ABDOMEN-PED Flashcards
1
Q
Inspect the abdomen with the infant lying___________
.
A
supine (and, optimally,
asleep)
2
Q
The infant’s abdomen is protuberant as a result of________________. You will easily notice abdominal wall
blood vessels and intestinal peristalsis.
A
poorly
developed abdominal musculature
3
Q
Inspect the newborn’s umbilical cord to detect abnormalities. What is the normal in infant?
A
Normally, there are two thick-walled umbilical arteries and one larger but thin-walled umbilical vein, which is usually located at the 12-o’clock position
Mas malaki ang VEIN
4
Q
A single umbilical artery may be
associated with ______________
A
congenital anomalies
or as an isolated anomaly
5
Q
The umbilicus in the newborn may have a:
A
- long cutaneous portion (umbilicus cutis)
- amniotic portion (umbilicus amnioticus),
6
Q
What covers the umbilicus cutis?
A
skin
Mnemonics : cutis “ KUTIS” : skin
7
Q
What covers the Umbilicus Amnioticus?
A
firm gelatinous substance.
8
Q
The amniotic
portiondries up and fallsoffwithin __________, whereas thecutaneous portion
_________________
A
- 2 weeks
- retracts to be flush with the abdominal wall.
9
Q
An **_______________ **at the base
of the navel is the development of
pink granulation tissue formed
during the healing process
A
umbilical granuloma
10
Q
- *Infection of the umbilical stump**
- *____________)** can be a serious condition
A
(omphalitis
11
Q
Umbilical hernias are detectable at a few weeks of age.
Most disappear by
_______________
A
1 year, nearly all by 5 years.
12
Q
Umbilical hernias in infants are
caused by a defect in the abdominal
wall and can be up to __________ in diameter
and quite protuberant with
intra-abdominal pressure.
A
6 cm
13
Q
In some normal infants, you will notice a____________.
This involves separation
of the two rectus abdominis muscles,causing amidline ridge, most
apparent when the infant contracts the abdominal muscles.
A benign condition
in most cases, it resolves during early childhood.
Chronic abdominal
distention may also predispose to this condition
A
diastasis recti
14
Q
Auscultation of a quiet infant’s abdomen is easy. You may
hear an orchestra of musical tinkling bowel sounds upon placement of your
stethoscope on the infant’s abdomen
A
15
Q
An increase in pitch or frequency of
bowel sounds is heard with____________
or, rarely, with____________
A
- gastroenteritis
- intestinal
obstruction.
16
Q
A silent, tympanic, distended and
tender abdomen suggests ____________
A
peritonitis.
17
Q
You can
percuss an infant’s abdomen as you
would an adult’s, but may note greater
tympanitic sounds because _____________.
A
of the
infant’s propensity to swallow air
18
Q
Percussion
is useful for determining the
____________ and __________
A
size of organs and abdominal masses
19
Q
A silent, tympanic, distended and
tender abdomen suggests _____________
A
peritonitis
20
Q
It is easy to palpate an infant’s abdomen
because infants _________________.
A
like being
touched
21
Q
A useful technique to relax
the infant, shown here, is to_______________
A pacifier may quiet
the infant in this position
A
22
Q
Start gently palpating the liver low in the abdomen, moving upward with your fingers.
This technique helps avoid missing an extremely enlarged liver
that extends down into the pelvis. With a careful examination, you can feel
the liver edge in most infants, _____________ below the right costal margin
A
1 to 2 cm
23
Q
One technique for assessing liver size in infants is** ________________**
Percuss and simultaneously auscultate, noting a change
in soundas you percuss over the liver or beyond it.
A
simultaneous percussion and auscultation.
24
Q
The___________ like the liver, is felt easily in most infants. It is soft with a sharp
edge,and itprojects downward like a tonguefromunder the left costal
margin.
The spleen is moveable and rarely extends more than 1 to 2 cm
below the left costal margin.
A
spleen,
25
Palpate the other abdominal structures.
You will commonly note **pulsations**
in the **epigastrium** caused by the\_\_\_\_\_\_\_\_\_\_\_\_.
This is felt on deep palpation to the
**left of the midline.**
aorta
26
An **enlarged, tender liver** may be
**due to\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
heart failure or to storage
diseases.
27
Among newborns, causes
of hepatomegaly include \_\_\_\_\_\_\_\_\_\_, \_\_\_\_\_\_\_\_\_\_, \_\_\_\_\_\_\_\_\_, \_\_\_\_\_\_\_\_
hepatitis,
storage diseases, vascular congestion,
and biliary obstruction.
