Adapted from Mosby’s Guide to Physical Examination, 6...
Transcript of Adapted from Mosby’s Guide to Physical Examination, 6...
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Pediatric Physical Exam
Adapted from Mosby’s Guide toPhysical Examination, 6th Ed.
M.JARI.MD
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Age Descriptors
Newborn birth to 1 monthsInfant 0-1 yearInfant 0 1 yearToddler 1-2 yearsChild 2+ years
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Vitals
PulseRespirationBlood pressureTempHeightWeight
infants and children
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Pulse
� Apical pulse� 5th intercostal space in
the midclavicular line
� Femoral pulse� use a point halfway from
the pubic tubercle to ASISas a guide
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Pulse
Age Beats per minute
Newborn 120-170
1 80 1601 year 80-160
3 years 80-120
6 years 75-115
10 years 70-110
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Respiration
Infants – rise and fall of the abdomen facilitatescounting
� Rate regularity and rhythm� Rate, regularity and rhythm� Depth� Respiratory Effort
� Retraction (ribs, supraclavicular notch)� Contraction of SCM’s� Flaring of nostrils� Paradoxic breathing
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Respiration
Age Respirations per minute
Newborn 30-60
1 2 30 601-2 mo 30-60
2-12mo 20-50
1-2 years 20-40
2-6 years 16-30
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Blood Pressure
� Cuff size (children)� Width should cover ~2/3 of the upper arm
or thigh
http://store.datascope.com/Assets/product_im
ages/0998
g
Too wide - underestimate BPToo narrow - artificially high BP
998-00-0003-21,22_s164_jpg.jpg
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Temperature
� Tympanic thermometers arebecoming increasingly popularbecoming increasingly popular� Accuracy depends on correct
technique� Must read tympanic membrane
� Shares blood supply with hypothalamus
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Temperature – Young Infants
� Traditional routes may be moreaccurate
Newborns: axillary temp correlateswell with core temp due to the infant’ssmall body mass and uniform skinblood flow
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Head Circumference
� Done at every “health visit”until 2 years of age; yearlyfrom 2-6 years of age
� Measure the largest circumference with thetape snug� Occipital protuberance to the supraorbital
prominence
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Chest Circumference
� Measure around the nipple line to thenearest 1/8 in (0.5 cm)� Firmly but not tight enough to cause� Firmly but not tight enough to cause
an indentation in the skin
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What if…?
� Head circumference increases rapidly orrises above percentile curves� Increased intracranial pressure
dDX H d h l tdDX: Hydrocephalus, etc.
� Head circumference grows slowly or falls offpercentile curves� Microcephaly
dDx: Craniosynostosis, etc.
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Congenital Syndromes…
� Down Syndrome & Turner Syndrome� associated with short stature
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Skin
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Newborn – Expected Variants� Transient puffiness of the hands, feet, eyelids, legs,
pubis or sacrum occurs in some newbornsNot a concern if it disappears within 2-3 days
� Some newborns are bald while others are born withan inordinate amount of head hairan inordinate amount of head hair
Sheds within 2-3 months and replaced by more permanenthair (new texture and color)
� Dark-skinned newborns do not always manifest theintensity of melanosis that will be readily evident in2-3 months
Exceptions: nail beds and skin of the scrotum
� Skin may look very red the first few days of lifeSkin color is partly determined by subcutaneous fat
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� Cutis marmorata� 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 ifacrocyanosis is persistent or more intense in the feetthan hands
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Vernix caseosa
� Whitish, moist, cheeselike substance� Mixture of sebum and skin cells
� Covers the infant’s body at birth� Covers the infant s body at birth� Protective
www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/Newborn/Vernix.jpg
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Lanugo
� Fine, silky hair coveringthe newborn� shoulders and back
� Shed within 10-14 days
Lanugo. This fine body hairresembling peach fuzz is present oninfants of 24 to 32 weeks' gestation.
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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 splotchyarea is seen at the nape ofthe neck.
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Mongolian spots
� Irregular areas of deep bluepigmentation usually in sacral andgluteal regions
*Seen predominantly in African, NativeAmerican, Asian or Latin descent
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Erythema toxicum
� Pink papular rash with vesiclessuperimposed� thorax, back, buttocks, and abdomen
� May appear 24-48 hrs after birth andresolves after several days
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Milia
� Common during thefirst 2-3 monthsfirst 2 3 months
� Small white discrete papules on theface and bridge of the nose� Plugged sebaceous glands
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Miliaria
aka “Heat rash”
� Caused by occlusion of sweat ductsCaused by occlusion of sweat ductsduring periods of heat and highhumidity
“Prickly Heat”(crystaline)
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Rashes
� Allergic rash� Contact dermatitis� Medications, supplements� Food sensitivity
� Diaper rash� Acid urine output� Yeast?
