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? Pediatric Physical Exam

الكلية كلية التمريض     القسم قسم التخصصات التمريضية     المرحلة 3
أستاذ المادة عبد المهدي عبد الرضا حسن الشحماني       03/11/2017 08:38:02


? Pediatric Physical Exam
? Adapted from Mosby’s Guide to Physical Examination, 6th Ed.
? Age Descriptors
Newborn birth to 2 months
Infant 0-1 year
Toddler 1-2 years
Child 2+ years
? Vitals
? Pulse
? Respiration
? Blood pressure
? Temp
? Height
? Weight
? Pulse
? Apical pulse
? 5th intercostal space in the midclavicular line
? Femoral pulse
? use a point halfway from the pubic tubercle to ASIS as a guide
? Pulse
? Respiration
Infants – rise and fall of the abdomen facilitates counting
? Rate, regularity and rhythm
? Depth
? Respiratory Effort
? Retraction (ribs, supraclavicular notch)
? Contraction of SCM’s
? Flaring of nostrils
? Paradoxic breathing
? Respiration
? Blood Pressure
? Cuff size (children)
? Width should cover ~2/3 of the upper arm or thigh
Too wide - underestimate BP
Too narrow - artificially high BP
? Temperature
? Tympanic thermometers are becoming increasingly popular
? Accuracy depends on correct technique
? Must read tympanic membrane
? Shares blood supply with hypothalamus
? Temperature – Young Infants
? Traditional routes may be more accurate
Newborns: axillary temp correlates well with core temp due to the infant’s small body mass and uniform skin blood flow
? Height – Infant
? Birth to 24-36 months
? Infant measuring mat OR
mark on a sheet of headrest paper
? Measure from the top of the head to the heel (foot dorsiflexed)
1. Tear a length of headrest paper
2. Lay the child on top of the paper
3. Mark the top of the child’s head
4. Ask mother to hold child in place
5. Extend leg and mark under the heel
(foot dorsiflexed)
? Height - Child
? Child is able to stand without support (24-36 months old)
? “Stature measuring device”
? Heels, buttocks and shoulders against the wall
? Looking straight ahead
? Outer canthus of the eye should line up with the external auditory canal
? Weight
? Infant platform scale
? More accurate
(ounces or grams)
? Infant may sit or lie
? Place paper or blank under the infant & “weigh it out”
? Head Circumference
? Done at every “health visit” until 2 years of age; yearly from 2-6 years of age
? Measure the largest circumference with the tape snug
? Occipital protuberance to the supraorbital prominence
? Chest Circumference
? Measure around the nipple line to the nearest 1/8 in (0.5 cm)
? Firmly but not tight enough to cause an indentation in the skin
? Recording Measurements
? Chart on appropriate growth curve for sex and age
? Identify the infant’s percentile
? Note any change or variation from the population standard or the child’s norm
? At Birth…
Average weight: 5 lb 8 oz – 8 lb 13oz
Average length: 18-22 in (45-55cm)
Head circumference: 13-14 in (33-35 cm)

Most babies born to the same parents weigh within 6oz of each other at birth
? Lower birth weight: consider an undisclosed congenital abnormality or intrauterine growth retardation
? Expected Growth
? Length increases by 50%in the 1st year of life
? Weight doubles by 6 months, triples by 1 year
? Head & Chest Circumference
? Newborn to 5 months: Head may be equal or exceed the chest by 2 cm
? 5 months to 2 years: Chest should closely approximate the head circumference
? > 2 years: Chest should exceed head circumference
? Growth Patterns
? Infancy
? Growth of the trunk predominates
? Fat increases until 9 months of age…
? Childhood
? Legs are the fastest growing body part
? Weight is gained at a steady rate
? Fat increases slowly until 7 yrs of age when a prepubertal fat spurt occurs before the true growth spurt
? Adolescence
? Trunk and legs elongate
? About 50% of the ideal weight is gained
? Skeletal mass and organ systems double in size
? Gender Differences
? Common Conditions

What might you detect by recording height, weight, head & chest circumference?
? Failure to Thrive
? Failure of an infant to grow at “normal rates”
? May be related to:
? Chronic disease
? Congenital disorder (brain, heart, kidney)
? Inadequate calories and protein
? Improper feeding methods
? Intrauterine growth retardation
? Emotional deprivation
? growth hormone levels will be low
? What if…?
? Head circumference increases rapidly or rises above percentile curves
? Increased intracranial pressure
dDX: Hydrocephalus, etc.
? Head circumference grows slowly or falls off percentile curves
? Microcephaly
dDx: Craniosynostosis, etc.
? Congenital Syndromes…
? Down Syndrome & Turner Syndrome
? associated with short stature
? Skin
? Newborn – Expected Variants
? Transient puffiness of the hands, feet, eyelids, legs, pubis or sacrum occurs in some newborns
Not a concern if it disappears within 2-3 days
? Some newborns are bald while others are born with an inordinate amount of head hair
Sheds within 2-3 months and replaced by more permanent hair (new texture and color)
? Dark-skinned newborns do not always manifest the intensity of melanosis that will be readily evident in 2-3 months
Exceptions: nail beds and skin of the scrotum
? Skin may look very red the first few days of life
Skin color is partly determined by subcutaneous fat
? 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 if acrocyanosis is persistent or more intense in the feet than hands
? Vernix caseosa
? Whitish, moist, cheeselike substance
? Mixture of sebum and skin cells
? Covers the infant’s body at birth
? Protective
? Lanugo
? Fine, silky hair covering the newborn
? shoulders and back
? Shed within 10-14 days
? Telangiectatic nevi
aka “stork bites”
? Flat, deep pink, localized areas usually seen in back of neck
? Mongolian spots
? Irregular areas of deep blue pigmentation usually in sacral and gluteal regions
*Seen predominantly in African, Native American, Asian or Latin descent
? Erythema toxicum
? Pink papular rash with vesicles superimposed
? thorax, back, buttocks, and abdomen
? May appear 24-48 hrs after birth and resolves after several days
? Common Conditions
? Milia
? Common during the first 2-3 months
? Small white discrete papules on the face and bridge of the nose
? Plugged sebaceous glands
? Miliaria
? Rashes
? Allergic rash
? Contact dermatitis
? Medications, supplements
? Food sensitivity
? Diaper rash
? Acid urine output
? Yeast?
? Eczematous rash
Younger children
? Face, elbow, knees
Older children & adults
? Hands, neck, inner elbows, back of knees, ankles
? Face (less often)
? Seborrheic Dermatitis
aka “Cradle Cap”
? scalp Lesions are scaling, adherent, thick, yellow, and crusted
? can spread over the ear and down the nape of the neck
*Can be also be seen on back, intertriginous & diaper areas
? Impetigo
“Honey colored crusts”
? Highly contagious Staph. or Strep. infection
? Causes pruritis, burning, and regional lymphadenpathy
? Ring worm
? Tinea corporis
? Tinea capitis
MC vector?
