1. Introduction & Consent: Introduces self, explains procedure, seeks verbal consent from parents/child, warms hands.
2. Positioning & Exposure: Child in supine position with knees slightly flexed; completely expose abdomen from xiphisternum to midthigh (including groin/genitalia), maintaining modesty.
3. Inspection:
   • Abdominal contour/shape (scaphoid/flat/distended), symmetry.
   • Movements with respiration (abdominal vs thoracoabdominal breathing).
   • Umbilicus (position, eversion, discharge, herniation).
   • Dilated superficial veins (note direction of blood flow), striae, visible peristalsis, visible pulsations, scars, sinuses.
4. Palpation:
   • Ask if and where there is pain (examine painful area last); look at the child's face for discomfort throughout.
   • Light / Superficial Palpation: Assess local temperature, guarding, rigidity, hyperesthesia, superficial tenderness in all 9 quadrants.
   • Deep Palpation:
     • Liver: Palpate from right iliac fossa upwards towards right costal margin along midclavicular line; characterize edge, surface, consistency, tenderness; measure liver span by percussion (normal: 5–8 cm depending on age).
     • Spleen: Palpate from right iliac fossa diagonally towards left costal margin; feel for splenic notch.
     • Kidneys: Bimanual ballottement in both flanks.
5. Percussion:
   • Map out liver and splenic dullness.
   • Percuss for ascites: Shifting dullness and fluid thrill (in massive ascites).
6. Auscultation:
   • Auscultate bowel sounds in all 4 quadrants (normal, sluggish, or hyperactive/borborygmi).
   • Listen for vascular bruits (renal/aortic) and friction rubs.
7. Hernial Orifices, External Genitalia, Spine & Anus: Check inguinal and femoral rings, palpate testes in scrotum, inspect perianal area and spine.
8. Re-cover abdomen, thank child and parents, and summarize positive/negative findings to the examiner.

1. Introduction & Rapport: Introduces self, explains procedure to child and mother, ensures child is calm and rested for 5 minutes.
2. Cuff Selection: Choose appropriate pediatric cuff size:
   • Inflatable bladder width must cover $\ge 40\mathrm{\%}$ of mid-arm circumference (or 75–80% of upper arm length).
   • Bladder length must encircle 80–100% of arm circumference.
3. Application: Apply cuff snugly on bare right upper arm with lower edge 2–3 cm above antecubital fossa; center bladder over brachial artery. Support arm at heart level.
4. Palpatory Method (Estimate Systolic BP): Palpate radial pulse, inflate cuff rapidly until pulse disappears; inflate 20–30 mmHg further, then slowly deflate (2–3 mmHg/sec) to note pressure when pulse reappears.
5. Auscultatory Method:
   • Place diaphragm of stethoscope lightly over brachial artery (not under the cuff).
   • Inflate cuff to 20–30 mmHg above estimated palpatory systolic BP.
   • Deflate slowly at 2–3 mmHg per second.
   • Systolic BP (SBP): Appearance of clear tapping sound (Korotkoff Phase I).
   • Diastolic BP (DBP): Complete disappearance of sounds (Korotkoff Phase V; Phase IV muffling in young children).
6. Measure in upper and lower extremities if evaluating for hypertension or coarctation.
7. Plot SBP and DBP on age-, sex-, and height-percentile blood pressure charts (AAP/WHO).
8. Assist child with clothing, thank child/mother, and report values and percentile to the examiner.

1. Informed Consent & Pre-procedure Check: Explain indication and risks to parents, obtain written informed consent. Check platelet count and coagulation profile; verify absence of contraindications (signs of raised ICP, focal deficits, severe cardiorespiratory instability, local infection at puncture site).
2. Monitoring & Equipment: Ensure continuous pulse oximetry, resuscitation equipment, and sterile LP kit ready (22G/24G spinal needle with stylet, sterile gloves/drape, collection tubes, manometer, antiseptic, local anesthetic).
3. Positioning: Place child in left lateral decubitus position on a firm surface with spine flexed (fetal position — knees drawn to abdomen and neck gently flexed, taking care not to compromise airway). Assistant holds child securely.
4. Landmark Identification: Draw an imaginary intercristal line connecting the highest points of both iliac crests (Tuffier's line), crossing the L3–L4 intervertebral space (safe level for LP in infants/children: L3–L4 or L4–L5).
5. Asepsis & Local Anesthesia: Thorough surgical hand wash, sterile gloves, gown; clean skin with antiseptic solution in concentric circles; place sterile fenestrated drape. Infiltrate 1% lignocaine locally into skin and subcutaneous tissue.
6. Needle Insertion:
   • Insert 22G spinal needle with stylet in midline at L3–L4 space, bevel pointing cranially/laterally, angled slightly towards umbilicus (10°–15° cephalad).
   • Advance slowly until a subtle "give-way / pop" sensation is felt as the ligamentum flavum and dura are pierced.
   • Withdraw stylet partially to observe spontaneous clear CSF flow.
7. CSF Collection & Pressure: Measure opening pressure with manometer if indicated; collect 1–2 mL of CSF into 3 sterile tubes (Tube 1: Biochemistry/glucose & protein, Tube 2: Microbiology/Gram stain & culture, Tube 3: Cell count & differential).
8. Completion & Post-Care: Reinsert stylet, withdraw spinal needle swiftly, apply firm pressure with sterile gauze, apply dressing. Place child supine for 30–60 minutes; monitor vitals and puncture site. Dispose of sharps in designated puncture-proof bin.