28
Several diseases can cause **splenomegaly,**
including \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* infections,
* hemolytic anemias,
* infiltrative disorders,
* inflammatory or autoimmune diseases,
* and portal hypertension.
29
Abnormal abdominal masses in
infants can be associated with
* the kidney (e.g., **hydronephrosis),**
* bladder (e.g., **urethral obstruction),**
* bowel (e.g., **Hirschsprung’s disease,**
* or i**ntussusception)**,
* and tumors
30
You may be able to **palpate the kidneys of infants** by carefully placing the fingers of one hand in **front of and those of the other behind each kidney.**
The**\_\_\_\_\_\_\_\_ **is a **sausagelike mas**s in the left lower quadrant.
descending colon
31
In **pyloric stenosis**, **deep palpation** in
the **right upper quadran**t or **midline
can reveal**an\_\_\_\_\_\_\_\_\_\_\_\_ or a**2-cm firm
pyloric mass**. While feeding, some
infants with this condition will have
**visible peristaltic waves pass across**
t**heir abdomen, followed b*_y projectile
vomiting._***
“olive,”
32
Liver Size in Healthy Term Newborns23
By palpation and percussion
Projection below right costal margin
Mean, 5.9 ± 0.7 cm
Mean, 2.5 ± 1.0 cm
33
The surface of the abdomen can be divided, for descriptive purposes:
1. Into quadrants:
2. Using the **old English method**, into **3 areas horizontally** an**d 3 areas vertically** for a total of **9 areas**
: RU, LU, RL, LL
34
PALPATE
Contour:
Flat
depressed/concave
prominent/full: 5 F’s
* fat
* flatus
* feces
* fluid
* fetus
35
Contour: note whether the abdomen has normal contour:**\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
flat is normal
36
1.in children with **malnutrition**, **failure to thrive,** and **anorexia**, the abdomen may be\_\_\_\_\_\_\_\_\_\_
CONCAVE
37
2.Abdominal distension **due to laxity** of the **abdominal wal**l is seen in \_\_\_\_\_\_\_\_, __________ and \_\_\_\_\_\_\_\_\_\_\_\_\_
rickets, celiac disease and hypothyroidism.
38
The **causes of fullnes**s can be **described using the Five F’s**:
* Fat,
* flatus,
* feces,
* fluid
* and fetus.
Note :**Considering the frequency of teenage pregnancy and obesity, these are the 5 important items to remember.**
39
Inspection
NB
Newborn
* Normally **full and convex**
* Flat/scaphoid abdomen
* prune belly syndrome
* Organomegaly
* Localized swelling
* Protruding masses
* Inguinal region
40
In the newborn, the abdomen is normally\_\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_.
41
A flat abdomen suggests \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
diaphragmatic hernia
42
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**gives the skin a **wrinkled appearance**: **prune belly syndrome**
Complete absence of the muscles of the abdominal wall
43
Localized swellings of the abdomen may be **due to masses in the abdominal wall or inside the abdomen.**
44
Massive _______________ ,may be easily visible and **identified by their location.**
hepatomegaly or splenomegaly
45
Masses coming out of the abdominal wall, such as an **umbilical hernia** are easy to recognize
46
**Masses of the inguinal region** are **usually due to** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
heria, hydrocele undescended testes or inguinal nodes
47
diaphragmatic hernia
48
Aabnormal opening in the diaphragms a **birth defect i**n which there is an \_\_\_\_\_\_\_\_\_\_\_\_.
abnormal opening in the diaphragm
The opening **allows part of the organs from the belly (stomach, spleen, liver, and intestines) to go up into the chest cavity** near the lungs.Thus presenting with a flat or scaphoid abdomen.
49
**prune belly syndrome**
50
UMBILICAL HERNIA
51
Inguinal hernia
52
Transillumination of hydrocele
53
Inspection
* Pulsations
* Movement of the abdominal wall
* Normal
* Diaphragmatic paralysis
* Peritonitis
54
1.Next, look for abnormal pulsations. In thin individuals, pulsations of the epigastric region may be seen, particularly if \_\_\_\_\_\_\_\_\_\_\_
excited.
55
But **epigastric pulsations** may **indicate pulsations** of the l\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
iver or enlargement of the right ventricle.