? Strawberry hemangioma
Expected resolution:
Birth: often not present or noticeable
1-2 months: becomes noticeable
1-6 months: grows most rapidly
12-18 months: begins to shrink
? Trichotillomania
May be related to:
? Excessive emotional stress
? Family circumstances, hospitalization, etc.
? Obsessive Compulsive Disorder
? External Clues to Internal Problems
? Faun tail nevus
? Tuft of hair overlying the spinal column usually in the lumbosacral area
? Associated with spina bifida occulta
? Café au lait spots
? Evenly pigmented patches
? light, dark brown, or black in dark skin
? Present at birth or shortly thereafter
May be related to:
? Neurofibromatosis
? Pulmonary stenosis
? Temporal lobe dysrhythmia
? Tuberous sclerosis
? Axillary Freckling or
Inguinal Freckling
? May occur in conjunction with café au lait spots
? Associated with neurofibromatosis
? Facial port-wine stain
When it involves the opthalmic division of the trigeminal nerve it may be associated with:
? Sturge-Weber syndrome
? seizures
? Occular defects
? Supernumerary nipples
Especially in the presence of other minor abnormalities…
? associated with renal abnormalities
? Examining the Newborn for Hyperbilirubinemia
*Natural daylight is preferred
? Examine the oral mucosa and sclera
? Inspect the whole body for “dermal icterus”
? Starts on the face and descends
? Bilirubin level is not high if only the face (5mg/dl)
? May be at a worrisome level if jaundice descends below the nipples (>12 mg/dl)
? Risk Factors
? Breast feeding
? b-glucuronidase
? Cephalhematoma or other cutaneous or subcutaneous bleeds
? Hemolytic disease
? Infection
? Physiologic Jaundice
? Present in 50% of newborns
? appears to be an inability of the liver to conjugate the bilirubin present in the blood
? Starts after the first day of life
? Usually disappears in 8-10 days
? May persist for 3-4 weeks
Treatment
? “Bili lamp” & “Bili Blanket” (blue lights), or direct sunlight (conjugate the bilirubin)
? Seldom rises above the 20mg/dl necessitating transfusion
? Pathological Jaundice
If jaundice is present in the first 24 hours or it is intense and/or persistent, you must consider pathological jaundice…
? RBC abnormalities & sensitivity
? Hemorrhage
? Impaired hepatic function
? Infections
? Toxoplasmosis
? Rubella
? Herpes
? Syphilis
? 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
? Schamroth Technique
? Place nail surfaces of corresponding fingers together
? Normal: diamond shaped window
? Clubbed: angle between distal tips increases
? Clubbing of the Nails
? Associated with:
? Respiratory disease
? Cardiovascular disease
? Thyroid disease
? Cirrhosis
? Colitis
? Skin Turgor
? Best evaluated by gently pinching a fold of the abdominal skin
“Tenting” indicates:
? Dehydration
? Malnutrition
? Immune and Lymphatic
? Immune & Lymphatic System
? Lymph nodes in the neonate react quickly to any mild stimulus
? especially cervical and postauricular chains
Theory: compensate for lack of antibodies by increased filtration and phagocytosis
? Ability to produce antibodies is still immature at birth but lymphoid tissue is plentiful
? Palatine Tonsils
? Much larger during early childhood than after puberty
? Enlargement of the tonsils in children is not necessarily an indication of a problem
? may obstruct nasopharynx ~> sleep apnea
? Obstructive Sleep Apnea
? Periodic cessation of breathing during sleep d/t airflow obstruction
? Can be seen in children with excessively large tonsils
? Loud snoring, restless sleep
? Daytime sleepiness
? Morning headaches
? Lymph Exam
It is not uncommon to find enlarge lymph nodes that may even be visible from a distance…
“Normal”
? Firm, discrete, moveable, <5mm
? Up to 1cm in cervical or inguinal regions
Investigate further if:
? Growing rapidly or suspiciously large (>2-3 cm)
? Fixed and immoveable
? Expected Regions of
Lymph Node Enlargement
? Common Conditions
? 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
? 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
? McIsaac Modification of the Centor Strep Score
Likelihood:
-1/0 = 1%; 1 = 10%; 2 = 17%; 3 = 35%; 4/5 = 51%
? Head and Neck
? Inspect the Head
? Scaling, crusting (seborheic dermatitis)
? Dilated veins (increased ICP)
? Excessive hair or unusual hairline
? Note symmetry of shape, bulging or swelling…
Cranial Molding
? During a vaginal birth the cranial bones shift and overlap
? Expect the skull to resume a “normal” shape and size within 1 week
? Unusual contour may be related to a variety of causes:
? Irregular closing of suture lines (craniosynostosis)
? Positional head deformity (PHD)
? Preterm infants: soft cranial bones flatten with the positioning and weight of the head
? Inspect the Face
? Spacing of features
? Symmetry
? Skin color
? Texture
? Paralysis
? Observe…
? Head control?
? Position?
? Movement?
? Note any:
? Jerking
? Tremors
? Inability to move head in one direction
? Palpate the Head
? Note any tenderness over the scalp
? Suture lines
? slight groove up to 6 months
? Fontanels
? should feel slightly depressed; some pulsation is expected
Post. fontanel closes ~2 months
Ant. fontanel closes by 24 months
Bulging?
? Infection
? Increased intracranial pressure
Depressed?
? Dehydration
Measure the Fontanels
? Anterior fontanel should
not exceed 4-5 cm
(<6 months)
? 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
? A ring <2 cm is expected on all regions of the head except the occiput (should be <1 cm)
? Illumination beyond these parameters suggest…
? Excess fluid
? Decreased brain tissue in the skull
Transillumination should be done on every infant and on an older child if there is a suspected intracranial lesion or rapidly increasing head circumference
? Inspect the Neck
? Symmetry, size, shape
? Edema
? Distended veins
? Pulsations
? Masses
? Webbing
? Excess skin
To inspect the newborn’s neck…
? Place the infant supine
? Elevate the upper back and let the head fall back into extension
? Palpate the Neck
? Sternocleidomastoid
? Note tone; hematoma
? Trachea
? Thyroid
? Difficult to palpate unless it’s enlarged
Goiter
? Intrauterine deprivation of thyroid hormone
? May cause respiratory distress
? Common Conditions
? Torticollis (“Wry Neck”)
? Birth injury
? Hematoma
? May be palpated shortly after birth
? Firm fibrous mass 2-3 weeks later
? Older children
? Result of trauma, muscle spasm, viral infection, drug ingestion, __________
? Management
First, consider the underlying cause
? Spinal cord tumor or congenital spinal anomoly?
? Birth trauma? Subluxation?
