pediatric physical exam (c su07)

7/24/2019 Pediatric Physical Exam (C SU07)

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Pediatric Physical Exam

Adapted from Mosbys Guide to

Physical Examination, 6thEd.


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Age Descriptors

e!born birth to " months

#nfant $%& year

'oddler &%" years

(hild ") years


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*itals

Pulse

+espiration

lood pressure'emp

-eight

eight

infants and children


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Pulse

Apical pulse /thintercostal space in

the midcla0icular line

1emoral pulse use a point half!ay from

the pubic tubercle to A2#2

as a guide


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Pulse

Age eats per minute

e!born &"$%&3$

& year 4$%&6$

5 years 4$%&"$

6 years 3/%&&/&$ years 3$%&&$


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+espiration

#nfants rise and fall of the abdomen facilitatescounting

+ate, regularity and rhythm Depth +espiratory Effort

+etraction 7ribs, supracla0icular notch8 (ontraction of 2(Ms 1laring of nostrils Paradoxic breathing


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+espiration

Age +espirations per minute

e!born 5$%4$

& year "$%9$

5 years "$%5$

6 years &6%""&$ years &6%"$


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lood Pressure

(uff si:e 7children8 idth should co0er ;"


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'emperature

'ympanic thermometers are

becoming increasingly popular Accuracy depends on correct

techni=ue

Must read tympanic membrane 2hares blood supply !ith hypothalamus


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'emperature >oung #nfants

'raditional routes may be more

accurate

e!borns? axillary temp correlates

!ell !ith core temp due to the infants

small body mass and uniform s@inblood flo!


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-eight #nfant

irth to "9%56 months

#nfant measuring mat +

mar@ on a sheet of headrest paper Measure from the top of the head to the

heel 7foot dorsiflexed8


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&. 'ear a length of headrest paper

". Bay the child on top of the paper5. Mar@ the top of the childs head

9. As@ mother to hold child in place

/. Extend leg and mar@ under the heel

7foot dorsiflexed8


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-eight % (hild

(hild is able to stand !ithoutsupport 7"9%56 months old8

C2tature measuring de0ice -eels, buttoc@s and shoulders

against the !all Boo@ing straight ahead

uter canthus of the eye should line up !iththe external auditory canal


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eight

#nfant platform scale More accurate

7ounces or grams8

#nfant may sit or lie

Place paper or blan@ under the infant C!eigh it out


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-ead (ircumference

Done at e0ery Chealth 0isit

until " years of ageF yearly

from "%6 years of age

Measure the largest circumference !ith the

tape snug

ccipital protuberance to the supraorbital

prominence


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(hest (ircumference

Measure around the nipple line to the

nearest &


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+ecording Measurements

(hart on appropriate gro!th cur0e for

sex and age

#dentify the infants percentile ote any change or 0ariation from the

population standard or the childs norm


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At irth

A0erage !eight? / lb 4 o: 4 lb &5o:

A0erage length? &4%"" in 79/%//cm8

-ead circumference? &5%&9 in 755%5/ cm8

Most babies born to the same parents !eigh

!ithin 6o: of each other at birth Bo!er birth !eight? consider an undisclosed congenital

abnormality or intrauterine gro!th retardation


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Expected Gro!th

Bength increases by /$Hin the &st year of life

eight doubles by 6 months, triples by & year

-ead (hest (ircumference e!born to / months? -ead may be e=ual or

exceed the chest by " cm / months to " years? (hest should closely

approximate the head circumference I " years? (hest should exceed head

circumference


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Gro!th Patterns

#nfancy Gro!th of the trun@ predominates 1at increases until J months of age

(hildhood Begs are the fastest gro!ing body part eight is gained at a steady rate 1at increases slo!ly until 3 yrs of age !hen a prepubertal

fat spurt occurs before the true gro!th spurt

Adolescence 'run@ and legs elongate About /$H of the ideal !eight is gained 2@eletal mass and organ systems double in si:e


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Gender Differences

Maes !emaes

roader shoulders greater musculature

ider pel0ic outlet

2light increase in bodyfat during early

adolescence beforethe gain in lean tissue

Persistent increase infat throughout

adolescence, occuringafter the pea@ gro!thspurt


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(ommon (onditions

hat might you detect by recording height,!eight, head chest circumferenceK


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1ailure to 'hri0e

1ailure of an infant to gro! at Cnormal rates

May be related to? (hronic disease (ongenital disorder 7brain, heart, @idney8 #nade=uate calories and protein

#mproper feeding methods #ntrauterine gro!th retardation Emotional depri0ation

gro!th hormone le0els !ill be lo!


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hat ifK

-ead circumference increases rapidly orrises abo0e percentile cur0es

#ncreased intracranial pressuredDL? -ydrocephalus, etc.

-ead circumference gro!s slo!ly or falls off

percentile cur0es Microcephaly

dDx? (raniosynostosis, etc.


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(ongenital 2yndromes

Do!n 2yndrome 'urner 2yndrome associated !ith short stature


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2@in


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e!born Expected *ariants

'ransient puffiness of the hands, feet, eyelids, legs,pubis or sacrum occurs in some ne!borns

ot a concern if it disappears !ithin "%5 days

2ome ne!borns are bald !hile others are born !ithan inordinate amount of head hair

2heds !ithin "%5 months and replaced by more

permanent hair 7ne! texture and color8

Dar@%s@inned ne!borns do not al!ays manifest theintensity of melanosis that !ill be readily e0ident in"%5 months

Exceptions? nail beds and s@in of the scrotum

2@in may loo@ 0ery red the first fe! days of life

2@in color is partly determined by subcutaneous fat


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(utis marmorata 'ransient mottling !hen infant is exposed to

decreased temperature

Acrocyanosis (yanosis 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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*ernix caseosa

hitish, moist, cheeseli@e substance Mixture of sebum and s@in cells

(o0ers the infants body at birth Protecti0e

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Banugo

1ine, sil@y hair co0ering

the ne!born shoulders and bac@

2hed !ithin &$%&9 days

Banugo. 'his fine body hairresembling peach fu:: is present on

infants of "9 to 5" !ee@s gestation.


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'elangiectatic ne0i

a@a Cstor@ bites

1lat, deep pin@, locali:ed areas usually

seen in bac@ of nec@

2tor@ bite, or salmon patch.

A typical light red splotchy

area is seen at the nape of

the nec@.


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Mongolian spots

#rregular areas of deep blue

pigmentation usually in sacral and

gluteal regions

N2een predominantly in African, ati0e

American, Asian or Batin descent


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Erythema toxicum

Pin@ papular rash !ith 0esicles

superimposed thorax, bac@, buttoc@s, and abdomen

May appear "9%94 hrs after birth and

resol0es after se0eral days


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(ommon (onditions


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Milia

(ommon during the

first "%5 months

2mall !hite discrete papules on the

face and bridge of the nose Plugged sebaceous glands


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Miliaria

a@a C-eat rash

(aused by occlusion of s!eat ductsduring periods of heat and highhumidity

CPric@ly -eat

7crystaline8


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+ashes

Allergic rash (ontact dermatitis

Medications, supplements 1ood sensiti0ity

Diaper rash Acid urine output

>eastK


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Ec:ematous rash

>ounger children 1ace, elbo!, @nees

lder children adults -ands, nec@, inner elbo!s,

bac@ of @nees, an@les 1ace 7less often8


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2eborrheic Dermatitis

a@a C(radle (ap scalp Besions are scaling, adherent,

thic@, yello!, and crusted can spread o0er the ear and do!n the

nape of the nec@

N(an be also be seen on bac@,

intertriginous diaper areas


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#mpetigo

C-oney colored crusts

-ighly contagious 2taph. or 2trep.

infection (auses pruritis, burning, and regional

lymphadenpathy


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+ing !orm

'inea corporis

'inea capitis

M( 0ectorK


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2tra!berry hemangioma

Expected resolution?

irth? often not present or noticeable

&%" months? becomes noticeable&%6 months? gro!s most rapidly

&"%&4 months? begins to shrin@


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'richotillomania

May be related to? Excessi0e emotional stress

1amily circumstances, hospitali:ation, etc.

