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Resources & Recommended Services for: Comprehensive Physical Assessment

Resources & Tools

*Individual ages may be selected to view all service recommendations for that age.

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Specific Service Recommendations by Age

Key
Symbol Indicates
1 Service is Routine for all
2 Service is Not Routine—Provide when indicated by risk assessment

Infancy

First week visits—Timing, frequency and content must be individualized according to the infant's unique medical, family and environmental circumstances.

Name Recommendations
Newborn 1 Wk 1 Mo 2 Mo 4 Mo 6 Mo 9 Mo 12 Mo
As part of a complete physical examination, the following should be particularly noted: 1 1 1 1 1 1 1 1
Respiratory rate, temperature, heart rate 1 0 0 0 0 0 0 0
Abdominal Masses 1 1 1 1 0 0 0 0
Ability to fix and follow a human face, ability to suck and swallow, breast engorgement, ear shape, patent nares, intact palate, femoral pulses, Moro reflex, muscle tone, symmetrical movements, response to human voice and other newborn abilities 1 0 0 0 0 0 0 0
Cardiac Murmers 1 1 1 1 1 1 1 1
Dehydration 0 1 0 0 0 0 0 0
Developmental hip dysplasia 1 1 1 1 1 1 1 1
Diaper dermatitis 0 0 1 0 0 0 0 0
Early childhood caries (baby bottle tooth decay) or dental injuries 0 0 0 0 0 0 0 1
Evidence of possible neglect or abuse 0 0 1 1 1 1 1 1
Examine the toddler's feet and observe her walking and gait. Reassure the parent about normal variations. 0 0 0 0 0 0 0 1
Genitalia / Rectum 1 0 0 0 0 0 0 0
Head shape, size, signs of trauma 1 0 0 0 0 0 0 0
Iritability or lethargy 0 1 1 0 0 0 0 0
Metrasus adductus 0 0 0 1 0 0 0 0
Neurologic problems 0 0 0 1 1 1 1 0
Pallor, jaundice, peripheral or central cyanosis 1 1 0 0 0 0 0 0
Problems with tendon reflexes, muscle tone or use of extremities 0 0 0 0 0 1 0 0
Skin mottling, erythema toxicum, hemagiomas, nevi, mongilian spots, Cafe Au Lait Spot, or birthmarks 1 0 0 0 0 0 0 0
Tachycardia 0 1 0 0 0 0 0 0
Tachypnea / retractions, air movement 1 1 0 0 0 0 0 0
Thrush 0 0 1 0 0 0 0 0
Tooth eruption 0 0 0 0 0 1 1 1
Torticollis 0 0 0 1 0 0 0 0

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Early and Middle Childhood

Name Recommendations
15 Mo 18 Mo 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 8 Yr 10 Yr
As part of a complete physical examination, the following should be particularly noted: 1 1 1 1 1 1 1 1 1
* Note - respect the child's privacy by using appropriate draping during the examination. 0 0 0 0 0 0 0 1 1
Cardiac Murmers 1 0 0 0 0 0 0 0 0
Caries, developmental dental anomalies, malocclusion, gingivitis, pathologic conditions, or dental injuries 0 0 0 0 0 0 1 1 1
Developmental hip dysplasia 1 0 0 0 0 0 0 0 0
Early childhood caries (baby bottle tooth decay) or dental injuries 1 1 1 0 0 0 0 0 0
Early childhood caries, developmental dental anomalies, malocclusion, pathologic conditions or dental injuries 0 0 0 1 1 1 0 0 0
Early puberty (girls). Evaluate for Sexual Maturity Rating or Tanner Stage. 0 0 0 0 0 0 0 1 0
Evaluate for Sexual Maturity Rating or Tanner Stage 0 0 0 0 0 0 0 0 1
Evidence of possible neglect or abuse 0 0 0 0 1 1 1 1 1
Examine the toddler's feet and observe her walking and gait. Reassure the parent about normal variations. 1 1 0 0 0 0 0 0 0
Excessive inuries or bruising that may indicate inadequate supervision or abuse and any other evidence of possible neglect or abuse. 1 1 1 1 0 0 0 0 0
Observe child's gait 0 0 0 0 1 0 0 0 0
Scoliosis (screen females initally at 10 yr. visit) 0 0 0 0 0 0 0 0 1
Skin mottling, erythema toxicum, hemagiomas, nevi, mongilian spots, Cafe Au Lait Spot, or birthmarks 1 1 1 1 0 0 0 0 0
Tooth eruption 1 1 0 0 0 0 0 0 0

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Adolescence

Name Recommendations
11 Yr 12 Yr 13 Yr 14 Yr 15 Yr 16 Yr 17 Yr 18 Yr 19 Yr 20 Yr
As part of a complete physical examination, the following should be particularly noted: 1 1 1 1 1 1 1 1 1 1
Acne and common dermatoses 1 1 1 1 1 1 1 1 1 1
Caries, developmental dental anomalies, malocclusion, gingivitis, pathologic conditions, or dental injuries 1 1 1 1 1 1 1 1 1 1
Evaluate for Sexual Maturity Rating or Tanner Stage 0 0 0 0 0 1 1 1 1 1
Evaluate for Sexual Maturity Rating or Tanner Stage. Evaluate if onset of puberty has not occured in females by age 13 or in males by age 14. 0 0 1 1 1 0 0 0 0 0
Evidence of eating disorders (e.g., extreme weight loss or gain, erosion of tooth enamel) 1 1 1 1 1 1 1 1 1 1
Evidence of possible neglect or abuse 1 1 1 1 1 1 1 1 1 1
Excessive Body Hair (Hirsutism) 0 0 0 0 1 1 1 1 1 1
For Females: An external genital exam should be performed. Examine genitals for normal development. Check for condyloma/leisons, vulvovaginitis. If adolescent is sexually active or has primary amenorrhea or menstrual complaints, perform pelvic exam and evaluate. Teach breast self-examination. 0 0 0 0 1 1 1 0 0 0
For Females: An external genital exam should be performed. Examine genitals for normal development. Check for condyloma/lesions, vulvovaginitis. If adolescent is sexually active, perform pelvic exam annually. 1 1 1 1 0 0 0 0 0 0
For Females: An external genital exam should be performed. Examine genitals for normal development. Check for condyloma/lesions, vulvovaginitis. If adolescent is sexually active or has primary amenorrhea or menstrual complaints, perform pelvic exam and evaluate. Teach breast self-examination and encourage monthly breast self-exams at home. 0 0 0 0 0 0 0 1 1 1
For Females: Offer pelvic examination and Pap smear (begin under 18 years if patient is sexually active) 2 2 2 2 2 2 2 1 1 1
For Males: An external genital exam should be performed. Examine genitals for normal development. Check for baricoceles, hernias, condyloma/lesions, testicular cancer. (Risk criteria for testicular cancer include history of undescended testes, single testicle.) Evaluate for gynomastia. 1 1 1 1 0 0 0 0 0 0
For Males: An external genital exam should be performed. Teach testicular self-examination. Examine genitals for normal development. Check for varicoceles, hernias, condyloma/lesions, testicular cancer. (Risk criteria for testicular cancer include history of undescended testes, single testicle.) Evaluate for gynomastia. 0 0 0 0 1 1 1 0 0 0
For Males: An external genital exam should be performed. Teach testicular self-examination. Examine genitals for normal development. Check for varicoceles, hernias, condyloma/lesions, testicular cancer. (Risk criteria for testicular cancer include history of undescended testes, single testicle.) Evaluate for gynomastia. 0 0 0 0 0 0 0 1 1 1
Scoliosis or kyphosis (screen males and females annually) 1 1 1 1 1 1 1 0 0 0
Sports inujuries, other orthopedic problems 1 1 1 1 1 1 1 1 1 1
Tatoos, piercing 1 1 1 1 1 1 1 1 1 1

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