Exam Routines Flashcards
Infant Developmental Exam
INTRODUCTION
- Introduce self and role
- Confirm name of child and who is accompanying
- Thank parent/child for coming to exam
- Gain permission
GENERAL OBSERVATION
- Ill or well
- Growth/nutrition
- Dysmorphic features
- Any mobility aids around patient? NG/PEG?
- Start by looking and commenting on as much as possible
GROSS MOTOR (POSTURE & MOVEMENT)
- Remember muscle control progresses from head down
- For mobile infants, just observe how they move about
Lie child supine and assess
- General tone/limb position and movements
- Offer child toy to reach for, watch antigravity movements
- Presence/absence of ATNR
- Roll
- Try to coax into side lying with toy and observe for roll
- Try to assist by putting pelvis in side lying position and coaxing with toy
Pull to sitting position (for 3-6m child)
- First assess grasp reflex, then hold hands firmly before pulling to sit
- Head lag
- Straightness of spine
- Upper limb and truncal tone
- Does infant pull to sit?
- Ability to sit unsupported
- Ventral suspension
- Extent of antigravity movement
Lie child prone (or have parent do so) and observe for:
- Head lift
- Torso lift and degree to which arms stretch forward
- Prone pivoting when coaxed with toy – demonstrates independent movement of
- Roll
- Crawl
Hold in standing position and assess
- Lower limb tone, scissoring, stepping
- Assess remaining primitive reflexes: moro, downward parachute, forward parachute
FINE MOTOR AND VISION
- Ask about concerns about vision
- Assess fixing and following. Does baby fix only in midline or follow toy? (don’t use noisy toy, as babies will turn to sound, which could be mistaken for fixing and following). Normal eye movements? Squint?
- Give interesting object. See how baby grasps and explores toy. Look for bringing to midline, passing from one hand to another and mouthing. Do both hands grasp equally well? In older infants comment on ability to let go of toy and object permanence.
- See how many small bricks baby will hold. If baby realises they can hold more than one brick, this demonstrates more cognitive sophistication and motor skill than when baby drops previous brick each time you hand a new one.
- Assess pincer grip using small object
- Try to elicit pointing.
SPEECH
Listen for variation in pitch, tone. Consonants, vowels. ‘Flat’ noises with little tone/pitch variation can be an early sign of speech delay.
HEARING
Comment on what you can observe before asking parents whether they have any concerns. Startles to loud noises? Turn to sound out of sight, eg rattle?
Other clues: recognition of name, recognition of familiar voices, mama/dada sounds – ask if you have a chance
SOCIAL
- Watch infant’s interactions with you and parent
- Comment on smiling
- Comment on games parent plays with child and how child responds
- Look for presence/absence of stranger awareness
- Make sure child and parents are comfortable with you before you try waving/clapping/playing peek-a-boo, etc.
- Questions: Able to indicate wants?
TO COMPLETE
Have question in mind in case you get a chance to ask them – focus on social/hearing unless child has been very uncooperative
ABDOMINAL EXAMINATION
INTRODUCTION
- Look around for alcohol gel and use it
- Introduce yourself to parent and child
- Ask for child’s name and age
- Confirm who child has with them
- Thank for coming to the exam
- Explain that you have been asked to examine the abdomen
- Ask for permission (from parent only if young child)
- Ask about any pain, tell child to stop you right away if anything you do hurts
- Position flat +/- expose as appropriate, ideally underwear only
INSPECT
- Make a show of taking a step back and inspecting from the end of the bed
- Growth/nutrition: body habitus, pallor, thin hair
- Paraphernalia – NGT/PEG, oxygen, IV access, monitors, meds
- General health/comfort at rest – also look at chest/resp status as may get a CF pt
- Dysmorphism, Cushing’s
- Colour (pink, pale, cyanosed, jaundiced)
- Obvious scars, stomas, distension
- Legs – erythema nodosum, pyoderma gangrenosum, etc.
