Templates do not just facilitate documentation but also can guide bedside observations. The person taking a history who uses OLD-CARTS might be reminded to ask a dimension of a symptom that otherwise would not have been elicited.


What does it mean to say a child is “well-appearing” or “ill-appearing?” I find the GCS (Glasgow Coma Scale) categories to be helpful:


Eyes – is the child attentive with the eyes

Motor – is the child appropriately active/reactive

Verbal – is the level of social interaction appropriate for age (eg comforted by the arms of the mother).


Using GCS can stimulate a more detailed description of what we mean when we describe an ill-appearing child.



-Use the categories of GCS to detail what it means for a child to be “ill-appearing.”



An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?


In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The population was strictly those less than 30 days of age, so it may not apply to older babies. The idea was inspired by bladder stimulation techniques used in adults with neurological diseases. There may be some element of a frontal lobe “release” reflex involved in the phenomenon.


The original study stacked the odds in their favor by feeding the babies, but follow-up studies all showed a greater than 50% success rate within 5 minutes. Thus, this technique is well worth trying in a low risk population.


Of note, the bladder tapping was 100 taps per minute. It is supposed to be gentle but the parents may quickly throw in the towel and ask for the catheter.


Take Home Points

-For the infant with a low suspicion of urinary tract infection, consider massage and bladder tapping to elicit a urination reflex


Herreros Fernández ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-9.


A 2 year old presents with leg pain and a limp after slipping on a “slip and slide” water toy slide. X-rays are negative. The child will step when asked but will not walk on his own. Is this an occult fracture?

This is a situation where the reference standard, radiography, has limitations in sensitivity. Studies show that using alternative tests reveal evidence of fracture, such as hematoma elevation on ultrasound (Lewis J Clin Ultrasound 2006) or MRI or delayed radiographs.

You go back and examine the leg, placing “bowing” stress on the leg. Sometimes it elicits pain and sometimes it does not. You press on different parts of the leg and it is difficult to localize but there does seem to be the most pain on the distal tibia.

You then twist the leg and foot spirally and the child shouts in pain. You make a clinical diagnosis of Toddler’s fracture. On follow-up, the mother reports that the child reverted to crawling for about 4 weeks before gingerly walking and then returning to normal use of the leg in about 6 weeks. Repeat xrays in the primary physician’s office remained negative. This was an occult tibial fracture.

Take Home Points

Negative x-rays do not rule out fracture

Twisting a long-bone can elicit pain from an occult fracture, especially one in a spiral pattern


A 5 week old presents with nasal congestion and difficulty breathing. RSV bronchiolitis is ultimately diagnosed. Can the patient go home?

Not every infant with bronchiolitis can be admitted. But the ED provider must be aware that the dreaded complication of apnea tends to occur in patients who are under 2-3 months old.

The studies on apnea from bronchiolitis are heterogeneous and the results are mixed. For example the incidence of apnea in newborns varies from <1% to 24% (Ralston J Pediatrics 2009).

One study of all bronchiolitis patients under one year of age found that all the apnea occurred in patients under 10 weeks of age, and 73% in those under 1 month of adjusted age (adjusting for prematurity).(Ricart Ped Infect Dis J 2014) Numerous studies show similar clustering in the newborn period.( Pruikkonen 2014, Arms 2008)

Take Home Points:

-Apnea in RSV is more likely in those under 2-3 months of age or who were premature


A patient presents with right-sided testicular pain and swelling for 1 hour, associated with nausea and vomiting. Physical examination shows tenderness and swelling in both the epididymis and testicle itself. The epididymis is anterior to the testicle, and palpation of the spermatic cord reveals a 1cm nodule about 2 cm above the testicle.


You call the urologist because the patient has spermatic cord torsion. While waiting you apply color Doppler ultrasound which confirms no flow. You try to untwist the testicle laterally but there is resistance and increase of pain. Should you wait for the urologist? Is there anything else you can do?


The idea that all torsion is medial, treated by “opening the book,” has been demonstrated to be false in every generation, yet the over-simplified teaching persists. Thanks to Sessions’ 2003 excellent article showing 1/3 incidence of lateral torsion, awareness is improving.


You go the opposite direction, detorsing medially. The patient experiences relief. Color Doppler ultrasound now shows arterial flow. Torsion can be up to 3 full turns so the patient still needs to go to the operating room. But you have restored arterial flow and improved the patient’s chance of testicular salvage.


Endpoints of manual reduction:

-lack of resistance to the reduction

-relief of pain

-resolution of abnormal lie

-testicle drops lower in the scrotum to a normal position

-may feel a “snap” into place (Hinman’s Atlas of Pediatric Urologic Surgery)

-untwisting of spermatic cord knot

-return of color ultrasound flow


Take Home Points:

-Torsion can occur in either direction, so use resistance and relief as your first endpoints

-Palpate the spermatic cord knot and note the lie and length as additional endpoints

-Use color Doppler ultrasound as the ultimate endpoint


Most people use the term “testicular torsion,” but throughout history it has also been called “spermatic cord torsion.” Many urologists prefer this term. One introduced it as “acute spermatic cord torsion, more commonly and not so exactly named testicular torsion (TT)…”(Drlik M. J Ped Urol 2013)

The reason spermatic cord torsion is a better term is that it accurately identifies the pathologic organ. By neglecting to call it by its right name, we don’t necessarily realize that we can palpate the actual pathology in this disease.