? Chiropractic care
? Mechanical adjustments
? Increased “tummy time”
? Exercises/stretches
? Plagiocephaly
Positional
? Parallelogram
? Frontal bulging
? Ear migrates anterior
Synostosis (lambdoid)
? Trapezoid
? No frontal bulging
? Ears even
? Craniosynostosis
? Premature union of cranial sutures
? Small head circumference (microcephaly)
? Rigid sutures
? Misshapen skull
? Usually not accompanied by mental retardation
? Microcephaly
Related to:
? Craniostenosis
? Cerebral dysgenesis
? Associated with mental retardation and failure of brain to develop normally
? Hydrocephalus
? Enlarged head
? Bossing of the skull
? Widening of sutures and fontanels
? Lethargy, irritability, weakness
? Sclera visible above the iris
? “Sunsetting sign”
? 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
? Bell’s palsy (facial palsy)
Asymmetry of facial features
? Eyelid will not
close completely
? Drooping corner of
mouth
? Loss of labonasial fold
? Down Syndrome
? Depressed nasal bridge
? Epicanthal folds
? Mongolian slant of eyes
? Low set ears
? Large tongue
? Fetal Alcohol Syndrome (FAS)
? Smooth philtrum
? Widespread eyes
? Inner epicanthal folds
? Mild ptosis
? Hirsute forhead
? Short nose
? Thin upper lip
? Eyes
? Development Table 11-1(Mosby)
By 2-3 months…
? Voluntary control of eye muscles
By 8 months…
? Can differentiate colors
By 9 months…
? Eye muscles coordinate; a single image is percieved
? Tips – Infant Eye Exam
? To encourage the infant to open their eyes…
? Use a dimly lit room
? Hold the infant upright, suspended under its arms facing you
? Have parent hold infant over a shoulder
? Inspect External Eye
? Size of eyes (symmetry?)
? Distance between the eyes
? Hypertelorism (widely spaced eyes)
? may be associated with mental retardation
? Slant of palpebral fissures
? Epicanthal folds
? Prominent in Asian populations, Down syndrome?
? Inspect Eyelids
To detect the “Setting Sun Sign”…
? Rapidly lower the infant from upright to supine position
? Look for sclera above the iris
Differentials include:
? Expected variant in newborn
? Hydrocephalus
? Brainstem lesion
? Clinical Note
Newborn…
? eyelids may be swollen or edematous, accompanied by conjunctival inflammation and drainage as a consequence of routinely administered antibiotics
Beyond the newborn period…
? redness, hemorrhage, discharge, granular appearance may indicate infection, allergy, or trauma
? Inspect
? Sclera
? Pupil
? Iris
? Conjunctiva
Coloboma
aka “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
? Strabismus?
Exoptropic vs. Esotropic
Tests include:
? Corneal light reflex (Hirschberg’s Test)
? Cross-Cover Test
? Cover-Uncover Test
? Corneal Light Reflex
aka Hirschberg’s Test
? Child stares at a penlight about 30 cm away
? Doctor looks at the reflection from each cornea
? In relationship to the pupil
Normal: symmetrical
Strabismus: asymmetrical
Pseudostrabismus
? Symmetrical corneal light reflex
? Common in Asian and Native American populations (prominent epicanthal folds)
? Disappears by 1 yoa
Strabismus (esotropic)
? Asymmetrical light reflex
? Cross-Cover Test
? Patient stares at penlight
? Doctor covers one eye and observes the uncovered eye for movement
Normal: no movement
Exotropic eye: moves lateral to medial
Esotropic eye: moves medial to lateral
? Cover-Uncover Test
? Patient stares at the penlight
? Doctor covers one eye and then observes as it is uncovered
Normal: no movement (remains fixed on the light)
Exotropic eye: moves lateral
Esotropic eye: moves medial
? Help to differentiate…
Paralytic Strabismus
? Impairment of extraocular muscles or their nerve supply
Nonparalytic Strabismus
? No primary muscle weakness
? Can focus with either eye but not both simultaneously… concern of developing amblyopia
? Infant Cranial Nerves (II, III, IV, VI)
1. Expect the infant to focus and track through 60 degrees
2. 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)
? 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
? Visual Acuity
Infant
? Grossly examined by observing the the infant’s preference for looking at certain objects
Younger Children
? Observe play with toys - stacking, building, or placing objects inside of others
? If tasks are performed well, vision difficulties are unlikely
? Snellen E Chart*
? Tested when a child can cooperate with the exam
? Usually ~3 years of age
? Ask which way the “legs” are pointing
*Also available with different shapes
? Tips – Snellen E Chart
1. Make it a “game”
2. Instruct the child to point finger in the direction of the legs of the E
3. Allow the child to practice following instructions before you administer the test
4. Parent may assist with covering eye
? Snellen E Chart
Remember:
? Test each eye seperately
? With and without corrective lenses
20/25 +2
Means that they can read all on the 20/25 line and 2 from the 20/20 line
“When testing visual acuity in the child, any difference in the scores between the eyes should be detected.”
? A 2 line difference (20/50 and 20/30) may indicate amblyopia
? Reduced vision in an eye that appears structurally normal
? In strabismus, the eye may be “unused”
? Anticipated Visual Activity
? Red Reflex
*Performed from birth on… should be elicited in every newborn!
? Observe for opacities, dark spots, or white spots within the circle of red glow
? Congenital cataracts
? Retinoblastoma
? Congenital Cataracts
? Requires a full metabolic, infectious, systemic, and genetic workup…
Common causes:
? Infectious diseases
? TOxoplasmosis, Rubella (MC), Cytomegalovirus, & Herpes
? Hypoglycemia
? Trisomies
? Prematurity
? Etc.
? Retinoblastoma
Congenital malignant tumor
<2 years old
Initial sign:
? “white” reflex
Fundoscopic exam:
? Ill-defined mass arising from the retina
? Chalky-white areas of calcification
? Fundoscopic Examination
Difficult to perform on a newborn or young infant…consider referral
? Often deferred until 2-6 months unless the patient presentation suggests a need
Eg. premature infant (retinopathy)
? Retinopathy of Prematurity
? Blood vessels are straightened and diverted temporally
? Cicatricial changes may be severe
? Retinal detachment
? Glaucoma
? Blindness
? Tips – Fundoscopic Exam
? Do not hold the child’s eyelid open forcibly
? Leads only to more resistance
? Often unable to keep eyes still and focused on a distant object
? Use a toy, picture, etc.
? Results may be better if the child sits on the parent’s lap
? May want to do the exam with the patient supine…
? Fundoscopic Exam – Supine
? Child laying supine on the exam table with head near the end
? Stand at the end of the table
? Use Rt. eye to examine the child’s Lt.
