Paediatric P/E Flashcards
General approach to general examination (Prof. G Chan)
- 高矮肥瘦
- Tall stature
- Short stature
- Obesity
- Thin - 紅黃藍白黑
- Polycythaemia
- Jaundice
- Cyanosis
- Pallor
- Hyperpigmentation (e.g. Cafe au lait spots) - 頭頸
- Head shape
- Neck (e.g. Thyroid) - 眼耳口鼻
- Syndromic facies
Neonatal P/E (From SpC OG)
General examination:
1. Size, Body proportion
2. Maturity
3. Gross malformation, Dysmorphic features
4. Colour / Cutaneous discolouration (e.g. Plethora, Pallor, Cyanosis, Jaundice, Skin mottling (Livedo reticularis))
5. Posture (Tone: Palpation)
6. Generalised edema
7. Activity
8. Abnormal masses
Head examination:
1. Size, Head circumference, Shape
2. Anterior fontanelle (size + pressure (assessed when upright)), Posterior fontanelle, Anterior + Posterior Lateral fontanelle (closed for term baby)
3. Sagittal suture (small dimple ~ finger tip), Coronal suture, Lambdoid suture, Metopic suture
4. Caput succadaneum, Cephalhaematoma, Subaponeurotic / Subgaleal haemorrhage
Face examination:
1. Dysmorphic facies (e.g. distance between eyes, epicanthic folds, nasal bridge, ear configuration, position of mouth + neck, eyes)
2. Oral cavity / Mouth lesion (e.g. cleft palate (e.g. Patau syndrome))
3. Eyes, Red reflex, Others (e.g. sunset eyes in Down’s syndrome, corneal opacity)
Neck examination:
1. Sternomastoid tumour
2. Cystic hygroma
3. Goitre
4. Redundant skin fold
5. Web neck
6. Fractured clavicles
Limbs examination:
1. Length
2. Soft tissue
3. Nails and digits
4. Deformities
5. Developmental dysplasia of hips (Ortolani, Barlow)
6. Lymphedema of foot (potential associated syndrome: Noonan syndrome)
Cardiovascular examination:
1. Inspection
- Peripheral vs Central cyanosis
- Palpation
- Pulses (Brachial vs Femoral pulses)
- Apex beat (Left 4th ICS (infant), 5th ICS (children), MCL) (may feel prominent RV impulse at LSB) - Auscultate
- Heart sounds, Murmur
- HR (~120)
Respiratory examination:
1. Inspection
- Respiratory pattern (Periodic respiration in preterm), RR (~40-50 / min)
- Respiratory distress (Tachypnea, Stridor, Grunting, Flaring of ala nasi, Intercostal / Subcostal / Sternal insucking)
- Asymmetry
- Chest deformity
- Percussion (not helpful)
- Auscultation
- Breath sounds, Added sounds
Abdominal examination:
1. Inspection
- Shape, Size, Umbilicus (erythema, purulent / blood stained discharge), Dilated veins, Visible peristalsis
- External genitalia, Perineum
- Hernia orifice
- Anal patency
- Palpation
- Superficial for mass / tenderness
- Deep for mass / organomegaly
- Liver (normal 1-2 cm below costal margin, soft in consistency), Spleen, Kidneys (lower pole occasionally ballotable), other masses - Percussion
- Liver border - Auscultation
- Bowel sounds
- Bruits
Spine examination:
1. Spina bifida, swellings
2. Stigmata of underlying spinal defect
- Midline dimples
- Mass
- Tuft of hair
- Haemangioma
3. Deformities (e.g. scoliosis)
Hips examination:
1. DDH
- Groin skin crease asymmetry (extra groin skin fold due to lateral femur displacement causing shortening of limb, in dislocated hip, can occur in normal baby as well)
- Decrease hip abduction, limb movement
- LLD: Galeazzi’s sign
- Ortolani, Barlow
Neurological examination (consider influence of gestational age, posture in uterus, state of wakefulness):
1. Alertness
2. Posture (e.g. flaccid, spasticity, focal abnormality (e.g. Erb’s palsy))
- Tight fisting: cerebral damage
- Frog-like posture: hypotonia
3. Muscle tone, Tendon jerks
- Pull baby to sitting position (normal: flexed elbow, minimal head lag, transiently maintain upright head, also test grasp reflex)