bsessi0e (ompulsi0e Disorder


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External (lues to #nternal

Problems


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1aun tail ne0us

'uft of hair o0erlying the spinal columnusually in the lumbosacral area

Associated !ith spina bifida occulta


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(afO au lait spots

E0enly pigmented patches light, dar@ bro!n, or blac@ in dar@ s@in

Present at birth or shortly thereafter

May be related to?

eurofibromatosis Pulmonary stenosis 'emporal lobe dysrhythmia 'uberous sclerosis

Suspect

neurofibromatosis if

you note >5 patcheswith diameters >1cm in

a child under 5


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Axillary 1rec@ling or

#nguinal 1rec@ling

May occur in conunction

!ith cafO au lait spots

Associated !ith neurofibromatosis


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1acial port%!ine stain

hen it in0ol0es the opthalmic di0ision

of the trigeminal ner0e it may be

associated !ith? 2turge%eber syndrome

sei:ures

ccular defects


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2upernumerary nipples

Especially in the presence of other

minor abnormalities

associated !ith renal abnormalities

E i i th b f


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Examining the e!born for

-yperbilirubinemia

Natural daylight is preferred

Examine the oral mucosa and sclera

#nspect the !hole body for Cdermal icterus 2tarts on the face and descends

ilirubin le0el is not high if only the face

7/mg


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+is@ 1actors

reast feeding

b%glucuronidase

(ephalhematoma or other cutaneous

or subcutaneous bleeds

-emolytic disease #nfection


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Physiologic Qaundice

Present in /$H of ne!borns appears to be an inability of the li0er to

conugate the bilirubin present in the blood

2tarts after the first day of life Rsually disappears in 4%&$ days May persist for 5%9 !ee@s

'reatment Cili lamp Cili lan@et 7blue lights8, or direct

sunlight 7conugate the bilirubin8 2eldom rises abo0e the "$mg


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Pathological Qaundice

If jaundice is present in the first 24 hours or it isintense and/or persistent, you must considerpathological jaundice

+( abnormalities sensiti0ity -emorrhage #mpaired hepatic function #nfections

'oxoplasmosis +ubella -erpes 2yphilis


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#nspection

(areful inspection of all s@in De0elop a pattern

Dont o0erloo@ body parts

Examine s@in creases Assymetrical creases on thighs

Possible hip dysplasia 2imian Bine 7hands feet8

possible Do!n syndrome


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2chamroth 'echni=ue

Place nail surfaces of

corresponding fingers

together

A. ormal? diamond shaped

!indo!

. (lubbed? angle bet!een

distal tips increases


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(lubbing of the ails

Associated !ith? +espiratory disease

(ardio0ascular disease 'hyroid disease

(irrhosis

(olitis


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2@in 'urgor

est e0aluated by gently pinching a

fold of the abdominal s@in

C'enting indicates? Dehydration Malnutrition


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#mmune and Bymphatic


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#mmune Bymphatic 2ystem

Bymph nodes in the neonate react =uic@ly to

any mild stimulus especially cer0ical and postauricular chains

'heory? compensate for lac@ of antibodies

by increased filtration and phagocytosis

Ability to produce antibodies is still immature atbirth but lymphoid tissue is plentiful


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Palatine 'onsils

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 ;I sleep apnea


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bstructi0e 2leep Apnea

Periodic cessation of breathing during

sleep d


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Bymph Exam

It is not uncommon to find enlarge lymph nodes

that may e!en be !isible from a distance

Cormal 1irm, discrete, mo0eable, S/mm

Rp to &cm in cer0ical or inguinal regions

#n0estigate further if? Gro!ing rapidly or suspiciously large 7I"%5 cm8

1ixed and immo0eable

Expected +egions of


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Expected +egions of

Bymph ode Enlargement

S& year S" years I" years

postauricularand occipital common common uncommon

cer0ical andsubmandibular

uncommon common

It is NEVER normal forsupraclavicular lymph nodes to be

enlarged!


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(ommon (onditions


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#nfectious Mononucleosis

Epstein%arr 0irus

NMay occur at any age 7M( in teens8 #nitial symptoms?

Pharyngitis, fe0er, fatigue, malaise

Exam 1indings? Enlarged anterior and posterior cer0ical chains 2plenomegaly, hepatomegaly, and


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2trep Pharyngitis

2ymptoms? 2ore throat and runny nose

-eadache, fatigue,

abdominal pain

Exam 1indings?

Palatal petichiae Enlarged anterior cer0ical nodes

"#hroat culture needed to confirm

f f ( 2 2


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Mc#saac Modification of the (entor 2trep 2core

Likelihood:

%&


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-ead and ec@


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#nspect the -ead

2caling, crusting 7seborheic dermatitis8

Dilated 0eins 7increased #(P8

Excessi0e hair or unusual hairline

ote symmetry of shape, bulging or

s!elling


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(ranial Molding During a 0aginal birth the cranial

bones shift and o0erlap

Expect the s@ull to resume a Cnormalshape and si:e !ithin & !ee@


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(aput succedaneum (ephalhematoma

2ubcutaneous edema 2ubperiosteal bleed

(rosses suture lines Does not cross suturesM( occiput M( parietal

2oft, poorly defined margins 1irm, !ell%defined edges


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Rnusual contour may be related to a

0ariety of causes?

#rregular closing of suture lines7craniosynostosis8

Positional head deformity 7P-D8

Preterm infants? soft cranial bones flatten

!ith the positioning and !eight of the

head


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#nspect the 1ace

2pacing of features

2ymmetry

2@in color 'exture

Paralysis


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bser0e

-ead controlK PositionK

Mo0ementK

ote any?

Qer@ing 'remors #nability to mo0e head in one direction


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Palpate the -ead

ote any tenderness o0er the scalp

2uture lines

slight groo0e up to 6 months 1ontanels

should feel slightly depressedF some pulsation isexpected

Post. fontanel closes ;" months

Ant. fontanel closes by "9 months


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ulgingK #nfection

#ncreased intracranial pressure

DepressedK Dehydration

Measure the 1ontanels Anterior fontanel should

not exceed 9%/ cm

7S6 months8

ot a

sensiti0e

indicator


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'ransilluminate

Dar@ room

'ransilluminator firm against scalp

egin at the midline frontal region and inch

o0er the entire head bser0e the ring of illuminationF note

asymmetry


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A ring S" cm is expected on all regions of

the head except the occiput 7should be S&

cm8 #llumination beyond these parameters suggest

Excess fluid

Decreased brain tissue in the s@ull

#ransillumination should be done on e!ery

infant and on an older child if there is a

suspected intracranial lesion or rapidly

increasing head circumference


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#nspect the ec@

2ymmetry, si:e, shape

Edema

Distended 0eins Pulsations

Masses

ebbing

Excess s@in


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'o inspect the ne!borns nec@

Place the infant supine

Ele0ate the upper bac@ and let the

head fall bac@ into extension


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Palpate the ec@

2ternocleidomastoid ote toneF hematoma

'rachea

'hyroid Difficult to palpate unless its enlarged

Goiter #ntrauterine depri0ation of thyroid hormone

May cause respiratory distress


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(ommon (onditions


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'orticollis 7Cry ec@8

irth inury -ematoma

May be palpated shortly after

birth 1irm fibrous mass "%5 !ee@s

later

lder children +esult of trauma, muscle

spasm, 0iral infection, drug

ingestion, VVVVVVVVVV


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Management

1irst, consider the underlying cause 2pinal cord tumor or congenital spinal anomolyK

irth traumaK 2ubluxationK

(hiropractic care

Mechanical adustments

#ncreased Ctummy time Exercises


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Plagiocephaly

%ositio-a 2ead,e3ormit+

ra-ios+-ostosis5am#doid6

o ridging Palpable ridge

Ear on flat side migratesfor!ard

Ears e0en or ear on flat sideappears to be more posterior

1orehead protrudes 7sameside as occipital flattening8 1orehead does not protrude

ald spot on side offlattening

o bald spot or central baldspot


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Positional

Parallelogram 1rontal bulging Ear migrates anterior

2ynostosis 7lambdoid8

'rape:oid o frontal bulging Ears e0en


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(raniosynostosis

Premature union of cranial sutures

2mall head circumference 7microcephaly8 +igid sutures Misshapen s@ull

Rsually not accompanied by mentalretardation


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Microcephaly

+elated to?