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Eczematous rash
Younger children� Face, elbow, knees
Older children & adults� Hands, neck, inner elbows,
back of knees, ankles� Face (less often)
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Seborrheic Dermatitis
aka “Cradle Cap”� scalp Lesions are scaling, adherent,
thick, yellow, and crustedy� can spread over the ear and down the
nape of the neck
*Can be also be seen on back,intertriginous & diaper areas
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Impetigo
“Honey colored crusts”
� Highly contagious Staph. or Strep.infection
� Causes pruritis, burning, and regionallymphadenpathy
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Ring worm
� Tinea corporis� Tinea capitis
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Strawberry hemangioma
Expected resolution:Birth: often not present or noticeable1-2 months: becomes noticeable1-6 months: grows most rapidly12-18 months: begins to shrink
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Trichotillomania
May be related to:May be related to:� Excessive emotional stress
� Family circumstances, hospitalization, etc.
� Obsessive Compulsive Disorder
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External Clues to InternalProblems
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Faun tail nevus
� Tuft of hair overlying the spinal column� Tuft of hair overlying the spinal columnusually in the lumbosacral area
� Associated with spina bifida occulta
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Café au lait spots
� Evenly pigmented patches� light, dark brown, or black in dark skin
� Present at birth or shortly thereafter� Present at birth or shortly thereafter
May be related to:� Neurofibromatosis� Pulmonary stenosis� Temporal lobe dysrhythmia� Tuberous sclerosis
Suspectneurofibromatosis ifyou note >5 patches
with diameters >1cm ina child under 5
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Axillary Freckling orInguinal Freckling
� May occur in conjunctionwith café au lait spotswith café au lait spots
� Associated with neurofibromatosis
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Facial port-wine stain
When it involves the opthalmic divisionof the trigeminal nerve it may beassociated with:� Sturge-Weber syndrome
� seizures� Occular defects
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Supernumerary nipples
Especially in the presence of otherminor abnormalities…� associated with renal abnormalities� associated with renal abnormalities
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Examining the Newborn forHyperbilirubinemia
*Natural daylight is preferred
� Examine the oral mucosa and sclera� Inspect the whole body for “dermal icterus”� 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)
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Inspection
� Careful inspection of all skin� 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
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Schamroth Technique
� Place nail surfaces ofcorresponding fingerstogether
A. Normal: diamond shapedwindow
B. Clubbed: angle betweendistal tips increases
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Clubbing of the Nails
� Associated with:� Respiratory disease� Cardiovascular disease� Cardiovascular disease� Thyroid disease� Cirrhosis� Colitis
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Skin Turgor
� Best evaluated by gently pinching afold of the abdominal skinfold of the abdominal skin
“Tenting” indicates:� Dehydration� Malnutrition
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Immune and Lymphatic
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Immune & Lymphatic System
� Lymph nodes in the neonate react quickly toany mild stimulus� especially cervical and postauricular chains
Theory: compensate for lack of antibodiesby increased filtration and phagocytosis� Ability to produce antibodies is still immature at
birth but lymphoid tissue is plentiful
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Palatine Tonsils
� Much larger during early childhood thanafter puberty
� Enlargement of the tonsils in children isnot necessarily an indication of aproblem� may obstruct nasopharynx ~> sleep apnea
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Lymph ExamIt 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
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Expected Regions ofLymph Node Enlargement
<1 year <2 years >2 yearspostauricular common common uncommonand occipital common common uncommon
cervical andsubmandibular uncommon common
It is NEVER normal for supraclavicularlymph nodes to be enlarged!
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Common Conditions
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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
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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
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Head and Neck
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Inspect the Head
� Scaling, crusting (seborheic dermatitis)� Dilated veins (increased ICP)� Excessive hair or unusual hairline� Excessive hair or unusual hairline
� Note symmetry of shape, bulging orswelling…
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Cranial MoldingCranial Molding� During a vaginal birth the cranial
bones shift and overlap� Expect the skull to resume a “normal”
shape and size within 1 week
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Caput succedaneum CephalhematomaSubcutaneous edema Subperiosteal bleedCrosses suture lines Does not cross suturesMC occiput MC parietalSoft, poorly defined margins Firm, well-defined edges
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� Unusual contour may be related to avariety of causes:� Irregular closing of suture lines� Irregular closing of suture lines
(craniosynostosis)� Positional head deformity (PHD)� Preterm infants: soft cranial bones flatten
with the positioning and weight of thehead
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Inspect the Face
� Spacing of features� Symmetry� Skin color� Skin color� Texture� Paralysis
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Observe…
� Head control?� Position?� Movement?Movement?