56
2. normally, the **abdominal wall moves with the respiratory cycle.** Becoming **more prominen**t during inspiration and collapsing during expiration.
This sequence is reversed during in\_\_\_\_\_\_\_\_\_\_\_\_
Movement of the abdominal wall with respiration are absent or diminished when there is guarding of the abdominal muscles, as in peritonitis.
diagphragmatic paralysis
**collapsing during inspiration** and becoming prominent during expiration.
57
Movement of the abdominal wall with respiration are \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_when there i**s guarding of the abdominal muscles, as in peritonitis.**
absent or diminished
58
INSPECTION
Peristalsis
* Pyloric stenosis
* Obstruction of the large intestines
59
Next, examine the abdomen for **peristaltic movements** of the **intestine**. Normally, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ask the patient to lie supine and observe the abdominal wall in a**n oblique light**. Look for peristaltic movements. Observe the location and direction of the wave.
may be visible in thin individuals.
60
In emaciated children and children with **pyloric stenosis, peristaltic movement of the stomac**h are\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_\_\_\_\_\_\_
visible over the LUQ and waves move from left to right when the child is given water to drink
61
Peristalsis of the large intestine due to obstruction is seen in the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
lower quadrants and the flanks, movement is from right to left.
62
Inspection
*
* Purplish striae
* Cullen’s sign
* Grey-Turner sign
* Distended veins
* Diastasis recti
* Bladder extrophy
63
**Purplish striae** over the **abdominal wal**l indicate\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_These turn whit in color with passage of time.
* recent weight gain,
* recent treatment with glucocorticoids or Cushing syndrome.
64
Purplish striae
65
Diastasis recti- separation of the rectus abdominis muscle into right and left halves. Normally, the two sides of the muscle are joined at the linea alba at the body midline. In the newborn, th**e rectus abdominis is not fully developed** and **may not be sealed together at midline**. Diastasis recti is more common in premature and African American newborns.
66
Exstrophy of the Bladder of a newborn. Exposed urinary bladder in the midline just above the symphysis.
67
Umbilicus Defects
Defect
* hernia
* Omphalocele
* Discharge
* watery/purulent/sero-sanguinous
* Granuloma
* Polyp
68
**A small defect of the abdominal wall at the umbilicus leading to an insignificant hernia** may be **present at birth**. The defect is usually less than \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
1 inch diameter
69
Examine the hernia for\_\_\_\_\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_.
reducibility and for consistency
70
An **uncomplicated hernia** is\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
soft and reducible
71
A strangulated hernia feels\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_\_\_\_\_\_
tense and does not reduce.
72
A large hernia of the abdominal contents into the base of the umbilicus, particularly in the presence of poor abdominal musculature is called an\_\_\_\_\_\_\_\_\_\_\_\_\_
omphalocele.
73
Omphalocele
74
: Abdominal wall defect in the fetus, located in the umbilicus. Often, a **membrane covers the exteriorized intestine**s.
Omphalocele
75
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_contain **not only intestines**, **but liver as well.**
**If only a very small defect is present,** this is often **referred to as *_"hernia of the umbilical cord._****_"_*
"Giant" omphaloceles
76
** Omphaloceles** are to be **differentiated from gastroschisis**, where the **defect is to the \_\_\_\_\_\_\_\_\_\_\_\_\_\_**
side (usually left) of the belly button.
77
Omphaloceles are often **associated with other anomalies,** including **congenital heart defects.**
Omphalocele **can also be part of a syndrome**, such as \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* Beckwith-Wiedemann syndrome,
* pentalogy of Cantrell
* and cloacal exstrophy.
78
Occasionally, there may be discharge from the umbilicus in the neonatal period.
Note whether the discharge is **watery (urine),** due to , \_\_\_\_\_\_\_\_\_\_\_\_\_\_or **urachal cyst\_\_\_\_\_\_\_\_\_\_\_\_\_\_**.
This **may be caused by an infected cord stump patent omphalomesenteric duct** – remnant of the embryonic yolk sac that has **failed to regress**, so that this could still have connections with the umbilical cord – leading to some discharge emanating from the umbilicus.
* persistent urachus ** **
* purulent or sero-sanguinous
79
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is a fibrous remnant of the **allantois,** a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord.
urachus
80
Occasionally, **granulation tissue persists after the cord falls off 6-18 days after birth**
**Polyps** should be distinguished from granuloma.\_\_\_\_\_\_\_\_\_\_\_\_\_
It is bright red and has mucoid discharge
81
Palpation
Auscultate first and then Palpate.