- Prone position (normal: raise head above crouch)
- Ventral suspension (normal: hold head in line with trunk momentarily, back straight, flexed limb; abnormal: inverted U shape)
- Vertical suspension by holding axilla (hypotonic: slip through shoulder)
4. Spontaneous movements
5. Primitive reflexes (Moro, Grasp, Suckling and Rooting)
- Present in mature babies
- Disappear by 4-6 months
- Moro reflex: hold head 45o —> suddenly let head fall back —> sudden extension of neck + abduction of upper + lower limbs + embracing movement (asymmetry —> brachial plexus injury / fractured clavicle)
- Grasp reflex (Finger + Toe grasp): put finger into palm on ulnar side —> finger flexed + grasp object
6. CN (Eye movements, Facial asymmetry, Swallowing)
Physical examination of MCA
Skull + Face:
1. Skull shape
- Normocephaly
- Dolichocephaly / Scaphocephaly (↑ AP diameter due to premature closure of sagittal suture)
- Plagiocephaly
- Brachycephaly (widened skull due to premature closure of coronal suture)
- Trigonocephaly (triangular skull due to premature closure of metopic suture)
- Holoprosencephaly (failure of cleavage of forebrain (left and right brain))
- Frontal bossing
- Fontanelle, sutures
- Facial general shape + expression (e.g. muscle weakness, CN7 palsy)
- Placement + positioning of facial parts
- Brows
- Synophorus (unibrow)
- Arching of brows - Eye
- Outer + Inner canthal distance
- Interpupillary distance (define hyper/hypotolerism)
- Palpebral fissure length
- Cyclopia
- Hyper/Hypotolerism
- Telecanthi
- Upslanting (midface hypoplasia) / Downslanting eyes (maxillary / zygomatic hypoplasia)
- Epicanthal folds (depressed / low nasal root)
- Coloboma of lids - Ear
- Low set (position lower than outer canthal line to prominent part of occiput)
- Rotation (low set ears often accompanied by posterior rotation —> arrest of migration of ear during development)
- Length (e.g. microtia)
- Preauricular sinus (sporadic / inherited, bilateral likely inherited, AD with reduced penetrance + variable expression, 3-10% syndromal association)
- Ear tags (20% associated anomalies)
- Often associated with renal abnormalities —> Renal USG
—> Renal USG in:
—> Preauricular pits, cup ears, ear tags, malformation / dysmorphic features
—> Family history of deafness, auricular / renal malformations / maternal history of GDM - Mouth
- Lips
- Protruding tongue
- Cleft lip + palate
- Micrognathia / Retrognathia - Nose
- Absence
- Supernumerary
- Long nose
- Broad tip
- Prominent nose
- Narrow bridge
- Depressed bridge
- Smooth philtrum (Fetal alcohol syndrome) - Hair
- Lower posterior hairline (look for neck webbing)
- Hair whorls (>=3 indicate underlying developmental CNS problems)
- Cutis aplasia - Neck
- Webbed neck (lymphedema / cystic hygroma prenatal dried up —> redundant skin at birth) - Limbs
- Rhizomelic (Proximal) / Mesomelic / Acromelic (Distal)
- Arthrogryposis (joint contracture)
- Joint hyperextensibility (Beighton score)
- Hemihypertrophy
Neurological P/E (From JC Multidisciplinary)
- General inspection
- General state (well / unwell, calm / irritable, alert / drowsy)
- Growth (weight, height, head circumference / OFC (occipital frontal circumference))
- Head size and shape (plagiocephaly, brachycephaly (Down’s), scaphocephaly (hydrocephalus))
- Dysmorphic features + deformity
- Neurocutaneous markers (cafe au lait spots: NF, hypopigmented macules: Tuberous sclerosis, port-wine stain: Sturge-Weber syndrome)
- Skin (hyper / hypopigmented lesions; rash) - Head + Neck
- Face (symmetrical / asymmetrical facial grimace, abnormal facial movement, facial expression)
