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Grading Sheet No. 5
Gullas College of Medicine
Department of Pediatrics
Grading Rubrics for Physical Exam of Infant/ Child
FULL NAME: _______________ SECTION: _________ SCORE: ___________
ID NUMBER: _______________ DATE: __________ SUB GROUP
A. At entry to patient’s room Done Not done
1. Greet Parent, introduce yourself and explain why you are there
2. Put on gloves, remove infant/ child clothes
2. General Observation
(a) Awake, conscious, or drowsy, state of comfort, abnormal gait or
coordination, degree of activity and facial expression
(b) Signs of respiratory distress
(c) Vital signs and anthropometric measurement
B. Skin
1. Observe for color (presence of cyanosis), texture, hydration
2. Observe and describe lesions or spots
3. Describe sensitivity and hair distribution
B. Head
1. Measure head circumference
2. Size and Shape (symmetry)
3. Bruising or swelling
4. Run hand over the scalp/Skin, take of hair distribution
5. Palpate fontanelles and sutures
C. Face/ Neck
1. Face- notes for symmetry, paralysis, facies (distance between
eyes, depth of nasolabial folds
2. Eyes – eye spacing, shape, palpebral fissure position, strabismus
a. Corneal light reflex
b. Pupillary light reflex
c. Visual acuity
d. Red-orange reflex
D. Nose
1. Examine the exterior, shape, septum, alar flaring, resp distress
during feeding or crying
2. Nasal mucosa- swelling, color, nasal discharge, patency
3. Tenderness on the sinuses
E. Mouth and throat
1. Observe for hoarseness, stridor, grunting
2. Lips- color, moist/dry, cleft lip, discoloration
3. Teeth- number, position, caries
4. Mucosa, gums- color, lesions/ ulcers
5. Palate, uvula and tonsils- cleft, erythema, swelling, exudates,
lesions
F. Neck
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1. observe position, swelling, webbing, position of trachea
2. Thyroid gland- size, contour, nodules, tenderness
3. Palpate lymph nodes- location, size, consistency
G. Chest
1. Inspect for symmetry, adynamic chest, shape (flat, Pectus),
retractions, observe for grunting, stridor, position of nipples,
breast, sternum
2. Lungs- Count RR
a. Tactile fremitus
b. Percussion- presence of flatness or dullness
c. Auscultate for breath sounds- identify abnormal breath
sounds (wheeze, rales, rhonchi)
3. Heart- identify and intensity of apex beat, precordial bulging,
thrills
a. Auscultate- Heart rate, murmur, friction rub
1. Heart rate -count heart rate, rhythm of heart beat
2. Check for murmur- location, timing, intensity/grading
H. Abdomen/Groin
1. Position patient to supine position, bend knees
2. Inspect shape (flat, protuberant), veins, umbilicus, hernia
3. Auscultate bowel sounds
4. Palpate for organs (liver, kidneys), assess for masses
5. Groin- palpate for femoral pulses, check for inguinal hernia
I. Genitalia Done Not done
1. Inspect for anomalies, ambiguous genitalia
2. Female – swelling/engorgement, discharges/bleeding, skin tags,
adhesions, note for pubertal changes
3. Male -note for pubertal changes
a. Penis- meatal opening, hypospadias, phimosis
b. Scrotum- size, presence of hydrocoele or hernia
J. Rectum and Anus
1. Inspect for rashes, fissure, prolapse, imperforate anus
2. Rectal examination- Note for muscle tone, character stool,
masses, tenderness
K. Extremities
1. General- inspect for symmetry, gait, deformity, hypertrophy or
atrophy, paralysis, gait
2. Joints- inspect for swelling, redness, tenderness, limitation of
motion
3. Hands and feet- complete set of fingers and toes, inspect foe
deformities, abnormalities (polydactyly, syndactyly, clubbing,
simian crease), size of thumbs and big toe, clubbing
L. Spine and Back
1. Observe posture, spine curvature, rigidity, spots, masses, tuffs of
hair
2. Palpate for tenderness
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3. Perform kidney punch sign
4. Assess degree of mobility
M. Neurologic Examination
1. Mental status – level of consciousness, intelligence, emotional
status, orientation, ability to understand and communicate.
2. Cranial Nerves
a. CN I- identify odor and disorder of smell
b. CN II and III -assess pupillary light reflex
c. CN III, IV and VI- assess ocular movements, ptosis
d. CN V- perform corneal reflex
e. CN VII- Observe facial symmetry, taste on the anterior portion of
the tongue
f. CN VIII- assess hearing and lateralization, air and bone
conduction, caloric test
g. CN IX and CN X- assess pharyngeal gag reflex, ability to swallow
and speak clearly
h. CN XI- strength of trapezium and sternocleidomastoid muscles
i. CN XII- deviation of tongue upon protrusion
3. Motor system – grading of muscle strength, active and passive
movements, observe for hyper/hypotonia, fasciculations, tremors
4. Sensory system– assess sensory to light touch, pain, position and
vibration
5. Cerebellar Function
a. Finger to nose test
b. Rapid alternating movement
c. Pronation and supination of the hands
d. Heel to toe walk
6. Reflex
a. Deep tendon reflexes- biceps, triceps, patellar, Achilles
b. Superficial reflexes- abdominal, cremasteric
c. Pathologic reflex- Babinski
N. Inform the patient and family that you are done with the PE.
Thank the patient and family for allowing you to do PE.
Score = no. of Dones/78=____/78= ____________
Name of Preceptors and signature:______________________________