(raniostenosis

(erebral dysgenesisAssociated !ith mental retardation and

failure of brain to de0elop normally


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-ydrocephalus

Enlarged head

ossing of the s@ull

idening of sutures and fontanels Bethargy, irritability, !ea@ness

2clera 0isible abo0e the iris

C2unsetting sign


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(raniotabes

2oftening of the s@ull

Demonstrated by pressing the bone along

the suture line bone pops in and out

Associated !ith? +ic@ets and hydrocephalus

(an be a Cnormal finding up to &


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ells palsy 7facial palsy8

Asymmetry of facial features

Eyelid !ill notclose completely

Drooping corner of

mouth Boss of labonasial fold


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Do!n 2yndrome

Depressed nasal bridge

Epicanthal folds

Mongolian slant of eyes Bo! set ears

Barge tongue


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1etal Alcohol 2yndrome 71A28

2mooth philtrum

idespread eyes

#nner epicanthal folds Mild ptosis

-irsute forhead

2hort nose 'hin upper lip


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Eyes


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De0elopment 'able &&%&7Mosby8

y "%5 months *oluntary control of eye muscles

y 4 months (an differentiate colors

y J months

Eye muscles coordinateF a single imageis percie0ed


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'ips #nfant Eye Exam

'o encourage the infant to open their

eyes

Rse a dimly lit room -old the infant upright, suspended under

its arms facing you

-a0e parent hold infant o0er a shoulder


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#nspect External Eye

2i:e of eyes 7symmetryK8

Distance bet!een the eyes

-ypertelorism 7!idely spaced eyes8 may be associated !ith mental retardation

2lant of palpebral fissures

Epicanthal folds Prominent in Asian populations, Do!n

syndromeK


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#nspect Eyelids

'o detect the C2etting 2un 2ign +apidly lo!er the infant from upright

to supine position

Boo@ for sclera abo0e the iris

Differentials include?

Expected 0ariant in ne!born -ydrocephalus

rainstem lesion


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(linical ote

e!born eyelids may be s!ollen or edematous,

accompanied by conuncti0al inflammation

and drainage as a conse=uence of routinelyadministered antibiotics

eyond the ne!born period

redness, hemorrhage, discharge, granularappearance may indicate infection, allergy,or trauma


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#nspect

2clera

Pupil

#ris (onuncti0a

(oloboma


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(oloboma

a@a CWeyhole pupil

Boss of functional pupil ften associated !ith other

congenital abnormalities

rushfield spots hite spec@s in a linear pattern around the

circumference of the iris

2uggests Do!n syndrome


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2trabismusK

Exoptropic 0s. Esotropic

'ests include? (orneal light reflex 7-irschbergs 'est8 (ross%(o0er 'est (o0er%Rnco0er 'est

(orneal Bight +eflex


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a@a -irschbergs 'est

(hild stares at a penlight about 5$ cma!ay

Doctor loo@s at the reflection fromeach cornea #n relationship to the pupil

ormal? symmetrical

2trabismus? asymmetrical

Pseudostrabismus


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Pseudostrabismus 2ymmetrical corneal light

reflex (ommon in Asian and

ati0e American

populations 7prominent

epicanthal folds8

Disappears by & yoa

2trabismus 7esotropic8 Asymmetrical light reflex


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(ross%(o0er 'est

Patient stares at penlight

Doctor co0ers one eye and obser0es

the unco0ered eye for mo0ement

ormal? no mo0ement

Exotropic eye? mo0es lateral to medialEsotropic eye? mo0es medial to lateral


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(o0er%Rnco0er 'est

Patient stares at the penlight Doctor co0ers one eye and then

obser0es as it is unco0ered

ormal? no mo0ement 7remains fixedon the light8

Exotropic eye? mo0es lateral

Esotropic eye? mo0es medial


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-elp to differentiate

Paralytic 2trabismus #mpairment of extraocular muscles or their ner0e

supply

onparalytic 2trabismus o primary muscle !ea@ness

(an focus !ith either eye but not bothsimultaneously concern of de0eloping amblyopia


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#nfant (ranial er0es 7##, ###, #*, *#8

&. Expect the infant to focus and trac@

through 6$ degrees

". ptical blin@ reflex 2hine a bright light at the infants eyes

ote the =uic@ closure of the eyes and

dorsiflexion of the head

5. (orneal light reflex 7-irschbergs8


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Extraocular Mo0ements % (hild

2ix cardinal fields of ga:e

Peripheral 0ision

Parent may hold the childs head still

Rse a teddy bear or toy

-a0e child sit on parents lap


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*isual Acuity

#nfant Grossly examined by obser0ing the the

infants preference for loo@ing at certain

obects

>ounger (hildren bser0e play !ith toys % stac@ing, building,

or placing obects inside of others #f tas@s are performed !ell, 0ision difficulties areunli@ely


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2nellen E (hartN

'ested !hen a child can

cooperate !ith the exam

Rsually ;5 years of age

As@ !hich !ay the Clegs are pointing

NAlso a0ailable !ith different shapes


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'ips 2nellen E (hart

&. Ma@e it a Cgame

". #nstruct the child to point finger in the

direction of the legs of the E5. Allo! the child to practice follo!ing

instructions before you administer the

test9. Parent may assist !ith co0ering eye


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2nellen E (hart

+emember?

'est each eye seperately

ith and !ithout correcti0e lenses

"$


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$%hen testing !isual acuity in the child,

any difference in the scores betweenthe eyes should be detected&'

A " line difference 7"$


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Anticipated *isual Acti0ity

Age *isual Acuity

5 years "$


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+ed +eflex

NPerformed from birth on should be

elicited in e0ery ne!bornX

bser0e for opacities, dar@ spots, or

!hite spots !ithin the circle of red

glo! (ongenital cataracts

+etinoblastoma


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(ongenital (ataracts

+e=uires a full metabolic, infectious,systemic, and genetic !or@up

(ommon causes? #nfectious diseases

'xoplasmosis, +ubella 7M(8, (ytomegalo0irus, -erpes

-ypoglycemia 'risomies Prematurity Etc.


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1 d i E i ti


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1undoscopic Examination

(ifficult to perform on a newborn or

young infantconsider referral

ften deferred until "%6 months unless

the patient presentation suggests a

needEg. premature infant 7retinopathy8

+ ti th f P t it


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+etinopathy of Prematurity

lood 0essels are straightened and

di0erted temporally

(icatricial changes may be se0ere

+etinal detachment

Glaucoma lindness

'i 1 d i E


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'ips 1undoscopic Exam

Do not hold the childs eyelid open forcibly Beads only to more resistance

ften unable to @eep eyes still and focused

on a distant obect Rse a toy, picture, etc.

+esults may be better if the child sits on theparents lap

May !ant to do the exam !ith the patientsupine

1 d i E 2 i


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1undoscopic Exam 2upine

(hild laying supine on the exam table !ithhead near the end

2tand at the end of the table

Rse +t. eye to examine the childs Bt.

'E? +etinal findings !ill appear Cupside do!n #nspect the optic disc, fo0ea, and 0essels as

they pass by

b 5 th


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e!born 5 months

2creening Method +e=uire 1urther E0aluation

+ed reflex AbnormalAsymmetric

(orneal light reflex Asymmetric

#nspection 2tructural abnormality

6 th &


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6 months & year


+ed reflex Abnormal or Asymmetric

(orneal light reflex Asymmetric

Differential occlusion1ailure to obect e=ually toco0ering each eye

1ix and follo! !itheach eye 1ailure to fix and follo!

