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Pediatric Physical Exam

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Presentation on theme: "Pediatric Physical Exam"— Presentation transcript:

1 Pediatric Physical Exam
Adapted from Mosby’s Guide to Physical Examination, 6th Ed.

2 Age Descriptors Newborn birth to 2 months Infant 0-1 year
Toddler 1-2 years Child 2+ years

3 Pulse Respiration Blood pressure Temp Height Weight
Vitals Pulse Respiration Blood pressure Temp Height Weight infants and children

4 Pulse Apical pulse Femoral pulse
5th intercostal space in the midclavicular line Femoral pulse use a point halfway from the pubic tubercle to ASIS as a guide

5 Pulse Age Beats per minute Newborn 120-170 1 year 80-160 3 years
80-120 6 years 75-115 10 years 70-110

6 Respiration Infants – rise and fall of the abdomen facilitates counting Rate, regularity and rhythm Depth Respiratory Effort Retraction (ribs, supraclavicular notch) Contraction of SCM’s Flaring of nostrils Paradoxic breathing

7 Respiration Age Respirations per minute Newborn 30-80 1 year 20-40
3 years 20-30 6 years 16-22 10 years 16-20

8 Blood Pressure Cuff size (children) Too wide - underestimate BP
Cuff size (children) Width should cover ~2/3 of the upper arm or thigh Too wide - underestimate BP Too narrow - artificially high BP

9 Temperature Tympanic thermometers are becoming increasingly popular
Accuracy depends on correct technique Must read tympanic membrane Shares blood supply with hypothalamus

10 Temperature – Young Infants
Traditional routes may be more accurate Newborns: axillary temp correlates well with core temp due to the infant’s small body mass and uniform skin blood flow

11 Height – Infant Birth to 24-36 months Infant measuring mat OR
mark on a sheet of headrest paper Measure from the top of the head to the heel (foot dorsiflexed)

12 Tear a length of headrest paper
Lay the child on top of the paper Mark the top of the child’s head Ask mother to hold child in place Extend leg and mark under the heel (foot dorsiflexed)

13 Height - Child Child is able to stand without support (24-36 months old) “Stature measuring device” Heels, buttocks and shoulders against the wall Looking straight ahead Outer canthus of the eye should line up with the external auditory canal

14 Weight Infant platform scale More accurate (ounces or grams)
Infant may sit or lie Place paper or blank under the infant & “weigh it out”

15 Head Circumference Done at every “health visit” until 2 years of age; yearly from 2-6 years of age Measure the largest circumference with the tape snug Occipital protuberance to the supraorbital prominence

16 Chest Circumference Measure around the nipple line to the nearest 1/8 in (0.5 cm) Firmly but not tight enough to cause an indentation in the skin

17 Recording Measurements
Chart on appropriate growth curve for sex and age Identify the infant’s percentile Note any change or variation from the population standard or the child’s norm

18 At Birth… Average weight: 5 lb 8 oz – 8 lb 13oz
Average length: in (45-55cm) Head circumference: in (33-35 cm) Most babies born to the same parents weigh within 6oz of each other at birth Lower birth weight: consider an undisclosed congenital abnormality or intrauterine growth retardation

19 Expected Growth Length increases by 50%in the 1st year of life
Weight doubles by 6 months, triples by 1 year Head & Chest Circumference Newborn to 5 months: Head may be equal or exceed the chest by 2 cm 5 months to 2 years: Chest should closely approximate the head circumference > 2 years: Chest should exceed head circumference

20 Growth Patterns Infancy Childhood Adolescence
Growth of the trunk predominates Fat increases until 9 months of age… Childhood Legs are the fastest growing body part Weight is gained at a steady rate Fat increases slowly until 7 yrs of age when a prepubertal fat spurt occurs before the true growth spurt Adolescence Trunk and legs elongate About 50% of the ideal weight is gained Skeletal mass and organ systems double in size

21 Gender Differences Males Females
Broader shoulders & greater musculature Wider pelvic outlet Slight increase in body fat during early adolescence before the gain in lean tissue Persistent increase in fat throughout adolescence, occuring after the peak growth spurt

22 Common Conditions What might you detect by recording height, weight, head & chest circumference?

23 Failure to Thrive Failure of an infant to grow at “normal rates”
May be related to: Chronic disease Congenital disorder (brain, heart, kidney) Inadequate calories and protein Improper feeding methods Intrauterine growth retardation Emotional deprivation growth hormone levels will be low

24 What if…? Head circumference increases rapidly or rises above percentile curves Increased intracranial pressure dDX: Hydrocephalus, etc. Head circumference grows slowly or falls off percentile curves Microcephaly dDx: Craniosynostosis, etc.

25 Congenital Syndromes…
Down Syndrome & Turner Syndrome associated with short stature

26 Skin

27 Newborn – Expected Variants
Transient puffiness of the hands, feet, eyelids, legs, pubis or sacrum occurs in some newborns Not a concern if it disappears within 2-3 days Some newborns are bald while others are born with an inordinate amount of head hair Sheds within 2-3 months and replaced by more permanent hair (new texture and color) Dark-skinned newborns do not always manifest the intensity of melanosis that will be readily evident in 2-3 months Exceptions: nail beds and skin of the scrotum Skin may look very red the first few days of life Skin color is partly determined by subcutaneous fat

28 Cutis marmorata Acrocyanosis
Transient mottling when infant is exposed to decreased temperature Acrocyanosis Cyanosis of hands & feet A common response to cold An underlying cardiac defect should be suspected if acrocyanosis is persistent or more intense in the feet than hands

29 Vernix caseosa Whitish, moist, cheeselike substance
Mixture of sebum and skin cells Covers the infant’s body at birth Protective

30 Lanugo Fine, silky hair covering the newborn Shed within 10-14 days
shoulders and back Shed within days Lanugo. This fine body hair resembling peach fuzz is present on infants of 24 to 32 weeks' gestation.

31 Telangiectatic nevi aka “stork bites”
Flat, deep pink, localized areas usually seen in back of neck Stork bite, or salmon patch. A typical light red splotchy area is seen at the nape of the neck.

32 Mongolian spots Irregular areas of deep blue pigmentation usually in sacral and gluteal regions *Seen predominantly in African, Native American, Asian or Latin descent

33 Erythema toxicum Pink papular rash with vesicles superimposed
thorax, back, buttocks, and abdomen May appear hrs after birth and resolves after several days

34 Common Conditions

35 Milia Common during the first 2-3 months
Small white discrete papules on the face and bridge of the nose Plugged sebaceous glands

36 Miliaria aka “Heat rash”
Caused by occlusion of sweat ducts during periods of heat and high humidity “Prickly Heat” (crystaline)

37 Rashes Allergic rash Diaper rash Contact dermatitis
Medications, supplements Food sensitivity Diaper rash Acid urine output Yeast?

