Module 1 NB Physical Exam Flashcards
General observation of baby
-step 1
-Asleep or awake?
-Skin warm or cool to touch?
-VS stable?
-Difficulty breathing?
In which direction do you assess a NB?
Head to Toe
-Head
-Face
-Neck
-Chest
-Abdomen
-Groin
-Extremities
-Back
-Neurologic
Step 2
Measure OFC
-plot on growth chart
Step 3
- Shape of patient’s head
-Anterior fontanelle
-Posterior fontanelle - Check infant’s skull for bruising and swelling
-Bruise that does not cross suture lines = cephalohematoma (bleeding below periosteum; common with forcep or vacuum delivery; increased risk of jaundice)
-Swelling that crosses suture lines = caput succedaneum (fluid accumulation above periosteum); usually resolves a few days after birth
-extensive swelling that crosses suture lines; bleeding due to rupture of emissary veins = subgaleal hemorrhage - run fingers over posterior head/scalp noting any areas where skin is missing or unusual texture, may be sign of cutis aplasia = congenital anomaly in which the scalp has not formed properly –> not inherently dangerous but should prompt thorough examination for other atypical physical features
CLAMS
Cranial sutures
-C=coronal suture
-L=Lambdoid suture
-A=Anterior fontanelle
M=Metopic suture
S=Sagittal suture
Skull design
Allows the skull to be malleable enough to fit through birth canal
-Often leads to temporary deformation called molding
Step 4
FACE
1. Assess ears/ear placement. Line from outer corner of eye to tip of ear and line perpendicular at temple to lobe should reveal if ear is tilted. Ear formation –> Helix formation? Crus? Pits? Skin Tags? May be associated with genetic conditions, hearing loss, or kidney anomalies
2. Assess eyes. Widely spaced? Opening of eye (palpebral fissues) point upward or downward? Pupil CHECK, red reflex.
3. Assess nose. Patency of nares (newborns are preferential nasal breathers). Hx of resp distress? Noisy breathing when feeding or crying? Patency proven by passing small french catheter through nares. Choanal atresia or choanal stenosis can occur.
4. Assess mouth and jaw. Place finger in mouth; healthy baby will reflexively suck on finger. Feel soft or hard palate. If cleft palate or lip found, refer to ENT. Elevate tongue and push past lower gum? If not, ankyloglossia (tongue tie) - may need frenotomy. Brief overall examination of overall mouth.
Asymmetric red reflex
-Congenital cataract
-Retinoblastoma
*refer to ophthalmology and genetic testing
Coloboma
-Missing pieces of tissue in the eye
*refer to ophthalmology and genetic testing
Choanal atresia
Characteristic finding associated with CHARGE syndrome –> coloboma of eye, heart abnormalities, atresia of the choanae, retardation of growth/development, genitourinary abnormalities, ear abnormalities
**refer to ENT and and medical genetics
Neck
- Webbing of neck (Turner Syndrome)? Or redundant skin (Noonan syndrome)?
- ## Run index finger along clavicles - should feel smooth without any crepitus, breaks, or step-offs. Fractures can occur during delivery, exp. shoulder dystocia
Chest
- Inspect the shape of the chest. Sternum flat? Sternum concave (pectus excavatum)? Sternum convex (pectus carinatum)? *common in some connective tissue and cardiac disorders (i.e. Marfan syndrome). Isolated pectus abnormality is considered a minor variant and is not cause for a genetic referral
- Listen to baby’s heart. Same landmarks for auscultation for older child or adult (4). Normal NB HR is between 120-160bpm (may need to listen for up to a min to hear clear systole or diastole).
-Patent ductus arteriosus (between aorta and pulmonary artery) murmur is benign and in full-term infant should resolve w/i first few days of life.
-Other heart murmurs (those that don’t improve within days) should be further evaluated - Assess respiration. (normal to take short pauses in breathing or breathe at slightly irregular rate for NB = periodic breathing). Four sites for auscultation (apex of lungs, side and back. Normal RR is 30-60bpm
Heart murmur investigation in the NB
-obtain pre and post ductal oxygen saturations, four extremity BPs, and EKG
Abdomen
-inspect abdomen. Distended? Skin around umbilical cord clean and dry? Outpouching of skin around umbilicus = umbilical hernia. Eval if umbilical hernia is reducible by pushing it gently back toward abd. (Firm hernia or is stuck in place may be incarcerated = should be evaluated by surgical specialist)
-palpate infant’s abd placing one hand ontop of other. Push gently.
-Right side of abd –> assess size of liver. Liver edge should not be palpable or lie very close to the NB’s ribs. Assess for masses on abd. Rare, but can find intra-abdominal neoplasms such as neuroblastoma or Wilms’ tumor.
Groin
-Assess femoral pulses (don’t push too hard). Unable to find or weak on one side, could ID aortic coarctation. Must then measure pre and post ductal oxygen saturations, and four extremity blood pressures
-check for presence of inguinal hernia
-Female genitalia: labia and clitoris may appear engorged as a result of maternal hormones; some NBs experience small amount of vaginal discharge or bleeding. Common finding is vaginal skin tags on posterior fourchette
-Male genitalia: assess if testicles are descended by palpating them through scrotum. Swollen, enlarged scrotum = hydrocele, or fluid collection around the testes which will spontaneously resolve. Examine penis for abnormal curvatures, and that the foreskin fully covers glans (hooded foreskin is often indicative of hypospadias - ventral displacement of urethral meatus)
-Assess patency of anus by using one hand to hold legs and other to gently spread apart gluteal cleft
-Hip dysplasia: congenital deformation or misalignment of hip joint; more common in families with hx of hip dysplasia, female, or breech presentation in utero. Assess hips one at a time using two maneuvers: 1. Barlow maneuver (first adduct hip by bringing thigh toward midline; apply gentle posterior pressure to knee). 2. Ortolani maneuver (flex infant’s knees to 90deg position then abduct legs by folding thigh outwards). ==> feel clunk or dislocation, follow up with primary care physician or orthopedic surgeon. Neonates with risk factors should have hip ultrasound at 4-6 weeks of life regardless of normal hip exam