#nspection 2tructural abnormality

5 ld


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;5 years old


*isual acuityS"$


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;/ years old


*isual acuity "$ # t t


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Modifying >our #nstruments

to


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Ears

De elopmental 1eat res


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De0elopmental 1eatures

External auditory canal shorter, has an

up!ard cur0e infant otoscopic exam Cpull do!n!ard

Eustachian tube relati0ely !ider, shorter

and more hori:ontal +eflux of nasopharyngeal secretions

Gro!th of adenoids may occlude theeustachian tube #nterferes !ith aeration of the middle ear

#nspect the Ear


130/288

#nspect the Ear

ell formed all landmar@s present

1lexible should ha0e instant recoil after bending

Position the tip of the auricle should cross an imaginary

line bet!een the outer canthus of the eye and

the prominent portion of the occiput 7EP8 o s@in tags or preauricular pits should be

present

(linical ote


131/288

(linical ote

Bo! or poorly shaped auricles

associated !ith renal disorders and

congenital abnormalities

Palpate


132/288

Palpate

Bymph nodes Pinna 'ragus Mastoid

'endernessK armthK

N#f pain is noted !ith palpation of the

mastoid, suspect mastoiditis

toscopic Exam #nfant


133/288

toscopic Exam #nfant

&. Bay the infant supine


134/288

e!born *ariants

>ou may note Bimited mobility Dullness and opacity of a pin@ or red tympanic

membrane Bight reflex may appear diffuse 'ympanic membrane is not conical for se0eral months

Auditory canal may be obstructed !ith 0ernix

")toscopic e*am should be performedwithin the first few wee+s of life

toscopic Exam (hild


135/288

toscopic Exam (hild

Pull auricle either do!n and bac@+ up and bac@ best 0ie! of the tympanic membrane

Postpone until the end of the 0isit est done on parents lap e prepared to use restraint if encouraging

the child fails As@ the parent to restrain the child

+estraining a (hild toscope


136/288

+estraining a (hild % toscope

1ace the child side!ays !ith one arm

placed around parents !aist

Parent holds the child firmly againsthis


137/288

(linical ote

C+ed reflex

#f the child is crying or has recently cried

0igorously dilation of blood 0essels in the

tympanic membrane can cause redness

ou cannot assume that redness of themembrane alone is a middle ear infection-

Pneumatic toscopy


138/288

Pneumatic toscopy

Assesses mobility of the tympanic

membrane needed to differentiate

Crying

Red Reex

Red

Moveable

Infection Red

No mobility

'ympanometry


139/288

'ympanometry

Accurate !ay to identify middle ear effusion Ear piece must be sealed in the canal to pro0ide

accurate reading

ax, ruptured membrane, tubes

Acoustic +eflectometry 7ne!er technology8 (heaper

Easier to get accurate results

Assessing -earing


140/288

Assessing -earing

bser0e response to a !hispered 0oice, toys, etc. As they get older, as@ child to perform tas@s in a

soft 0oice Rse !ords that ha0e meaning for them May !ant to ha0e a parent do it Ma@e sure theyre not responding to air

mo0ement or 0isual stimulus

eber, +inne, and 2ch!abach tests Rsed only !hen a child understands directions

and can cooperate !ith the examiner Rsually 5%9 years of age

Expected -earing +esponse


141/288

Expected -earing +esponse

Birt to !mont"

#tartle reex$ crying$ce""ation of breating ormovement in re"pon"e to

"udden noi"e% quiet" toparent&" voice

' to ( mont" )urn" ead to*ard "ourceof "ound but may not

al*ay" recogni+e locationof "ound% re"pond" toparent&" voice% en,oy""ound producing toy"


142/288

( to -. mont" Re"pond" to o*n name$telepone ringing$ andper"on&" voice$ even if not

loud% begin" locali+ing"ound" above and belo*$turn" ead '/ degree"to*ard" "ound

-. to -0 mont" Recogni+e" and locali+e""ource of "ound% imitate""imple *ord" and "ound"

(ommon (onditions


143/288

(ommon (onditions

titis Externa


144/288

titis Externa

#nfection of the auditory canal

-istory of trauma or moist en0ironment #tching in the ear canal #ntense pain !ith mo0ement of pinnaF che!ing Discharge may be !atery at first, then purulent

thic@ mixed !ith pus and epithelial cells Musty, foul%smelling

(onducti0e hearing loss 7exudate and s!elling8 (anal is red, edematousF tympanic membrane

obscure

acterial titis Media


145/288

acterial titis Media

#nfection of the middle ear M( infection in childhood ften follo!s or accompanies R+'#

1e0er, feeling of bloc@age, tugging earlobe,anorexia, irritability, di::iness, 0omiting diarrhea

Deep%seated earache

Discharge if tympanic membrane ruptures orthrough tympanostomy tubesF foul%smelling

(onducti0e hearing loss 7fills !ith pus8 'ympanic membrane may be red, thic@ened,

bulgingF full, limited, or no mo0ement

titis Media !ith Effusion


146/288


(ollection of li=uid 7effusion8 in the

middle ear

Associated !ith?

Allergies

Enlarged lymph tissue bstructed or dysfunctional eustachian tube



147/288

2tic@ing or crac@ing sound on ya!ning or

s!allo!ingF no signs of acute infection

Pain is uncommonF feeling of fullness

Discharge is uncommon (onducti0e hearing loss as middle ear fills !ith

fluid

#f chronic, may delay speech de0elopment

temporarily 'ympanic membrane is retracted, impaired

mobility, yello!ishF air fluid le0el and


148/288

ose

De0elopment


149/288

De0elopment

Maxillary and ethmoid sinuses present at birth, though 0ery small

2phenoid sinus tiny ca0ity at birth not fully de0eloped until puberty

1rontal sinus de0elops by 3%4 years

#nspection


150/288

#nspection

2ymmetric appearance Positioned in the 0ertical midline on the face nly minimal mo0ement of the nares !ith

breathing should be apparent

Possible congenital abnormality if 2addle%shaped nose !ith a lo! bridge and

broad base 2hort small nose Barge nose

CAdenoidal or CAllergic 2alute


151/288

Adenoidal or Allergic 2alute

'rans0erse crease at the

uncture bet!een the cartilage and

the bone of the nose

(hildren often !ipe their noses !ith an

up!ard s!eep of the palm of the hand #f repeated often enough, causes a crease

#nternal ose


152/288

#nternal ose

Rsually ade=uate to tilt the nose tip

up!ard

#nspect by shining a light inside Bargest otoscopic speculum may be used

(linical note? some say that a Cgreyishmembrane may indicate chronic allergies

asal Patency


153/288

asal Patency

Must be determined at the time of birth

Mouth closed, occlude one naris and then

the other bser0e the respiratory pattern

ith total obstruction, the infant !ill not be ableto inspire or expire through the noncompressednaris

dDx? 2eptal de0iation, choanal atresia

(hoanal Atresia


154/288

(hoanal Atresia

(ongenital nasal obstruction

of the posterior nares Qunction bet!een nasal ca0ity and

nasopharynx

e!borns may experience respiratory

distress and difficulty feeding

bligatory nose breathers

Copyright 2006University of Washington.

Nill breathe

!hen

crying

2inuses
http://www.washington.edu/http://www.washington.edu/http://www.washington.edu/http://www.washington.edu/


155/288

2inuses

#nfant Maxillary and ethmod sinuses are small 1e! problems arise in these areas and

examination is generally unnecessary

(hild Maxilary sinuses should be palpated 1e! sinus problems occur since the sinuses

are still de0eloping

#here is wide !ariation howe!er&&& do not ruleout sinusitis simply on the basis of age-

2inusitis


156/288

2inusitis

#nfection of one or more paranasal sinuses May be a complication of a 0iral R+'#, dental infection,

allergies, or a structural defect of the nose

2igns in children include? upper respiratory symptoms nasal discharge lo!%grade fe0er daytime cough malodorous breath cer0ical adenopathy intermittent painless morning eye s!elling facial pain or headache


157/288

Mouth 'hroat



158/288


2ali0ation increases by 5 months

#nfant drools until s!allo!ing is learned

'eeth

"$ deciduous teeth appear 76%"9 months8

Eruption of permanent teeth begins about 6

years of age and is completed by &9%&/ yrs 5rdmolar 7C!isdom tooth8 ;&4 years old