38 Eczematous rash Younger children Older children & adults
Face, elbow, knees Older children & adults Hands, neck, inner elbows, back of knees, ankles Face (less often)

39 Seborrheic Dermatitis
aka “Cradle Cap” scalp Lesions are scaling, adherent, thick, yellow, and crusted can spread over the ear and down the nape of the neck *Can be also be seen on back, intertriginous & diaper areas

40 Impetigo “Honey colored crusts”
Highly contagious Staph. or Strep. infection Causes pruritis, burning, and regional lymphadenpathy

41 Ring worm Tinea corporis Tinea capitis MC vector?

42 Strawberry hemangioma
Expected resolution: Birth: often not present or noticeable 1-2 months: becomes noticeable 1-6 months: grows most rapidly 12-18 months: begins to shrink

43 Trichotillomania May be related to: Excessive emotional stress
Family circumstances, hospitalization, etc. Obsessive Compulsive Disorder

44 External Clues to Internal Problems

45 Faun tail nevus Tuft of hair overlying the spinal column usually in the lumbosacral area Associated with spina bifida occulta

46 Café au lait spots Evenly pigmented patches
light, dark brown, or black in dark skin Present at birth or shortly thereafter May be related to: Neurofibromatosis Pulmonary stenosis Temporal lobe dysrhythmia Tuberous sclerosis Suspect neurofibromatosis if you note >5 patches with diameters >1cm in a child under 5

47 Axillary Freckling or Inguinal Freckling
May occur in conjunction with café au lait spots Associated with neurofibromatosis

48 Facial port-wine stain
When it involves the opthalmic division of the trigeminal nerve it may be associated with: Sturge-Weber syndrome seizures Occular defects

49 Supernumerary nipples
Especially in the presence of other minor abnormalities… associated with renal abnormalities

50 Examining the Newborn for Hyperbilirubinemia
*Natural daylight is preferred Examine the oral mucosa and sclera Inspect the whole body for “dermal icterus” Starts on the face and descends Bilirubin level is not high if only the face (5mg/dl) May be at a worrisome level if jaundice descends below the nipples (>12 mg/dl)

51 Risk Factors Breast feeding
b-glucuronidase Cephalhematoma or other cutaneous or subcutaneous bleeds Hemolytic disease Infection

52 Physiologic Jaundice Present in 50% of newborns
appears to be an inability of the liver to conjugate the bilirubin present in the blood Starts after the first day of life Usually disappears in 8-10 days May persist for 3-4 weeks Treatment “Bili lamp” & “Bili Blanket” (blue lights), or direct sunlight (conjugate the bilirubin) Seldom rises above the 20mg/dl necessitating transfusion

53 Pathological Jaundice
If jaundice is present in the first 24 hours or it is intense and/or persistent, you must consider pathological jaundice… RBC abnormalities & sensitivity Hemorrhage Impaired hepatic function Infections Toxoplasmosis Rubella Herpes Syphilis

54 Inspection Careful inspection of all skin Examine skin creases
Develop a pattern Don’t overlook body parts Examine skin creases Assymetrical creases on thighs Possible hip dysplasia Simian Line (hands & feet) possible Down syndrome

55 Schamroth Technique Place nail surfaces of corresponding fingers together Normal: diamond shaped window Clubbed: angle between distal tips increases

56 Clubbing of the Nails Associated with: Respiratory disease
Cardiovascular disease Thyroid disease Cirrhosis Colitis

57 Skin Turgor Best evaluated by gently pinching a fold of the abdominal skin “Tenting” indicates: Dehydration Malnutrition

58 Immune and Lymphatic

59 Immune & Lymphatic System
Lymph nodes in the neonate react quickly to any mild stimulus especially cervical and postauricular chains Theory: compensate for lack of antibodies by increased filtration and phagocytosis Ability to produce antibodies is still immature at birth but lymphoid tissue is plentiful

60 Palatine Tonsils Much larger during early childhood than after puberty
Enlargement of the tonsils in children is not necessarily an indication of a problem may obstruct nasopharynx ~> sleep apnea

61 Obstructive Sleep Apnea
Periodic cessation of breathing during sleep d/t airflow obstruction Can be seen in children with excessively large tonsils Loud snoring, restless sleep Daytime sleepiness Morning headaches Developmental delay Frequent infection

62 Lymph Exam “Normal” Investigate further if:
It is not uncommon to find enlarge lymph nodes that may even be visible from a distance… “Normal” Firm, discrete, moveable, <5mm Up to 1cm in cervical or inguinal regions Investigate further if: Growing rapidly or suspiciously large (>2-3 cm) Fixed and immoveable

63 Expected Regions of Lymph Node Enlargement
<1 year <2 years >2 years postauricular and occipital common uncommon cervical and submandibular It is NEVER normal for supraclavicular lymph nodes to be enlarged!

64 Common Conditions

65 Infectious Mononucleosis
Epstein-Barr virus *May occur at any age (MC in teens) Initial symptoms: Pharyngitis, fever, fatigue, malaise Exam Findings: Enlarged anterior and posterior cervical chains Splenomegaly, hepatomegaly, and/or a rash may be noted

66 *Throat culture needed to confirm
Strep Pharyngitis Symptoms: Sore throat and runny nose Headache, fatigue, & abdominal pain Exam Findings: Palatal petichiae Enlarged anterior cervical nodes *Throat culture needed to confirm

67 McIsaac Modification of the Centor Strep Score
Symptom or sign Points Temperature >38°C (100.4°F)  1 Absence of cough  Tender anterior cervical adenopathy Tonsillar swelling or exudates  Age less than 15 years  Age at least 45 years -1 Likelihood: -1/0 = 1%; 1 = 10%; 2 = 17%; 3 = 35%; 4/5 = 51% Diagnosing Strep Throat: Are There Reliable Clues? - July 1, American Academy of Family Physicians. Available at

68 Head and Neck

69 Inspect the Head Scaling, crusting (seborheic dermatitis)
Dilated veins (increased ICP) Excessive hair or unusual hairline Note symmetry of shape, bulging or swelling…

70 During a vaginal birth the cranial bones shift and overlap
Cranial Molding During a vaginal birth the cranial bones shift and overlap Expect the skull to resume a “normal” shape and size within 1 week

71 Caput succedaneum Cephalhematoma Subcutaneous edema
Subperiosteal bleed Crosses suture lines Does not cross sutures MC occiput MC parietal Soft, poorly defined margins Firm, well-defined edges

72 Unusual contour may be related to a variety of causes:
Irregular closing of suture lines (craniosynostosis) Positional head deformity (PHD) Preterm infants: soft cranial bones flatten with the positioning and weight of the head

73 Inspect the Face Spacing of features Symmetry Skin color Texture
Paralysis

74 Observe… Head control? Position? Movement? Note any: Jerking Tremors
Inability to move head in one direction

75 Palpate the Head Note any tenderness over the scalp Suture lines
slight groove up to 6 months Fontanels should feel slightly depressed; some pulsation is expected Post. fontanel closes ~2 months Ant. fontanel closes by 24 months

76 Not a sensitive indicator
Bulging? Infection Increased intracranial pressure Depressed? Dehydration Measure the Fontanels Anterior fontanel should not exceed 4-5 cm (<6 months) Not a sensitive indicator

77 Transilluminate Dark room Transilluminator firm against scalp
Begin at the midline frontal region and inch over the entire head Observe the ring of illumination; note asymmetry

78 A ring <2 cm is expected on all regions of the head except the occiput (should be <1 cm)
Illumination beyond these parameters suggest… Excess fluid Decreased brain tissue in the skull Transillumination should be done on every infant and on an older child if there is a suspected intracranial lesion or rapidly increasing head circumference

79 Inspect the Neck Symmetry, size, shape Edema Distended veins
Pulsations Masses Webbing Excess skin

80 To inspect the newborn’s neck…
Place the infant supine Elevate the upper back and let the head fall back into extension

81 Palpate the Neck Sternocleidomastoid Trachea Thyroid
Note tone; hematoma Trachea Thyroid Difficult to palpate unless it’s enlarged Goiter Intrauterine deprivation of thyroid hormone May cause respiratory distress

82 Common Conditions

83 Torticollis (“Wry Neck”)
Birth injury Hematoma May be palpated shortly after birth Firm fibrous mass 2-3 weeks later Older children Result of trauma, muscle spasm, viral infection, drug ingestion, __________

84 Management First, consider the underlying cause Chiropractic care
Spinal cord tumor or congenital spinal anomoly? Birth trauma? Subluxation? Chiropractic care Mechanical adjustments Increased “tummy time” Exercises/stretches