That is why it took until 2011 for an article to assess the sensitivity and specificity of palpation of the spermatic cord knot.(Al-Terki A. Spermatic Cord Knot: A Clinical Finding in Patients with Spermatic Cord Torsion. Adv Urol 2011) With a reported 86% sensitivity and 100% specificity in 46 patients, this is worth our attention.

The knot of spermatic cord torsion may be located in the inguinal canal in neonates, but it is usually in the scrotum in adolescents and adults. We should palpate the spermatic cord in the acute scrotum. If the results of this first article are replicated, this may turn out to be the most important part of the physical examination of the acute scrotum.

Take Home Points:

-“Spermatic cord torsion” is a more accurate term than testicular torsion

-Spermatic cord torsion can often be felt as a knot on physical examination


Spermatic cord knot: a clinical finding in patients with spermatic cord torsion. Al-Terki A…Adv Urol. 2011

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In the last 2 posts we discussed techniques for winning rapport and trust with children and for using distraction and play. We discussed a case of a 16 month old with scalp tenderness. In that case none of these techniques worked. So what do you do next?

Parent’s Arms

Most children between the ages of 1 and 3 will become more calm when examined in the arms of their mother or father. The child calms down, and clings to the mother and sometimes that is enough for examination.

Examination By Proxy

If all else fails you can deputize the mother to do the localizing examination. In this case she tries but the child still cries. You decide to leave the room to let her calm down and you ask the mother try to better define the area that is tender. You suggest a gentle scalp massage starting away from any areas of pain.

Come Back Later

Once the limbic system is aroused and heated it takes a few minutes to cool off. Come back later to reassess the child. Of course, treating pain is important for enabling a good examination.

You come back and she thinks it is the left ear. You expect external otitis but see nothing. Then you look at the scalp in that area and see bulging and redness behind the ear. You order a CT scan and find mastoiditis with abscess formation.

Take Home Points:

-Examine the child in the parent’s arms if needed for calmness

-In the uncooperative child, try localization by proxy


In the previous post we talked about using proper greetings and explanation to win rapport and trust. We talked about a 16 month old with scalp pain that could not be localized. Often efforts at rapport and trust do not work. What do you do next?

For straightforward presentations there is nothing wrong with physical restraint and looking in the ears against resistance etc. William Carlos Williams has a short story “The Use of Force” where he makes this into a morally ambiguous act about subduing another person. Nonsense! Tell the child that you help kids feel better and you are going to check for owies. If you see resistance, have the parent hold the kid and proceed.

But sometimes the presentation is not clear and we need skill in winning a child’s compliance.


Use objects in the room for distraction but these do not always work. Blowing up a glove into a balloon and drawing a happy face works pretty well. Having the glove talk to them is even better. Smartphone photos are great, the child is usually mesmerized.


You might tell them a story; “there is a mouse on the loose in here, have you seen the mouse?” The mouse story, if it works, is good because the mouse can run to wherever you want to examine. “Let me check your ears for the mouse.”

Other forms of play might be to state your commands in ways that captivate the child’s imagination; “pant like a dog” elicits better compliance for oropharyngeal examination than “say ah.” For the abdominal examination, say “let me check your abdomen and see what you had for lunch.”

Take Home Points:

-Use distraction to help localize tenderness

-Use imaginative play to make the examination more fun


A 16 month old presented with pain in the scalp. The examiner was not able to localize it further because the child was uncooperative and crying. What now?

To localize pain in a toddler, we need the child’s cooperation. There are three ways to achieve this. The first approach is to win rapport and trust.

Introduction: I start with a proper introduction to the child on eye to eye level. If they are old enough to understand, I might say “I am the guy who fixes owies.” (sometimes followed by a comical search for “owies” well away from the affected area).

Non-clinical touch: The first touch should be non-threatening. I sometimes do a formal handshake for humor, or a pat on the back, or a light touch of the foot as I say hello.

Say his or her name:

Use his or her first name frequently to enhance familiarity.

Anticipatory Guidance

Demonstrate the exam on yourself or on the child’s mother first. This is really important with the otoscope. The best model is a cooperative older sibling.

If this works, great! Sometimes it does not. Read my next post for the second approach, on distraction and play.

Take Home Points:

-Treat kids like little adults: With respect. Introduce yourself, use an age-appropriate physical greeting, and address them by their name.

-Explain things in advance: model the examination on yourself or a family member.


A mother brings her 2 year old child in for a limp. The student believes the patient has ankle pain because she cried when she grabbed the ankle. After that she cried with everything. After calming the child down you watch her walk and it is abnormal but you wonder how to interpret this.


The last time I tried really hard to analyze gait and make recommendations, it was so complicated that no one could remember it. I now have a more simple approach. An abnormal gait is either neurologic or orthopedic. If there is pain, it tends to be orthopedic. No pain suggests neurologic.


Next, don’t just watch the gait. Imitate it. Follow the child. This allows your proprioceptive neurons to do the thinking for you.


When you do that on this child you see she is splinting her hip. You examine the calmed child and get good range of motion of the ankle and knee. Internal and external rotation of the hip seems to cause discomfort. Now your differential is transient synovitis vs septic arthritis and you proceed from there.


Take Home Points:

Painful gait abnormalities are usually orthopedic. Painless are usually neurologic.

Walk the walk: imitate the gait so you can feel what they are doing with their gait