Absent bowel sounds?
Technique :
Ask child to point to where it hurts – palpate this area last.
Relax the tense abdomen
82
An a**bsent bowel** sound **may indicate**\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**Proceed with caution during palpatio**n.
a surgical or medical emergency.
83
The **technique of palpation** of the abdomen is an **ar**t.
Even the **most cooperative children may tense up during this procedure.**
In small children, the **abdominal wall tenses up when they \_\_\_\_\_\_\_\_\_\_\_**
**cry.**
84
A cold pair of hands elicits a \_\_\_\_\_\_\_\_\_\_\_\_\_\_, and the abdomen gets tight.
Some children are so ticklish.
protective spasm
85
Distract the child
Engage child in conversation, make the child laugh.
Examine child **sitting up or lying prone.**
Flex child’s hips then ask child to take a deep breath.
Palpate quickly during expiration.
86
Crying child:
wait until the crying child relaxes the tension the abdominal wall at the **end o expiratory phase of crying**, then when the **child takes a deep breath, press your fingers as the abdomen relaxes.**
87
Ticklish child:
place your hand **on top of the child’s hand**, **but with the index finger somewhat overlapping**.
Palpate the abdomen with the child’s own hand, except your index finger can dip in a little just over the edge of the child’s hand. (child cannot tickle himself)
88
PALPATION
Note areas of tenderness – location/point of maximum intensity
Elicit rebound tenderness – press firmly then suddenly release and remove fingers from abdominal wall.
Note areas of tenderness – location/point of maximum intensity
Elicit rebound tenderness – press firmly then suddenly release and remove fingers from abdominal wall.
89
Location of tenderness:
Hepatitis:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tenderness along the edge of liver
90
Duodenal ulcer:tenderness on\_\_\_\_\_\_\_\_\_\_\_-
* RUQ, to right of the midline
91
Appendiceal infection:\_\_\_\_\_\_\_\_\_\_\_-
tendernes on RLQ / Splenic rupture or infarct: tenderness on LUQ
92
Perinephric abscess\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
; loin tenderness / Peritonitis: diffuse tenderness
93
\_\_\_\_\_\_\_\_\_\_\_\_\_\_: relieved by pressure and squeezing/ Pain due to intraabdominal inflammation; aggravated by pressure
Pain due to spasm of intestines
94
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ – pain/tenderness on withdrawal of the palpating fingers indicates peritoneal irritation.
(+) rebound tenderness
95
Tone of abdominal wall:
Hard,tense feeling – \_\_\_\_\_\_\_\_\_\_\_\_\_\_
indicates serious intraabdominal pathology
96
TONE OF ABDOMINAL WALL
Board-like ridigity –\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
peritonitis
97
Diffuse firmness – \_\_\_\_\_\_\_\_\_\_\_\_\_\_
chest disease/ muscle spasm (i.e. tetanus)
98
Localized firmness – \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
mass (e.g. midline firm mass may be a full bladder)
99
Very soft abdominal wall –\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
prune belly syndrome
100
Palpable mass
Mass on RLQ – cecum or appendix
Mass on RUQ – liver
Mass on LUQ – spleen or stomach
Flank mass – related to kidney
101
Palpation after stomach has been emptied (after vomiting).
**Flex hip to relax anterior abdominal wall.**
Palpate point midway between umbilicus and costal margin (along lateral border of right rectus muscle)
**Kneading up-and-down motion of the fingertips to feel for the olive-like swelling of the pyloric mass**
Pyloric Stenosis
102
Vague,diffuse, periumbilical pain that localizes to RLQ. Coughing – aggravates pain.
Classical: **Focal point tenderness on the Mc Burney’s point**
Flank pain if appendix located along the paracolic gutter, pain only on deep palpation.
Tenderness on deep rectal examination if appendix retrocecal/pelvic location.
Appendicitis
103
Vague,diffuse, periumbilical pain that localizes to RLQ. **Coughing – aggravates pain.**
Classical: **Focal point tenderness on the Mc Burney’s point**
Flank pain if appendix located along the paracolic gutter, pain only on deep palpation.
Tenderness on deep rectal examination if appendix retrocecal/pelvic location.