85 Positional Head Deformity Craniosynostosis (lambdoid)
Plagiocephaly Positional Head Deformity Craniosynostosis (lambdoid) No ridging Palpable ridge Ear on flat side migrates forward Ears even or ear on flat side appears to be more posterior Forehead protrudes (same side as occipital flattening) Forehead does not protrude Bald spot on side of flattening No bald spot or central bald spot

86 Positional Parallelogram Frontal bulging Ear migrates anterior Synostosis (lambdoid) Trapezoid No frontal bulging Ears even

87 Craniosynostosis Premature union of cranial sutures
Small head circumference (microcephaly) Rigid sutures Misshapen skull Usually not accompanied by mental retardation

88 Microcephaly Related to: Craniostenosis Cerebral dysgenesis
Associated with mental retardation and failure of brain to develop normally

89 Hydrocephalus Enlarged head Bossing of the skull
Widening of sutures and fontanels Lethargy, irritability, weakness Sclera visible above the iris “Sunsetting sign”

90 Craniotabes Softening of the skull
Demonstrated by pressing the bone along the suture line… bone pops in and out Associated with: Rickets and hydrocephalus Can be a “normal” finding up to 1/3 of all newborn infants more common in premature infants

91 Bell’s palsy (facial palsy)
Asymmetry of facial features Eyelid will not close completely Drooping corner of mouth Loss of labonasial fold

92 Down Syndrome Depressed nasal bridge Epicanthal folds
Mongolian slant of eyes Low set ears Large tongue

93 Fetal Alcohol Syndrome (FAS)
Smooth philtrum Widespread eyes Inner epicanthal folds Mild ptosis Hirsute forhead Short nose Thin upper lip

94 Eyes

95 Development Table 11-1(Mosby)
By 2-3 months… Voluntary control of eye muscles By 8 months… Can differentiate colors By 9 months… Eye muscles coordinate; a single image is percieved

96 Tips – Infant Eye Exam To encourage the infant to open their eyes…
Use a dimly lit room Hold the infant upright, suspended under its arms facing you Have parent hold infant over a shoulder

97 Inspect External Eye Size of eyes (symmetry?)
Distance between the eyes Hypertelorism (widely spaced eyes) may be associated with mental retardation Slant of palpebral fissures Epicanthal folds Prominent in Asian populations, Down syndrome?

98 Inspect Eyelids To detect the “Setting Sun Sign”…
Rapidly lower the infant from upright to supine position Look for sclera above the iris Differentials include: Expected variant in newborn Hydrocephalus Brainstem lesion

99 Clinical Note Newborn…
eyelids may be swollen or edematous, accompanied by conjunctival inflammation and drainage as a consequence of routinely administered antibiotics Beyond the newborn period… redness, hemorrhage, discharge, granular appearance may indicate infection, allergy, or trauma

100 Inspect Sclera Pupil Iris Conjunctiva

101 Coloboma aka “Keyhole pupil” Brushfield spots Loss of functional pupil
Often associated with other congenital abnormalities Brushfield spots White specks in a linear pattern around the circumference of the iris Suggests Down syndrome

102 Strabismus? Exoptropic vs. Esotropic Tests include:
Corneal light reflex (Hirschberg’s Test) Cross-Cover Test Cover-Uncover Test

103 Corneal Light Reflex aka Hirschberg’s Test
Child stares at a penlight about 30 cm away Doctor looks at the reflection from each cornea In relationship to the pupil Normal: symmetrical Strabismus: asymmetrical

104 Strabismus (esotropic)
Pseudostrabismus Symmetrical corneal light reflex Common in Asian and Native American populations (prominent epicanthal folds) Disappears by 1 yoa Strabismus (esotropic) Asymmetrical light reflex

105 Cross-Cover Test Patient stares at penlight
Doctor covers one eye and observes the uncovered eye for movement Normal: no movement Exotropic eye: moves lateral to medial Esotropic eye: moves medial to lateral

106 Cover-Uncover Test Patient stares at the penlight
Doctor covers one eye and then observes as it is uncovered Normal: no movement (remains fixed on the light) Exotropic eye: moves lateral Esotropic eye: moves medial

107 Help to differentiate…
Paralytic Strabismus Impairment of extraocular muscles or their nerve supply Nonparalytic Strabismus No primary muscle weakness Can focus with either eye but not both simultaneously… concern of developing amblyopia

108 Infant Cranial Nerves (II, III, IV, VI)
Expect the infant to focus and track through 60 degrees Optical blink reflex Shine a bright light at the infant’s eyes Note the quick closure of the eyes and dorsiflexion of the head Corneal light reflex (Hirschberg’s)

109 Extraocular Movements - Child
Six cardinal fields of gaze Peripheral vision Parent may hold the child’s head still Use a teddy bear or toy Have child sit on parent’s lap

110 Visual Acuity Infant Grossly examined by observing the the infant’s preference for looking at certain objects Younger Children Observe play with toys - stacking, building, or placing objects inside of others If tasks are performed well, vision difficulties are unlikely

111 Snellen E Chart* Tested when a child can cooperate with the exam
Usually ~3 years of age Ask which way the “legs” are pointing *Also available with different shapes

112 Tips – Snellen E Chart Make it a “game”
Instruct the child to point finger in the direction of the legs of the E Allow the child to practice following instructions before you administer the test Parent may assist with covering eye

113 Snellen E Chart Remember: Test each eye seperately
With and without corrective lenses 20/25 +2 Means that they can read all on the 20/25 line and 2 from the 20/20 line

114 A 2 line difference (20/50 and 20/30) may indicate amblyopia
“When testing visual acuity in the child, any difference in the scores between the eyes should be detected.” A 2 line difference (20/50 and 20/30) may indicate amblyopia Reduced vision in an eye that appears structurally normal In strabismus, the eye may be “unused”

115 Anticipated Visual Activity
Age Visual Acuity 3 years 20/50 4 years 20/40 5 years 20/30 6 years 20/20

116 *Performed from birth on… should be elicited in every newborn!
Red Reflex *Performed from birth on… should be elicited in every newborn! Observe for opacities, dark spots, or white spots within the circle of red glow Congenital cataracts Retinoblastoma

117 Congenital Cataracts Requires a full metabolic, infectious, systemic, and genetic workup… Common causes: Infectious diseases TOxoplasmosis, Rubella (MC), Cytomegalovirus, & Herpes Hypoglycemia Trisomies Prematurity Etc.

118 Retinoblastoma Congenital malignant tumor <2 years old
Initial sign: “white” reflex Fundoscopic exam: Ill-defined mass arising from the retina Chalky-white areas of calcification

119 Fundoscopic Examination
Difficult to perform on a newborn or young infant…consider referral Often deferred until 2-6 months unless the patient presentation suggests a need Eg. premature infant (retinopathy)

120 Retinopathy of Prematurity
Blood vessels are straightened and diverted temporally Cicatricial changes may be severe Retinal detachment Glaucoma Blindness

121 Tips – Fundoscopic Exam
Do not hold the child’s eyelid open forcibly Leads only to more resistance Often unable to keep eyes still and focused on a distant object Use a toy, picture, etc. Results may be better if the child sits on the parent’s lap May want to do the exam with the patient supine…

122 Fundoscopic Exam – Supine
Child laying supine on the exam table with head near the end Stand at the end of the table Use Rt. eye to examine the child’s Lt. NOTE: Retinal findings will appear “upside down” Inspect the optic disc, fovea, and vessels as they pass by

123 Newborn – 3 months Screening Method Require Further Evaluation
Red reflex Abnormal Asymmetric Corneal light reflex Inspection Structural abnormality

