2 - Examination and Practical Procedures Flashcards

1
Q

When is a newborn examination carried out?

A
  • In first 72 hours
  • Secondly at 6-8 weeks old
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2
Q

What is the purpose of the Newborn Infant Physical Examination (NIPE) ?

A
  • Screen for congenital abnormalities that will benefit from early intervention
  • To make referrals for further tests or treatment as appropriate
  • To provide reassurance to the parents
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3
Q

Where should you do a newborn examination?

A
  • Private area which provides confidentiality for parents
  • The room should be warm and well lit naturally
  • Make sure that the parents are present for the newborn check as this is an ideal time to answer queries and provide reassurance
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4
Q

What oxygen saturations do you need to measure in the newborn and why?

A
  • Pre-ductal and post-ductal (based on position of ductus arteriosus)
  • Normal saturations are 96% or above. There should not be more than a 2% difference between the pre-ductal and post-ductal saturations
  • Certain congenital heart conditions are duct-dependent, meaning they rely on the mixing of blood across the ductus arteriosus. When the ductus arteriosus closes there can be a rapid deterioration in symptoms. These duct-dependent conditions may be picked up by measuring the difference in pre-ductal and post-ductal saturations
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5
Q

How do you measure pre and post ductal oxygen saturations?

A
  • Pre-ductal saturations: baby’s right hand. The right hand receives blood from the right subclavian artery, a branch of the brachiocephalic artery, which branches from the aorta before the ductus arteriosus
  • Post-ductal saturations: in either foot. The feet receive blood traveling from the descending aorta, which occurs after the ductus arteriosus
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6
Q

What are the general points you need to cover in a newborn baby exam?

A
  • General appearance
  • Head
  • Shoulders and Arms
  • Chest
  • Abdomen
  • Genitals
  • Legs
  • Back
  • Reflexes
  • Any skin markings
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7
Q

What are we looking at in general appearance of baby in the newborn exam?

A
  • Colour: jaundice, pallor, cyanosis
  • Posture
  • Tone
  • Cry
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8
Q

What are we looking at when looking at the head of a baby in the newborn exam?

A
  • Size: Head cirumference
  • Shape
  • Fontanelle: posterior and anterior palpation for dehydration and raised ICP
  • Ears: skin tags, low set ears and asymmetry. Suggest hearing screening
  • Eyes: slight squints are normal, epicanthic folds can indicate Down’s, purulent discharge could indicate infection
  • Red reflex: Absent with congenital cataracts and retinoblastoma.
  • Mouth: cleft lip or tongue tie. Put little finger in mouth to check palate and suckle reflex
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9
Q

What is the definition of the following head abnormalities you may find in a newborn?

  • Caput succedaneum
  • Cephalhaematoma
  • Subgaleal haemorrhages
  • Craniosynostosis
A
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10
Q

How can you tell the difference between caput succedaneum and cephalohematoma?

A
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11
Q

What are we looking at when looking at the shoulders and arms of a baby in the newborn exam?

A
  • Neck lumps
  • Shoulder symmetry: check for a clavicle fracture
  • Arm movements: check for an Erbs palsy
  • Brachial pulses
  • Radial pulses
  • Palmar creases: a single palmar crease is associated with Down’s, but can be normal
  • Digits: number of digits and if fingers are straight or curved (clinodactyly)
  • Sats probe on the right wrist for a pre-ductal reading
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12
Q

What are we looking at when looking at the chest of a baby in the newborn exam?

A
  • Respiratory rate: look for respiration distress, symmetry and listen for stridor
  • Heart sounds: listen for murmurs, heart sounds, heart rate and identify which side the heart is on. Work upwards
  • Breath sounds: listen for symmetry, good air entry and added sounds
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13
Q

What is normal heart rate and respiratory rate in a newborn?

A

RR: 40-60

HR: 120-150

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14
Q

What are some signs of respiratory distress in a newborn?

A
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15
Q

What are we looking at when looking at the abdomen of a baby in the newborn exam?

A
  • Inspect: umbilicus, groin for hernias, distension
  • Palpate: liver, spleen, kidneys, bladder
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16
Q

What are we looking at when looking at the genitals of a baby in the newborn exam?

A
  • Check sex and record any ambiguity
  • Palpate testes and scrotum: check both are present and descended, check for hernias or hydroceles
  • Inspect the penis for hypospadias, epispadias and urination
  • Inspect the anus to check if it is patent
  • Ask about meconium
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17
Q

What are we looking at when looking at the legs of a baby in the newborn exam?