Appendicits
104
If the appendix **has perforated**, the findings will be those of \_\_\_\_\_\_\_\_\_\_\_\_
The child will appear toxic and pale, lying still. The **abdomen rigid on palpation** with **generalized guarding**, the **bowel sounds will be absent.** A **mass may be palpable in the RLQ,** on exam of abdomen or during rectal exam.
peritonitis.
105
Liver
Child lies supine **without pillow.**
**Right handed examiner stands o**n th**e right side of the child**
**Palpate from RLQ upwards**
**Auscultate over the liver**
106
The liver is normally located on the **right side** and **its size varies with the age** and **size of the child**.
In addition, the size of the liver as determined by palpation will be different from the size determined by percussion. Neither is as accurate as the size determined by imaging techniques.
Palpate the left lobe of the liver at the epigastrium. This is impt in tropics where amebic liver abscess and portal hypertension is common. What lobe of liver will be more prominent?
**Auscultate liver since hepatic rub can be heard in perihepatitis, liver abscess and leukemic infiltration of liver.**
L lobe will be more prominent than R
107
The liver is normally located on the right side and its size varies with the age and size of the child.
In addition, the **size of the liver as determined by palpation will be different from the size determined by percussion.**
**Neither is as accurate as the size determined by\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
Palpate the left lobe of the liver at the epigastrium. This is impt in tropics where amebic liver abscess and portal hypertension is common. L lobe will be more prominent than R
Auscultate liver since hepatic rub can be heard in perihepatitis, liver abscess and leukemic infiltration of liver.
** imaging techniques.**
108
Liver
Measure the size below the costal margin at the MCL
* 0-6mos N 3.0 – 3.5 cm
* 6mos – 4yrs N 0 – 3.0 cm
* 4 – 10yrs N \<2.0cm
* over 10yrs N \<1.0cm
109
LIVER
Measuring the **total height** of the liver
**Percuss along MCL**, fingers parallel to ribs, **mark intercostal space** when d**ullness first noted (upper border).**
**Percuss RLQ** and move upwards towards costal margin, mark the point at which dullness is first noted.
**Measure vertical height between 2 points**
110
Spleen
## Footnote
Spleen on left side
Palpable if enlarged at least 3x normal
Technique
RLQ to LUQ
Short’s maneuver
Percussion
Auscultate for splenic rub (perisplenitis)
111
The spleen is normally located on the left side.
It is palpable once it is enlarged to at least ____________ its size.
3x
112
Start palpating over the RLQ and proceed diagonally to the LUQ. Feel for the edge of the spleen. If spleen is not palpable with patient supine, examine pt in the \_\_\_\_\_\_\_\_\_\_\_.
Pt lying on the right side: examiner facing the patient, do the **Short’s maneuver:** place your left hand over the left lower ribs, midscapular line, push spleen gently, use your right hand to palpate the spleen.
right lateral position
113
Other Intraabdominal Organs and Masses
Appendix vs Cecal mass vs Ovarian mass
Intussusception
Kidney
114
Masses over the RLQ usually are related to the appendix but may be due to cecal mass or to ovarian mass (female)
In\_\_\_\_\_\_\_\_\_\_\_\_\_, an **ill-defined sausage-shaped** mass is felt over the RUQ and associated with this, the **RLQ is found to be empty.**
Intussusception
115
Palpation of the kidneys may be difficult in **obese children.** In normal children, one uses deep bimanual palpation to feel the kidneys.
With patient supine, abdomen relaxed, place the palm of one hand posteriorly at the flank, pushing the kidneus forward. Place the other hand anteriorly,
Over the anterior abdominal wall below the costal margin and feel for the kidney during deep inspiration.
116
Describe the Mass
Is it firm, hard, soft, or cystic?
Does it move with respiration?
Is it movable?
Is there bruit or murmur? Is it pulsatile?
117
Percussion for Fluid
Normal: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tympanitic except when percussing over solid organs or a full bladder (dull sound)
118
Percussion for fluid
Intestinal obstruction or paralytic ileus :\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
highly tympanitic
119
percussion for fluid
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ : dull on percussion
Fluid/fat/mass
120
How to detect free fluid
**Bulging flanks (also in obese)**
Listen for **transition from resonant to dull**
Elicit **“shifting dullness”**
Elicit **“fluid wave”**
121
Shifting dullness:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
with the patient supine, percuss over area of dullness.
Ask patient to roll over and lie on opposite side of to the percussed dullness.
After fluid has settled on the dependent position, percuss again. Percussion now will give a tympanic note over the same area where it was dull when pt was supine.