NOTE:
? Retinal findings will appear “upside down”
? Inspect the optic disc, fovea, and vessels as they pass by
? Newborn – 3 months
? 6 months – 1 year
? ~3 years old
? ~5 years old
? Modifying Your Instruments
? Oto/ophthalmoscope
? Decorative covers
http://quickmedical.com/ pediapals/products
? Ears
? Developmental Features
? External auditory canal – shorter, has an upward curve
? infant otoscopic exam – “pull downward”
? Eustachian tube – relatively wider, shorter and more horizontal
? Reflux of nasopharyngeal secretions
? Growth of adenoids may occlude the eustachian tube
? Interferes with aeration of the middle ear
? Inspect the Ear
? Well formed
? all landmarks present
? Flexible
? should have instant recoil after bending
? Position
? the tip of the auricle should cross an imaginary line between the outer canthus of the eye and the prominent portion of the occiput (EOP)
? No skin tags or preauricular pits should be present
? Clinical Note
? Low or poorly shaped auricles… associated with renal disorders and congenital abnormalities
? Palpate
? Lymph nodes
? Pinna
? Tragus
? Mastoid
? Tenderness?
? Warmth?
*If pain is noted with palpation of the mastoid, suspect mastoiditis…
? Otoscopic Exam – Infant
1. Lay the infant supine/prone
2. Turn head to the side
3. Hold otoscope so that the ulnar surface of your hand rests against the infant’s head
*Prevent trauma to auditory canal
1. Other hand stabilizes infant’s head
2. Pull auricle down to straighten the canal
? Newborn Variants
You may note…
? Limited mobility
? Dullness and opacity of a pink or red tympanic membrane
? Light reflex may appear diffuse
? Tympanic membrane is not conical for several months
? Auditory canal may be obstructed with vernix
*Otoscopic exam should be performed within the first few weeks of life
? Otoscopic Exam – Child
? Pull auricle either down and back OR up and back
? best view of the tympanic membrane
? Postpone until the end of the visit
? Best done on parent’s lap
? Be prepared to use restraint if encouraging the child fails
? Ask the parent to restrain the child
? Restraining a Child - Otoscope
? Face the child sideways with one arm placed around parent’s waist
? Parent holds the child firmly against his/her trunk
? One arm restrains the head
? One arm restrains the body
? Doctor further stabilizes the child’s head while inserting the otoscope
? Clinical Note
“Red reflex”
? If the child is crying or has recently cried vigorously… dilation of blood vessels in the tympanic membrane can cause redness

You cannot assume that redness of the membrane alone is a middle ear infection!
? Pneumatic Otoscopy
? Assesses mobility of the tympanic membrane
? needed to differentiate
? Tympanometry
? Accurate way to identify middle ear effusion
? Ear piece must be sealed in the canal to provide accurate reading
? Wax, ruptured membrane, tubes
Acoustic Reflectometry (newer technology)
? Cheaper
? Easier to get accurate results
? Assessing Hearing
? Observe response to a whispered voice, toys, etc.
? As they get older, ask child to perform tasks in a soft voice…
? Use words that have meaning for them
? May want to have a parent do it
? Make sure they’re not responding to air movement or visual stimulus
Weber, Rinne, and Schwabach tests
? Used only when a child understands directions and can cooperate with the examiner
? Usually 3-4 years of age
? Expected Hearing Response
? Common Conditions
? 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
? 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
? Otitis Media with Effusion
? Collection of liquid (effusion) in the middle ear
Associated with:
? Allergies
? Enlarged lymph tissue
? Obstructed or dysfunctional eustachian tube
? Otitis Media with Effusion
? Sticking or cracking sound on yawning or swallowing; no signs of acute infection
? Pain is uncommon; feeling of fullness
? Discharge is uncommon
? Conductive hearing loss as middle ear fills with fluid
? If chronic, may delay speech development temporarily
? Tympanic membrane is retracted, impaired mobility, yellowish; air fluid level and/or bubbles
? Nose
? Development
? Maxillary and ethmoid sinuses
? present at birth, though very small
? Sphenoid sinus
? tiny cavity at birth
? not fully developed until puberty
? Frontal sinus
? develops by 7-8 years
? Inspection
? Symmetric appearance
? Positioned in the vertical midline on the face
? Only minimal movement of the nares with breathing should be apparent
Possible congenital abnormality if…
? Saddle-shaped nose with a low bridge and broad base
? Short small nose
? Large nose
? “Adenoidal” or “Allergic Salute”
? Transverse crease at the juncture between the cartilage and the bone of the nose
? Children often wipe their noses with an upward sweep of the palm of the hand
? If repeated often enough, causes a crease
? Internal Nose
? Usually adequate to tilt the nose tip upward
? Inspect by shining a light inside
? Largest otoscopic speculum may be used
Clinical note: some say that a “greyish” membrane may indicate chronic allergies
? Nasal Patency
Must be determined at the time of birth…
? Mouth closed, occlude one naris and then the other
? Observe the respiratory pattern
? With total obstruction, the infant will not be able to inspire or expire through the noncompressed naris
dDx: Septal deviation, choanal atresia
? Choanal Atresia
? Congenital nasal obstruction of the posterior nares
? Junction between nasal cavity and nasopharynx
? Newborns may experience respiratory distress and difficulty feeding
? Obligatory nose breathers
? Sinuses
Infant
? Maxillary and ethmod sinuses are small
? Few problems arise in these areas and examination is generally unnecessary
Child
? Maxilary sinuses should be palpated
? Few sinus problems occur since the sinuses are still developing
There is wide variation however... do not rule out sinusitis simply on the basis of age!