� Note any:� Jerking� Tremors� Inability to move head in one direction
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Palpate the Head
� Note any tenderness over the scalp
� Suture lines� slight groove up to 6 monthsg g p
� Fontanels� should feel slightly depressed; some pulsation is
expected
Post. fontanel closes ~2 monthsAnt. fontanel closes by 24 months
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Bulging?� Infection� Increased intracranial pressureDepressed?� Dehydration
Not asensitiveindicator
Measure the Fontanels� Anterior fontanel should
not exceed 4-5 cm(<6 months)
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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
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Inspect the Neck
� Symmetry, size, shape� Edema� Distended veins� Distended veins� Pulsations� Masses� Webbing� Excess skin
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To inspect the newborn’s neck…
� Place the infant supine� Elevate the upper back and let the
head fall back into extension
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Palpate the Neck
� Sternocleidomastoid� Note tone; hematoma
� Trachea� Trachea
� Thyroid� Difficult to palpate unless it’s enlarged
Goiter� Intrauterine deprivation of thyroid hormone� May cause respiratory distress
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Common Conditions
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Torticollis (“Wry Neck”)
� Birth injury� Hematoma
� May be palpated shortly afterbirthbirth
� Firm fibrous mass 2-3 weekslater
� Older children� Result of trauma, muscle
spasm, viral infection, drugingestion, __________
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Craniosynostosis
� Premature union of cranial sutures
� Small head circumference (microcephaly)( p y)� Rigid sutures� Misshapen skull
� Usually not accompanied by mentalretardation
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Microcephaly
Related to:� Craniostenosis� Cerebral dysgenesis
� Associated with mental retardation andfailure of brain to develop normally
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Hydrocephalus
� Enlarged head� Bossing of the skull� Widening of sutures and fontanelsWidening of sutures and fontanels� Lethargy, irritability, weakness� Sclera visible above the iris
� “Sunsetting sign”
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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
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Bell’s palsy (facial palsy)
Asymmetry of facial features
� Eyelid will not� Eyelid will notclose completely
� Drooping corner ofmouth
� Loss of labonasial fold
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Down Syndrome
� Depressed nasal bridge� Epicanthal folds� Mongolian slant of eyes� Mongolian slant of eyes� Low set ears� Large tongue
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Eyes
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Development Table 11-1(Mosby)
By 2-3 months…� Voluntary control of eye muscles
By 8 monthsBy 8 months…� Can differentiate colors
By 9 months…� Eye muscles coordinate; a single image
is percieved
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Inspect External Eye
� Size of eyes (symmetry?)� Distance between the eyes
� Hypertelorism (widely spaced eyes)� Hypertelorism (widely spaced eyes)� may be associated with mental retardation
� Slant of palpebral fissures� Epicanthal folds
� Prominent in Asian populations, Downsyndrome?
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Inspect Eyelids
To detect the “Setting Sun Sign”…� Rapidly lower the infant from upright
to supine positionL k f l b th i i� Look for sclera above the iris
Differentials include:� Expected variant in newborn� Hydrocephalus� Brainstem lesion
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Clinical Note
Newborn…� eyelids may be swollen or edematous,
accompanied by conjunctival inflammationand drainage as a consequence of routinelyg q yadministered antibiotics
Beyond the newborn period…� redness, hemorrhage, discharge, granular
appearance may indicate infection, allergy,or trauma
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Inspect
� Sclera� Pupil� Iris� Iris� Conjunctiva
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Colobomaaka “Keyhole pupil”� 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
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Strabismus?Exoptropic vs. Esotropic
Tests include:� Corneal light reflex (Hirschberg’s Test)� Cross-Cover Test� Cover-Uncover Test
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Infant Cranial Nerves (II, III, IV, VI)
1. Expect the infant to focus and trackthrough 60 degrees
O i l bli k fl2. Optical blink reflex� Shine a bright light at the infant’s eyes� Note the quick closure of the eyes and
dorsiflexion of the head
3. Corneal light reflex (Hirschberg’s)
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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
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Visual Acuity
Infant� Grossly examined by observing the the
infant’s preference for looking at certainobjectsj
Younger Children� Observe play with toys - stacking, building,
or placing objects inside of others� If tasks are performed well, vision difficulties are
unlikely
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Snellen E Chart*
� Tested when a child cancooperate with the exam� Usually ~3 years of age� Usually 3 years of age
� Ask which way the “legs” are pointing
*Also available with different shapes
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Snellen E Chart
Remember:� Test each eye seperately� With and without corrective lenses� With and without corrective lenses
20/25 +2Means that they can read all on the 20/25line and 2 from the 20/20 line
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Anticipated Visual Activity
Age Visual Acuity
3 years 20/50
4 years 20/40
5 years 20/30
6 years 20/20
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Red Reflex
*Performed from birth on… should beelicited in every newborn!