122
To elicit fluid wave:
Pt supine, another observer places hand vertically on midline of the abdominal wall. Then examiner places the palm of hand on one side and taps
With the fingers on the opposite flank. Feel the fluid wave created by the tap.
123
Bowel Sounds (auscultation)
L**isten to bowel sounds *_before palpation_***
124
Best heard along a\_\_\_\_\_\_\_\_\_\_\_\_\_, starting **1 inch to left and above umbilicus and running toward the RLQ
Listen to murmurs**
diagonal line
125
Bowel sounds have a _____________ quality.
gurgling
126
Bowel sounds are** increased and have a higher pitch** in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
gastroenteritis/ metalic quality during early intestinal obstruction.
127
High pitched sounds in \_\_\_\_\_\_\_\_\_\_\_\_\_\_.
gastroenteritis
128
Absent sounds in\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
paralytic ileus and late obstruction
129
Distant sounds in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ascites and peritonitis.
130
Listen to murmurs, esp **over the flank for systolic murmur** of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
renal artery stenosis.
131
Inguinal Region
Hernia
Indirect hernia
Bulge, **may extend to scrotum**
Enlarges when child cries/becomes smaller when reduced by external manipulation or when not straining
Thicken spermatic cord
Incarcerated hernia
132
If an **indirect hernia** cannot be **reduced,** suspect \_\_\_\_\_\_\_\_\_\_\_where there is associated pain and signs of obstruction.
incarceration
133
Produces a fluctuant swelling of the scrotum or along the spermatic cord.
* *Transilluminates**
* *Physiologic up to 3 months of age** and fluid is reabsorbed
Hydrocele
134
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**: cystic mass along the **inguinal canal in females **– **hydrocele of the tunica vaginalis.**
**Hydrocele of the canal of Nuck**
135
Guidelines during PE
Be considerate of **shyness and privacy.**
Explain procedure: **age-appropriate language.**
Decide on the necessity and appropriateness of parental presence.
If examining the child/adolescent without the parent, make sure a nurse or aide is present.
136
Male Genitalia
Newborn
Penile length __________ size and shape, urethra opens at tip
Prepuce easily retractable, meatal opening easily observed
Scrotum highly pigmented, L lower than R
Testes in scrotal sac
2.5-3.5cm, cylindrical
137
Abnormalities:
Size and shape of penis
Large – \_\_\_\_\_\_\_\_\_\_\_\_\_
precocious puberty, CAH
138
Penis size
Small –
hypoplasia: hypopituitarism, Klinefelter syndrome
139
## Footnote
Penis size
Curved – \_\_\_\_\_\_\_\_\_\_\_\_\_\_
hypospadia
140
Prepuce
\_\_\_\_\_\_\_\_\_\_\_\_
phimosis
141
Size:Enlargement of penis is seen in \_\_\_\_\_\_\_\_\_\_\_lesions of the **CNS, testicular tumors, congenital adrenal hyperplasia (penis large, testes normal size)**
precocious puberty,
Note: Precocious puberty: both testes and penis are large.
142
If the penis is small**, is it true hypoplasia or an apparently small penis?**
The penis may appear small in **obese boys** and the **true size not appreciated unless the prepubic fat tissue is pushed in to reveal the full length of the shaft.**
143
True hypoplasia may be seen in certain congenital malformation syndromes, such as\_\_\_\_\_\_\_\_
Look at the shape : curved in hypospadia
hypopituitarism, and Klinefelter syndrome.
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Examine the Prepuce: if the the preputial sac is very narrow and cannot be r etracted, it is called \_\_\_\_\_\_\_\_\_\_\_
phimosis
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Examine the Prepuce: if the the preputial sac is very narrow and cannot be r etracted, it is called\_\_\_\_\_\_\_\_\_\_
phimosis
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What are the Abnormalities inUrethral orifice
Hypospadia
Epispadia
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What are the Abnormalities in Scrotum
* Undescended testes/Retractile testes
* Large scrotum
* Color of scrotum
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The **urethral orifice** is located at the **tip of the penis**.
If it is located on the undersurface of the urethra, it is \_\_\_\_\_\_\_\_\_\_\_. This is usually associated with **cryptorchidism** and **hermaphroditism**.
hypospadia
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When the urethral orifice is located on the dorsum of the penis, this is \_\_\_\_\_\_\_\_\_\_\_-often associated with **extrophy of the bladder.**
epispadia
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Normally, **there should be no urethral discharge** in a male at **any age**. If it occurs, one should think of\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
foreign bodies, gonorrhea, Reiter’s syndrome.