? Sinusitis
? Infection of one or more paranasal sinuses
? May be a complication of a viral URTI, dental infection, allergies, or a structural defect of the nose
Signs in children include:
? upper respiratory symptoms
? nasal discharge
? low-grade fever
? daytime cough
? malodorous breath
? cervical adenopathy
? intermittent painless morning eye swelling
? NO facial pain or headache
? Mouth & Throat
? 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
? Inspection
? Tongue
? should fit well in the floor of the mouth
? protrude beyond the alveolar ridge
? Frenulum
? usually attaches midway between the ventral surface of the tongue and its tip
Macroglossia
(abnormally large tongue)
? Congenital hypothyroidism
? Congenital abnormalities
? Down Syndrome
Short Frenulum
? Feeding problems
? Speech difficulties
? Gums
? smooth; serrated edge along the buccal margins
? Teeth
? count deciduous teeth
? note any unusual sequence of eruption
Natal Teeth
? Teeth or tooth buds in a newborn
? Potential for aspiration
? May be removed
Retention Cysts
(aka Epstein Pearls)
? Appear along the buccal margins of the gums
? Pearl-like retention cysts
? Disappear in 1-2 months
Baby bottle syndrome
? Multiple brown caries on upper and lower incisors
d/t bedtime bottle of juice/milk
Black or grey colored teeth
? Pulp decay
d/t oral iron therapy
Mottled or pitted teeth
? Enamel dysplasia
d/t tetracycline treatment during tooth development
Flattened edges on the teeth
? Bruxism – unconscious grinding of the teeth
? Buccal mucosa
? Should be pink and moist, no lesions
? Scrape any white patches with a tongue blade

Nonadherent = milk deposits
Adherent = candidiasis (thrush)
? Palate
? Should be well-formed with no cleft
Infant
? 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
? Cleft Lip and Palate
? Congenital malformation
? Fissure in the upper lip and/or palate
? Complete cleft – extends through the lip and hard and soft palates to the nasal cavity
? Partial Cleft – any of the tissues
Long term issues:
? feeding problems
? speech difficulties
? improper tooth development and alignment
? chronic otitis media
? hearing loss
Tonsils
? Should blend with the color of the pharynx
? Peak size between 2 - 6 years
? Should retain unobstructed passage
Graded to describe their size
1+ visible
2+ halfway between tonsillar pillars and the uvula
3+ nearly touching the uvula
4+ touching each other
? 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
? Peritonsillar Abscess
? Infection of the tissue between the tonsil and pharynx
? Complication of tonsillitis
? Dyphagia, drooling, severe sore throat with pain radiating to the ear, muffled voice, fever
? Tonsil, tonsillar pillar and adjacent soft palate become red and swollen
? Tonsil may appear pushed forward or backward, possibly displacing the uvula
? Drooling
? Normal in infancy
If it persists past 12 months…
? consider a neurologic disorder
If acute…
? consider epiglotitis
? Epiglottitis
Suspected with…
? Sudden high fever
? Drooling
? Croupy cough
? Sore throat
? Apprehension & focus on breathing
? Tripod position, neck extended
*Impending airway obstruction d/t acute inflammation of the epiglottis
? Inserting tongue blade may result in complete airway obstruction
? Treat this as a medical emergency
? Tips – Infant Mouth Exam
? Crying provides an opportunity to examine the mouth
? Avoid depressing the tongue
? Stimulates the “Tongue Thrust Reflex”
? Makes visualization of the mouth difficult
? Insert your gloved finger into the infant’s mouth, fingerpad to the roof of the mouth
? Evaluate the infant’s suck
? Should have a strong suck, tongue pushing vigorously upward against the finger
? Palpate the hard and soft palates
? Palatal arch should be dome shaped
? No palpable clefts
? Soft palate should rise symmetrically when the infant cries
? Stimulate a gag reflex by touching the tonsillar pillars
? Tips – Child Mouth Exam
? To reduce fear, let the child hold and manipulate the tongue blade and light
? Start by asking to see their teeth
? Usually not threatening
? Ask the child to protrude the tongue and say “ah”, a tongue blade is often unnecessary
? To raise the palate, ask the child to pant “like a puppy”
? If child refuses to open mouth…
? Insert a tongue blade through the lips to the back molars
? Gently but firmly insert the tongue blade between the back molars and press the blade to the tongue
? This should stimulate the gag reflex
? Gives you a brief view of the mouth and oropharynx
“Children of any age who are not too big to sit on a parent’s lap are better examined there than on the examining table.”
? Restraining a Child – Oral Exam
? Seated in the parent’s lap, back to the parent and legs between the adult’s legs
? Parent can reach around to restrain the child’s arms with one arm and control the child’s head with the other
? Can usually be accomplished without forcing
? Force only makes them more angry…
? Restraining a Child - Supine
If the child actively resists…
? Place child supine on the exam table
? Parent holds arms extended above the head and assists in restraining the head
? Doctor lies across the child’s trunk and stabilizes the child’s head
? Third person may need to hold the child’s legs
? Chest and Lungs
? Newborn Apgar Score
? Subjective qualitative evaluation
? done at 1 and 5 minutes
? determine “survivability” of the newborn by observing the level of function of 5 components
? Muscle tone
? Heart rate
? Reflex irritability
? Color
? Respiratory rate
? Apgar Score

? Depressed Respiration
? Maternal environment during labor
? Sedatives
? Compromised blood supply to the child
? Mechanical obstruction by mucus
? Neurological damage (birth trauma)?
? Infants rely primarily on the diaphragm for respiratory effort (C3,4,5…)
? Development
? Bony structure is more prominent than the adult d/t a relatively thin chest wall
? More cartilaginous and yielding
? How will this affect the adjustment?
? Xiphoid process is often more prominent and a bit more moveable
? Inspection
? Chest is generally round
? A-P diameter approximately the same as the transverse
If the “roundness” of a child’s chest persists past the 2nd year, suspect a possible chronic obstructive pulmonary problem…
? Cystic Fibrosis
? Autosomal recessive disorder of exocrine glands
? Sweat glands
? Salt loss in sweat (“taste salty”)
? Lungs
? Frequent and progressive pulmonary infections (thick mucus)
? Pancreas
? Sticky, foul smelling stool
Intrauterine growth retardation
? Smaller chest circumference compared to the head
Poorly controlled diabetes
? Relatively larger chest circumference
? Nipples
? Symmetry in size
? Swelling
? Discharge
? Supernumerary
? Measure distance between the nipples
? Should be ¼ chest circumference
? 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
? Respiratory Rhythm
? Note regularity of respiration
? Premature infants are more likely to have irregular respiratory patterns
Periodic breathing
? sequence of relatively vigorous respiratory efforts followed by apnea of as long as 10-15 seconds
? Periodic Breathing
Cause for concern if …
? Apneic episodes tend to be prolonged
? Baby becomes centrally cyanotic
? In the term infant periodic breathing should wane a few hours after birth
? Persistence in preterm infants is relative to gestational age
? Apneic periods should diminish in frequency as they approach term status
? Observe Chest Expansion
? If asymmetric, suspect inability to fill one of the lungs
? Pneumothorax
? Presence of air/gas in the pleural cavity
? Diaphragmatic hernia
? mayl hear “clicks & gurgles”
? 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
? Auscultation – Infant
? Localization of breath sounds is difficult
? Breath sounds are easily transmitted from one segment to another
*Difficult to detect absence of breath sounds in any given area
? Auscultation – Child
? May not be able to give enough of an expiration to satisfy you (<5 years old)
? Especially with subtle wheezing
? Ask them to “blow out” your penlight
? Ask them to blow away a bit of tissue in your hand
? Listen after they run up and down the hallway
? Chest wall is thinner and more resonant than adult’s
? Breath sounds may sound louder, harsher, and more bronchial
? Hyperresonance is common
? Easy to miss the dullness of underlying consolidation (percussion)
“If you sense some loss of resonance, give it as much importance as you would give frank dullness in the adult.”