� Observe for opacities, dark spots, orwhite spots within the circle of red glow� Congenital cataracts� Retinoblastoma
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Congenital Cataracts
� Requires a full metabolic, infectious,systemic, and genetic workup…
Common causes:� Infectious diseases
� TOxoplasmosis, Rubella (MC), Cytomegalovirus, &Herpes
� Hypoglycemia� Trisomies� Prematurity� Etc.
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Ears
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Developmental Features
� External auditory canal – shorter, has anupward curve� infant otoscopic exam – “pull downward”
� Eustachian tube – relatively wider, shorterand more horizontal� Reflux of nasopharyngeal secretions
� Growth of adenoids may occlude theeustachian tube� Interferes with aeration of the middle ear
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Inspect the Ear
� Well formed� all landmarks present
� Flexibleh ld h i t t il ft b di� should have instant recoil after bending
� Position� the tip of the auricle should cross an imaginary
line between the outer canthus of the eye andthe prominent portion of the occiput (EOP)
� No skin tags or preauricular pits should bepresent
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Clinical Note
� Low or poorly shaped auricles…associated with renal disorders andcongenital abnormalitiesg
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Palpate
� Lymph nodes� Pinna� Tragus� Mastoid
� Tenderness?� Warmth?
*If pain is noted with palpation of themastoid, suspect mastoiditis…
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Otoscopic Exam – Infant
1. Lay the infant supine/prone2. Turn head to the side3. Hold otoscope so that the ulnar surface ofp
your hand rests against the infant’s head*Prevent trauma to auditory canal
4. Other hand stabilizes infant’s head5. Pull auricle down to straighten the canal
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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 performedwithin the first few weeks of life
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Otoscopic Exam – Child
� Pull auricle either down and backOR 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
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Restraining a Child - Otoscope
� Face the child sideways with one armplaced around parent’s waist
� Parent holds the child firmly against� Parent holds the child firmly againsthis/her trunk� One arm restrains the head� One arm restrains the body
� Doctor further stabilizes the child’shead while inserting the otoscope
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Clinical Note
“Red reflex”
� If the child is crying or has recently criedt e c d s c y g o as ece t y c edvigorously… dilation of blood vessels in thetympanic membrane can cause redness
You cannot assume that redness of themembrane alone is a middle ear infection!
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Pneumatic Otoscopy
� Assesses mobility of the tympanicmembranemembrane� needed to differentiate
Crying –Red Reflex
RedMoveable
Infection RedNo mobility
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Common Conditions
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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
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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
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Otitis Media with Effusion
� Collection of liquid (effusion) in themiddle ear
Associated with:� Allergies� Enlarged lymph tissue� Obstructed or dysfunctional eustachian tube
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� Sticking or cracking sound on yawning orswallowing; no signs of acute infection
� Pain is uncommon; feeling of fullness� Discharge is uncommon
Otitis Media with Effusion
� 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
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Nose
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Development
� Maxillary and ethmoid sinuses� present at birth, though very small
Sphenoid sinus� Sphenoid sinus� tiny cavity at birth� not fully developed until
puberty
� Frontal sinus� develops by 7-8 years
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Inspection
� Symmetric appearance� Positioned in the vertical midline on the face� Only minimal movement of the nares with
b thi h ld b tbreathing should be apparent
Possible congenital abnormality if…� Saddle-shaped nose with a low bridge and
broad base� Short small nose� Large nose
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“Adenoidal” or “Allergic Salute”
� Transverse crease at thejuncture between thecartilage and the bone
f thof the nose
� Children often wipe their noses with anupward sweep of the palm of the hand� If repeated often enough, causes a crease
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Nasal Patency
Must be determined at the time of birth…
� Mouth closed, occlude one naris and thenthe otherthe other
� Observe the respiratory pattern� With total obstruction, the infant will not be able
to inspire or expire through the noncompressednaris
dDx: Septal deviation, choanal atresia
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Choanal Atresia
� Congenital nasal obstructionof the posterior nares� Junction between nasal
it d hcavity and nasopharynx
� Newborns may experience respiratorydistress and difficulty feeding� Obligatory nose breathers
Copyright © 2006 University of Washington.