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Normally the left scrotum is at a lower level than the right, but one side **is not larger than the other.**
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If there is disparity between sizes of the scrotum: check if \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
testes are within the scrotal sac:
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If on palpation, a **testicular mass is felt along the inguinal canal,** gently push it into the scrotum with the thumb and index finger of the other hand, if this can be done the testis is descended, even if it goes back up quickly. This is called a \_\_\_\_\_\_\_\_\_\_\_\_\_
“retractile testis”
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If the mass is felt along the inguinal canal but cannot be pushed down into the scrotum it is\_\_\_\_\_\_\_\_\_\_\_. I
undescended testis
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if the testis is not felt anywhere, the testis is probably \_\_\_\_\_\_\_\_\_\_\_- (provided it is a male)
inside the abdomen
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* Large scrotum
* Thickened skin
* Fluid in the sac
* Intestines in the scrotum
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* Tenderness
* Color
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A large scrotum may indicate one of the following
1. Thickened skin as in elephantiasis
2. Fluid in the sac (hydrocele)
3. Intestines in the scrotum ( hernia): a large scrotum that becomes small when the child is lying down or when the child is relaxed but gets large from coughing or straining, is probably an hernia
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Masses that cannot be reduced may be normal or can be tumors.
Tenderness of the scrotum may be due to orchitis, inflammation, epididymitis or torsion of the testis or of the appendix of the epididymis, strangulation or incarceration of hernia. Ultrasound exam of the testis is indicated since torsion of the testis requires urgent correction.
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Normal color of the scrotum is\_\_\_\_\_\_\_\_\_\_\_\_ than the rest of the body.
darker
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Redness with tenderness indicates \_\_\_\_\_\_\_\_\_\_\_
inflammation or torsion.
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Blue lines along the scrotal sac indicate \_\_\_\_\_\_\_\_\_\_\_\_\_--
varicocele.
is an enlargement of the veins within the loose bag of skin that holds your testicles (scrotum).
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In older children and adolescents, determine the state of sexual development by examining the state of sexual development by examining the size of the penis, scrotum, testicular size and pubic hair. See the normal stages of development
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Female Genitalia
Proper preparation and good explanation
Sensitivity to feelings and shyness
Proper positioning
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Examination of te genitalia may be a\_\_\_\_\_\_\_\_\_\_\_
. Therefore, proper preparation and good explanations are essential. One should be sensitive to the child’s feelings and shyness. The examination should not be abrupt or threatening. When examining adolescent girls, make sure a female nurse or the mother is present. Examine under good light .
traumatic experience for children of any age
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Proper positioning is essential for good examination of the genitalia. In young infants and children who cannot cooperate, examine the child sitting on her mother’s lap in a\_\_\_\_\_\_\_\_\_\_\_\_\_position.
Support the child’s feet on your knees and ask the child to place the soles of her feet together. This diverts the child’s attention and also fully abducts the thighs.
semirecumbent
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Look at the general hygiene, smell and staining of pants; don’t forget to look for **lice if pubic hair is present**
Urethral discharge is uncommon at any age. If present,
Look for cyst, caruncle or prolapse around the urethral oriface
Look for foreign bodies by separating the labia. FB in the vagina is a common cause of vaginal discharge and bleeding.
* it may indicate mechanical irritation, physiologic (for 2-3 yrs before menstruation starts), or inflammation.
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Look at the general hygiene, smell and staining of pants; don’t forget to look for lice if pubic hair is present
Urethral discharge is uncommon at any age. If present, it may indicate mechanical irritation, physiologic (for 2-3 yrs before menstruation starts), or inflammation.
Look for cyst, caruncle or prolapse around the urethral oriface
Look for foreign bodies by separating the labia. FB in the vagina is a common cause of vaginal discharge and bleeding.
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Vaginal discharge
* Newborn
* Foreign body
* Normal menstruation
* Watery discharge
* Purulent discharge
* Cheesy discharge
* Gray discharge
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Look for discharge and the characteristics of the vaginal discharge. Bloody vaginal discharge seen in the newborn period often is due to\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-.
estrogen withdrawal and is physiologic
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In older infants, a\_\_\_\_\_\_\_\_ is a common cause for vaginal discharge which is intermittent, blood stained and foul smelling.
foreign body
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In adolescent girls, bloody vaginal discharge is usually due to \_\_\_\_\_\_\_\_\_\_\_\_\_..
normal menstruation
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Watery discharge may be caused by**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
** local irritation or local infections**
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. Purulent discharge, in adolescent girls, suggests\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
gonococcal infection .