? Tips – Lung Exam
? Percussion is usually unreliable in the infant
? Examiner’s fingers may be too large
? A sob is frequently followed by a deep breath
? Allows the evaluation of vocal resonance
? Feel for tactile fremitus
? Whole hand, palm and fingers
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 increase oxygen levels
? If persistent, cause for concern
Stridor
? High pitched, piercing sound
? Cannot be dismissed as inconsequential… especially when inspiration is longer than expiration
? Floppy epiglottis
? Congenital defects
? Croup
? Edematous response
? Infection
? Allergen
? Smoke
? Chemicals
? Aspirated foreign body
? Increased Respiratory Effort
? Retraction at the supraclavicular notch
? Contraction of the SCM’s
? Flaring of the nostrils
? Obvious intercostal exertion (retractions)
? Tachypnea
? Does a loss of synchrony between L and R occur during the respiratory effort? Is there a lag in movement of the chest on one side? Atelectasis? Diaphragmatic hernia?
? Is there stridor? Croup? Epiglottitis?
? Is there retraction at the suprasternal notch, intercostally, or at the xiphoid process?
? Do the nares dilate and flare with respiratory effort? Is pneumonia present?
? Is there an audible expiratory grunt? Is it audible with the stethoscope only or without? Is there lower airway obstruction? Focal atelectasis?
? Is there paradoxic breathing?
? Common Conditions
? Tracheomalacia
? Floppiness of the trachea
? Trachea changes in response to varying pressures of inspiration and expiration resulting in “noisy breathing”
? Wheezing, inspiratory stridor
*Generally benign and self-limiting with age
dDx: vascular lesion, tracheal stenosis, foreign body
Also: Laryngomalacia & Laryngotracheomalacia
? Bronchiolitis
? Viral
? RSV (respiratory syncytial virus)
? Most common <6 months
Expiration becomes difficult due to hyperinflation of lungs
Exam findings:
? Increased A-P diameter of thoracic cage
? Hyperresonant percussion
? Coughing
? Comes in “fits” and tends to be harsh
? Tachypnea
? Rapid, short breaths; expiratory phase prolonged
? Possible wheezing and crackles
? Infant appears anxious
? Generalized retraction
? Perioral cyanosis
? Influenza
? Generalized febrile illness (viral)
? Mild cases may just seem like a cold BUT the very young are at higher risk
? Respiratory tract may be over-whelmed (interstitial inflammation and necrosis)
? Cough
? Fever
? Malaise
? Headache
? Coryza
? Mild sore throat
? Crackles
? Rhonchi
? Tachypnea
? Substernal pain
? Pneumonia
? Inflammatory response of the bronchioles and alveolar space to an infective agent
? Bacterial, fungal , or viral
? Exudates lead to lung consolidation
? Dyspnea, tachypnea, and crackles
? Diminished breath sounds; dullness to percussion
? Bronchitis
? Inflammation of the mucus membranes of the bronchial tubes
Acute bronchitis
? Fever and chest pain
Chronic bronchitis
? Variety of causes
? Excessive secretion of mucus
? Asthma
? COPD characterized by airway inflammation
? mucosal edema
? increased secretions
? bronchoconstriction
Hyperreactivity to allergens, anxiety, URTI, smoke, exercise, cold air, etc.
? Croup
? Viral
? Particularly parainfluenza viruses
? Most commonly:
? Very young children (1 ½ to 3 years old)
? Boys > girls
? Some are prone to recurrent episodes
dDx: epiglottitis, aspirated foreign body
? Often begins in the evening after the child has gone to sleep
? Awakens suddenly, frightened
? Harsh stridorous cough
? “Bark of a seal”
? Labored breathing
? Retraction
? Inspiratory stridor
? NOT always fever
? Epiglottitis
? Haemophilus influenzae type B
? Incidence appears to have reduced…
? MC: 3-7 years old
? Acute, life-threatening
? Begins suddenly and progresses rapidly to full obstruction of the airway
Treat this as a medical emergency
Inserting tongue blade may be deadly!
? Child sits straight up with neck extended, head held forward
? Appears very anxious and ill
? Unable to swallow
? Drooling from the open mouth
? Cough is NOT common
? Heart
? Fetal Circulation
? Compensates for the non-functional fetal lung
? Blood passes directly from the R to L atrium through the foramen ovale
? Right ventricle pumps blood through the ductus arteriosus
? At birth... functional closure of foramen ovale and the ductus arteriosus closes within 24-48 hours
? Patent Ductus Arteriosus
? Blood flows through the ductus during systole and diastole
? Increases pressure in the pulmonary circulation
? Increased workload for the right ventricle
Small shunt: may be asymptomatic
Large shunt: may have dyspnea on exertion
“Machinery murmer”
? Harsh, loud, continuous murmur
? 1st - 3rd intercostal spaces & lower sternal border
? Usually unaltered by postural changes
? Patent Foramen Ovale
? Allows blood to flow between the right and left atria
? Usually asymptomatic
? May exhibit cyanosis with exertion (especially if other congenital heart defects are present)
? Heart Exam
? Examine within the first 24 hours and again at 2-3 days of age
? Changes from fetal to systemic and pulmonary circulation
? Complete evaluation of heart function includes skin, lungs, & liver…
? Congestive heart failure in the infant may present with a large, firm liver (hepatomegaly)
? Unlike adults, this finding may be noted before pulmonary crackles
? Inspection
? Color: should be “pink”
Purplish?
dDx: polycythemia
Ashy, white?
dDx: shock
Central cyanosis?
dDx: congenital heart disease
Distribution & intensity of discoloration.
Extent of change after exertion.
? Severe cyanosis evident at birth or shortly after suggests:
? Transposition of the great vessels
? Tetralogy of Fallot (blue)
? Tricuspid atresia
? relies on ASD & VSD for oxygenation of blood
? Severe septal defect
? Severe pulmonic stenosis
? Cyanosis that does not appear until after the neonatal period suggests:
? Pure pulmonic stenosis
? Eisenmenger complex - only develops in some cases
? right-to-left shunting (VSD is MC) combined with pulmonary hypertension
? Tetralogy of Fallot (pink)
? Septal defects
Bulging?