HANDS
- Cannula scars
- Xanthoma
- Nails – leukonychia, koilonychias
- Make a show of looking for clubbing! (IBD, CF, chronic malabsorption, cirrhosis)
- Turn hands over - palmar erythema, creases
ARMS
- AV dialysis shunt
- Have child bend elbows, look for dermatitis herpetiformis
- Check for hepatic flap (and tacrolimus tremor)
FACE
- Sclerae - jaundice, blue sclerae (seen in IDA)
- Eyes - cataract, KF rings
- Xanthoma - cholestasis
- Conjunctiva - anaemia (can have child pull down lid and look up)
- Spider naevi
- Oral mucosa - pigmentation (Peutz-Jeghers), angular cheilitis, ulcers
- Tongue - stomatitis, large tongue (BWS, Down)
- Teeth - dental caries at back in GORD, front in poor diet
- Cushingoid? - always be alert to signs of steroid toxicity
NECK
- Scars, lines, ports
- Supraclavicular lymphadenopathy (Virchow’s node)
- Ideally check for axillary LN
ABDOMEN
Inspect
- Distension, asymmetry
- Scars (loin, groin, laparoscopic, flank)
- Scratch marks
- Injections sites! Lipohypertrophy….
- Abnormal vessels – caput medusa (drain from umbilicus)
- Herniae/visible lumps
Palpate + percuss
- Explain, reassure shouldn’t hurt, etc
- Go down on knees!
- Superficial
- Deep
- Liver - percuss resonant to dull and characterise
- Spleen - as for liver; consider having child roll towards you
- Kidneys – ballot
- Percuss down towards the bladder
- Percuss from the midline to the flank + shifting dullness as appropriate
- Flank dullness/ shifting dullness only if distended
- Suspected hernia: ask to cough; routinely check over incisions
- Ideally check groins for LN + hernias
Auscultate
- Bowel sounds
- Hepatic rub or bruit
- Renal bruit
- Listen over suspected hernia
- Listen over AV fistulae
BACK
With child leaning forward
- Inspect for scars
- Feel for cervical lymphadenopathy
- Consider checking for renal angle tenderness
- Consider percussing over left 12th rib – if resonant, splenomegaly is unlikely
LEGS
- ?any skin changes
- Be alert to hemihypertrophy
- Check for pitting oedema over ankles
COMPLETION
- Measure height and weight and plot on a centile chart +/- anthropometry
- Examine the hernial orifices, external genitalia, perianal area
- Check for fluid thrill/shifting dullness if not already done
- Consider BP, urinalysis
CVS Exam scheme
INTRODUCTION
Look around for alcohol gel and use it
Introduce yourself to parent and child
Ask for child’s name and age
Confirm who child has with them
Thank for coming to the exam
Explain that you have been asked to examine chest
Ask for permission (from parent only if young child)
Ask about any pain, tell child to stop you right away if anything you do hurts
Position +/- expose patient at 45 ° or if very young examine on parent’s lap
INSPECT
Growth
General health/comfort at rest
Dysmorphism
Paraphernalia – oxygen, feeding tubes, IV access, monitors, meds
Colour (pink, pale, cyanosed, jaundiced)
Work of breathing
Obvious scars
NB: In the small child who is quiet, consider auscultating first, but explain rationale to examiner.
HANDS/ARMS
Perfusion (cool or warm hands)
Cannula scars - ?ex-prem
Fingers/wrists for syndromic features
Nails, and make a show of looking for clubbing
Turn hand over and inspect palmar aspect
PULSES
Check both radial/brachial pulses: Symmetry, rhythm, character, COUNT RATE & RR
Consider checking for radiofemoral delay now + check for groin scars
Foot pulses in a neonate (unlikely in exam)
OFFER TO MEASURE BLOOD PRESSURE
Say you would confirm with second reading
Upper limit of systolic: 90 + 2(child’s age)
FACE
Again look for dysmorphic features
Conjunctival pallor
Oral mucosa for central cyanosis
Dental status
? high arched palate
NECK
JVP in older children
Catheter scars
Webbing, loose nuchal skin, etc
CHEST
Inspect
Expose fully where possible
Chest wall deformities
Visible impulses
Scars: lift arms/bra straps up (explain, ask permission!)