*Will breathewhen crying
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Sinuses
Infant� Maxillary and ethmod sinuses are small� Few problems arise in these areas and
examination is generally unnecessaryg y y
Child� Maxilary sinuses should be palpated� Few sinus problems occur since the sinuses
are still developing
There is wide variation however... do not ruleout sinusitis simply on the basis of age!
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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: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
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Mouth & Throat
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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 14-15 yrs� 3rd molar (“wisdom tooth”) ~18 years old
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Inspection
� Tongue� should fit well in the floor of the mouth� protrude beyond the alveolar ridge� protrude beyond the alveolar ridge
� Frenulum� usually attaches midway between the
ventral surface of the tongue and its tip
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Macroglossia(abnormally large tongue)
� Congenital hypothyroidism� Congenital abnormalities� Down Syndrome
Short Frenulum� Feeding problems� Speech difficulties
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� Gums� smooth; serrated edge along the buccal
marginsg
� Teeth� count deciduous teeth� note any unusual sequence of eruption
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Natal Teeth� Teeth or tooth buds in
a newborn� Potential for aspiration� May be removed
Retention CystsRetention Cysts(aka Epstein Pearls)
� Appear along the buccalmargins of the gums
� Pearl-like retention cysts� Disappear in 1-2 months
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Baby bottle syndrome� Multiple brown caries on upper
and lower incisorsd/t bedtime bottle of juice/milk
Black or grey colored teeth� Pulp decay
/d/t oral iron therapyMottled or pitted teeth� Enamel dysplasia
d/t tetracycline treatment during tooth developmentFlattened edges on the teeth� Bruxism – unconscious grinding of the teeth
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� Buccal mucosa� Should be pink and moist, no lesions� Scrape any white patches with a tongue blade
Nonadherent = milk depositsAdherent = candidiasis (thrush)
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� Palate� Should be well-formed with no cleft
I f tInfant� 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
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Cleft Lip and Palate
� Congenital malformation� Fissure in the upper lip and/or palate
� Complete cleft – extends through the lip andhard and soft palates to the nasal cavityp y
� Partial Cleft – any of the tissues
Long term issues:� feeding problems� speech difficulties� improper tooth development and alignment� chronic otitis media� hearing loss
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Tonsils� Should blend with the color of the pharynx� Peak size between 2 - 6 years� Should retain unobstructed passage� Should retain unobstructed passage
Graded to describe their size1+ visible2+ halfway between tonsillar
pillars and the uvula3+ nearly touching the uvula4+ touching each other
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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
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Peritonsillar Abscess
� Infection of the tissue between the tonsil andpharynx
� Complication of tonsillitis
� Dyphagia, drooling, severe sore throat with painradiating to the ear, muffled voice, fever
� Tonsil, tonsillar pillar and adjacent soft palatebecome red and swollen
� Tonsil may appear pushed forward or backward,possibly displacing the uvula
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� Drooling� Normal in infancy
If it persists past 12 months…� consider a neurologic disorder
If acute…� consider epiglotitis
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Tips – Infant Mouth Exam
� Crying provides an opportunity to examinethe mouth
� Avoid depressing the tongue� Stimulates the “Tongue Thrust Reflex”� Makes visualization of the mouth difficult
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Tips – Child Mouth Exam
� To reduce fear, let the child hold andmanipulate 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”
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If child refuses to open mouth…
� Insert a tongue blade through the lipsto the back molars
� Gently but firmly insert the tongue� Gently but firmly insert the tongueblade between the back molars andpress the blade to the tongue
� This should stimulate the gag reflex� Gives you a brief view of the mouth and
oropharynx
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Chest and Lungs
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Newborn Apgar Score
� Subjective qualitative evaluation� done at 1 and 5 minutes� determine “survivability” of the newborn by
b i th l l f f ti f 5 tA ctivity
P ulse
G rimace
A ppearance
R espirations
observing the level of function of 5 components
� Muscle tone� Heart rate� Reflex irritability� Color� Respiratory rate
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Apgar Score
0 1 2
Heart rate Absent <100 >100
Respiratory / Easy; GoodRespiratoryeffort Absent Slow/irregular Easy; Good
crying
Muscle tone Limp Some flexionof extremities
Activemotion
Reflex irritability No response Grimace, slow Lusty cry
Color Blue/pale Acrocyanosis Pink
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Depressed Respiration
� Maternal environment during labor� Sedatives� Compromised blood supply to the child� Compromised blood supply to the child
� Mechanical obstruction by mucus� Neurological damage (birth trauma)?