#nspection


159/288

#nspection

'ongue should fit !ell in the floor of the mouth

protrude beyond the al0eolar ridge

1renulum

usually attaches mid!ay bet!een the0entral surface of the tongue and its tip

Macroglossia

7 b ll l t 8


160/288

7abnormally large tongue8

(ongenital hypothyroidism (ongenital abnormalities

Do!n 2yndrome

2hort 1renulum 1eeding problems

2peech difficulties


161/288

atal 'eeth 'eeth or tooth buds in


162/288

a ne!born

Potential for aspiration May be remo0ed

+etention (ysts7a@a Epstein Pearls8

Appear along the buccal

margins of the gums

Pearl%li@e retention cysts Disappear in &%" months

aby bottle syndrome Multiple bro!n caries on upper


163/288

Multiple bro!n caries on upper

and lo!er incisors

d


164/288


165/288

Palate 2hould be !ell%formed !ith no cleft

#nfant arro!, flat palate roof or a high, arched palateK

may result in feeding and speech problems associated !ith congenital anomolies

(hild -ighly arched palateK

seen in chronic mouth breathers

(left Bip and Palate


166/288

p

(ongenital malformation 1issure in the upper lip and


167/288

'onsils 2hould blend !ith the color of the pharynx Pea@ si:e bet!een " % 6 years

2hould retain unobstructed passage

Graded to describe their si:e

&) 0isible

") half!ay bet!een tonsillar

pillars and the u0ula

5) nearly touching the u0ula

9) touching each other

'onsillitis


168/288

#nflammation or infection of the tonsils 1re=uently caused by streptococci

2ore throat, referred pain to the ears, dysphagia,

fe0er, fetid breath, and malaise

'onsils appear red and s!ollenF purulent exudate

yello! follicles are associated !ith strep.

Anterior cer0ical lymph nodes enlarged

Peritonsillar Abscess


169/288

#nfection of the tissue bet!een the tonsil and

pharynx (omplication of tonsillitis

Dyphagia, drooling, se0ere sore throat !ith pain

radiating to the ear, muffled 0oice, fe0er

'onsil, tonsillar pillar and adacent soft palate

become red and s!ollen 'onsil may appear pushed for!ard or bac@!ard,

possibly displacing the u0ula


170/288

Drooling ormal in infancy

#f it persists past &" months

consider a neurologic disorder

#f acute consider epiglotitis

Epiglottitis


171/288

p g

2uspected !ith 2udden high fe0er Drooling (roupy cough 2ore throat Apprehension focus on breathing

'ripod position, nec@ extended

N#mpending air!ay obstruction d


172/288

(rying pro0ides an opportunity to examine

the mouth

A0oid depressing the tongue 2timulates the C'ongue 'hrust +eflex Ma@es 0isuali:ation of the mouth difficult

#nsert your glo0ed finger into the infantsmouth fingerpad to the roof of the mouth


173/288

mouth, fingerpad to the roof of the mouth

E0aluate the infants suc@ 2hould ha0e a strong suc@, tongue pushing

0igorously up!ard against the finger

Palpate the hard and soft palates Palatal arch should be dome shaped o palpable clefts 2oft palate should rise symmetrically !hen the

infant cries 2timulate a gag reflex by touching the

tonsillar pillars

'ips (hild Mouth Exam


174/288

'o reduce fear, let the child hold andmanipulate the tongue blade and light

2tart by as@ing to see their teeth Rsually not threatening

As@ the child to protrude the tongue and sayCah, a tongue blade is often unnecessary

'o raise the palate, as@ the child to pantCli@e a puppy

#f child refuses to open mouth


175/288

#nsert a tongue blade through the lips

to the bac@ molars

Gently but firmly insert the tongueblade bet!een the bac@ molars and

press the blade to the tongue

'his should stimulate the gag reflex Gi0es you a brief 0ie! of the mouth and

oropharynx

$.hildren of any age who are not too big to

sit on a parents lap are better e*amined there


176/288

p p

than on the e*amining table&'

+estraining a (hild ral Exam


177/288

2eated in the parents lap, bac@ to the

parent and legs bet!een the adults legs

Parent can reach around to restrain the

childs arms !ith one arm and control thechilds head !ith the other

(an usually be accomplished !ithout forcing 1orce only ma@es them more angry

+estraining a (hild % 2upine


178/288

#f the child acti0ely resists

Place child supine on the exam table

Parent holds arms extended abo0e the head

and assists in restraining the head Doctor lies across the childs trun@ and

stabili:es the childs head

'hird person may need to hold the childslegs


179/288

(hest and Bungs

e!born Apgar 2core


180/288

A ctivity

P ulse

G rimaceA ppearance

R espirations

2ubecti0e =ualitati0e e0aluation done at & and / minutes

determine Csur0i0ability of the ne!born by

obser0ing the le0el of function of / components

Muscle tone

-eart rate

+eflex irritability (olor

+espiratory rate

Apgar 2core


181/288

$ & "

-eart rate Absent S&$$ I&$$

+espiratoryeffort Absent 2lo!


182/288

Maternal en0ironment during labor 2edati0es

(ompromised blood supply to the child

Mechanical obstruction by mucus

eurological damage 7birth trauma8K #nfants rely primarily on the diaphragm for

respiratory effort 7(5,9,/8

De0elopment


183/288

ony structure is more prominent than

the adult d


184/288

(hest is generally round A%P diameter approximately the same as

the trans0erse

#f the Croundness of a childs chest

persists past the "nd year, suspect a

possible chronic obstructi0e pulmonaryproblem

(ystic 1ibrosis


185/288

Autosomal recessi0e

disorder of exocrine glands 2!eat glands

2alt loss in s!eat 7Ctaste salty8

Bungs 1re=uent and progressi0e pulmonary

infections 7thic@ mucus8 Pancreas

2tic@y, foul smelling stool

#ntrauterine gro!th retardation 2maller chest circumference compared to


186/288

2maller chest circumference compared to

the head

Poorly controlled diabetes

+elati0ely larger chest circumference

ipples


187/288

2ymmetry in si:e

2!elling

Discharge 2upernumerary

Measure distance bet!een the nipples 2hould be Y chest circumference

reast de0elopment in a

ne!born d


188/288

(ount for & minute A0erage? 9$%6$ rpm 74$ rpm is not

uncommon8

#f room temp is 0ery !arm or cool,

0ariation in the rate occurs

Most often tachypnea 2ometimes bradypnea

+espiratory +hythm


189/288

ote regularity of respiration Premature infants are more li@ely to ha0e

irregular respiratory patterns

Periodic breathing se=uence of relati0ely 0igorous respiratory

efforts follo!ed by apnea of as long as &$%&/seconds

Periodic reathing


190/288

(ause for concern if Apneic episodes tend to be prolonged aby becomes centrally cyanotic

#n the term infant periodic breathing should!ane a fe! hours after birth

Persistence in preterm infants is relati0e to

gestational age Apneic periods should diminish in fre=uency

as they approach term status

bser0e (hest Expansion


191/288

#f asymmetric, suspect inability to fill

one of the lungs

Pneumothorax Presence of air


192/288

+ib cage and sternum Boss of symmetry

Rnusual masses

(repitus 1ractured cla0icle 7birth trauma8

May sho! no e0idence of pain

Liphoid Mobile and prominent

Auscultation #nfant


193/288

Bocali:ation of breath sounds is

difficult

reath sounds are easily transmittedfrom one segment to another

NDifficult to detect absence of breathsounds in any gi0en area

Auscultation (hild


194/288

May not be able to gi0e enough of anexpiration to satisfy you 7S/ years old8 Especially !ith subtle !hee:ing

As@ them to Cblo! out your penlight As@ them to blo! a!ay a bit of tissue in

your hand Bisten after they run up and do!n thehall!ay

(hest !all is thinner and more resonantthan adults


195/288

than adult s

reath sounds may sound louder, harsher,and more bronchial

-yperresonance is common Easy to miss the dullness of underlying

consolidation 7percussion8

$If you sense some loss of resonance, gi!e it as

much importance as you would gi!e fran+

dullness in the adult&'

'ips Bung Exam


196/288

Percussion is usually unreliable in the infant Examiners fingers may be too large

A sob is fre=uently follo!ed by a deepbreath Allo!s the e0aluation of 0ocal resonance