? Precordium tends to bulge over an enlarged heart if the enlargement is long-standing
? Thoracic cage is more cartilaginous and yielding in children
? 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
? Apical Impulse
? 4th - 5th left intercostal space, medial to the midclavicular line
? Apex of the heart is higher, heart lies more horizontal

*Adult heart position is reached by age 7
? 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
? Dextrocardia & Sinus Invertus
? Dextrocardia
? Right thoracic heart & normally placed stomach and liver
? May be associated with other anomolies
? Sinus Invertus
? Heart and stomach are on the right, liver on the left
? Not very common
? Pulses
? Brachial, radial, and femoral pulses are palpable
Weak or thin pulse dDx:
? Decreased cardiac output
? Peripheral vasoconstriction
Bounding pulse dDx:
? L to R shunt; PDA (patent ductus arteriosus)
Difference in pulse amplitude between femoral and radial pulses dDx:
? Coarctation of the Aorta
? Heart Rate
? Heart rate is more variable
? Infants: eating, sleeping, and waking
? Children: exercise, tension, fever
? h HR 10-20 beats for each degree temp. h
Sinus arrhythmia is common in children
? Rate varies in a cyclical pattern
? Faster on inspiration
? Slower on expiration
Fixed tachycardia may indicate difficulty
? Heart Rate
? 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
A murmur is usually NOT a significant congenital anomaly. Paradoxically, a significant congenital anomaly may be unaccompanied by a murmur…
? Must investigate if…
? persists beyond 2nd or 3rd day of life
? is intense
? fills systole
? occupies diastole to any extent
? almost always significant
? radiates widely
? Venous hum
Caused by turbulence of blood flow in the internal jugular vein
? Continuous low-pitched sound
? Louder during diastole
? Common in children
? Usually has no pathologic significance
Ask child to sit with head turned away & tilted slightly upward
? Auscultate supraclavicular space
? Blood Pressure
? Flush Technique (Infant)
? Place cuff on upper arm (or leg)
? Elevate and wrap the arm firmly with an elastic bandage from fingers to antecubital space
? Empty veins and capillaries
? Inflate cuff to a pressure above the systolic reading you expect
? Lower the arm and remove the bandage
? Arm will be pale
? Diminish pressure gradually until you see a sudden “flush” and return to usual color
? Blood Pressure
? Blood pressure is measured the same as in the adult after 2 years
? To facilitate the exam…
? Explain the process
? Let them explore the sphygmomanometer
? Make sure to use the correct cuff size!
? Cover 2/3 of arm
? Hypertension – Infant
? A sustained increase in BP is almost always significant in the newborn
? Stenosis of renal artery
? Coarctation of the aorta
? Cystic disease of the kidney
? Neuroblastoma
? Wilms tumor
? Hydronephrosis
? Adrenal hyperplasia
? CNS disease
? Hypertension – Child
? Do not make the diagnosis of hypertension based on one reading
? An elevated systolic but normal diastolic may be d/t transient anxiety
Significant 90th percentile
Severe 95th percentile
*If consistently above the 95th percentile, dDx include:
? Kidney disease
? Renal arterial disease
? Coarctation of the aorta
? If there’s known heart disease…
Take careful note of:
? Weight gain (or loss)
? Developmental delay
? Cyanosis
? Congenital heart defects that impede oxygenation
? Clubbing
? fingers and toes
? Congenital Defects
? Ventricular Septal Defect
? Allows oxygenated blood to leak from the left ventricle into the right
? Smaller defects may heal on their own; may be asymptomatic
? Larger defects may require surgery
? Heart failure
? Pulmonary hypertension
? Endocarditis
? Arrhythmias
? Delayed growth
*Murmur tends to be holosystolic
? Atrial Septal Defect
? Allows oxygenated blood to leak from the left atrium into the right
? Minor cases may be asymptomatic
? Larger defects may require surgery
*May not sound particularly impressive
(especially in an overweight child)
? More apt to be significant if…
? Palpable thrust
? Radiation through to the back
? Coarctation of the Aorta
? Narrowing in a portion of the aorta
? MC: descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum
? Can cause several life-threatening complications
? Severe hypertension
? Aortic aneurysm, dissection or rupture
? Endocarditis
? Brain hemorrhage
? Stroke
? Heart failure and premature coronary artery disease
*Repair is typically recommended before age 10
? Compare radial and femoral pulses
? Normal: peak at the same time (or femoral slightly earlier)
? Coarctation: delay and/or decreased amplitude of the femoral pulse (noted bilaterally)
? Compare blood pressure in arms and legs
? Normal: BP legs = arms, or BP legs > arms
? Coarctation: BP arms > legs
? Systolic murmur
? Audible over the precordium and sometimes the back
? Tetralogy of Fallot
1. VSD
2. Pulmonary valve stenosis
3. Overriding aorta
4. Right ventricular hypertrophy
? Cyanosis: lips, fingers and toes
? Poor eating
? Inability to tolerate exercise
? Arrhythmias
? Delayed growth and development
*Surgical repair of the defects is required early in life
Infants may have…
? “Tet spells”, central cyanosis
? Paroxysmal dyspnea with loss of consciousness
As they get older…
? Clubbing of fingers and toes
Exam findings:
? Parasternal heave
? Precordial prominence
? Systolic ejection murmur heard over the 3rd intercostal space
? Sometimes radiating to the left side of the neck
? Common Conditions
? Acute Rheumatic Fever
? Complication of strep. pharangitis (or skin infection) ~> connective tissue disease
? May result in serious cardiac valve involvement
? MC mitral or aortic valves
? MC children between 5-15 years of age
? Prevention is the best therapy
? i.e. adequate treatment for strep. infections
? Recent strep infection
? Fever
? Migratory polyarthritis
? Erythema marginatum
? Pink margins, pale centers
? Chorea (jerky body movements)
? Firm, painless subcutaneous nodules
? Elbows, knees, wrists
? Murmur
? Mitral regurgitation; aortic insufficiency
? Friction rub (pericarditis)
? Congestive heart failure
? Cardiomegaly
Jone’s Criteria – Diagnosis of Rheumatic Fever
? 2 major manifestations or 1 major + 2 minor manifestations
? High probability of acute rheumatic fever
*If there’s evidence of a preceding strep infection
? Kawasaki Disease
? Acute illness (fever)
? Etiology unknown
? Infectious? Carpet cleaners?
? MC children under 5; males > females
? Can be self-limiting, recover in a few days
? Complications: vasculitis ~> aneurysms
? Critical concern: cardiac involvement (vasculitis of the coronary artery)
Signs & symptoms:
? Fever (few days – 3 weeks)
? Conjunctivitis (red eyes)
? Rash (stomach, chest, genitals)
? Desquamation
? Strawberry tongue
? Chapped lips
? Lyphadenopathy
? Edema of hands and feet
? Systemic vasculitis
Medical Management:
? Gamma globulin, Aspirin
? Abdomen
? 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
? Ticklish?
? Firm touch
? Place the child’s hand under your palm leaving your fingers free to palpate
? Tenderness and pain can be difficult to detect and localize
? Distract the child with a toy
? Start away from the area suspected
? Observe for changes… as you move to identify the area of greatest pain
? Change in pitch of crying
? Rejection of the opportunity to suck
? Drawing the knees to the abdomen
? Facial expression
? Constriction of pupils
? 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
Infant…
? Abdomen should be rounded and dome shaped
Distended abdomen?
? Feces, mass, organ enlargement
Scaphoid abdomen?
