skin, cardiovascular, abdominal, neurological, development as well as vital signs. Remember to examine the teeth and gums (especially with immunosuppressed patients at risk of infection). Temporomandibular joint restriction may associate with poor oral health.
Remind yourself of the normal major motor milestones and normal development – it is much easier to identify abnormalities when you know and understand what is normal!