1eel for tactile fremitus

hole hand, palm and fingers

(rac@les and +onchi ot uncommon immediately after birth 7fluid


197/288

ot uncommon immediately after birth 7fluid

has not completely cleared8 #f asymmetric, a problem should be suspected

dDx? aspiration of meconium

+espiratory Grunting #nfant tries to expel trapped air or fetal lung

fluid !hile trying to retain air and increase

oxygen le0els #f persistent, cause for concern

2tridor -igh pitched, piercing sound


198/288

(annot be dismissed as inconse=uentialespecially !hen inspiration is longer thanexpiration

1loppy epiglottis (ongenital defects (roup

Edematous response #nfection

Allergen

2mo@e

(hemicals

Aspirated foreignbody

#ncreased +espiratory Effort


199/288

+etraction at the supracla0icular notch

(ontraction of the 2(Ms

1laring of the nostrils b0ious intercostal exertion

7retractions8

'achypnea

C2ee%sa! respirations

Does a loss of synchrony bet!een B and + occurduring the respiratory effortK #s there a lag inmo0ement of the chest on one sideK AtelectasisKDiaphragmatic herniaK


200/288

Diaphragmatic herniaK

#s there stridorK (roupK EpiglottitisK

#s there retraction at the suprasternal notch,intercostally, or at the xiphoid processK

Do the nares dilate and flare !ith respiratory effortK #spneumonia presentK

#s there an audible expiratory gruntK #s it audible !iththe stethoscope only or !ithoutK #s there lo!er air!ay

obstructionK 1ocal atelectasisK

#s there paradoxic breathingK


201/288

(ommon (onditions

'racheomalacia


202/288

1loppiness of the trachea 'rachea changes in response to 0arying

pressures of inspiration and expiration resulting inCnoisy breathing hee:ing, inspiratory stridor

NGenerally benign and self%limiting !ith age

dDx? 0ascular lesion, tracheal stenosis, foreign body

Also? Baryngomalacia Baryngotracheomalacia

ronchiolitis


203/288

*iral +2* 7respiratory syncytial 0irus8

Most common S6 months

Expiration becomes difficult due to

hyperinflation of lungs

Exam findings? #ncreased A%P diameter of thoracic cage

-yperresonant percussion


204/288

(oughing (omes in Cfits and tends to be harsh

'achypnea

+apid, short breathsF expiratory phase prolonged Possible !hee:ing and crac@les

#nfant appears anxious

Generali:ed retraction Perioral cyanosis

#nfluen:a


205/288

Generali:ed febrile illness 70iral8 Mild cases may ust seem li@e a cold R' the

0ery young are at higher ris@ +espiratory tract may be o0er%!helmed

7interstitial inflammation and necrosis8

(ough 1e0er

Malaise -eadache (ory:a Mild sore throat

(rac@les +honchi 'achypnea 2ubsternal pain

Pneumonia


206/288

#nflammatory response of the

bronchioles and al0eolar space to an

infecti0e agent

acterial, fungal , or 0iral

Exudates lead to lung consolidation Dyspnea, tachypnea, and crac@les

Diminished breath soundsF dullness to

percussion

#2PE('# 'achypnea2hallo! breathing


207/288

2hallo! breathing

1laring of nostrilsccasional cyanosis

Bimited mo0ementF splinting

PABPA'# #ncreased fremitus 7consolidation8PE+(R22# Dullness 7consolidation8

AR2(RB'A'# *ariety of crac@lesccasional rhochi

ronchial breath sounds

Egophony, bronchophony, !hisperedpectorilo=uy

ronchitis


208/288

#nflammation of the mucusmembranes of the bronchial tubes

Acute #ro-chitis 1e0er and chest pain

hro-ic #ro-chitis *ariety of causes Excessi0e secretion of mucus

oth can sho! 0arying

degrees of in0ol0ement

bstruction Atelectasis

Most often =uite mild

#2PE('# ccasional tachypnea

ccasional shallo! breathing


209/288

ccasional shallo! breathing

ften no de0iation from expectedfindings

PABPA'# 'actile fremitus undiminished

PE+(R22# +esonance

AR2(RB'A'# reath sounds may be prolonged

ccasional crac@les

ccasional expiratory !hee:es

Asthma


210/288

(PD characteri:ed by air!ayinflammation mucosal edema

increased secretions bronchoconstriction

-yperreacti0ity to allergens, anxiety,R+'#, smo@e, exercise, cold air, etc.

#2PE('# 'achypnea

Dyspnea


211/288

Dyspnea

PABPA'# 'achycardia

Diminished fremitus

PE+(R22# -yper%resonance

Bimited diaphragmatic descentFlo!er diaphragmatic le0el

AR2(RB'A'# Prolonged expiration

hee:esDiminished lung sounds

(roup


212/288

*iral Particularly parainfluen:a 0iruses

Most commonly?

*ery young children 7& Z to 5 years old8 oys I girls

2ome are prone to recurrent episodes

dDx? epiglottitis, aspirated foreign body


213/288

ften begins in the e0ening after the childhas gone to sleep A!a@ens suddenly, frightened

-arsh stridorous cough Car@ of a seal Babored breathing +etraction

#nspiratory stridor ' al!ays fe0er

Epiglottitis


214/288

-aemophilus influen:ae type #ncidence appears to ha0e reduced

M(? 5%3 years old

Acute, life%threatening egins suddenly and progresses rapidly to full

obstruction of the air!ay

'reat this as a medical emergency

#nserting tongue blade may be deadlyX


215/288

(hild sits straight up !ith

nec@ extended, head held

for!ard

Appears 0ery anxious and ill Rnable to s!allo!

Drooling from the open mouth

(ough is ' common


216/288

-eart

1etal (irculation


217/288

(ompensates for the non%functional fetal lung lood passes directly from the + to

B atrium through the 3orame-

o7ae +ight 0entricle pumps blood through the

ductus arteriosus

At birth... functional closure of forameno0ale and the ductus arteriosus closes!ithin "9%94 hours

Patent Ductus Arteriosus


218/288

lood flo!s through the ductus duringsystole and diastole

#ncreases pressure in the pulmonary circulation

#ncreased !or@load for the right 0entricle

2mall shunt? may be asymptomatic

Barge shunt? may ha0e dyspnea on exertion

CMachinery murmer

-arsh, loud, continuous murmur &st % 5rd intercostal spaces lo!er sternal border

Rsually unaltered by postural changes

Patent 1oramen 0ale


219/288

Allo!s blood to flo! bet!een the

right and left atria

Rsually asymptomatic May exhibit cyanosis !ith exertion 7especially if

other congenital heart defects are present8

-eart Exam


220/288

Examine !ithin the first "9 hours and againat "%5 days of age (hanges from fetal to systemic and pulmonary

circulation

(omplete e0aluation of heart functionincludes s@in, lungs, li0er (ongesti0e heart failure in the infant may

present !ith a large, firm li0er 7hepatomegaly8 Rnli@e adults, this finding may be noted

before pulmonary crac@les

#nspection


221/288

(olor? should be Cpin@

PurplishK

dDx? polycythemia

Ashy, !hiteK

dDx? shoc@

(entral cyanosisKdDx? congenital heart disease

Distribution intensityof discoloration.

Extent of change after

exertion.

2e0ere cyanosis e0ident at birth or shortly aftersuggests? 'ransposition of the great 0essels 'etralogy of 1allot 7blue8

Al!ays

cyanotic


222/288

'etralogy of 1allot 7blue8 'ricuspid atresia

relies on A2D *2D for oxygenation of blood 2e0ere septal defect 2e0ere pulmonic stenosis

(yanosis that does not appear until after theneonatal period suggests? Pure pulmonic stenosis Eisenmenger complex % only de0elops in some cases

right%to%left shunting 7*2D is M(8 combined !ith pulmonaryhypertension

'etralogy of 1allot 7pin@8 2eptal defects


223/288

ulgingK

Precordium tends to bulge o0er an

enlarged heart if the enlargement is

long%standing 'horacic cage is more cartilaginous and

yielding in children

(apillary +efill


224/288

(apillary refill time is 0ery rapid up to " yrs

S & second 7normal8

Prolonged capillary refill time 7I " seconds8dDx?