124 6 months – 1 year Screening Method Require Further Evaluation
Red reflex Abnormal or Asymmetric Corneal light reflex Asymmetric Differential occlusion Failure to object equally to covering each eye Fix and follow with each eye Failure to fix and follow Inspection Structural abnormality

125 ~3 years old Screening Method Require Further Evaluation Visual acuity
<20/50; 2 lines of difference between the eyes Red reflex Abnormal or asymmetric Corneal light reflex; Cover-uncover Asymmetric; ocular refixation movements Stereoacuity Failure to appreciate random dot stereogram Inspection Structural abnormality

126 ~5 years old Screening Method Require Further Evaluation Visual acuity
20/30 or worse Red reflex Abnormal or asymmetric Corneal light reflex; Cover-uncover Asymmetric; ocular refixation movements Stereoacuity Failure to appreciate random dot stereogram Inspection Structural abnormality

127 Modifying Your Instruments
Oto/ophthalmoscope Decorative covers pediapals/products

128 Ears

129 Developmental Features
External auditory canal – shorter, has an upward curve infant otoscopic exam – “pull downward” Eustachian tube – relatively wider, shorter and more horizontal Reflux of nasopharyngeal secretions Growth of adenoids may occlude the eustachian tube Interferes with aeration of the middle ear

130 Inspect the Ear Well formed Flexible Position
all landmarks present Flexible should have instant recoil after bending Position the tip of the auricle should cross an imaginary line between the outer canthus of the eye and the prominent portion of the occiput (EOP) No skin tags or preauricular pits should be present

131 Clinical Note Low or poorly shaped auricles… associated with renal disorders and congenital abnormalities

132 *If pain is noted with palpation of the mastoid, suspect mastoiditis…
Palpate Lymph nodes Pinna Tragus Mastoid Tenderness? Warmth? *If pain is noted with palpation of the mastoid, suspect mastoiditis…

133 Otoscopic Exam – Infant
Lay the infant supine/prone Turn head to the side Hold otoscope so that the ulnar surface of your hand rests against the infant’s head *Prevent trauma to auditory canal Other hand stabilizes infant’s head Pull auricle down to straighten the canal

134 *Otoscopic exam should be performed within the first few weeks of life
Newborn Variants You may note… Limited mobility Dullness and opacity of a pink or red tympanic membrane Light reflex may appear diffuse Tympanic membrane is not conical for several months Auditory canal may be obstructed with vernix *Otoscopic exam should be performed within the first few weeks of life

135 Otoscopic Exam – Child Pull auricle either down and back OR up and back best view of the tympanic membrane Postpone until the end of the visit Best done on parent’s lap Be prepared to use restraint if encouraging the child fails Ask the parent to restrain the child

136 Restraining a Child - Otoscope
Face the child sideways with one arm placed around parent’s waist Parent holds the child firmly against his/her trunk One arm restrains the head One arm restrains the body Doctor further stabilizes the child’s head while inserting the otoscope

137 Clinical Note “Red reflex”
If the child is crying or has recently cried vigorously… dilation of blood vessels in the tympanic membrane can cause redness You cannot assume that redness of the membrane alone is a middle ear infection!

138 Pneumatic Otoscopy Assesses mobility of the tympanic membrane
needed to differentiate Crying – Red Reflex Red Moveable Infection No mobility

139 Tympanometry Accurate way to identify middle ear effusion
Ear piece must be sealed in the canal to provide accurate reading Wax, ruptured membrane, tubes Acoustic Reflectometry (newer technology) Cheaper Easier to get accurate results

140 Assessing Hearing Observe response to a whispered voice, toys, etc.
As they get older, ask child to perform tasks in a soft voice… Use words that have meaning for them May want to have a parent do it Make sure they’re not responding to air movement or visual stimulus Weber, Rinne, and Schwabach tests Used only when a child understands directions and can cooperate with the examiner Usually 3-4 years of age

141 Expected Hearing Response
Birth to 3 months Startle reflex, crying, cessation of breathing or movement in response to sudden noise; quiets to parent’s voice 4 to 6 months Turns head toward source of sound but may not always recognize location of sound; responds to parent’s voice; enjoys sound producing toys

142 6 to 10 months Responds to own name, telephone ringing, and person’s voice, even if not loud; begins localizing sounds above and below, turns head 45 degrees towards sound 10 to 12 months Recognizes and localizes source of sound; imitates simple words and sounds

143 Common Conditions

144 Otitis Externa Infection of the auditory canal
History of trauma or moist environment Itching in the ear canal Intense pain with movement of pinna; chewing Discharge may be watery at first, then purulent & thick mixed with pus and epithelial cells Musty, foul-smelling Conductive hearing loss (exudate and swelling) Canal is red, edematous; tympanic membrane obscure

145 Bacterial Otitis Media
Infection of the middle ear MC infection in childhood Often follows or accompanies URTI Fever, feeling of blockage, tugging earlobe, anorexia, irritability, dizziness, vomiting & diarrhea Deep-seated earache Discharge if tympanic membrane ruptures or through tympanostomy tubes; foul-smelling Conductive hearing loss (fills with pus) Tympanic membrane may be red, thickened, bulging; full, limited, or no movement

146 Otitis Media with Effusion
Collection of liquid (effusion) in the middle ear Associated with: Allergies Enlarged lymph tissue Obstructed or dysfunctional eustachian tube

147 Otitis Media with Effusion
Sticking or cracking sound on yawning or swallowing; no signs of acute infection Pain is uncommon; feeling of fullness Discharge is uncommon Conductive hearing loss as middle ear fills with fluid If chronic, may delay speech development temporarily Tympanic membrane is retracted, impaired mobility, yellowish; air fluid level and/or bubbles

148 Nose

149 Development Maxillary and ethmoid sinuses Sphenoid sinus Frontal sinus
present at birth, though very small Sphenoid sinus tiny cavity at birth not fully developed until puberty Frontal sinus develops by 7-8 years

150 Inspection Symmetric appearance
Positioned in the vertical midline on the face Only minimal movement of the nares with breathing should be apparent Possible congenital abnormality if… Saddle-shaped nose with a low bridge and broad base Short small nose Large nose

151 “Adenoidal” or “Allergic Salute”
Transverse crease at the juncture between the cartilage and the bone of the nose Children often wipe their noses with an upward sweep of the palm of the hand If repeated often enough, causes a crease

152 Internal Nose Usually adequate to tilt the nose tip upward
Inspect by shining a light inside Largest otoscopic speculum may be used Clinical note: some say that a “greyish” membrane may indicate chronic allergies

153 Nasal Patency Must be determined at the time of birth…
Mouth closed, occlude one naris and then the other Observe the respiratory pattern With total obstruction, the infant will not be able to inspire or expire through the noncompressed naris dDx: Septal deviation, choanal atresia

154 *Will breathe when crying
Choanal Atresia Congenital nasal obstruction of the posterior nares Junction between nasal cavity and nasopharynx Newborns may experience respiratory distress and difficulty feeding Obligatory nose breathers Copyright © 2006 University of Washington. *Will breathe when crying

155 Sinuses Infant Maxillary and ethmod sinuses are small
Few problems arise in these areas and examination is generally unnecessary Child Maxilary sinuses should be palpated Few sinus problems occur since the sinuses are still developing There is wide variation however... do not rule out sinusitis simply on the basis of age!