1. Introduction & Safety: Introduces self, explains procedure, ensures a safe, well-lit, unobstructed walking path; stands close to prevent falls.
2. Casual Walking: Ask child to walk barefoot in a straight line for 10–15 paces, turn around, and return:
   • Observe stance width, stride length, speed, arm swing, trunk stability, balance during turning.
   • Cerebellar ataxia: Broad-based, unsteady, staggering "drunken" gait with irregular steps and lurching toward side of cerebellar lesion.
   • Sensory ataxia: Stamping gait with heavy heel-strikes, worse in dark / eyes closed.
   • Spastic hemiparetic/diplegic: Circumduction / scissoring gait.
3. Tandem Walking (Heel-to-Toe): Ask child to walk in a straight line placing heel directly in front of opposite toe (accentuates subtle midline vermian cerebellar ataxia).
4. Toe and Heel Walking: Ask child to walk on toes (tests S1/calf strength) and heels (tests L4/L5 dorsiflexor strength).
5. Romberg Test: Ask child to stand with feet together, arms at sides, eyes open, then close eyes for 30 seconds:
   • Sensory ataxia (dorsal column lesion): Steady with eyes open, marked swaying/falling with eyes closed (Positive Romberg).
   • Cerebellar ataxia: Unsteady with eyes open, no significant worsening with eyes closed (Negative Romberg / cerebellar instability).
6. Check rapid turn test and perform other cerebellar signs (finger-nose, dysdiadochokinesia).
7. Thanks child and parents; reports impression to examiner.

1. Introduction & Consent: Introduces self, explains examination, warms hands, properly exposes right upper limb (and contralateral limb for comparison).
2. Inspection:
   • Muscle bulk and symmetry (look for wasting or pseudohypertrophy in deltoid, biceps, thenar, hypothenar, interossei muscles).
   • Mid-upper arm circumference (MUAC) measurement if indicated.
   • Involuntary movements (fasciculations, tremors, chorea, athetosis).
   • Posture and deformities (wrist drop, claw hand, flexion posture).
3. Palpation & Tone:
   • Palpate muscle bulk/consistency.
   • Assess tone by gentle passive movements across wrist, elbow, and shoulder joints (hypotonia vs spasticity/clasp-knife vs rigidity/lead-pipe).
4. Power Assessment (MRC Scale 0 to 5):
   • Shoulder: Abduction (C5), Adduction (C6/C7).
   • Elbow: Flexion (C5/C6 - Biceps), Extension (C7 - Triceps).
   • Wrist: Flexion (C7/C8), Extension (C6/C7).
   • Hand & Fingers: Grip strength (C8/T1), Finger abduction/interossei (T1), Thumb opposition (T1).
5. Deep Tendon Reflexes (DTRs):
   • Biceps reflex (C5, C6)
   • Supinator / Brachioradialis reflex (C5, C6)
   • Triceps reflex (C7, C8)
6. Coordination: Finger-to-nose test, rapid alternating movements (dysdiadochokinesia).
7. Help child redress, thank child and parents, and summarize motor findings to the examiner.

