Children vary greatly in their ability to cooperate with a physical examination. One should take a few moments to gain the confidence of the child before any painful examination or procedures occur. Allowing the child to rest or be on the caregiver's lap may help. Remove clothing to avoid missing an incarcerated hernia, petechiae, visible masses, or peristalsis. Look first and then feel. Consider some nontouch maneuvers and observations such as the child's responses during coughing, walking, climbing onto the table, or jumping up and down.

The child can be invited to self-palpate or palpate with the physician. Start in the least painful areas. Also evaluate extraabdominal areas such as the pharynx, mucous membranes, neck, lung fields, inguinal regions, femoral triangles, testes, and scrotum. Failure to do so may result in delayed or missed diagnoses. Never omit the rectal examination and guaiac test. The diagnosis of Hirschsprung disease, volvulus, or intussusception will be missed without them.

The most important studies include a urinalysis, a complete blood count and differential, and a test of the stool for occult blood. Other tests, ultrasound, and x-ray evaluation should be guided by history, physical examination, how ill the child appears, and the differential diagnoses. Electrolyte and amylase studies, a pregnancy test, and chest and abdominal x-rays may be useful in certain cases. Computed tomography and ultrasonography are also helpful in the evaluation of stable patients with acute pain.1

Once the history, physical examination, and laboratory studies are completed, one should have a list of differential diagnoses. If a child is critically ill, resuscitation and evaluation must be simultaneous. Early consultation must be part of the child's care. If the child is ill but stable and the findings are equivocal, then the patient should be admitted for observation and reassessment.

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