A
  • Observe the legs and hips for equal movements, skin creases, tone and talipes (club foot)
  • Barlows and Ortolani manoeuvres
  • Count the toes
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18
Q

How do we do Barlow’s test?

A

Adduct hip (bringing the thigh towards the midline) whilst applying light pressure on the knee with your thumb, directing force posteriorly

If hip unstable, the femoral head will slip over the posterior rim of the acetabulum, producing a palpable sensation of subluxation or dislocation.

If the hip is dislocatable the test is considered positive. The Ortolani manoeuvre is then used to confirm the positive finding

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19
Q

How do we do Ortolani’s test?

A

Used to confirm posterior dislocation of the hip joint

1. Flex the hips and knees of a supine infant to 90°.

2. With your index fingers placing anterior pressure on the greater trochanters, gently and smoothly abduct the infant’s legs using your thumbs.

A positive sign is a distinctive ‘clunk’ which can be heard and felt as the femoral head relocates anteriorly into the acetabulum

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20
Q

What are we looking at when looking at the back of a baby in the newborn exam?

A

Inspect and palpate for:

  • Scoliosis
  • Hair tufts
  • Naevi
  • Birthmarks
  • Sacral pits
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21
Q

What reflexes do we check in the newborn baby exam?

A
  • Moro reflex: when rapidly tipped backwards the arms and legs will extend
  • Suckling reflex: placing a finger in the mouth will prompt them to suck
  • Rooting reflex: tickling the cheek will cause them to turn towards the stimulus
  • Grasp reflex: placing a finger in the palm will cause them to grasp
  • Stepping reflex: when held upright and the feet touch a surface they will make a stepping motion
22
Q

What skin findings on a newborn exam do you need to note down?

A
  • Haemangiomas
  • Port wine stains
  • Mongolian blue spot
  • Cradle cap
  • Desquamation
  • Erythema toxicum
  • Milia
  • Acne
  • Naevus simplex (“stork bite”)
  • Moles
  • Transient pustular melanosis
23
Q

What referral do you need to make for the following findings on a newborn exam:

  • Positional talipes
  • Structural talipes
  • Undescended testes
  • Haemangiomas
  • Clicky hips
  • Cephalohaematomas
  • Boney injuries
A

Positional talipes: Foot can still be moved into the normal position, refer to physio

Structural talipes: Refer orthopaedic surgeon.

Undescended testes: monitoring and referral to a urologist.

Haemangiomas: near eyes, mouth or airway may require referral for treatment with beta blockers (i.e. propranolol)

Clicky hips: referral for hip ultrasound to rule out developmental dysplasia of the hips

Cephalohaematomas: monitoring for jaundice and anaemia.

Boney injuries: xray to look for fractures (e.g. clavicular fracture).

24
Q

If a baby has a soft systolic murmur on a newborn exam, what should you suspect?

A
  • If grade 2 or less in otherwise healthy well neonates may be monitored, as these often resolve after 24 – 48 hours. Due to a patent foramen ovale that closes shortly after birth
  • Any suspicion of heart failure or congenital heart disease requires referral to cardiology for an ECG and echocardiogram
25
Q

How do you finish up a newborn baby exam?

A
  • Offer to dress baby
  • Discuss any abnormalities with a senior
  • Document findings on the newborn and infant physical examination (NIPE) computer system and in the baby’s red book
  • Explain, reassure and answer any questions with the parents
  • Arrange referrals and followup if required
26
Q

How do you perform a respiratory examination on a child?

A
  1. Intro, consent, PPE
  2. Inspection inc sounds and around the bed
  3. Hands: tremor, eczema as atopy and asthma, CRT, clubbing
  4. Pulse: femoral in babies
  5. Face
  6. Tracheal position
  7. Inspect chest
  8. Palpate apex beat
  9. Percuss
  10. Chest expansion (not in young/babies)
  11. Auscultate
  12. Same on posterior
  13. Lymph nodes
  14. Pedal or Sacral Oedema
27
Q

What is normal respiratory rate in children?

A
28
Q

What are some dysmorphisms you may look out for when doing paediatric cardiorespiratory exams?

A
29
Q

What signs help demonstrate the work of breathing in children?

A
30
Q

How do you complete a paediatric respiratory exam?

A
  • Vital Signs
  • ENT
  • Growth charts
31
Q

How do you do a paediatric cardiovascular exam?

A

If baby always do 3 quiet things first (palpate femoral pulses, auscultate heart, auscultate lungs)

Same as adult but check for hepatomegaly and palpate femorals

https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist-Paediatric-Cardiovascular-Examination.pdf

32
Q

When has a child got hepatomegaly and what does this indicate?