1. Introduction & Exposure: Introduces self, takes consent, exposes neck, chest, abdomen, and limbs appropriately.
2. Tissue & Mucosal Signs:
   • Oral mucosa and tongue: Moist (euvolemic) vs dry/parched (volume depletion).
   • Axillae: Check axillary moisture.
   • Eyes: Normal vs sunken eyes, presence/absence of tears on crying.
   • Skin Turgor: Perform skin pinch on abdominal wall at level of umbilicus (normal: retracts immediately; slow $>1\text{ sec}$ or very slow $>2\text{ sec}$ in dehydration).
3. Peripheral Perfusion & Capillary Refill:
   • Palpate peripheral extremities (warm vs cold/clammy).
   • Capillary Refill Time (CRT): Press thumb nail bed or sternum for 5 seconds and release (normal $\le 2\text{ seconds}$; $>3\text{ seconds}$ indicates poor perfusion/shock).
4. Cardiovascular / Hemodynamic Signs:
   • Peripheral pulses: Rate, rhythm, volume (thready in hypovolemia, bounding in hypervolemia/high output).
   • Blood Pressure & Postural Drop: Measure lying and standing BP (orthostatic drop in SBP $>20\text{ mmHg}$ or DBP $>10\text{ mmHg}$ indicates volume depletion).
   • Jugular Venous Pressure (JVP): Inspect at 45° angle (elevated JVP $>2\text{--}3\text{ cm}$ above sternal angle indicates volume overload/right heart failure).
5. Signs of Fluid Overload:
   • Dependent peripheral edema: Pitting edema over medial malleoli, pretibial area, and sacrum.
   • Respiratory: Tachypnea, bilateral basilar fine crackles/crepitations, pleural effusion.
   • Abdomen: Tender hepatomegaly, ascites.
6. Report clinical volume status (dehydrated, euvolemic, or fluid-overloaded) to the examiner.

1. Introduction & Screening: Greet mother, verify child's identity and age (16 months), screen for contraindications (severe immunocompromise/immunodeficiency, anaphylaxis to neomycin/gelatin, recent IVIG/blood products within 3–11 months).
2. Hand Hygiene & Vaccine Inspection:
   • Wash hands thoroughly with soap and water.
   • Inspect MMR lyophilized vaccine vial, sterile water diluent ampoule, expiry date, and Vaccine Vial Monitor (VVM) stage.
3. Reconstitution:
   • Draw entire volume of provided sterile water diluent with a mixing syringe.
   • Slowly inject diluent into the MMR vial down the side of the glass; swirl gently to dissolve completely without foaming.
   • Keep reconstituted vial on ice pack away from direct light; use within 4 hours.
4. Dose & Syringe Loading: Draw exactly 0.5 mL of reconstituted vaccine into a sterile 0.5 mL auto-disable / tuberculin syringe with a 25G, 5/8-inch needle.
5. Site & Administration:
   • Site: Anterolateral aspect of upper thigh (or upper outer aspect of deltoid muscle).
   • Clean skin with sterile water if visibly soiled (avoid spirit/alcohol wipes for live viral vaccines).
   • Pinch subcutaneous tissue gently; insert needle at a 45° angle subcutaneously.
   • Inject the full 0.5 mL dose smoothly; withdraw needle and apply gentle pressure with dry cotton (do not massage).
6. Post-Vaccination Counseling:
   • Advise waiting for 30 minutes in clinic to observe for acute allergic reactions.
   • Counsel on expected delayed reactions (mild fever and rash 5–12 days post-vaccination).
   • Dispose of sharps in puncture-proof sharps container; record in immunization card and schedule next dose (at 4–6 years).

1. Introduction & Consent: Introduce self, establish rapport with child and parents, ask if the child has pain anywhere.
2. Gait:
   • Observe the child walking 10 paces, turning, and returning.
   • Walk on tiptoes and on heels (tests ankle and subtalar joints).
3. Arms (Upper Limbs):
   • Put hands out straight in front (palms down), inspect dorsum of hands, wrists, fingers.
   • Turn hands over (palms up), inspect palmar aspect and thenar/hypothenar eminence.
   • Make a tight fist (tests finger flexion) and touch thumb to each fingertip (fine dexterity).
   • "Prayer sign" and reverse prayer sign (tests wrist extension and flexion).
   • Touch back of neck with elbows back (shoulder abduction and external rotation).
   • Reach hands high above head with arms straight (elbow extension and shoulder elevation).
4. Legs (Lower Limbs):
   • Inspect knees and ankles standing (alignment: valgus/varus).
   • Lie on couch: Assess passive knee flexion and extension while palpating for joint effusion and joint line crepitus.
   • Assess internal and external rotation of hips with hip and knee flexed at 90°.
   • Inspect soles of feet for flat arches or deformities.
5. Spine & Neck:
   • Cervical spine: Look up at ceiling, chin to chest, turn head to left and right, ear to shoulder.
   • Thoracolumbar spine: Inspect spine from behind and side for scoliosis/kyphosis/lordosis; palpate spinous processes.
   • Forward bending test (Adams forward bend test) with knees straight to check spinal curvature and flexibility.
6. Thank child and parents; report findings systematically to the examiner.