? Abdominal contents are displaced
? Abdominal and chest movements should be synchronous
? slight bulge of the abdomen at the beginning of respiration
Toddler
? Abdomen protrudes slightly
“pot-bellied”
After age 5…
? Abdomen may become concave when laying supine
? Respirations continue to be abdominal until 6-7 years of age
? In young children, restricted abdominal respiration may be related to peritoneal irritation
Umbilical stump
? should be dry and odorless
Inspect all skin folds for:
? Discharge
? Redness
? Induration
? Skin warmth
? Granulomatous tissue
? Granuloma
? Serous or serosanguinous discharge once the stump has separated
? No other signs of infection
? Umbilicus is usually inverted
? Often everts with increased abdominal pressure
? Note any protrusion through the umbilicus or rectus abdominus muscle
? Hernia
? Diastasis recti
? Umbilical Hernia
? Protrusion of omentum and intestine through the umbilical opening
? Common in infants
? Reach maximum size by 1 month
? Generally close spontaneously by 1-2 years
? To determine size, measure the diameter of the opening (not the protruding contents)
? Should “reduce” with light pressure
? Diastasis Recti
? Midline separation (1-4 cm) of the rectus abdominus
? between the xiphoid and umbilicus
? No need to repair in most cases
? herniation through the rectus abdominus does require surgery
? Usually resolves by 6 years of age
Peristaltic Waves
? Use tangential lighting
? Observe abdomen at eye level
Usually not visible
? Sometimes seen in thin, malnourished babies
? Suggests intestinal obstruction
? Auscultation
? Peristalsis (“metalic tinkling”)
? Heard every 10-30 seconds
? Bowel sounds should be present 1-2 hours after birth
? No bruits or venous hum should be detected
? Light Palpation
? Knees flexed
? Place your hand gently on the abdomen
? Thumb at the right upper quadrant
? Index finger at the left upper quadrant
? Press very gently at first, only gradually increasing pressure
? Identify the spleen, liver, and masses close to the surface
Spleen
? Palpable 1-2 cm below the left costal margin for the first few weeks after birth
? A detectable spleen tip is common in well infants but increase in spleen size may indicate:
? blood dyscrasias
? septicemia
Liver (lower border)
? Newborn: just below the right costal margin
? Infants & toddlers: 1-3cm below
? Children: 1-2cm below
Hepatomegaly: lower border >3 cm below the right costal margin
? Infection
? Cardiac failure
? Liver disease
? Deep Palpation
? Palpate all quadrants for masses
? Location
? Size
? Shape
? Tenderness
? Consistency
Transillumination can be used to distinguish cystic from solid masses…
? Fixed masses should be investigated with special studies if…
? Laterally mobile
? Pulsatile
? Palpate the aorta for signs of enlargement
? Located along vertebral column
If any suspicion of neoplasm exists, limit palpation of the mass
? May cause injury or spread of malignancy!
? 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
? Neuroblastoma
? Frequently appears as a mass in the adrenal medulla
? Malignancy in early childhood
? Firm, fixed, non-tender, irregular and nodular abdominal mass
? Malaise
? Loss of appetite
? Weight loss
? Protrusion of eye(s)
? Other symptoms may occur with:
? compression of the mass or
? metastasis to adjacent organs
? Percussion
? May be more tympanic (vs. adults)
? Swallow air when feeding & crying
Tympany with distended abdomen?
? Gas
Dullness with distended abdomen?
? Fluid, solid mass
? Examine the Bladder
? Palpate and percuss over the suprapubic area
? Determine size
? Distention?
? Rebound Tenderness
? Observe child’s facial expression and pupils
? Be cautious…
Once a child has experienced palpation that is too intense, a subsequent examiner has little chance for easy access to the abdomen
? Common Conditions
? What if you find… ?
? Sausage-shaped mass in the left lower quadrant
…Feces in the sigmoid colon
…Constipation
? Midline, suprapubic mass
…Feces in the rectosigmoid colon
…Hirschsprung disease
? Hirschsprung Disease aka
Congenital Aganglionic Megacolon
? Absence of parasympathetic ganglion cells in a segment of the colon… no peristalsis
Newborn:
? May fail to pass meconium in the first 24-48 hrs
Older infants and young children:
? Intestinal obstruction or severe constipation
? Failure to thrive
? Abdominal distention
? Episodes of vomiting and diarrhea
? What if you find… ?
? Sausage-shaped mass in the left or right upper quadrant
…Intussusception
? Intussusception
? Prolapse of one segment of intestine into another resulting in intestinal obstruction
? MC 3-12 months old; cause is unknown
? Acute intermittent abdominal pain
? Abdominal distention
? Vomiting
? Stools mixed with blood and mucus
? Red current jelly appearance
? Sausage-shaped mass in R or L upper quadrant
? R lower quadrant feels empty (Dance sign)
? Intussusception – “ABCDEF”
A bdominal or anal “sausage”
B lood from the rectum
C olic: babies draw up their legs
D istention, dehydration, and shock
E mesis
F ace pale
? What if you find… ?
? Olive-shaped mass in the right upper quadrant (deep palpation) immediately after the infant vomits
…Pyloric stenosis
? Pyloric Stenosis
? Hypertrophy of the circular muscle of the pylorus or obstruction of the pyloric sphincter
? Regurgitation ~> projectile vomiting
? Feeding eagerly (even after vomiting)
? Failure to gain weight
? Signs of dehydration
? Small, rounded mass palpable in the R upper quadrant
? especially after the child vomits
? Gastroesophageal Reflux (GER)
? Relaxation or incompetence of the lower esophagus persisting beyond the newborn period
? Regurgitation and vomiting
? Weight loss and failure to thrive
? Respiratory problems
? aspiration
? Bleeding from esophagitis
? Biliary Atresia
? Congenital obstruction or absence of some or all of the bile duct system
? Jaundice
? Becomes apparent at 2-3 weeks
? Hepatomegaly
? Abdominal distention
? Poor weight gain
? Pruritis
? Stools become lighter in color
? Urine darkens
? Meconium Ileus
? Thickening and hardening of meconium in the lower intestine ~> intestinal obstruction
? Failure to pass meconium
? 1st 24 hrs after birth
? Abdominal distention
*Must consider cystic fibrosis
? Meckel Diverticulum
? Outpouching of the ileum
? MC congenital anomaly of the GI tract
? Varies in size & presentation
? May be asymptomatic
? Intestinal obstruction? Diverticulitis?
? Bright or dark red rectal bleeding
? Little abdominal pain
? Symptoms like those of acute appendicitis
? Omphalocele
? Intestine present in the umbilical cord or protruding from the umbilical area
? Visible through a thick transparent membrane
? Necrotizing Enterocolitis
? Inflammatory disease of the gastrointestinal mucosa
? Associated with prematurity
? Immaturity of the GI tract
? Abdominal distention
? Occult blood in stool
? Respiratory distress
? Often fatal: perforation and septicemia


المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .