Children __ mo old and less are easily managed on an examing table while _ mo to _ years are usally better handled in moms lap
6 mo examining table
8mo to 3 yrs in moms lap
In a young child what exams do you perform first
Heart
Lungs
Abdomen
What exams do you perform last in a young child
throat and ears
If a portion of your exam is going to be painful or uncomfortable for the child do you tell them
yes! be warm honest and tell them that it is necesary
What are the 5 areas of which developemental milestones are assessed
Physical
Motor
Cognitive
Emotional
Social
On a quick head to toe exam of a child what do you vitals/general is important
HR 120-160
Resp 30-60
temp under 100.4
BP 70/50
Consider environmental risk factors
On a quick head to toe exam of a child what do you Head charactristics are important
Note shape lacs, bulges, bruising
Fontanelles
Size
Bulge
Enlarged more than 4cm hypothyroidism
Closed = craniosynostosis
On a quick head to toe exam of a child what do you ENT findings are important
Note patency
ear tags
cleft lip
suck reflex
bilateral red reflex
On a quick head to toe exam of a child what do you Neck things are important
Ensure no ducts, cysts bulges
Midline= thyroid disorder
Ant to SCM look for brachial cleft cysts
Posterior to SCM loof for cystic hygroma
Ensure no marks on the back of the head
On a quick head to toe exam of a child what do you Chest findings are important
Ensure no clavical fracture
Ensure breathing without distress
auscultate the heart and lungs
most congenital heart disorders present with systemic symptoms
murmures not heard initially
On a quick head to toe exam of a child what Abdominal findings are important too look for
Ensure soft and round
scaphoid = diaphragmatic hernia
ensure no masses
examine umbilical cord for anatomy
On a quick head to toe exam of a child what Hip findings are important too look for
Barlow: click when hip dislocates posteriorly
Ortalani: clunk when hip relocates posteriorly
These tests are specific but not sensitive and should be repeated at follow up visits
Lower extremity pulses
Elevated pulse pressrue = PDA
Decreased pulse pressure = coarctation of the aorta
In an infant/baby a decreased lower extremity pulse pressure indicates
coarctation of the aorta
In an infant/baby increased lower extremity pulse pressure indicates
PDA
On a quick head to toe exam of a child what GU findings are important too look for
Note testes are decended bilaterally
Ensure no hernia, hydrocele, hypospadias etc
Ensure anus patent, no tracts
On a quick head to toe exam of a child what Extremities findings are important too look for
count digits
check cap refil
check for deformity or asymetry
On a quick head to toe exam of a child what Back findings are important to look for
Ensure spine symmetry
Note lumbosacral hair tuft (spina bifida)
Note gluteal pit in fold
On a quick head to toe exam of a child what Skin findings are important to look for
Identify bruising, marks
Jaundice
Notice vernix caseosa
Lanugo in preterm
On a quick head to toe exam of a child what Neuro findings are important to look for
General tone
Reflexes: suck, rooting (gone by 2mo), Fencer (gone by 4 mo), Moro (gone by 4 mo), Grasp (gone by 4 mo)
The first year of life is...
B. Infancy
The neonatal period is when?
the first 28 days the post neonatal period is 29 days to 1 year
When is a newborn most responsive to a physical exam
1-2 hours after feeding b/c they are not too hungary or full
If you are having trouble gettin a newborn to open their eyes what can you do
dim the lights
After birth the Apgar score is assessed at __ and __ mins
1 and 5
What does the Apgar score include? what is its max and min score?
Scoring is based on 0-2 for each category
Total scores range form 0-10
Heart rate: absent 0, less than 100= 1, >100 = 2
Respiratory effort: absent = 0, slow and irregular = 1, good =2
Muscle tone: Flaccid =0, some flesion of arms and legs = 1, active movement = 2
Reflex irritability: no responses = 0, Grimace = 1, crying vigorously sneeze or cough= 2
Color: Blue or pale = 0, pink body blue extremities = 1, pink all over 2
8-10 at one min is normal
5-7 at one min is some nervous sytem depression
0-4 at one min is severe depression immediate rescesutation
8-10 at 5 mins is normal
0-7 at 5 mins is high risk for subsequent central nervous sytem and other organ system dysfunction
If the apgar score is more than __ at 5 mins then proceed to a full exam
8
What are the 5 components of apgar
Heart rate
Respiration
Color
Reflex/irritability
movement/muscle tone
A preterm baby is a baby less than __ wks
37
A term baby is a baby __-__ wks
37-42
A post term baby is a baby less than __ wks
42
Wt under 1,000gms is
D. extremely low birthweight
Wt under 1,500gms is
A. Very low birth weight
Wt under 2,500gms is
D. Normal birth weight
B. Low birth weight
Wt above or equal to 2,500gms is
C. Normal birth weight
Preterm AGA infants are prone to what conditions
RDS
Apnea
PDA
infection
Preterm SGA infants are prone to what conditions
asphyxia
hypoglycemia
hypocalcemia
Full term babies lie in what position
symmetric position with limbs semiflexed and legs partially abducted
Breech babies lie in what position
legs and head are extended
Frank breech babies lie in what postion
legs are abducted and externally rotated
In the first several hours after birth on your assessment of a child you note asymmetric movmetn of the arms and or legs what does this tell you?
CNS of PCS deficits birth injuries or congenital anomalies it means you FURTHER INVESTIGATE
T or F a new born should have a flexed tight fist with slow athetoid posturing movements
True (I just think jay will like the word athetoid)
Athetosis is a symptom characterized by involuntary convoluted, writhing movements of the fingers, arms, legs, and neck. If found in older children it is a sign of CP
T or F tremor during vigorous crying and from 4 days after birth throught the rest of infancy is normal
False, tremor is normal after vigorous crying, but is not normal after 4 days post birth. At this time a tremor indicates CNS disease
What is the formula for a childs systolic BP? what is the formual for normal diastolic BP?
SBP= 80 + age X2
DBP = 2/3 SBP
What children should be in rear facing car seats
less than 20 lbs or less than 12 mo
What children should be in front facing car seats?
children 20-40 lbs and 1-4 y.o
what children should be in a booster seat
4-8 y.o. and 40-80 lbs
Is it recommended for infants to sleep supine or prone
supine
cooing occurs at __ months, babbling occurs at ___ mo and 1-3 words at ___ mo
Cooing = 2mo
Babbling = 6mo
1-3 words = 12 mo
Interest in either the red sox, Bruins or Celtics occurs around the first 1-3 words in children born in Boston
What are the 4 areas of assessment in the Denver Developmental Screening Tool
Personal-social
Fine motor adaptive
Language
Gross motor
A DDQ score of > 85 is __
normal
a DDQ score of 70-85 is __
possibly delayed and needs to be followed
a DDQ score of less than 70 is __
delayed
T or F it is normal to have a 10% loss of body weight during the 1st week of life, but they should be expected to gain it back by 2 wks
True
a Baby's size doubles by _mo and triples by _ months
4 and 12
What are two signs that a child is falling off the growth curve and action should be taken
an infant less than 5% with no obvious cause
Infant that crosses two percentile lines or major channels consecutively without cause
deviations greater thant __ standard deviations from normal for their age are reason for futher evaluation
2
What are the parameters for "failure to thrive"
Growth less than 5th percentile for age
Growth drop >2 quartiles in first 6 mo
Weight for height below the 5th percentile
how many years from birth should you continue to measure head circumference
2
Small head with premature closure of sutures is a condition know as
microcephaly
A head circumference above teh 97th percentile or 2 STD above the mean is
macrocephaly
What are some causes for sustained hypertension in an infant?
Coarctation of the aorta
Congenital renal malformation
renal artery disease
pulse of __ to __ in an infant is SVT
180-200bpm
Fever can raise a infants respiration rate __ breaths for every degree centigrade
10
Rapid shallow RR in newborns is a sign of what pathology
cyanotic cardiac disease
Tetrology of Fallot and TGV right to left shunting and metabolic acidosis
Tachypnea for birht -2 mo is ___ and tachypnea for 2-12mo is ___
>60 breaths /min
>50 breaths /min
> __ degrees F is a fever for an infant and this is of greatest concern in a child less than 2-3 mo
100
__ is a fine downy hair growth covering a newborn especially on the shoulders and the back prominent in premature infants
Lanugo
___ is a lattice like bluish mottled appearanc on the trunk arms and legs that may last for months after birth
Cutis marmorata
____ is a blue cast to the hands and fee then exposed to cold very common in early infancy and the first few days of life. if it does not resolve within 8 hrs of warming you should be concerned for ____ check oral and mucosa of toung for signs of central cyanosis
Acrocyanosis
Cyanotic congenital heart disease
___ is a transient cyanosis of one half of the body or one extremity that occasionally occurs in newborns
Harlequin Dyschromia
___ is a cheesy white material covering the infant at birth. it is composed of sebum and dequamated epithelial cells
Vernix caseosa
_____ is scattered vesicles on an erythematous base usually on the face and trunk. results from obstruction of sweat glands/ducts. Disappears spontaneously after a few weeks
Miliaria rubra
___ may appear similar to HSV or S. aureus infection. Appears on 2-3 days of life. Erythematous macules/papules with central pinpoint vessicles on an erythematous base over the entire body. Microscopic evaluation reveals eosinophils. Appear similar to flea bites and dissapear within 1wk of birth
Erythema toxicum
May appear similar to HSV or S. aureus infection. Common in black infants. Small vesicopustules over a brown macular base taht are present at birth and located on the head, neck, back and extremities. Resolve in 24-48 hrs. Pigmented macules resolve in 1-3 moths. Microscopic examination of contents reveals neutrophils but lesions are sterile
Pustular melanosis
___ are Pinhead, smooth white raised areas without surrounding erythema on the nose, chin and forehead. Result from retention of sebum in the openings of sebaceous glands. Usually appear within the first few weeks and disappear over several weeks
milia
What is a midline nevus flammeus, AKA an eyelid patch, AKA a salmon patch, AKA a stork bite, AKA angel kisses
A birthmark on the upper eyelid (eyelid patch) that fades in one year
Flat irregular light pink patches that can also be seen on the nape of the neck (stork bite) or forehead or upper lip (angel kisses)
Fades with age
Not true nevi they result from distended capillaries.
Diasappear in 1 yr
___ is a light brown pigmented lesion. It usually has boarders that are uniform. it is noted in more than 10% of black infants. If more than 5 of these are present then it is concerning for neruofibromatosus
Cafe au lait spots
__ are common dark bluish spots in dark skinned infants
mongolian spots
___ is a bluish purple or deep magenta lesion. that can be large or small
Port wine stain
A port wine stain found in the V1 branch of the trigeminal nerve could indicate what
sturge weber syndrome
Physiologic jaundice occurs in half of all newborns is appears on the _ or __ day and peaks on the __ day and usually disappears within a __ it is best noted in the natural sunlight and can be autmented by stretching the skin taught
2nd or third day
5th day
dissapears in a week
Significant edema is noted in teh hands and feet of newborn girls with __ syndrome
Turners
Where is the meotopic suture located
it is the suture that comes down the front of the forehead and makes up the center spindle of the peace sign that the anterior fontanel makes
the posterior fontanelle sloses by __ months
2
a __ can cause a loud cranial bruit in an infant
AV fistula
___ is an asymmetric head swelling that crosses the suture lines over the occipitoparietal region. Caused by capillary distention and extravasation of blood and fluid from vacuume assisted birth. Disappears in 1-2 days
Caput secundum
found in premature infants. The head is long in the ocipito frontal diameter but narrow in the bitemporal diameter. The skull usually normalizes in 2 days
Dolichocephaly
asymmetry of the cranial vault caused by caused by mostly lying on one side usually shows flattenign of the parieto-occipital region on the dependent side and a prominent of the frontal region on the oposite side evens out as teh baby becomes more active. Back sleeping has increased the prevalence of plagiocephaly
Plagiocephaly
Dandy walker malformation
Dandy–Walker syndrome (DWS), or Dandy–Walker complex, is a congenital brain malformation involving the cerebellum
and the fluid filled spaces around it. A key feature of this syndrome
is the partial or even complete absence of the part of the brain located
between the two cerebellar hemispheres (cerebellar vermis).[1] The Dandy–Walker complex is a genetically sporadic disorder that occurs one in every 25,000 live births, mostly in females.[2]
What is a blue dot sign
The appearance of a small dark blue spot on transillumination in
patients with torsion of the testicular appendage or epididymis,
accompanied by intense pain at or near the head of the epididymis or
testis, and an isolated tender palpable nodule
premature closure of of cranial sutures leaves a raised bony ridge at the suture line and an abnormally shaped skull
craniosynostosis
spongy springy feeling of cranial bones. Can be caused by increased intracranial pressure, metabolic disturbances and infections
Craniotabes
hydrocephalus
also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, tunnel vision, and mental disability. Hydrocephalus can also cause death.
__ is a shortened chin caused by the head flexed on the sternum in utero
Micrognathia
Upslanting of the palpebral fissures indicates
Down Syndrome
Down Slanting of the palpebral fissures indicates
Noonan's syndrome
Short palpebral fissures indicates
Fetal alcohol Syndrome
Epicanthic fold
If a newborn cannot open their eyes what does it suggest
congenital ptosis, occulomotor palsy or mechanical issue
Dolls eyes reflex
Seen during the first 10 days of life. The eyes remain fixed in one direction if the head is turned without the body.
Colobamas
Key shaped iris
may be seen with naked eye in babies
Brushfield's spots
ring of white spots on the iris.
Strongly suggests Down syndrome
What are the visual milestones
Birth: blinks and may reguard face
1 month; fixes on objects
1.5-2 months: coordinated eye movements
3 months: eyes converge baby reaches
12 months: acutity around 20/50
Small deformed or low set ears suggests congenital defects especially ___ disease
renal (weird right?)
T or F the TM is not visible for the first few days of life on otoscopic exam
true
Acoustic Blink Reflex
blinking of the pts eyes in response to sudden sharp sound. snap your fingers or use a bell or beeper from about 1 ft away. Hard to produce wthin the first few days of life after repeated testing in a short period of time b/c habituation occurs
Give some milestones/Signs of a hearing child at..
0-2 mo
2-3 mo
3-4mo
6-7mo
0-2 mo: startle response and blink to sudden nosie, calming down with soothing music or voice
2-3 mo: change in body movement s in response to music. change in facial expression to familiar sounds
3-4mo: turing eyes and head to sound
6-7mo: turing to listen ot voices and conversation
___ is a congenital disorder where the back of the nasal passage is blocked, usually by abnormal bony or soft tissue formed during fetal development
Choanal atresia
At birth the ___ are the only sinuses developed
ethmoid sinuses
When does pneumatization of the frontal sinus take place? when do the first sinus infections occur
2-4 pneumatization of frontal
6-10 y.o. sinus infection
sphenioid sinus present at birth but does not become significant until 5th to 8th year
Enanthem
are medical terms for a rash (small spots) on the mucous membranes.[1] These are characteristic of patients with smallpox, measles, and chicken pox.
Bohn's Nodule
are smooth whitish bumps or cysts which are sometimes found in the mouths of newborns. They are found at the junction of the hard and soft palate, and along lingual and buccal parts of the dental ridges, away from the midline. These nodules are 1-3 mm in size, and filled with keratin.
The nodes are a result of cystic degeneration of epithelial rests of
the dental lamina (rests of Serres). They are benign, and usually
disappear within the first three months of life. Bohn's nodules are
similar in appearance to Epstein's pearls, which develop on the roof of the mouth.
Epsteins pearls
white or yellow rounded mucosal retention cysts seen on the alveolar ridge and posterior midline of the hard palate. They disappear within 1-2 months
Prominent toung in a newborn could mean
congenital hypothyroidism
Downs syndrome
Shrill high pitched cry of a newborn means
high intracranial pressure and in infants born to narcotic addicted moms
Hoarse cry in an infant means
hypocalcemic tetany or
congenital hypothyroidism
Continout inspiratory and expeiratory stridor in an infant
upper airway obstruction, small larynx, delay of development of the cartilage in the tracheal rings
Absense of cry in a newborn
severe illness
vocal cord paralysis
profound brain damage
Tooth eruption what isthe rule of thumb
1 tooth for every month of age between 6 and 26 mo
small dimplings or openings anterior to the midportion of the SCM + or minus a sinus tract
Brachial cleft cysts
Periaruicular cysts and sinuses
common pinhole size pits uusally anterior to the helix often bilateral with or without hearing defects
cyst just above the thyroid. small firm mobile mass that moves upward with tounge protrusion detected after 2 yrs
thyroglossal duct cysts
"wry neck" from bleeding into the SCM from stretching at birth. A firm mass is felt within 2-3 wks after birth and diasappears after months
Congenital torticolis
Pectus excavatum
funnel chest
pectus carinatum
pigeon chest
Apnea in a newborn greater than 20 seconds and accompanied by bradycardia is concering for
SIDS
Thoracoabdominal paradox
inward movement of the chest and outward movement of the abdomen during breathing. normal in newborns. Concern for muscle weakness in older children
Rasberry red toung in a an infant suggests
oxygen desaturation
An infant presents with tachypnea, tachycardia, and hepatomegaly with no increased work of breathing what do you suspect
CHF
abnormally weak pulses in the lower extremities or the femoral arteries in children is
coarctation of the aorta
full pulses in the dorsalis pedis and posterior tibial pulses are
PDA OR
truncus arteriosus
when the breast tissue developse in the first 6-24 months in the absense of other pubertal signs it is called
premature thelarche
The umbilcal cord should have what vessels
3 vessels
2 deoxy arteries
and 1 large oxygenated vein
Diastasis recti
separateion of the two rectus muscles. resolves in early childhood
an Olive type mass on palpation of the RUQ with peristaltic wave and projectile vomiting suggest
pyloric stenosis
Newborn stool is this color ___ but progresses to ___ over a few days
black and tarry and progresses to tan peachy honey colored
This tests for prescence of a posteriorly dislocated hip
"clunk"
Infant is supine. Flex the knees at the place where the index finger ov the greater trochanters then abduct the hip simultanously until the legs touch the table
Ortilani
ability to dislocate an intact but unstable hip (what is the test)
Barlow
how do you perform a Barlow test
flex the knees and place the index finger over the greater trochanters press down and attempt to put your thumbs to the table
Galeazzi test
flexed the knees and place feet up on the table and look for varying knee height
Tibial torsion corrects itself during the second year of life it is pathologic only in associated with foot deformities
__ clubfoot is due to uterine molding. able to reduce to nl on postion exam and may follow or treat with serial casting if severe
Extrinsic (supple)
___ clubfoot is idiopathic and causes resulting in abnormal bone structures not able to be reduced on exam serial casting and may need surgery
Intrinsic or rigid
Metatarsus adductus
adduction of the forefoot withotu inverions
What is state regulation?
ability to modulate the level of arousal in response ti different degrees of stimulation