1. Introduction, Consent & Asepsis: Introduces self, explains procedure, ensures warm draft-free room, washes and warms hands.
2. Weight Measurement (Electronic Infant Weighing Scale):
   • Place clean disposable paper sheet on weighing pan.
   • Zero/tare the digital weighing scale.
   • Undress neonate completely (remove diaper).
   • Place baby gently in center of pan; wait for infant to be still and read weight to nearest 5–10 grams.
   • Report weight and immediately cover baby to prevent hypothermia.
3. Length Measurement (Infantometer):
   • Place infant supine on firm infantometer.
   • Assistant holds baby's head firmly against fixed headboard in Frankfurt horizontal plane (line from lower margin of orbit to superior margin of auditory meatus is vertical).
   • Examiner holds knees flat against baseboard with left hand and moves sliding footboard firmly against heels with toes pointing upwards.
   • Read crown-to-heel length to the nearest 0.1 cm.
4. Head Circumference (Occipitofrontal Circumference - OFC):
   • Use a flexible, non-stretchable narrow measuring tape.
   • Place tape across the widest part: anteriorly just above the eyebrows and supraorbital ridges, laterally above the ears, and posteriorly over the maximal prominence of the occiput.
   • Pull tape snug to compress hair; take 3 measurements and record the largest reading to nearest 0.1 cm.
5. Plot weight, length, and OFC on WHO/Fenton growth charts; report percentiles to the examiner.

1. Introduction & Rapport: Engage child in a relaxed, playful manner with colorful age-appropriate testing toys/cubes/paper.
2. Gross Motor:
   • Walks up and down stairs using alternate feet.
   • Hops steadily on one foot for 2–3 hops.
   • Throws ball overhand with coordination and catches a bounced ball.
3. Fine Motor & Adaptive:
   • Copies a square ($◻$) and a cross ($+$).
   • Draws a person ("Draw-a-Man") with $\ge 3\text{--}4$ identifiable parts (head, trunk, limbs).
   • Builds a 3-step bridge with 5 wooden cubes; cuts along a straight line with blunt safety scissors.
4. Language & Communication:
   • Speaks in complete 5- to 6-word sentences; tells a coherent story/event.
   • Identifies and names 4 primary colors (red, blue, green, yellow).
   • Counts 4 objects accurately; understands prepositions (in front, behind, under).
5. Personal & Social:
   • Unbuttons buttons and dresses/undresses with minimal assistance.
   • Washes and dries hands and face independently.
   • Engages in cooperative group play and role-play games.
6. Summary to Examiner: "All demonstrated milestones are consistent with a developmental age of 4 years."

1. Method of Elicitation:

   • Adductor Angle: Infant supine with legs extended; gently abduct both legs laterally as far as possible; measure angle formed between thighs.
   • Popliteal Angle: Infant supine, pelvis flat; flex thighs onto abdomen, then extend lower legs at knees until resistance is felt; measure posterior angle formed at popliteal fossa.
   • Heel-to-Ear Maneuver: Supine with pelvis flat; draw feet straight up towards ears without lifting pelvis off table; measure angle between thighs and trunk.
   • Scarf Sign: Draw infant's hand across chest towards opposite shoulder; note position of elbow relative to midline.
   • Foot Dorsiflexion Angle: Flex foot dorsally against anterior lower leg; measure angle between dorsum of foot and anterior border of leg.

2. Normal Values by Age (Amiel-Tison Norms):

Age Range	Adductor Angle	Popliteal Angle	Scarf Sign	Foot Dorsiflexion
1–3 months	40°–80°	80°–100°	Elbow does not cross midline	60°–70°
4–6 months	70°–110°	100°–120°	Elbow reaches/crosses midline	60°–70°
7–9 months	110°–140°	120°–150°	Elbow passes beyond contralateral axillary line	60°–70°
10–12 months	140°–160°	150°–170°	Elbow easily passes beyond contralateral axillary line	60°–70°

3. Clinical Utility:
   • Evaluates passive muscle tone and maturation of the corticospinal pathways in infants (0–12 months).
   • Early detection of hypertonia / spasticity (decreased angles / tight joints) in Spastic Cerebral Palsy.
   • Early detection of hypotonia (excessively wide angles) in lower motor neuron or central hypotonia syndromes.

(a) Elicitation of Soft Neurological Signs:

1. Motor Coordination & Rapid Alternating Movements:
   • Rapid finger tapping (thumb-to-fingers in sequence).
   • Rapid alternating hand pronation-supination on thighs.
   • Foot tapping (alternate heel-toe tapping on floor).
   • Observe for motor persistence, dysmetria, and involuntary mirror movements (synkinesis) in the opposite hand.
2. Motor Incoordination & Overflow:
   • Fog's test: Ask child to walk on lateral borders of feet; observe for involuntary posturing/overflow movements in outstretched arms.
   • Tandem walking and hopping on one foot.
3. Sensory & Perceptual Integration:
   • Double simultaneous tactile stimulation (extinction test / face-hand test).
   • Graphesthesia: Identify numbers traced on palm with eyes closed.
   • Astereognosis: Identify familiar objects (coin, key) by touch alone.
   • Left-right orientation and finger agnosia.
4. Spatial Orientation & Praxis:
   • Constructive praxis: Copying geometric designs, tying shoelaces, buttoning/unbuttoning clothes.

