UCKIN Newborn PE - ID WEEK 2019
Transcript of UCKIN Newborn PE - ID WEEK 2019
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The Physical Examina4on of the Newborn
Robert Shelly, MD, FAAP
Pediatrics and Internal Medicine
Quincy, Washington, EUA
Objec4ves:
• To describe the technique of performing a physical exam of a newborn infant.
• To describe the physical exam findings in a normal, healthy newborn infant.
• To provide examples some abnormali4es in the newborn physical exam that may indicate serious underlying disease.
General Appearance
• The infant at rest normally maintains the extremi4es in the flexed posi4on, and moves all extremi4es equally.
• The infant’s color should be pink at the lips and oral mucosa. Normally, the extremi4es are blue in the first 1-‐2 days aWer birth (acrocyanosis).
*Central cyanosis can indicate heart disease, polycythemia, or respiratory disease*
Look for signs of respiratory distress: nasal flaring, grun4ng, or retrac4ons
Measurements
• Weight, length, and head circumference should be measured and compared to normal values.
• Low weight suggests premature birth, poor maternal nutri4on, poor placental blood flow, or intrauterine infec4on.
• Heavy weight suggests poorly controlled maternal diabetes.
• Small head circumference is seen with the same condi4ons that cause low birth weight, as well some gene4c condi4ons.
• A large head circumference suggests hydrocephalus.
Vital Signs
• The rectal temperature should be between 36.5 and 37.5
• The respiratory rate should be counted for one full minute, and the normal rate is 40-‐60 per minute.
• The heart rate is normally 120-‐160 while awake, decreasing some4mes to 85-‐90 during sleep.
The Skin
• You may see some common normal findings: Mongolian Spots, Transient Neonatal Pustular Melanosis, Erythema Toxicum, and neonatal acne
• There are a few skin findings that indicate serious disease, such as the purpura associated with congenital infec4ons and the vesicles of neonatal herpes simplex virus.
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Head
• Examine the fontanelles: a large anterior fontanelle may indicate increased intracranial pressure. A sunken fontanelle could indicate dehydra4on.
• Bruising and bleeding into the soW 4ssues of the scalp are common and usually cause no problem, but large amounts of swelling can cause a dangerous anemia.
Head, Con4nued
• Look for abnormal shape of the pinna or pits or skin tags in front of the pinna—this indicates a risk for hearing loss in the infant.
• Look for asymmetry of the face that could indicate facial nerve injury, especially in infants delivered with forceps.
• If there is any respiratory distress, verify that both nares are patent.
Eyes
• Look for jaundice—jaundice is always abnormal in the first 24 hours of life. Jaundice at a later age can be benign, but warrants checking serum bilirubin level if available.
• Look for inflamma4on and drainage—gonorrhea and chlamydia are two common causes of eye conjun4vi4s in newborns.
• A calm, awake newborn can focus on a face at a distance of about 60 cm.
• Look for the “red” reflex in both eyes with an opthalmoscope .
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Mouth
• The most important abnormality to look for is a cleW palate.
• Put your gloved finger in the mouth to feel for a submucosal cleW of the palate, and to assure that the infant has a strong suck.
Chest
• Examine both clavicles for fracture. • A small amount of breast 4ssue is normal in both males and females due to exposure to maternal hormones. A small amount of thin white milk is some4mes secreted.
• Listen to the lungs—crackles can indicate retained fluid, infec4on or heart failure. Absent breath sounds can indicate a pneumothorax.
The Heart and Pulses
• S1 is caused by closure of the tricuspid and mitral valve, S2 is caused by closure of the aor4c and pulmonary valve. Train yourself to hear the splilng of the S2.
• Many normal infants will have a transient, soW murmur in the first day of life. Some serious murmurs do not emerge un4l the second or third day of life.
• Feel the femoral pulses. If they are not strong, coarcta4on of the aorta is possible.
Abdomen
• The umbilicus should contain 3 vessels. The surrounding skin should not be inflamed.
• It is normal to feel the liver 1-‐2 cm below the costal margin.
• The most common cause of a mass in the abdomen of the newborn is a malformed kidney.
• Small umbilical hernias are common, and usually resolve in early childhood without surgery.
The genitals
• In females, a small amount of whi4sh discharge is normal due to the effect of maternal hormones. A small amount of vaginal bleeding can be seen in the first week of life.
• In males, verify that both testes are descended into the scrotum. If they are not descended by 6-‐12 months of age, referral for surgery is indicated.
• A hydrocele is a normal finding in the scrotum, and can be dis4nguished from a hernia by transillumina4on of the scrotum.
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Back
• Look for a cleW, hemangioma, or tuW of hair in the midline of the lower back, above the gluteal crease. That could indicate an underlying abnormality of the spinal column.
Neurologic Exam
The child should be reac4ve to s4muli, have a strong suck, and have good muscle tone.
• The “Moro” or “startle” reflex should be symmetric. If not, the infant could have a birth injury to the clavicle or brachial plexus.
• The infant should have a “grasp” reflex. If not, this could represent a more uncommon injury to the brachial plexus.
Hips
• In the newborn, and throughout infancy check at each visit for developmental dysplasia of the hips.
-‐”Ortolani” and “Barlow” maneuvers
-‐Symmetry of thigh and leg folds
-‐”Galeazzi” maneuver