Palpate
Apex (feel for dextrocardia) location, character
Right ventricular heave
Thrills: LLSB, ULSB, URSB, suprasternal notch, carotids
Consider checking central CRT
Auscultate
Heart sounds: Both present? S1 normal? S2 normal? Is S2 louder than S1 over apex? S3 or S4?
Apex (mitral) + in left lateral position
Tricuspid, pulmonary, aortic
Listen for radiation to the neck if you hear an ESM or aortic murmur
With child leaning forward over tricuspid area
Listen (and have a last peek for missed scars) to the back: PS radiation, cardiac wheeze in infants, basal crackles
ABDOMEN
Feel for liver +/- spleen if you have time
Groin for scars if possible!
LEGS
Check for ankle oedema
TO COMPLETE MY EXAMINATION I WOULD LIKE TO:
- Measure height and weight and plot on a centile chart.
- If not done: BP, JVP, femoral pulses and radio-femoral delay, liver edge
- Saturations
- If any features of IE: fundoscopy, urine dip, spleen
- Obvious investigations to consider: CXR, ECG, echo
CVS presentation scheme
Turn to examiner and offer to complete exam with BP, JVP, saturations, etc. Give examiner a chance to ask you to proceed.
- I have examined the cardiovascular system of x-month/year-old Y.
- Y appears (comment on growth), and I would like to plot his/her growth on an appropriate centile chart.
- Paraphernalia: Oxygen, monitoring, feeding tubes, IV access, meds, etc
- Comfort at rest, effort of breathing
- Dysmorphism
- Other obvious things on general inspection, e.g.:
- Colour
- Scars
- Chest wall deformity
- Clubbing (and other obvious hand signs if present)
- Pulses: radial/brachial rate, rhythm, character, symmetry, radio-femoral delay; respiratory rate
- Face and neck signs if present: central cyanosis if not already commented, scars, ports, JVP
- On examination of the praecordium…
- Non-obvious scars
- Apex beat location/character, heaves/thrills
- Heart sounds: presence of S1,2 + additional sounds, intensity; only comment on splitting if you are very sure
- Murmurs: Grade, where in the cycle, where heard, where loudest, respiration, manoeuvres, radiation
- Lung fields, liver, oedema
- Groin scars if you got that far
- In summary, ….include comment on heart failure, cyanosis, any other apparent complications
- Differential diagnoses that I would consider…..commenting on features for/against
- Complications that I would be alert to….think nutrition, heart failure, IE, emboli, decompensation with intercurrent respiratory infections, specific problems associated with underlying syndrome if relevant…
- Baseline investigations that I would consider include….
Abdominal presentation scheme
To complete my examination I would like to plot growth on a centile chart, examine the hernial orifices, external genitalia and perianal area and measure the blood pressure. And as appropriate: urinalysis, check for fluid thrill/shifting dullness. Would you like me to do any of these now?
- I have examined the abdomen of x-month/year-old Y.
- Y appears (comment on growth), and I would like to plot his/her growth on an appropriate centile chart.
- Comfort at rest and dysmorphism
- Paraphernalia: NGT, PEG, IV access, meds, stomas etc.
- Other readily apparent findings on general inspection:
- Colour – pallor, jaundice
- Obvious scars, distension, leg rashes
- Clubbing (and other obvious hand signs if present)
- Arm signs if present: fistulas, dermatitis herpetiformis, tremor/flap
- Face signs if obvious
- Neck signs if obvious: scars, lymph nodes – comment on lymphadenopathy here regardless
- Chest signs if relevant: chest wall deformities, ports
- On closer inspection of the abdomen…distension +/- and….
- On palpation:
- Comment on general softness and tenderness
- Describe palpable masses in terms of location, firmness, tenderness, ability to get above it, movement with respiration, percussion note, size, ballotable, auscultation.
- If hernia: reducibility, bowel sounds and response to coughing
- Percussion: e.g. rest of abdomen resonant …shifting dullness
- Auscultation: bowel sounds, bruits, AV fistulae, etc
- Legs: pitting oedema, skin changes
- In summary, ….include comment on growth/nutrition.
- Differential diagnoses that I would consider…..commenting on features for/against
- Complications that I would be alert to include…
- Baseline investigations that I would consider include….