(b) Clinical Utility of Soft Neurological Signs:

• NSS represent subtle non-focal abnormalities in motor control, sensory processing, and integration without focal neuroanatomical lesions.
• Found in higher prevalence in neurodevelopmental disorders: ADHD, Developmental Coordination Disorder (Dyspraxia), Specific Learning Disabilities (Dyslexia), and Autism Spectrum Disorder.

1. Introduction & General Assessment: Introduces self, takes consent, measures temperature (fever), notes toxic appearance, pallor.
2. Peripheral Stigmata of Infective Endocarditis:
   • Hands & Nails:
     • Splinter hemorrhages (linear subungual hemorrhages).
     • Osler nodes: Painful, tender, erythematous raised nodules on pads of fingers/toes (immunological).
     • Janeway lesions: Non-tender, flat, erythematous/hemorrhagic macules on palms and soles (micro-embolic).
     • Digital clubbing.
   • Eyes: Conjunctival petechiae/hemorrhages; ophthalmoscopy for Roth spots (pale retinal spots surrounded by hemorrhage).
   • Skin: Generalized petechiae, purpuric rash.
3. Cardiovascular Examination:
   • Palpate pulses for rate, rhythm, and character.
   • Precordial auscultation: Auscultate all 4 valve areas for new or changing murmurs (especially aortic or mitral regurgitation), prosthetic valve clicks, or friction rubs.
4. Abdominal Examination: Palpate for splenomegaly (present in ~30–50% of chronic IE) and tender hepatomegaly (heart failure).
5. Signs of Heart Failure / Complications: Raised JVP, pulmonary rales/crackles, peripheral pedal edema.
6. Re-cover child, thank family, and present findings according to Duke criteria.

1. Introduction & Consent: Greet parents, introduce self, seek permission to examine the infant.
2. Craniofacial Inspection & Palpation:
   • Head Circumference: Measure maximal occipitofrontal circumference (OFC) with non-stretchable tape; plot on growth chart (OFC $>+2\text{ SD}$ / $>97\text{th}$ percentile or crossing percentiles rapidly).
   • Cranial Shape & Forehead: Macrocephaly with frontal bossing.
   • Scalp: Scalp is thin, shiny, and stretched with engorged, dilated, tortuous superficial scalp veins.
   • Sutures & Fontanelles: Palpate cranial sutures (widely split/separated); palpate anterior fontanelle (large, tense, bulging, non-pulsatile).
   • Percussion: Macewen's sign ("cracked-pot" sound on skull percussion).
   • Transillumination: Transillumination test positive in severe hydrocephalus / hydranencephaly.
3. Ocular Signs:
   • Setting-Sun Sign: Downward deviation of ocular globes with sclera visible above iris due to periaqueductal pressure on vertical gaze center.
   • Assess pupillary reflexes and check for 6th cranial nerve (abducens) palsy (strabismus).
   • Fundus examination for papilledema or optic atrophy.
4. Neurological & Motor Examination:
   • Hypertonia and spasticity in lower extremities (corticospinal tract stretching), exaggerated deep tendon reflexes, ankle clonus, extensor plantar response.
   • High-pitched "cerebral" cry, irritability, poor feeding, vomiting.
5. Spine Examination: Inspect and palpate spine for spina bifida / myelomeningocele or neurocutaneous markers.
6. Re-dress baby, thank parents, and report findings to examiner.

1. Introduction & Position: Introduces self, warms hands, exposes chest properly, ensures child is comfortable seated or standing.
2. Confirmation of Inspection Findings: Palpate for localized chest wall tenderness, rib deformities, palpable rhonchi, pleural friction rubs, or subcutaneous emphysema (crepitus).
3. Tracheal Position:
   • Place index and ring fingers on sternal heads of sternocleidomastoid muscles; gently insert tip of middle finger into suprasternal notch over trachea.
   • Assess central position vs deviation to right/left.
4. Apex Beat: Palpate apex beat (normal: 4th left ICS in $<4\text{ yr}$, 5th left ICS inside midclavicular line in older children); check for mediastinal displacement.
5. Chest Expansion (Upper & Lower Lobes):
   • Anterior Chest: Place palms on lower chest with fingers grasping lateral rib cages; extend thumbs midline until they meet over lower sternum without tension. Instruct child to inhale deeply; observe symmetric divergence of thumbs (normal: 3–5 cm separation).
   • Posterior Chest: Place hands around lateral chest walls with thumbs apposed midline over T10 spinous process; observe thumb separation on maximal deep inspiration.
6. Tactile Vocal Fremitus (TVF):
   • Place ulnar border of hand / palm flat on corresponding areas of anterior, lateral, and posterior chest walls sequentially.
   • Ask child to repeat "99" or "one-one-one" each time; compare vibratory intensity between symmetrical lung zones (increased in consolidation/cavity, decreased in effusion/pneumothorax/collapse).
7. Help child redress, thank child/mother, and report palpatory findings to examiner.