156 Sinusitis Infection of one or more paranasal sinuses
May be a complication of a viral URTI, dental infection, allergies, or a structural defect of the nose Signs in children include: upper respiratory symptoms nasal discharge low-grade fever daytime cough malodorous breath cervical adenopathy intermittent painless morning eye swelling NO facial pain or headache

157 Mouth & Throat

158 Developmental Features
Salivation increases by 3 months Infant drools until swallowing is learned Teeth 20 deciduous teeth appear (6-24 months) Eruption of permanent teeth begins about 6 years of age and is completed by yrs 3rd molar (“wisdom tooth”) ~18 years old

159 Inspection Tongue Frenulum should fit well in the floor of the mouth
protrude beyond the alveolar ridge Frenulum usually attaches midway between the ventral surface of the tongue and its tip

160 (abnormally large tongue)
Macroglossia (abnormally large tongue) Congenital hypothyroidism Congenital abnormalities Down Syndrome Short Frenulum Feeding problems Speech difficulties

161 Gums Teeth smooth; serrated edge along the buccal margins
count deciduous teeth note any unusual sequence of eruption

162 Natal Teeth Retention Cysts (aka Epstein Pearls)
Teeth or tooth buds in a newborn Potential for aspiration May be removed Retention Cysts (aka Epstein Pearls) Appear along the buccal margins of the gums Pearl-like retention cysts Disappear in 1-2 months

163 Black or grey colored teeth
Baby bottle syndrome Multiple brown caries on upper and lower incisors d/t bedtime bottle of juice/milk Black or grey colored teeth Pulp decay d/t oral iron therapy Mottled or pitted teeth Enamel dysplasia d/t tetracycline treatment during tooth development Flattened edges on the teeth Bruxism – unconscious grinding of the teeth

164 Buccal mucosa Should be pink and moist, no lesions
Scrape any white patches with a tongue blade Nonadherent = milk deposits Adherent = candidiasis (thrush)

165 Palate Infant Should be well-formed with no cleft
Narrow, flat palate roof or a high, arched palate? may result in feeding and speech problems associated with congenital anomolies Child Highly arched palate? seen in chronic mouth breathers

166 Cleft Lip and Palate Congenital malformation
Fissure in the upper lip and/or palate Complete cleft – extends through the lip and hard and soft palates to the nasal cavity Partial Cleft – any of the tissues Long term issues: feeding problems speech difficulties improper tooth development and alignment chronic otitis media hearing loss

167 Tonsils Should blend with the color of the pharynx
Peak size between years Should retain unobstructed passage Graded to describe their size 1+ visible 2+ halfway between tonsillar pillars and the uvula 3+ nearly touching the uvula 4+ touching each other

168 Tonsillitis Inflammation or infection of the tonsils
Frequently caused by streptococci Sore throat, referred pain to the ears, dysphagia, fever, fetid breath, and malaise Tonsils appear red and swollen; purulent exudate yellow follicles are associated with strep. Anterior cervical lymph nodes enlarged

169 Peritonsillar Abscess
Infection of the tissue between the tonsil and pharynx Complication of tonsillitis Dyphagia, drooling, severe sore throat with pain radiating to the ear, muffled voice, fever Tonsil, tonsillar pillar and adjacent soft palate become red and swollen Tonsil may appear pushed forward or backward, possibly displacing the uvula

170 Drooling Normal in infancy If it persists past 12 months…
consider a neurologic disorder If acute… consider epiglotitis

171 Epiglottitis Suspected with… Sudden high fever Drooling Croupy cough
Sore throat Apprehension & focus on breathing Tripod position, neck extended *Impending airway obstruction d/t acute inflammation of the epiglottis Inserting tongue blade may result in complete airway obstruction Treat this as a medical emergency NO TONGUE BLADE!

172 Tips – Infant Mouth Exam
Crying provides an opportunity to examine the mouth Avoid depressing the tongue Stimulates the “Tongue Thrust Reflex” Makes visualization of the mouth difficult

173 Evaluate the infant’s suck
Insert your gloved finger into the infant’s mouth, fingerpad to the roof of the mouth Evaluate the infant’s suck Should have a strong suck, tongue pushing vigorously upward against the finger Palpate the hard and soft palates Palatal arch should be dome shaped No palpable clefts Soft palate should rise symmetrically when the infant cries Stimulate a gag reflex by touching the tonsillar pillars

174 Tips – Child Mouth Exam To reduce fear, let the child hold and manipulate the tongue blade and light Start by asking to see their teeth Usually not threatening Ask the child to protrude the tongue and say “ah”, a tongue blade is often unnecessary To raise the palate, ask the child to pant “like a puppy”

175 If child refuses to open mouth…
Insert a tongue blade through the lips to the back molars Gently but firmly insert the tongue blade between the back molars and press the blade to the tongue This should stimulate the gag reflex Gives you a brief view of the mouth and oropharynx

176 “Children of any age who are not too big to sit on a parent’s lap are better examined there than on the examining table.”

177 Restraining a Child – Oral Exam
Seated in the parent’s lap, back to the parent and legs between the adult’s legs Parent can reach around to restrain the child’s arms with one arm and control the child’s head with the other Can usually be accomplished without forcing Force only makes them more angry…

178 Restraining a Child - Supine
If the child actively resists… Place child supine on the exam table Parent holds arms extended above the head and assists in restraining the head Doctor lies across the child’s trunk and stabilizes the child’s head Third person may need to hold the child’s legs

179 Chest and Lungs

180 Newborn Apgar Score Subjective qualitative evaluation
done at 1 and 5 minutes determine “survivability” of the newborn by observing the level of function of 5 components Muscle tone Heart rate Reflex irritability Color Respiratory rate A ctivity P ulse G rimace A ppearance R espirations

181 Apgar Score 1 2 Heart rate Absent <100 >100 Respiratory effort
1 2 Heart rate Absent <100 >100 Respiratory effort Slow/irregular Easy; Good crying Muscle tone Limp Some flexion of extremities Active motion Reflex irritability No response Grimace, slow Lusty cry Color Blue/pale Acrocyanosis Pink

182 Depressed Respiration
Maternal environment during labor Sedatives Compromised blood supply to the child Mechanical obstruction by mucus Neurological damage (birth trauma)? Infants rely primarily on the diaphragm for respiratory effort (C3,4,5…)

183 Development Bony structure is more prominent than the adult d/t a relatively thin chest wall More cartilaginous and yielding How will this affect the adjustment? Xiphoid process is often more prominent and a bit more moveable

184 Inspection Chest is generally round
A-P diameter approximately the same as the transverse If the “roundness” of a child’s chest persists past the 2nd year, suspect a possible chronic obstructive pulmonary problem…

185 Cystic Fibrosis Autosomal recessive disorder of exocrine glands
Sweat glands Salt loss in sweat (“taste salty”) Lungs Frequent and progressive pulmonary infections (thick mucus) Pancreas Sticky, foul smelling stool

186 Intrauterine growth retardation
Smaller chest circumference compared to the head Poorly controlled diabetes Relatively larger chest circumference

187 Nipples Symmetry in size Swelling Discharge Supernumerary
Measure distance between the nipples Should be ¼ chest circumference Breast development in a newborn d/t hormonal influences

188 Respiratory Rate Count for 1 minute
Average: rpm (80 rpm is not uncommon) If room temp is very warm or cool, variation in the rate occurs Most often tachypnea Sometimes bradypnea

189 Respiratory Rhythm Note regularity of respiration
Premature infants are more likely to have irregular respiratory patterns Periodic breathing sequence of relatively vigorous respiratory efforts followed by apnea of as long as seconds

190 Periodic Breathing Cause for concern if …
Apneic episodes tend to be prolonged Baby becomes centrally cyanotic In the term infant periodic breathing should wane a few hours after birth Persistence in preterm infants is relative to gestational age Apneic periods should diminish in frequency as they approach term status

191 Observe Chest Expansion
If asymmetric, suspect inability to fill one of the lungs Pneumothorax Presence of air/gas in the pleural cavity Diaphragmatic hernia mayl hear “clicks & gurgles”

192 Palpate Rib cage and sternum Xiphoid Loss of symmetry Unusual masses
Crepitus Fractured clavicle (birth trauma) May show no evidence of pain Xiphoid Mobile and prominent

193 Auscultation – Infant Localization of breath sounds is difficult
Breath sounds are easily transmitted from one segment to another *Difficult to detect absence of breath sounds in any given area

194 Auscultation – Child May not be able to give enough of an expiration to satisfy you (<5 years old) Especially with subtle wheezing Ask them to “blow out” your penlight Ask them to blow away a bit of tissue in your hand Listen after they run up and down the hallway

195 Chest wall is thinner and more resonant than adult’s
Breath sounds may sound louder, harsher, and more bronchial Hyperresonance is common Easy to miss the dullness of underlying consolidation (percussion) “If you sense some loss of resonance, give it as much importance as you would give frank dullness in the adult.”

196 Tips – Lung Exam Percussion is usually unreliable in the infant
Examiner’s fingers may be too large A sob is frequently followed by a deep breath Allows the evaluation of vocal resonance Feel for tactile fremitus Whole hand, palm and fingers

197 Crackles and Ronchi Respiratory Grunting
Not uncommon immediately after birth (fluid has not completely cleared) If asymmetric, a problem should be suspected… dDx: aspiration of meconium Respiratory Grunting Infant tries to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen levels If persistent, cause for concern

198 Stridor High pitched, piercing sound
Cannot be dismissed as inconsequential… especially when inspiration is longer than expiration Floppy epiglottis Congenital defects Croup Edematous response Infection Allergen Smoke Chemicals Aspirated foreign body

199 Increased Respiratory Effort
Retraction at the supraclavicular notch Contraction of the SCM’s Flaring of the nostrils Obvious intercostal exertion (retractions) Tachypnea “See-saw” respirations

200 Does a loss of synchrony between L and R occur during the respiratory effort? Is there a lag in movement of the chest on one side? Atelectasis? Diaphragmatic hernia? Is there stridor? Croup? Epiglottitis? Is there retraction at the suprasternal notch, intercostally, or at the xiphoid process? Do the nares dilate and flare with respiratory effort? Is pneumonia present? Is there an audible expiratory grunt? Is it audible with the stethoscope only or without? Is there lower airway obstruction? Focal atelectasis? Is there paradoxic breathing?

201 Common Conditions

202 Tracheomalacia Floppiness of the trachea
Trachea changes in response to varying pressures of inspiration and expiration resulting in “noisy breathing” Wheezing, inspiratory stridor *Generally benign and self-limiting with age dDx: vascular lesion, tracheal stenosis, foreign body Also: Laryngomalacia & Laryngotracheomalacia

203 Bronchiolitis Viral Most common <6 months
RSV (respiratory syncytial virus) Most common <6 months Expiration becomes difficult due to hyperinflation of lungs Exam findings: Increased A-P diameter of thoracic cage Hyperresonant percussion

204 Possible wheezing and crackles Infant appears anxious
Coughing Comes in “fits” and tends to be harsh Tachypnea Rapid, short breaths; expiratory phase prolonged Possible wheezing and crackles Infant appears anxious Generalized retraction Perioral cyanosis

205 Influenza Generalized febrile illness (viral)
Crackles Rhonchi Tachypnea Substernal pain Generalized febrile illness (viral) Mild cases may just seem like a cold BUT the very young are at higher risk Respiratory tract may be over-whelmed (interstitial inflammation and necrosis) Cough Fever Malaise Headache Coryza Mild sore throat

206 Pneumonia Inflammatory response of the bronchioles and alveolar space to an infective agent Bacterial, fungal , or viral Exudates lead to lung consolidation Dyspnea, tachypnea, and crackles Diminished breath sounds; dullness to percussion

207 INSPECTION PALPATION PERCUSSION AUSCULTATION Tachypnea
Shallow breathing Flaring of nostrils Occasional cyanosis Limited movement; splinting PALPATION Increased fremitus (consolidation) PERCUSSION Dullness (consolidation) AUSCULTATION Variety of crackles Occasional rhochi Bronchial breath sounds Egophony, bronchophony, whispered pectoriloquy

208 Bronchitis Inflammation of the mucus membranes of the bronchial tubes
Acute bronchitis Fever and chest pain Chronic bronchitis Variety of causes Excessive secretion of mucus Both can show varying degrees of involvement Obstruction Atelectasis Most often quite mild

209 INSPECTION Occasional tachypnea Occasional shallow breathing Often no deviation from expected findings PALPATION Tactile fremitus undiminished PERCUSSION Resonance AUSCULTATION Breath sounds may be prolonged Occasional crackles Occasional expiratory wheezes

210 Asthma COPD characterized by airway inflammation mucosal edema
increased secretions bronchoconstriction Hyperreactivity to allergens, anxiety, URTI, smoke, exercise, cold air, etc.

211 INSPECTION Tachypnea Dyspnea PALPATION Tachycardia Diminished fremitus PERCUSSION Hyper-resonance Limited diaphragmatic descent; lower diaphragmatic level AUSCULTATION Prolonged expiration Wheezes Diminished lung sounds

212 Croup dDx: epiglottitis, aspirated foreign body Viral Most commonly:
Particularly parainfluenza viruses Most commonly: Very young children (1 ½ to 3 years old) Boys > girls Some are prone to recurrent episodes dDx: epiglottitis, aspirated foreign body

213 Often begins in the evening after the child has gone to sleep
Awakens suddenly, frightened Harsh stridorous cough “Bark of a seal” Labored breathing Retraction Inspiratory stridor NOT always fever

214 Epiglottitis Haemophilus influenzae type B MC: 3-7 years old
Incidence appears to have reduced… MC: 3-7 years old Acute, life-threatening Begins suddenly and progresses rapidly to full obstruction of the airway Treat this as a medical emergency Inserting tongue blade may be deadly!

215 Child sits straight up with neck extended, head held forward
Appears very anxious and ill Unable to swallow Drooling from the open mouth Cough is NOT common

216 Heart

217 Fetal Circulation Compensates for the non-functional fetal lung
Blood passes directly from the R to L atrium through the foramen ovale Right ventricle pumps blood through the ductus arteriosus At birth... functional closure of foramen ovale and the ductus arteriosus closes within hours

218 Patent Ductus Arteriosus
Blood flows through the ductus during systole and diastole Increases pressure in the pulmonary circulation Increased workload for the right ventricle Small shunt: may be asymptomatic Large shunt: may have dyspnea on exertion “Machinery murmer” Harsh, loud, continuous murmur 1st - 3rd intercostal spaces & lower sternal border Usually unaltered by postural changes

219 Patent Foramen Ovale Allows blood to flow between the right and left atria Usually asymptomatic May exhibit cyanosis with exertion (especially if other congenital heart defects are present)

220 Heart Exam Examine within the first 24 hours and again at 2-3 days of age Changes from fetal to systemic and pulmonary circulation Complete evaluation of heart function includes skin, lungs, & liver… Congestive heart failure in the infant may present with a large, firm liver (hepatomegaly) Unlike adults, this finding may be noted before pulmonary crackles

221 Inspection Color: should be “pink” Purplish? Ashy, white?
dDx: polycythemia Ashy, white? dDx: shock Central cyanosis? dDx: congenital heart disease Distribution & intensity of discoloration. Extent of change after exertion.