2ignificant dehydration

-ypo0olemic shoc@

Apical #mpulse


225/288

9th % /th left intercostal space, medial

to the midcla0icular line Apex of the heart is higher, heart lies

more hori:ontal

NAdult heart position is reached by age 3

EnlargementK PositionK


226/288

Pneumothorax 2hifts apical pulse a!ay from the area of

pneumothorax

Diaphragmatic hernia M( on the left side 2hifts the heart to the right

Dextrocardia Apical impulse on the right

Dextrocardia 2inus #n0ertus


227/288

Dextrocardia +ight thoracic heart normally placed stomach

and li0er May be associated !ith other anomolies

2inus #n0ertus -eart and stomach are on the right, li0er on the

left ot 0ery common

Pulses


228/288

rachial, radial, and femoral pulses arepalpable

ea@ or thin pulse dDx? Decreased cardiac output Peripheral 0asoconstriction

ounding pulse dDx? B to + shuntF PDA 7patent ductus arteriosus8

Difference in pulse amplitude bet!een femoral andradial pulses dDx? (oarctation of the Aorta

-eart +ate


229/288

-eart rate is more 0ariable #nfants? eating, sleeping, and !a@ing (hildren? exercise, tension, fe0er

-+ &$%"$ beats for each degree temp.

2inus arrhythmia is common in children +ate 0aries in a cyclical pattern

1aster on inspiration

2lo!er on expiration1ixed tachycardia may indicate difficulty

-eart +ate


230/288

Age eats per minute

e!born &"$%&3$

& year 4$%&6$

5 years 4$%&"$

6 years 3/%&&/

&$ years 3$%&&$

Auscultation


231/288

Murmers +elati0ely fre=uent in the first 94 hours Most are innocentF transition from fetal to

pulmonic circulation

89--oce-t mumers: Disappear !ithin "%5 days 7Cshort8 Grade # or ## intensity 7Csoft8

2ystolic Rnaccompanied by other signs and

symptoms

C2

A murmur is usually ' a significant

congenital anomaly. Paradoxically, a

significant congenital anomaly may be


232/288

g g y y

unaccompanied by a murmur

Must in0estigate if

persists beyond "nd or 5rd day of life is intense

fills systole

occupies diastole to any extent almost al!ays significant

radiates !idely


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*enous hum

(aused by turbulence of blood flo! in the

internal ugular 0ein (ontinuous lo!%pitched sound

Bouder during diastole (ommon in children Rsually has no pathologic significance

As@ child to sit !ith head turned a!ay tilted slightly up!ard Auscultate supracla0icular space

lood Pressure


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1lush 'echni=ue 7#nfant8 Place cuff on upper arm 7or leg8 Ele0ate and !rap the arm firmly !ith an elastic

bandage from fingers to antecubital space

Empty 0eins and capillaries #nflate cuff to a pressure abo0e the systolic

reading you expect Bo!er the arm and remo0e the bandage

Arm !ill be pale

Diminish pressure gradually until you see asudden Cflush and return to usual color

lood Pressure


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lood pressure is measured the same as in

the adult after " years

'o facilitate the exam Explain the process

Bet them explore the sphygmomanometer

Ma@e sure to use the correct cuff si:eX (o0er "


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A sustained increase in P is almost al!ays

significant in the ne!born 2tenosis of renal artery

(oarctation of the aorta (ystic disease of the @idney

euroblastoma

ilms tumor

-ydronephrosis Adrenal hyperplasia

(2 disease

-ypertension (hild


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Do not ma@e the diagnosis of hypertension basedon one reading

An ele0ated systolic but normal diastolic may be d


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'a@e careful note of? eight gain 7or loss8 De0elopmental delay (yanosis

(ongenital heart defects that impedeoxygenation

(lubbing fingers and toes

(ongenital Defects


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Atrial 2eptal Defect


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Allo!s oxygenated blood to lea@ from the

left atrium into the right

Minor cases may be asymptomatic

Barger defects may re=uire surgery

NMay not sound particularly impressi0e

7especially in an o0er!eight child8

More apt to be significant if Palpable thrust

+adiation through to the bac@

(oarctation of the Aorta


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arro!ing in a portion of the aorta M(? descending aortic arch near the

origin of the left subcla0ian artery andligamentum arteriosum

(an cause se0eral life%threatening complications 2e0ere hypertension Aortic aneurysm, dissection or rupture Endocarditis rain hemorrhage

2tro@e -eart failure and premature coronary artery disease

N+epair is typically recommended before age &$


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(ompare radial and femoral pulses ormal? pea@ at the same time 7or femoral

slightly earlier8 (oarctation? delay and


244/288


245/288

#nfants may ha0e C'et spells, central cyanosis Paroxysmal dyspnea !ith loss of consciousness

As they get older (lubbing of fingers and toes

Exam findings? Parasternal hea0e

Precordial prominence 2ystolic eection murmur heard o0er the 5rd

intercostal space 2ometimes radiating to the left side of the nec@

(ommon (onditions


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Acute +heumatic 1e0er


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(omplication of strep. pharangitis 7or s@in

infection8 ;I connecti0e tissue disease May result in serious cardiac 0al0e in0ol0ement

M( mitral or aortic 0al0es

M( children bet!een /%&/ years of age

Pre0ention is the best therapy i.e. ade=uate treatment for strep. infections

+ecent strep infection 1e0er Migratory polyarthritis

E th i t


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Erythema marginatum Pin@ margins, pale centers (horea 7er@y body mo0ements8 1irm, painless subcutaneous nodules

Elbo!s, @nees, !rists

Murmur Mitral regurgitationF aortic insufficiency

1riction rub 7pericarditis8 (ongesti0e heart failure (ardiomegaly

Qones (riteria Diagnosis of +heumatic 1e0er " maor manifestations or & maor ) " minor manifestations

-igh probability of acute rheumatic fe0er

N#f th id f di t i f ti


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N#f theres e0idence of a preceding strep infection

Major Ma-i3estatio-s Mi-or Ma-i3estatio-s

(arditis

Polyarthritis(horea

Erythema marginatum

2ubcutaneous nodules

.linical

%Pre0ious rheumatic fe0er orrheumatic heart disease

%Arthralgia

%1e0er

0aboratory

%Acute phase reactions? E2+, (%reacti0e protein, leu@ocytosis

%Prolonged P%+ inter0al on E(-

Wa!asa@i Disease

A t ill 7f 8


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Acute illness 7fe0er8 Etiology un@no!n

#nfectiousK (arpet cleanersK

M( children under /F males I females

(an be self%limiting, reco0er in a fe! days (omplications? 0asculitis ;I aneurysms

(ritical concern? cardiac in0ol0ement 70asculitisof the coronary artery8

2igns symptoms? 1e0er 7fe! days 5 !ee@s8

(onuncti0itis 7red eyes8

+ash 7stomach, chest, genitals8


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Des=uamation

2tra!berry tongue

(happed lips

Byphadenopathy

Edema of hands and feet

2ystemic 0asculitis

Medical Management? Gamma globulin, Aspirin

1bd


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1bdomen

'ips Abdomen Exam

+ l ti d i t


253/288

+elaxation and =uiet ottle


254/288

'enderness and pain can be difficult todetect and locali:e Distract the child !ith a toy 2tart a!ay from the area suspected bser0e for changes as you mo0e to identify

the area of greatest pain (hange in pitch of crying +eection of the opportunity to suc@ Dra!ing the @nees to the abdomen 1acial expression (onstriction of pupils

#nspection

M t ith i ti


255/288

Mo0ement !ith respiration

2hape

(ontour

Pulsations

Pulsations? common in infants Distended 0eins dDx? 0ascular obstruction,

abdominal distension or abdominal obstruction 2pider ne0i dDx? li0er disease

#nfant

Abdomen should be rounded and dome

shaped


256/288

Distended abdomenK 1eces, mass, organ enlargement

2caphoid abdomenK Abdominal contents are displaced

Abdominal and chest mo0ements should be

synchronous

slight bulge of the abdomen at the beginning ofrespiration

'oddler Abdomen protrudes slightly

Cpot%bellied


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After age / Abdomen may become conca0e

!hen laying supine

+espirations continue to be abdominal until6%3 years of age

#n young children, restricted abdominalrespiration may be related to peritoneal irritation