1. Introduction & Consent: Greet child and parents, take consent, warm hands, expose chest and extremities.
2. Peripheral Arterial Signs of Wide Pulse Pressure in AR:
   • Water-Hammer / Corrigan's Pulse: Palpate radial pulse, elevate child's forearm vertically above heart; feel rapid upstroke and sudden collapse (collapsing pulse).
   • Corrigan's Sign: Visible vigorous pulsations of carotid arteries in the neck ("dancing carotids").
   • de Musset's Sign: Rhythmical head bobbing / nodding synchronous with each heartbeat.
   • Quincke's Sign: Alternating flushing and blanching of the nail bed when light pressure is applied to the fingernail tip.
   • Müller's Sign: Systolic pulsation of the uvula and soft palate on mouth inspection.
   • Landolfi's Sign: Systolic pupillary constriction and diastolic dilation.
   • Lighthouse Sign: Alternating facial flushing and pallor.
   • Rosenbach's Sign: Pulsatile liver on deep abdominal palpation.
   • Gerhardt's Sign: Pulsatile spleen.
   • Duroziez's Sign: Auscultate femoral artery with stethoscope diaphragm applying gentle compression (systolic murmur with proximal compression, diastolic murmur with distal compression).
   • Traube's Sign ("Pistol-Shot Sounds"): Booming pistol-shot sounds auscultated over the femoral arteries.
   • Hill's Sign: Systolic blood pressure in popliteal/lower extremity exceeds brachial/upper extremity SBP by $>20\text{ mmHg}$ ($>60\text{ mmHg}$ in severe AR).
3. Precordial Examination: Hyperdynamic displaced apex beat; early diastolic high-pitched decrescendo murmur best heard at 3rd left ICS (Erb's point) on leaning forward in end-expiration; Austin Flint murmur (apical mid-diastolic rumble).
4. Redress child, thank family, and summarize findings.

1. Introduction & Exposure: Introduces self, takes consent, exposes child maintaining dignity.
2. General Appearance & Neurological State:
   • Scleral icterus / jaundice, fetor hepaticus (musty sweet breath).
   • Assess Hepatic Encephalopathy: Grade I (sleep reversal, mild confusion), Grade II (drowsy, asterixis), Grade III (stuporous), Grade IV (coma).
   • Asterixis (Flapping Tremor): Ask child to hyperextend arms, dorsiflex wrists, and spread fingers for 30 seconds with eyes closed; observe for irregular jerky lapses of posture.
   • Constructional apraxia (inability to draw a 5-pointed star or simple shapes).
3. Upper Limb & Cutaneous Stigmata:
   • Palmar erythema (mottled erythema over thenar/hypothenar eminences).
   • Leukonychia (Terry's white nails) and digital clubbing.
   • Dupuytren's contracture.
   • Multiple spider angiomas (spider nevi) in SVC territory (face, neck, upper chest, arms) — blanch with central pressure.
   • Bruising / petechiae / purpura (coagulopathy).
4. Head & Neck: Bilateral painless parotid gland enlargement, Kayser-Fleischer rings (slit lamp in Wilson disease).
5. Abdominal Examination:
   • Distended abdomen with tense ascites.
   • Dilated abdominal wall collateral veins radiating from umbilicus (Caput Medusae — blood flows away from umbilicus).
   • Liver: Shrunken, non-palpable liver in fulminant failure/cirrhosis (or hard, nodular enlarged liver in early cirrhosis).
   • Splenomegaly (portal hypertension).
6. Endocrine Stigmata: Gynecomastia, sparse body hair, testicular atrophy.
7. Lower Extremities: Bilateral pitting pedal/pretibial edema.
8. Redress child, thank family, and present structured summary to examiner.