� Infants rely primarily on the diaphragm forrespiratory effort (C3,4,5…)
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Development
� Bony structure is more prominent thanthe adult d/t a relatively thin chest wall
M til i d i ldi� More cartilaginous and yielding� How will this affect the adjustment?
� Xiphoid process is often moreprominent and a bit more moveable
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Inspection
� Chest is generally round� A-P diameter approximately the same as
the transverse
If the “roundness” of a child’s chestpersists past the 2nd year, suspect apossible chronic obstructive pulmonaryproblem…
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Nipples
� Symmetry in size� Swelling� Discharge
Breast development in anewborn d/t hormonalinfluences
� Discharge� Supernumerary
� Measure distance between the nipples� Should be ¼ chest circumference
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Respiratory Rate
� Count for 1 minute� Average: 40-60 rpm (80 rpm is not
uncommon))
If room temp is very warm or cool,variation in the rate occurs� Most often tachypnea� Sometimes bradypnea
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Respiratory Rhythm
� Note regularity of respiration� Premature infants are more likely to have
irregular respiratory patternsg p y p
Periodic breathing� sequence of relatively vigorous respiratory
efforts followed by apnea of as long as 10-15seconds
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Periodic Breathing
Cause for concern if …� Apneic episodes tend to be prolonged� Baby becomes centrally cyanotic
� In the term infant periodic breathing shouldwane a few hours after birth
� Persistence in preterm infants is relative togestational age� Apneic periods should diminish in frequency
as they approach term status
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Observe Chest Expansion
� If asymmetric, suspect inability to fillone of the lungs
� Pneumothorax� Presence of air/gas
in the pleural cavity
� Diaphragmatic hernia� mayl hear “clicks & gurgles”
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Palpate
� Rib cage and sternum� Loss of symmetry� Unusual masses� Crepitus
� Fractured clavicle (birth trauma)� May show no evidence of pain
� Xiphoid� Mobile and prominent
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Auscultation – Infant
� Localization of breath sounds isdifficult
B th d il t itt d� Breath sounds are easily transmittedfrom one segment to another
*Difficult to detect absence of breathsounds in any given area
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Auscultation – Child
� May not be able to give enough of anexpiration 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
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� Chest wall is thinner and more resonantthan 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 asmuch importance as you would give frankdullness in the adult.”
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Tips – Lung Exam
� Percussion is usually unreliable in the infant� Examiner’s fingers may be too large
� A sob is frequently followed by a deepbreath� Allows the evaluation of vocal resonance� Feel for tactile fremitus
� Whole hand, palm and fingers
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Crackles and Ronchi� 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 increaseoxygen levels� If persistent, cause for concern
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Stridor� High pitched, piercing sound
� Cannot be dismissed as inconsequential…especially when inspiration is longer thanexpiration
Fl i l tti � Ed t� Floppy epiglottis� Congenital defects� Croup
� Edematous response� Infection� Allergen� Smoke� Chemicals� Aspirated foreign
body
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Increased Respiratory Effort
� Retraction at the supraclavicular notch� Contraction of the SCM’s� Flaring of the nostrils� Flaring of the nostrils� Obvious intercostal exertion
(retractions)� Tachypnea
“See-saw” respirations
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� Does a loss of synchrony between L and R occurduring the respiratory effort? Is there a lag inmovement 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? Ispneumonia present?
� Is there an audible expiratory grunt? Is it audible withthe stethoscope only or without? Is there lower airwayobstruction? Focal atelectasis?
� Is there paradoxic breathing?