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Whitish cheesy discharge is associated with\_\_\_\_\_\_\_\_\_\_\_\_\_whereas
Candida infection,
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watery or gray discharge may be associated with\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
trichomonas infection.
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Examine the clitoris, a **large clitoris** may be **normal variation or may indicate \_\_\_\_\_\_\_\_\_.**
**precocious puberty**
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In \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_the clitoris is small
gonadal dysgenesis and hypopituitarism,
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. If there is no tissue surrounding the superior aspect of what appears to be the clitoris,\_\_\_\_\_\_\_\_\_\_\_\_\_\_
it is probably not a clitoris.
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In prepubertal girls,\_\_\_\_\_\_\_\_ may fuse the sides of the labia. Normally these can be separated easily, and they will always separate spontaneously in association with the vaginal pH change in puberty.
senechiae
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Examine the labia majora. They may be fused in congenital adrenal hyperplasia, giving the appearance of a \_\_\_\_\_\_\_\_-.
scrotum
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Labia majoa are **hypoplastic and the clitoris appears large** in \_\_\_\_\_\_\_\_\_\_\_\_\_
Trisomy-18 syndrome.
Labia majora maliit tapos malaki si clitoris
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Look for an imperforate hymen, particularly in the presence of what appears to be an enlarged uterus in an adolescent girl.
Look for evidence of sexual abuse.
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Ambiguous Genitalia
* Large clitoris
* Small penis
* Hypospadia
* Undescended testis
* Fused labia majora
* Inguinal hernia with a mass in a “female” infant
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Ambiguity is characterized by the presence of the following:
If ambiguous genitalia is suspected in the newborn period, investigation is required prior to sex assignment.
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Ambiguous Genitalia
Intersexuality
Female pseudohermaphrodite
Male pseudohermaphrodite
1. Intersexuality: When there is discrepancy between the morphology of the gonads and of the external genitalia.
2. If in an XX female with ovaries, the external genitalia are virilized – female pseudohermaphrodite.
3. If in an XY male with testes, the external genitalia are ambiguous or female, the child is a male pseudohermaphrodite
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Anus and Rectum
Left lateral position
Location of anus
Imperforate anus
fistular communications
Fissures
Nodular lesions
Proper preparation and gentle methods are crucial for a good examination and future cooperation. It is best to examine these ares with the child lying on hi or her left side.
On inspection, look for the locations of the anus: in certain congenital malformations, the opening may be too far forward, close to the genitalia.
There may be no opening at all, or the opening of the rectum may be through a fistula, or into the vagina or urethra. Passage of meconium through the vagina or urethra suggests that rectourethral or rectovaginal communication exists.
Look for cracks and fissures in the mucocutaneous junction: “fissure-in-ano” This may be related to pinworms, constipation, eczema or other mechanical irritation. Painful fissures may cause constipation and blood streaks in the stools.
Conditions that cause nodular lesions in and sround the anus are: rectal tags, polyps, hemorrhoids, prolapse of th rectum, anorectal abscess.
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Anus and Rectum
Rectal examination
* Child in left lateral position
* Use the little finger/gloved index finger
* Feel for sphincter tone
* Tenderness during examination
* Masses
Look at the child’s face for evidence of pain and examine the stool obtained by rectal examination.
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Rectal exam is done with the child in the left lateral position. In most children, particularly the small ones, use your little finger. In older children use the gloved index finger. Grease this properly, AS the finger enters the rectum, feel for the sphincter tone. If the anal opening is tight, it may denote anal stenosis or an anxious child. But if the finger cannot be moved in at all, think of agenesis of the rectum or imperforate anus. Do not force.
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In conditions associated with spibal cord lesions, the sphincter does not grip the finger – poor or absent tone.
Tenderness on entering the rectum may indicate\_\_\_\_\_\_\_\_\_\_\_\_\_ Fecal masses, polyps, hemorrhoids may also be felt in rectum.
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An empty rectum may sugges\_\_\_\_\_\_\_\_\_\_\_\_\_\_
intestinal obstruction or megacolon
. In megacolon a sudden widening of ampulla proximal to the line of agenesis of ganglia.
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