1. Introduction & Rapport: Greet child by name, establish warm, friendly communication to eliminate anxiety.
2. General Appearance & Consciousness: Note alertness, behavior, cooperation, emotional affect, eye contact, and grooming.
3. Orientation:
   • Time: What time of day is it? What day, month, and year is it?
   • Place: Where are we right now? What is the name of this hospital/city?
   • Person: What is your name? Who is this person sitting next to you?
4. Attention & Concentration:
   • Digit Span Test: Ask child to repeat 3–4 numbers forward (e.g., 3-8-2-5) and 3 numbers backward.
   • Serial subtraction: Subtract 3 or 7 from 100, or recite days of week/months backwards.
5. Memory:
   • Immediate Recall: Repeat 3 unrelated words (e.g., Apple, Table, Penny) immediately.
   • Recent Memory: What did you have for breakfast today? Ask for the 3 words after 5 minutes.
   • Remote Memory: When is your birthday? What festival did you celebrate last month?
6. Speech & Language:
   • Fluency, clarity, articulation, volume, and comprehension of 3-step commands ("Take this paper, fold it in half, put it on table").
   • Naming common objects (pen, watch), repeating complex phrases, reading and writing.
7. Intelligence & Abstract Thinking: Simple age-appropriate calculations (e.g., $4+6$, $15-7$), explaining similarities (e.g., "How are an apple and an orange alike?").
8. Thank child and parents; present concise assessment to examiner.

1. Introduction & Consent: Greet child and parents, explain procedure, ensure adequate lighting.
2. Inspection at Rest:
   • Facial symmetry, forehead wrinkle symmetry, palpebral fissure width, blink frequency.
   • Symmetry of nasolabial folds, corners of mouth, and involuntary facial twitches.
3. Motor Testing of Facial Muscles (Upper & Lower Face):
   • Frontalis: Ask child to look up at ceiling / raise eyebrows; observe forehead wrinkling.
   • Orbicularis Oculi: Ask child to close eyes tightly ("do not let me open them"); attempt to gently lift upper eyelids.
   • Orbicularis Oris: Ask child to whistle, puff out cheeks against resistance (observe for air leak), and pout lips.
   • Buccinator: Ask child to blow out a candle or hold water in mouth.
   • Levator Anguli Oris / Zygomaticus: Ask child to show teeth / smile broadly; observe symmetry of mouth retraction.
   • Platysma: Grimace or depress lower lip against resistance.
4. Differentiating UMN vs LMN 7th Nerve Palsy:
   • LMN Facial Palsy (Bell's Palsy): Ipsilateral upper AND lower facial paralysis (forehead wrinkles lost, inability to close eye with Bell's phenomenon, mouth deviates to opposite side).
   • UMN Facial Palsy (Stroke/Cortical): Contralateral LOWER facial paralysis only with sparing of forehead wrinkling and eye closure (due to bilateral cortical representation of upper face).
5. Sensory & Special Function (Taste):
   • Test taste sensation on anterior 2/3 of tongue using sterile cotton swabs dipped in sweet (sugar), salty (salt), sour (lemon juice), and bitter solutions; child points to written chart without speaking. Rinse mouth between solutions.
6. Parasympathetic Functions: Enquire about lacrimation (Schirmer's test) and salivation; check corneal reflex (afferent CN V1, efferent CN VII).
7. Thank child and parents; report findings to examiner.

1. Introduction & Explanation: Greet child and parents, explain that you will touch different areas lightly with your finger.
2. Cervical Dermatomes (C2 to C8):
   • C2: Occiput / behind the ear.
   • C3: Supraclavicular fossa / high neck.
   • C4: Acromioclavicular joint / top of shoulder.
   • C5: Lateral aspect of upper arm (deltoid region).
   • C6: Lateral forearm, dorsal base of the thumb.
   • C7: Dorsum of the middle finger.
   • C8: Medial border of the hand / little finger.
3. Lumbar Dermatomes (L1 to L5):
   • L1: Inguinal crease / upper groin area.
   • L2: Anterior upper-to-mid thigh.
   • L3: Medial femoral condyle / anterior knee.
   • L4: Medial malleolus / medial side of great toe.
   • L5: Dorsum of foot at the 3rd metatarsophalangeal joint / web space of 1st and 2nd toes.
4. Re-cover/dress child, thank child and parents, and confirm completion to examiner.