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INSPECTION TachypneaShallow breathingFlaring of nostrilsOccasional cyanosisLimited movement; splinting
PALPATION I d f it ( lid ti )PALPATION Increased fremitus (consolidation)
PERCUSSION Dullness (consolidation)
AUSCULTATION Variety of cracklesOccasional rhochiBronchial breath soundsEgophony, bronchophony, whisperedpectoriloquy
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INSPECTION Occasional tachypneaOccasional shallow breathingOften no deviation from expectedfindings
PALPATION Tactile fremitus undiminishedO act e e tus u d s edPERCUSSION Resonance
AUSCULTATION Breath sounds may be prolongedOccasional cracklesOccasional expiratory wheezes
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INSPECTION TachypneaDyspnea
PALPATION TachycardiaDiminished fremitus
PERCUSSION Hyper-resonancePERCUSSION Hyper-resonanceLimited diaphragmatic descent;lower diaphragmatic level
AUSCULTATION Prolonged expirationWheezesDiminished lung sounds
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Heart
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Fetal Circulation
� Compensates for thenon-functional fetal lung� Blood passes directly from
the R to L atrium throughthe R to L atrium throughthe foramen ovale
� Right ventricle pumps bloodthrough the ductus arteriosus
� At birth... functional closure of foramenovale and the ductus arteriosus closeswithin 24-48 hours
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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 asymptomaticLarge shunt: may have dyspnea on exertion
“Machinery murmer”� Harsh, loud, continuous murmur� 1st - 3rd intercostal spaces & lower sternal border� Usually unaltered by postural changes
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Patent Foramen Ovale
� Allows blood to flow betweenthe right and left atria
� Usually asymptomatic� May exhibit cyanosis with exertion (especially if
other congenital heart defects are present)
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Heart Exam
� Examine within the first 24 hours and againat 2-3 days of age� Changes from fetal to systemic and pulmonary
circulation
� Complete evaluation of heart functionincludes 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
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Inspection
� Color: should be “pink”
Purplish?dDx: polycythemiaAshy, white?dDx: shockCentral cyanosis?dDx: congenital heart disease
Distribution & intensityof discoloration.Extent of change afterexertion.
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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
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Apical Impulse
� 4th 5th left intercostal space medial� 4th - 5th left intercostal space, medialto the midclavicular line� Apex of the heart is higher, heart lies
more horizontal
*Adult heart position is reached by age 7
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Enlargement? Position?
� Pneumothorax� 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
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Dextrocardia & Sinus Invertus
� Dextrocardia� Right thoracic heart & normally placed stomach
and liver� May be associated with other anomolies� May be associated with other anomolies
� Sinus Invertus� Heart and stomach are on the right, liver on the
left� Not very common
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Pulses
� Brachial, radial, and femoral pulses arepalpable
Weak or thin pulse dDx: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 andradial pulses dDx:� Coarctation of the Aorta
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Heart Rate
� Heart rate is more variable� Infants: eating, sleeping, and waking� Children: exercise, tension, fever
� � HR 10-20 beats for each degree temp. �g p
Sinus arrhythmia is common in children� Rate varies in a cyclical pattern
� Faster on inspiration� Slower on expiration
Fixed tachycardia may indicate difficulty
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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
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Auscultation
� Murmers� 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”
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A murmur is usually NOT a significantcongenital anomaly. Paradoxically, asignificant congenital anomaly may beunaccompanied by a murmur…
� Must investigate if…g� persists beyond 2nd or 3rd day of life� is intense� fills systole� occupies diastole to any extent
� almost always significant
� radiates widely
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� Venous humCaused by turbulence of blood flow in theinternal jugular vein� Continuous low-pitched sound
L d d i di t l� 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
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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 systolicreading you expect
� Lower the arm and remove the bandage� Arm will be pale
� Diminish pressure gradually until you see asudden “flush” and return to usual color
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Blood Pressure
� Blood pressure is measured the same as inthe 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
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Hypertension – Infant
� A sustained increase in BP is almost alwayssignificant in the newborn� Stenosis of renal artery� Coarctation of the aorta� Cystic disease of the kidney� Neuroblastoma� Wilms tumor� Hydronephrosis� Adrenal hyperplasia� CNS disease
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Hypertension – Child
� Do not make the diagnosis of hypertension basedon one reading
� An elevated systolic but normal diastolic may be d/ttransient anxiety
Significant 90th percentileSevere 95th percentile
*If consistently above the 95th percentile, dDx include:� Kidney disease� Renal arterial disease� Coarctation of the aorta
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If there’s known heart disease…
Take careful note of:� Weight gain (or loss)� Developmental delayDevelopmental delay� Cyanosis
� Congenital heart defects that impedeoxygenation
� Clubbing� fingers and toes
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Abdomen
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Tips – Abdomen Exam
� Relaxation and quiet� 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