A
  • If liver edge felt 2cm below costal margins
  • Sign of heart failure
33
Q

Where do you feel the apex beat in a child?

A
34
Q

What may coarse bilateral crackles suggest in a CVS exam of a child?

A

Congestive Heart Failure

35
Q

How do you do an abdominal examination in a child?

A

Same as on adults

  • ‘What did you last have to eat, let’s find it, if not I will have to listen for it’
  • ‘Can you jump up and down’ - Not possible if guarding
36
Q

How may the following masses present on an abdo exam of a child

  • Neuroblastoma
  • Wilm’s tumour
  • Intussupection
  • Faecal impaction
A
37
Q

Have you ever seen Birun and Shiv in the same room?

A

No, they are the same person.

38
Q

What techniques can you use to undertake practical procedures in paediatrics?

A
  • Get on same level as child
  • Distraction
  • Play specialists/therapists
  • Topical anaesthetics
39
Q

How do you report on a CXR?

A

Remember children usually AP

40
Q

How can you assess the age of a child on a CXR?

A

Humeral heads physis present: child, ossification starts around 14 yrs

No humeral heads: preterm neonate as ossification occurs at term

Umbilical clips: less than 2 weeks old

41
Q

How does an inhaled foreign body show on CXR of a child?

A

Hyperlucent thorax on the side foreign body is

42
Q

What is vater syndrome?

A
43
Q

What investigations should you do?

A
  • Skeletal survey
  • If under 1 with neurology or encephalopathy need CT head

Do a follow up skeletal surgery in 11-14 days

44
Q

What are the four types of fractures in paediatrics?

A

Buckle: Compression fracture from axial loading. Usually at metaphysis of long bones

Greenstick: Fracture on one side of the cortex only, mid diaphyseal

45
Q

How are fractures through the growth plate classified?

A
46
Q

How do we measure peak expiratory flow in children?

A
  • Stand upright
  • Meter is level
  • Fingers are not over the gauge
  • Breathe out maximally
  • Then take a deep breath
  • Place mouth around the mouthpiece
  • Ensure a tight seal
  • Breath out as hard and as fast as they can
  • Should make a huffing sound
  • Repeat 3 times
  • The highest recording from the 3 attempts
  • Plot this against their height
47
Q

What fractures in children are common in suspected physical abuse?

A

Buckle: Compression fracture from axial loading. Usually at metaphysis of long bones

Greenstick: Fracture on one side of the cortex only, mid diaphyseal

48
Q

How does inhaler technique vary for different age groups of children?

A

Use spacer as child cannot coordinate clicking and breathing

  • Up to 6 months: lie flat or 45 degrees in parents arms and use facemask
  • 6 months-3 years: sit up and hold the inhaler level and use facemark
  • 3 years+: use a mouthpiece - listen for clicks.
49
Q

How do we measure the head circumference of a child?

A

Useful for under 2’s

  • Placed above ears and midway between the eyebrows and the hairline to the occipital prominence at the back of the head
  • Record to the nearest millimetre and repeat 3 times
  • The maximum of these 3 is recorded and plotted on the growth chart
50
Q

How do you explain to a parent how to give an inhaler with a facemask?

A
  • Put two halves of spacer together and attach face mask
  • Remove cap of inhaler and shake it
  • Hold mask over mouth and nose in upright or 45 degree position to keep valve open
  • Make sure child lying on back
  • Press inhaler and let child take 5-6 breaths or 20 seconds
  • If second dose take inhaler out and shake before second dose

LISTEN FOR CLICKS - if no clicks not adequate breaths

51
Q

How do you explain to a teenager how to use their inhaler?

A
  • Take cap off, shake and press to release test spray
  • Check dose to check not empty
  • Shake inhaler
  • Sit or stand up straight and tilt chin up
  • Breathe out completely until lungs feel empty
  • Put lips around inhaler to make seal and start breathing in slowly
  • Press and breathe in slowly until lungs full
  • Hold breath for 10 seconds
  • Shake before any second doses
  • Rinse mouth if steroid inhaler
52
Q

How can you explain to a parent how to use their child’s autoinjector?

A
  • Lie child flat and elevate legs
  • Remove the safety cap
  • Place the tip of auto-injector against front or side of thigh, holding the auto-injector at right angles to the leg
  • Press hard and steadily into the thigh and keep in place for 10 seconds after click
  • Remove the auto-injector from the thigh, massage the injection site
  • Give a second injection after 5-15 minutes
  • Ensure an ambulance is on its way. Stay in position until medical assistance arrives
  • Auto-injectors need to be discarded in a safe manner, give to hospital or ambulance