Rmbilical stump


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Rmbilical stump should be dry and odorless

#nspect all s@in folds for? Discharge +edness #nduration

2@in !armth Granulomatous tissue

Granuloma


259/288

2erous or serosanguinous discharge

once the stump has separated

o other signs of infection

Rmbilicus is usually in0erted


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Rmbilicus is usually in0erted ften e0erts !ith increased abdominal

pressure

ote any protrusion through theumbilicus or rectus abdominus muscle -ernia Diastasis recti

Rmbilical -ernia

Protrusion of omentum and


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Protrusion of omentum andintestine through theumbilical opening

(ommon in infants +each maximum si:e by & month Generally close spontaneously by &%" years

'o determine si:e, measure the diameter of

the opening 7not the protruding contents8 2hould Creduce !ith light pressure

Diastasis +ecti

Midline separation 7& 9 cm8


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Midline separation 7&%9 cm8

of the rectus abdominus bet!een the xiphoid and umbilicus

o need to repair in most cases herniation through the rectus abdominus

does re=uire surgery

Rsually resol0es by 6 years of age

Peristaltic a0es


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Peristaltic a0es Rse tangential lighting bser0e abdomen at eye le0el

Rsually not 0isible 2ometimes seen in thin, malnourished

babies 2uggests intestinal obstruction

Auscultation

Peristalsis 7Cmetalic tin@ling8


264/288

Peristalsis 7 metalic tin@ling 8 -eard e0ery &$%5$ seconds

o!el sounds should be present &%"

hours after birth

o bruits or 0enous hum should be

detected

Bight Palpation

Wnees flexed


265/288

Wnees flexed Place your hand gently on the abdomen

'humb at the right upper =uadrant

#ndex finger at the left upper =uadrant Press 0ery gently at first, only gradually

increasing pressure

#dentify the spleen, li0er, and masses

close to the surface

2pleen


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2pleen Palpable &%" cm belo! the left costal margin

for the first fe! !ee@s after birth

A detectable spleen tip is common in !ellinfants but increase in spleen si:e mayindicate?

blood dyscrasias septicemia

Bi0er 7lo!er border8 Bi0er 2cratch test
http://medinfo.ufl.edu/other/opeta/abdo/AB_ch11.htmlhttp://medinfo.ufl.edu/other/opeta/abdo/AB_ch11.html


267/288

Bi0er 7lo!er border8 e!born? ust belo! the right costal margin

#nfants toddlers? &%5cm belo!

(hildren? &%"cm belo!

-epatomegaly? lo!er border I5 cm belo!

the right costal margin

#nfection (ardiac failure

Bi0er disease

Bi0er 2cratch test

Deep Palpation

Palpate all =uadrants for masses
http://medinfo.ufl.edu/other/opeta/abdo/AB_ch11.html


268/288

Palpate all =uadrants for masses Bocation

2i:e

2hape

'enderness

(onsistency

'ransillumination can be used to distinguishcystic from solid masses

1ixed masses should be in0estigated !ith


269/288

1ixed masses should be in0estigated !ithspecial studies if Baterally mobile Pulsatile

Palpate the aorta for signs of enlargement Bocated along 0ertebral column

#f any suspicion of neoplasm exists, limit

palpation of the mass May cause inury or spread of malignancyX

ephroblastoma 7ilms 'umor8

M( intraabdominal tumor of childhood


270/288

M( intraabdominal tumor of childhood7"%5 years of age8

Malignant

1irm, non%tender mass deep !ithin the flan@ nly slightly mo0eable

ot usually crossing the midlineF sometimes

bilateral

Possibly? Bo!%grade fe0er

-ypertension

euroblastoma

1re=uently appears as a mass in the


271/288

1re=uently appears as a mass in theadrenal medulla

Malignancy in early childhood

1irm, fixed, non%tender, irregular and nodularabdominal mass Malaise Boss of appetite eight loss

Protrusion of eye7s8 ther symptoms may occur !ith?

compression of the mass or metastasis to adacent organs

Percussion

May be more tympanic 70s adults8


272/288

May be more tympanic 70s. adults8 2!allo! air !hen feeding crying

'ympany !ith distended abdomenK Gas

Dullness !ith distended abdomenK

1luid, solid mass

Examine the ladder

Palpate and percuss o0er the


273/288

Palpate and percuss o0er thesuprapubic area

Determine si:e

DistentionK

+ebound 'enderness

bser0e childs facial expression and


274/288

bser0e child s facial expression andpupils

e cautious

)nce a child has e*perienced palpation

that is too intense, a subseuent e*aminer

has little chance for easy access to theabdomen

(ommon (onditions


275/288

(ommon (onditions

hat if you find K

2ausage%shaped mass in the left lo!er


276/288

2ausage shaped mass in the left lo!er=uadrant

1eces in the sigmoid colon

(onstipation

Midline, suprapubic mass

1eces in the rectosigmoid colon-irschsprung disease

-irschsprung Disease a@a(ongenital Aganglionic Megacolon

Absence of parasympathetic ganglion cells


277/288

Absence of parasympathetic ganglion cellsin a segment of the colon no peristalsis

e!born? May fail to pass meconium in the first "9%94 hrs

lder infants and young children? #ntestinal obstruction or se0ere constipation 1ailure to thri0e Abdominal distention Episodes of 0omiting and diarrhea

hat if you find K

2ausage%shaped mass in the left or


278/288

2ausage shaped mass in the left orright upper =uadrant

#ntussusception

#ntussusception

Prolapse of one segmentof intestine into another


279/288

Prolapse of one segmentof intestine into anotherresulting in intestinal obstruction

M( 5%&" months oldF cause is un@no!n

Acute intermittent abdominal pain Abdominal distention *omiting 2tools mixed !ith blood and mucus

+ed current elly appearance 2ausage%shaped mass in + or B upper =uadrant + lo!er =uadrant feels empty 7Dance sign8

#ntussusception CA(DE1

A bdominal or anal Csausage


280/288

A bdominal or anal sausage

lood from the rectum

( olic? babies dra! up their legs

D istention, dehydration, and shoc@

E mesis

1 ace pale

hat if you find K


281/288

li0e%shaped mass in the right upper

=uadrant 7deep palpation8 immediately

after the infant 0omitsPyloric stenosis

Pyloric 2tenosis

-ypertrophy of the circular


282/288

-ypertrophy of the circularmuscle of the pylorus orobstruction of the pyloric sphincter

+egurgitation ;I proectile 0omiting 1eeding eagerly 7e0en after 0omiting8 1ailure to gain !eight 2igns of dehydration

2mall, rounded mass palpable in the + upper=uadrant especially after the child 0omits

Gastroesophageal +eflux 7GE+8

+elaxation or incompetence of the lo!er


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+elaxation or incompetence of the lo!eresophagus persisting beyond the ne!born

period

+egurgitation and 0omiting

eight loss and failure to thri0e

+espiratory problems

aspiration leeding from esophagitis

iliary Atresia

(ongenital obstruction or absence of some


284/288

gor all of the bile duct system

Qaundice

ecomes apparent at "%5 !ee@s -epatomegaly

Abdominal distention

Poor !eight gain

Pruritis 2tools become lighter in color

Rrine dar@ens

Meconium #leus

'hic@ening and hardening of meconium in


285/288

g gthe lo!er intestine ;I intestinal obstruction

1ailure to pass meconium &st "9 hrs after birth

Abdominal distention

NMust consider cystic fibrosis

Mec@el Di0erticulum

utpouching of the ileum


286/288

p g M( congenital anomaly of

the G# tract *aries in si:e presentation

May be asymptomatic #ntestinal obstructionK Di0erticulitisK

right or dar@ red rectal bleeding

Bittle abdominal pain 2ymptoms li@e those of acute appendicitis

mphalocele

#ntestine present in the umbilical cord or


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pprotruding from the umbilical area *isible through a thic@ transparent membrane

ecroti:ing Enterocolitis

#nflammatory disease of the gastrointestinal


288/288

y gmucosa Associated !ith prematurity

#mmaturity of the G# tract

Abd i l di t ti

pediatric physical exam (c su07)

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