222 Severe cyanosis evident at birth or shortly after suggests:
Transposition of the great vessels Tetralogy of Fallot (blue) Tricuspid atresia relies on ASD & VSD for oxygenation of blood Severe septal defect Severe pulmonic stenosis Cyanosis that does not appear until after the neonatal period suggests: Pure pulmonic stenosis Eisenmenger complex - only develops in some cases right-to-left shunting (VSD is MC) combined with pulmonary hypertension Tetralogy of Fallot (pink) Septal defects Always cyanotic

223 Bulging? Precordium tends to bulge over an enlarged heart if the enlargement is long-standing Thoracic cage is more cartilaginous and yielding in children

224 Capillary Refill Capillary refill time is very rapid up to 2 yrs
< 1 second (normal) Prolonged capillary refill time (> 2 seconds) dDx: Significant dehydration Hypovolemic shock

225 Apical Impulse 4th - 5th left intercostal space, medial to the midclavicular line Apex of the heart is higher, heart lies more horizontal *Adult heart position is reached by age 7

226 Enlargement? Position? Pneumothorax Diaphragmatic hernia Dextrocardia
Shifts apical pulse away from the area of pneumothorax Diaphragmatic hernia MC on the left side Shifts the heart to the right Dextrocardia Apical impulse on the right

227 Dextrocardia & Sinus Invertus
Right thoracic heart & normally placed stomach and liver May be associated with other anomolies Sinus Invertus Heart and stomach are on the right, liver on the left Not very common

228 Pulses Brachial, radial, and femoral pulses are palpable
Weak or thin pulse dDx: Decreased cardiac output Peripheral vasoconstriction Bounding pulse dDx: L to R shunt; PDA (patent ductus arteriosus) Difference in pulse amplitude between femoral and radial pulses dDx: Coarctation of the Aorta

229 Heart Rate Heart rate is more variable
Infants: eating, sleeping, and waking Children: exercise, tension, fever h HR beats for each degree temp. h Sinus arrhythmia is common in children Rate varies in a cyclical pattern Faster on inspiration Slower on expiration Fixed tachycardia may indicate difficulty

230 Heart Rate Age Beats per minute Newborn 120-170 1 year 80-160 3 years
80-120 6 years 75-115 10 years 70-110

231 Auscultation Murmers “S” Relatively frequent in the first 48 hours
Most are innocent; transition from fetal to pulmonic circulation “Innocent mumers” Disappear within 2-3 days (“short”) Grade I or II intensity (“soft”) Systolic Unaccompanied by other signs and symptoms “S”

232 A murmur is usually NOT a significant congenital anomaly
A murmur is usually NOT a significant congenital anomaly. Paradoxically, a significant congenital anomaly may be unaccompanied by a murmur… Must investigate if… persists beyond 2nd or 3rd day of life is intense fills systole occupies diastole to any extent almost always significant radiates widely

233 Ask child to sit with head turned away & tilted slightly upward
Venous hum Caused by turbulence of blood flow in the internal jugular vein Continuous low-pitched sound Louder during diastole Common in children Usually has no pathologic significance Ask child to sit with head turned away & tilted slightly upward Auscultate supraclavicular space

234 Blood Pressure Flush Technique (Infant)
Place cuff on upper arm (or leg) Elevate and wrap the arm firmly with an elastic bandage from fingers to antecubital space Empty veins and capillaries Inflate cuff to a pressure above the systolic reading you expect Lower the arm and remove the bandage Arm will be pale Diminish pressure gradually until you see a sudden “flush” and return to usual color

235 Blood Pressure Blood pressure is measured the same as in the adult after 2 years To facilitate the exam… Explain the process Let them explore the sphygmomanometer Make sure to use the correct cuff size! Cover 2/3 of arm

236 Hypertension – Infant A sustained increase in BP is almost always significant in the newborn Stenosis of renal artery Coarctation of the aorta Cystic disease of the kidney Neuroblastoma Wilms tumor Hydronephrosis Adrenal hyperplasia CNS disease

237 Hypertension – Child Do not make the diagnosis of hypertension based on one reading An elevated systolic but normal diastolic may be d/t transient anxiety Significant 90th percentile Severe 95th percentile *If consistently above the 95th percentile, dDx include: Kidney disease Renal arterial disease Coarctation of the aorta

238 If there’s known heart disease…
Take careful note of: Weight gain (or loss) Developmental delay Cyanosis Congenital heart defects that impede oxygenation Clubbing fingers and toes

239 Congenital Defects

240 Ventricular Septal Defect
Allows oxygenated blood to leak from the left ventricle into the right Smaller defects may heal on their own; may be asymptomatic Larger defects may require surgery Heart failure Pulmonary hypertension Endocarditis Arrhythmias Delayed growth *Murmur tends to be holosystolic

241 Atrial Septal Defect Allows oxygenated blood to leak from the left atrium into the right Minor cases may be asymptomatic Larger defects may require surgery *May not sound particularly impressive (especially in an overweight child) More apt to be significant if… Palpable thrust Radiation through to the back

242 Coarctation of the Aorta
Narrowing in a portion of the aorta MC: descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum Can cause several life-threatening complications Severe hypertension Aortic aneurysm, dissection or rupture Endocarditis Brain hemorrhage Stroke Heart failure and premature coronary artery disease *Repair is typically recommended before age 10

243 Compare radial and femoral pulses
Normal: peak at the same time (or femoral slightly earlier) Coarctation: delay and/or decreased amplitude of the femoral pulse (noted bilaterally) Compare blood pressure in arms and legs Normal: BP legs = arms, or BP legs > arms Coarctation: BP arms > legs Systolic murmur Audible over the precordium and sometimes the back

244 Tetralogy of Fallot VSD Pulmonary valve stenosis Overriding aorta
Right ventricular hypertrophy Cyanosis: lips, fingers and toes Poor eating Inability to tolerate exercise Arrhythmias Delayed growth and development *Surgical repair of the defects is required early in life

245 Infants may have… “Tet spells”, central cyanosis Paroxysmal dyspnea with loss of consciousness As they get older… Clubbing of fingers and toes Exam findings: Parasternal heave Precordial prominence Systolic ejection murmur heard over the 3rd intercostal space Sometimes radiating to the left side of the neck

246 Common Conditions

247 Acute Rheumatic Fever Complication of strep. pharangitis (or skin infection) ~> connective tissue disease May result in serious cardiac valve involvement MC mitral or aortic valves MC children between 5-15 years of age Prevention is the best therapy i.e. adequate treatment for strep. infections

248 Recent strep infection
Fever Migratory polyarthritis Erythema marginatum Pink margins, pale centers Chorea (jerky body movements) Firm, painless subcutaneous nodules Elbows, knees, wrists Murmur Mitral regurgitation; aortic insufficiency Friction rub (pericarditis) Congestive heart failure Cardiomegaly

249 Jone’s Criteria – Diagnosis of Rheumatic Fever
2 major manifestations or 1 major + 2 minor manifestations High probability of acute rheumatic fever *If there’s evidence of a preceding strep infection Major Manifestations Minor Manifestations Carditis Polyarthritis Chorea Erythema marginatum Subcutaneous nodules Clinical -Previous rheumatic fever or rheumatic heart disease -Arthralgia -Fever Laboratory -Acute phase reactions: ESR, C-reactive protein, leukocytosis -Prolonged P-R interval on ECH

250 Kawasaki Disease Acute illness (fever) Etiology unknown
Infectious? Carpet cleaners? MC children under 5; males > females Can be self-limiting, recover in a few days Complications: vasculitis ~> aneurysms Critical concern: cardiac involvement (vasculitis of the coronary artery)

251 Signs & symptoms: Medical Management: Fever (few days – 3 weeks)
Conjunctivitis (red eyes) Rash (stomach, chest, genitals) Desquamation Strawberry tongue Chapped lips Lyphadenopathy Edema of hands and feet Systemic vasculitis Medical Management: Gamma globulin, Aspirin