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� Ticklish?� Firm touch� Place the child’s hand under your palm leaving
your fingers free to palpate
� Tenderness and pain can be difficult todetect and localize� Distract the child with a toy� 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
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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
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Infant…� Abdomen should be rounded and dome
shapedDistended abdomen?� Feces, mass, organ enlargement
Scaphoid abdomen?� Abdominal contents are displaced
� Abdominal and chest movements should besynchronous� slight bulge of the abdomen at the beginning of
respiration
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Toddler� Abdomen protrudes slightly
“pot-bellied”
After age 5…� Abdomen may become concave
when laying supine
� Respirations continue to be abdominal until6-7 years of age� In young children, restricted abdominal
respiration may be related to peritoneal irritation
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Umbilical stump� should be dry and odorless
Inspect all skin folds for:Inspect all skin folds for:� Discharge� Redness� Induration� Skin warmth� Granulomatous tissue
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Granuloma
� Serous or serosanguinous dischargeonce the stump has separated
� No other signs of infection
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� Umbilicus is usually inverted� Often everts with increased abdominal
pressure
� Note any protrusion through theumbilicus or rectus abdominus muscle� Hernia� Diastasis recti
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Umbilical Hernia
� Protrusion of omentumand intestine through theumbilical opening
� Common in infants� Reach maximum size by 1 month� Generally close spontaneously by 1-2 years
� To determine size, measure the diameter ofthe opening (not the protruding contents)
� Should “reduce” with light pressure
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Diastasis Recti
� Midline separation (1-4 cm)of the rectus abdominus� between the xiphoid and umbilicus� 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
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Peristaltic Waves� Use tangential lighting� Observe abdomen at eye levelObserve abdomen at eye level
Usually not visible� Sometimes seen in thin, malnourished
babies� Suggests intestinal obstruction
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Auscultation
� Peristalsis (“metalic tinkling”)� Heard every 10-30 seconds� Bowel sounds should be present 1-2� Bowel sounds should be present 1 2
hours after birth
� No bruits or venous hum should bedetected
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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 graduallyincreasing pressure
� Identify the spleen, liver, and massesclose to the surface
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Spleen� Palpable 1-2 cm below the left costal margin
for the first few weeks after birth
� A detectable spleen tip is common in wellinfants but increase in spleen size mayindicate:� blood dyscrasias� septicemia
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Liver (lower border)� Newborn: just below the right costal margin� Infants & toddlers: 1-3cm below
Liver Scratch test
� Children: 1-2cm below
Hepatomegaly: lower border >3 cm belowthe right costal margin� Infection� Cardiac failure� Liver disease
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Deep Palpation
� Palpate all quadrants for masses� Location� Size� Shape� Tenderness� Consistency
Transillumination can be used to distinguishcystic from solid masses…
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� Fixed masses should be investigated withspecial studies if…� Laterally mobile� Pulsatile� Pulsatile
� Palpate the aorta for signs of enlargement� Located along vertebral column
If any suspicion of neoplasm exists, limitpalpation of the mass� May cause injury or spread of malignancy!
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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
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Neuroblastoma
� Frequently appears as a mass in theadrenal medulla
� Malignancy in early childhoodFirm fixed non tender irregular and nodular� Firm, fixed, non-tender, irregular and nodularabdominal 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
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Percussion
� May be more tympanic (vs. adults)� Swallow air when feeding & crying
Tympany with distended abdomen?� GasDullness with distended abdomen?� Fluid, solid mass
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Examine the Bladder
� Palpate and percuss over thesuprapubic area
� Determine size� Determine size� Distention?
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Rebound Tenderness
� Observe child’s facial expression andpupils
� Be cautious� Be cautious…
Once a child has experienced palpationthat is too intense, a subsequent examinerhas little chance for easy access to theabdomen
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Intussusception� Prolapse of one segment
of intestine into anotherresulting 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)
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Intussusception – “ABCDEF”
A bdominal or anal “sausage”B lood from the rectumC olic: babies draw up their legsC olic: babies draw up their legsD istention, dehydration, and shockE mesisF ace pale
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What if you find… ?
� Olive-shaped mass in the right upperquadrant (deep palpation) immediatelyquadrant (deep palpation) immediatelyafter the infant vomits…Pyloric stenosis
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Pyloric Stenosis
� Hypertrophy of the circularmuscle of the pylorus orobstruction 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
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Gastroesophageal Reflux (GER)
� Relaxation or incompetence of the loweresophagus persisting beyond the newbornperiod
� Regurgitation and vomiting� Weight loss and failure to thrive� Respiratory problems
� aspiration� Bleeding from esophagitis
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Omphalocele
� Intestine present in the umbilical cord orprotruding from the umbilical area� Visible through a thick transparent membrane