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10/2/10 1 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 12 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 4060 per minute. The heart rate is normally 120160 while awake, decreasing some4mes to 8590 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.

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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•  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