Pediatric Generic Physical Exam

Appearance, consolability, interaction with caregiver, work of breathing, and activity level — the calm before the formal exam.

HR, RR, BP (cite the cuff size), temp, SpO2. Compare every value to age-appropriate norms; cite the comparison in your head, the number on the page.

Weight, height, head circumference (under 3y), BMI percentile. The numbers downstream — every dose — come from the weight on this page.

Fontanelle (under 18mo), tympanic membranes, oropharynx, mucosal hydration, eye red reflex. Document what the parent says they saw at home, not just the bedside finding.

Lymphadenopathy, torticollis, masses. Strap muscles mass is a normal variant; flag only asymmetry.

Rate, rhythm, murmurs, femoral pulses (coarctation screen in infants), cap refill. Innocent murmurs are common; call them out so a follow-up visit doesn’t re-trigger a workup.

Work of breathing first (retractions, nasal flaring, grunting), then auscultation. A wheezing infant is reassuring only after accessory-muscle use is ruled out.

Order matters here as in adults. Document the hernia exam for infants; the umbilicus in a neonate resolves on its own, document when.

Hip exam (Ortolani/Barlow under 6mo), scoliosis screen (school-age), gait (when walking). The hip click of an infant is a finding, not a discharge summary.

Rashes, birthmarks, jaundice (with Kramer zone in neonates). A rash is one paragraph, not one line — morphology + distribution + the texture the parent saw at home.

Mental status, cranial nerves (age-adjusted), motor, gait, reflexes. Milestones only when the visit is a well-child check.

A clear one-paragraph summary. The MDM cross-references this paragraph, so the EHR reads the impression as the spine of the note.