1. Differential Diagnoses Considered First:
   • Drug-induced (Salbutamol/Asthalin nebulization, theophylline, valproate).
   • Hypoglycemia, thyrotoxicosis, hypocalcemia.
   • Cerebellar tremor (Intention tremor / ataxia).
   • Post-infectious encephalitis / metabolic encephalopathy / Wilson disease.
   • Physiological / shivering / infantile tremor syndrome (ITS).
2. Clinical Examination Steps:
   • Consent & Vitals: Temperature, PR (tachycardia in salbutamol/thyrotoxicosis), RR (acidotic breathing in metabolic disease), BP.
   • Characterize Tremor:
     • Rest tremor vs Postural tremor (with arms outstretched) vs Kinetic / Intention tremor (worsens approaching target in finger-nose test).
     • Frequency, amplitude, symmetry, involvement of head/neck (titubation) or tongue.
   • Neurological & Cerebellar Examination:
     • Sensorium and interaction.
     • Cranial nerves, nystagmus, ocular saccades.
     • Tone (hypotonia in cerebellar disease, rigidity), DTRs, gait/ataxia.
     • Neurocutaneous markers (cafe-au-lait spots, hypopigmented macules).
   • Systemic Signs: Pallor, knuckle hyperpigmentation, sparse hypopigmented hair (Infantile Tremor Syndrome), hepatomegaly, splenomegaly.
3. Thank child and parents; present structured differential diagnosis and examination findings to the examiner.

1. Differential Diagnoses Considered:
   • Normal variants: Familial (Genetic) Short Stature, Constitutional Delay of Growth and Puberty (CDGP).
   • Endocrine: Growth Hormone Deficiency (GHD), Hypothyroidism, Cushing syndrome.
   • Syndromic / Genetic: Turner syndrome, Down syndrome, Noonan syndrome, Skeletal dysplasias (Achondroplasia).
   • Systemic / Chronic illness: Celiac disease, Malnutrition, CKD, Cyanotic CHD, Chronic liver disease.
2. Anthropometry & Proportions:
   • Measure standing height, weight; plot on WHO growth charts to confirm short stature ($<-2\text{ SD}$).
   • Upper-to-Lower Segment (US:LS) Ratio: Measure lower segment (pubic symphysis to floor); upper segment = $\text{Height}-\text{LS}$. (Normal US:LS at 5 yr $\approx 1.15\text{--}1.2$; increased in skeletal dysplasias/hypothyroidism, normal in GHD/Turner).
   • Arm span measurement.
3. General & Dysmorphic Examination:
   • Turner syndrome stigmata: Webbed neck, low posterior hairline, cubitus valgus (increased carrying angle), broad shield chest with widely spaced nipples, short 4th metacarpal, high-arched palate.
   • Endocrine signs: Truncal obesity, round moon facies, purple striae, buffalo hump (Cushing); dry skin, periorbital puffiness, delayed relaxation of deep tendon jerks, goiter (Hypothyroidism); microphallus/midline defects (GHD).
   • Nutritional & Chronic Disease Signs: Pallor, rickets signs (wrist widening, rachitic rosary), clubbing, jaundice, abdominal distension, signs of malabsorption.
4. Systemic Examination: Cardiac murmur (coarctation/aortic stenosis in Turner), chest rales, organomegaly.
5. Thank family and report clinical findings to examiner.

1. Introduction & Consent: Introduce self, explain procedure to child and parents, ensure privacy, wash and warm hands.
2. Inguinal Lymph Node Examination:
   • Child supine with groin fully exposed; flex contralateral hip and knee slightly to relax abdominal/groin musculature.
   • Palpate horizontal group (along and just below the inguinal ligament) and vertical group (along the proximal great saphenous vein in the femoral triangle) bilaterally using the pads of fingers.
3. Axillary Lymph Node Examination (5 Groups):
   • Support child's relaxed right forearm with your right forearm/hand.
   • Insert left hand high into apex of right axilla with fingers flat against thoracic wall:
     • Apical group: High in axillary apex.
     • Central group: Against mid-chest wall (lateral to 4th rib).
     • Anterior (Pectoral) group: Palpate behind anterior axillary fold (pectoralis major).
     • Posterior (Subscapular) group: Palpate along posterior axillary fold (latissimus dorsi/subscapularis) from behind.
     • Lateral group: Palpate along upper medial aspect of humerus.
   • Reverse hands to examine left axilla (support left arm with left hand, examine with right hand).
4. Epitrochlear Lymph Node Examination:
   • Flex child's elbow to 90°; cup posterior elbow with your palm.
   • Palpate groove 2–3 cm above and anterior to the medial epicondyle of humerus using the thumb/fingertips in an anteroposterior rolling motion.
5. Characterize Lymph Nodes: Note exact anatomical site, size (diameter in cm), consistency (soft, firm, rubbery, hard/stony), tenderness, mobility (discrete/freely mobile vs matted/fixed to underlying tissue/overlying skin), overlying erythema/warmth.
   • (Pathological cutoffs: Epitrochlear $>0.5\text{ cm}$, Inguinal $>1.5\text{ cm}$, Axillary/Cervical $>1.0\text{ cm}$).
6. Redress child, thank family, and present findings to the examiner.