252 Abdomen

253 Tips – Abdomen Exam Relaxation and quiet Use the respiratory cycle
Bottle/pacifier/nursing On parent’s lap Dr. sits facing the parent, knees touching Use the respiratory cycle Abdomen should be soft during inspiration If abdomen remains hard during both inspiration and expiration, suspect peritoneal irritation

254 Tenderness and pain can be difficult to detect and localize
Ticklish? Firm touch Place the child’s hand under your palm leaving your fingers free to palpate Tenderness and pain can be difficult to detect and localize Distract the child with a toy Start away from the area suspected Observe for changes… as you move to identify the area of greatest pain Change in pitch of crying Rejection of the opportunity to suck Drawing the knees to the abdomen Facial expression Constriction of pupils

255 Inspection Movement with respiration Shape Contour Pulsations
Pulsations: common in infants Distended veins dDx: vascular obstruction, abdominal distension or abdominal obstruction Spider nevi dDx: liver disease

256 Abdomen should be rounded and dome shaped
Infant… Abdomen should be rounded and dome shaped Distended abdomen? Feces, mass, organ enlargement Scaphoid abdomen? Abdominal contents are displaced Abdominal and chest movements should be synchronous slight bulge of the abdomen at the beginning of respiration

257 Abdomen protrudes slightly “pot-bellied” After age 5…
Toddler Abdomen protrudes slightly “pot-bellied” After age 5… Abdomen may become concave when laying supine Respirations continue to be abdominal until 6-7 years of age In young children, restricted abdominal respiration may be related to peritoneal irritation

258 Umbilical stump should be dry and odorless Inspect all skin folds for: Discharge Redness Induration Skin warmth Granulomatous tissue

259 Granuloma Serous or serosanguinous discharge once the stump has separated No other signs of infection

260 Umbilicus is usually inverted
Often everts with increased abdominal pressure Note any protrusion through the umbilicus or rectus abdominus muscle Hernia Diastasis recti

261 Umbilical Hernia Protrusion of omentum and intestine through the umbilical opening Common in infants Reach maximum size by 1 month Generally close spontaneously by 1-2 years To determine size, measure the diameter of the opening (not the protruding contents) Should “reduce” with light pressure

262 Diastasis Recti Midline separation (1-4 cm) of the rectus abdominus
between the xiphoid and umbilicus No need to repair in most cases herniation through the rectus abdominus does require surgery Usually resolves by 6 years of age

263 Use tangential lighting Observe abdomen at eye level
Peristaltic Waves Use tangential lighting Observe abdomen at eye level Usually not visible Sometimes seen in thin, malnourished babies Suggests intestinal obstruction

264 Auscultation Peristalsis (“metalic tinkling”)
Heard every seconds Bowel sounds should be present 1-2 hours after birth No bruits or venous hum should be detected

265 Light Palpation Knees flexed Place your hand gently on the abdomen
Thumb at the right upper quadrant Index finger at the left upper quadrant Press very gently at first, only gradually increasing pressure Identify the spleen, liver, and masses close to the surface

266 Spleen Palpable 1-2 cm below the left costal margin for the first few weeks after birth A detectable spleen tip is common in well infants but increase in spleen size may indicate: blood dyscrasias septicemia

267 Newborn: just below the right costal margin
Liver Scratch test Liver (lower border) Newborn: just below the right costal margin Infants & toddlers: 1-3cm below Children: 1-2cm below Hepatomegaly: lower border >3 cm below the right costal margin Infection Cardiac failure Liver disease

268 Deep Palpation Palpate all quadrants for masses
Location Size Shape Tenderness Consistency Transillumination can be used to distinguish cystic from solid masses…

269 Fixed masses should be investigated with special studies if…
Laterally mobile Pulsatile Palpate the aorta for signs of enlargement Located along vertebral column If any suspicion of neoplasm exists, limit palpation of the mass May cause injury or spread of malignancy!

270 Nephroblastoma (Wilms Tumor)
MC intraabdominal tumor of childhood (2-3 years of age) Malignant Firm, non-tender mass deep within the flank Only slightly moveable Not usually crossing the midline; sometimes bilateral Possibly: Low-grade fever Hypertension

271 Neuroblastoma Frequently appears as a mass in the adrenal medulla
Malignancy in early childhood Firm, fixed, non-tender, irregular and nodular abdominal mass Malaise Loss of appetite Weight loss Protrusion of eye(s) Other symptoms may occur with: compression of the mass or metastasis to adjacent organs

272 Percussion May be more tympanic (vs. adults)
Swallow air when feeding & crying Tympany with distended abdomen? Gas Dullness with distended abdomen? Fluid, solid mass

273 Examine the Bladder Palpate and percuss over the suprapubic area
Determine size Distention?

274 Rebound Tenderness Observe child’s facial expression and pupils
Be cautious… Once a child has experienced palpation that is too intense, a subsequent examiner has little chance for easy access to the abdomen

275 Common Conditions

276 What if you find… ? Sausage-shaped mass in the left lower quadrant
…Feces in the sigmoid colon …Constipation Midline, suprapubic mass …Feces in the rectosigmoid colon …Hirschsprung disease

277 Hirschsprung Disease aka Congenital Aganglionic Megacolon
Absence of parasympathetic ganglion cells in a segment of the colon… no peristalsis Newborn: May fail to pass meconium in the first hrs Older infants and young children: Intestinal obstruction or severe constipation Failure to thrive Abdominal distention Episodes of vomiting and diarrhea

278 What if you find… ? Sausage-shaped mass in the left or right upper quadrant …Intussusception

279 Intussusception Prolapse of one segment of intestine into another resulting in intestinal obstruction MC 3-12 months old; cause is unknown Acute intermittent abdominal pain Abdominal distention Vomiting Stools mixed with blood and mucus Red current jelly appearance Sausage-shaped mass in R or L upper quadrant R lower quadrant feels empty (Dance sign)

280 Intussusception – “ABCDEF”
A bdominal or anal “sausage” B lood from the rectum C olic: babies draw up their legs D istention, dehydration, and shock E mesis F ace pale

281 What if you find… ? Olive-shaped mass in the right upper quadrant (deep palpation) immediately after the infant vomits …Pyloric stenosis

282 Pyloric Stenosis Hypertrophy of the circular muscle of the pylorus or obstruction of the pyloric sphincter Regurgitation ~> projectile vomiting Feeding eagerly (even after vomiting) Failure to gain weight Signs of dehydration Small, rounded mass palpable in the R upper quadrant especially after the child vomits

283 Gastroesophageal Reflux (GER)
Relaxation or incompetence of the lower esophagus persisting beyond the newborn period Regurgitation and vomiting Weight loss and failure to thrive Respiratory problems aspiration Bleeding from esophagitis

284 Biliary Atresia Congenital obstruction or absence of some or all of the bile duct system Jaundice Becomes apparent at 2-3 weeks Hepatomegaly Abdominal distention Poor weight gain Pruritis Stools become lighter in color Urine darkens

285 Meconium Ileus Thickening and hardening of meconium in the lower intestine ~> intestinal obstruction Failure to pass meconium 1st 24 hrs after birth Abdominal distention *Must consider cystic fibrosis

286 Meckel Diverticulum Outpouching of the ileum
MC congenital anomaly of the GI tract Varies in size & presentation May be asymptomatic Intestinal obstruction? Diverticulitis? Bright or dark red rectal bleeding Little abdominal pain Symptoms like those of acute appendicitis

287 Omphalocele Intestine present in the umbilical cord or protruding from the umbilical area Visible through a thick transparent membrane

288 Necrotizing Enterocolitis
Inflammatory disease of the gastrointestinal mucosa Associated with prematurity Immaturity of the GI tract Abdominal distention Occult blood in stool Respiratory distress Often fatal: perforation and septicemia


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