- Eyes (spontaneous eye opening, ptosis, nystagmus, ophthalmoplegia)
- Mouth (drooling) - Musculoskeletal
Inspection:
- Spine (tuft of hair, dimple, curve)
- Spontaneous movement
- Posture (resting posture, spontaneous active movement)
- Hand preference (before 24 months is abnormal)
Palpation:
- Tone
—> Hypotonia: scarf sign, traction maneuver, ventral suspension (inverted U shape), vertical suspension
—> Hypertonia: spasticity (pyramidal tract lesion), dystonia (basal ganglion lesion (extrapyramidal tract)), rigidity (rare, basal ganglion lesion (extrapyramidal tract))
- Muscle bulk
—> Anterior horn cell disease (Atrophy, Fasciculation) (e.g. SMA)
—> Muscular dystrophy (Pseudohypertrophy e.g. gastrocnemius, deltoids) (e.g. Duchenne)
—> Myotonic dystrophy (Myotonia by tapping over thenar eminence)
- Power
- Deep tendon reflex, Primitive reflexes
—> Hyperreflexia / Crossed adductor reflex
—> Hyporeflexia
—> Ankle clonus (newborn - 2 months: 3-6 beats of clonus; persistence + sustained: UMN lesion)
—> Babinski reflex (normal before 1 yo)
- External genitalia
- Response to touch
- Consciousness / Alertness
- CN system
- Motor system
- Sensory system
- Vibration
- Proprioception
- Light touch
- Pain - Cerebellar system
- Rapid alternating test (Dysdiadochokinesia)
- Finger-to-nose test (Intentional tremor + Dysmetria)
- Heel shin test
- Tandem walking
- Truncal ataxia
Rheumatological P/E (SpC Paed OPD)
History:
1. Pain during movement
2. Dressing difficulty
3. Walking upstairs / downstairs difficulty
***pGALS
1. General inspection (Front, Back, Side)
- Skin for rashes
- Muscle bulk
- Joint (deformity e.g. valgus, swelling)
- Face (micrognathia, asymmetry)
- Ankle
- Back (skin creases, shoulder level for scoliosis)
2. Gait
- Normal walking
- Heel walking
- Tip-toe
3. Arms
- Hands: dorsum + palm, touch tip of fingers with each other, make a fist, squeeze MCP
- Wrist: press against each other, extend + flex
- Reach up
- Look up
- Put hands behind neck
- Lateral flexion of neck
- Open mouth + put 3 fingers into mouth
4. Legs
- Knee effusion
- Active flexion
- Passive flexion of knee + hip
- External + Internal rotation of knee + hip
5. Spine
- Observe curvature from back + side
- Bend forward
CVS P/E (SpC Paed)
6 steps:
1. General inspection
- Growth (e.g. Failure to thrive): Height, Weight (drop first), HC (usually spared)
—> Short stature: Turner syndrome (Coarctation, Bicuspid aortic valve, MVP, AS)
—> Tall stature: Marfan syndrome
- Dysmorphism
—> Down syndrome (Upslanting palpebral fissures, Prominent medial epicanthic folds, Flat nasal bridge, Tongue protrusion —> AVSD, VSD, PDA)
—> Williams syndrome (Mild mental retardation, Prominent lips, Open lips, Long philtrum, Anteverted nostrils —> Supravalvular AS, Pulmonary arterial stenosis)
—> Noonan syndrome (Prominent medial epicanthic folds, Downslanting palpebral fissures, Large low set ears —> PS, HCM, ASD)
—> DiGeorge syndrome (Long face, Short + Upslanting palpebral fissures, Long nose + Broad nasal bridge, Low set ears —> Conotruncal lesions: TOF, Pulmonary atresia with VSD, Interrupted aortic arch)
—> Turner syndrome (Coarctation of aorta, Bicuspid aortic valve, MVP, AS) - Cyanosis (5 g/dL of DeoxyHb, masked by anaemia, more apparent in polycythaemia)
—> Prolonged cyanosis may cause polycythaemia —> injected conjunctiva
—> Absence of respiratory S/S —> should alert of cyanotic heart disease - Clubbing (chronic hypoxaemia)
- Hands + Feet
—> Single palmar crease, Clinodactyly, Sandal gap toes: Down syndrome
—> Polydactyly: Ellis–Van Creveld syndrome
—> Long slender finger, hyperextensible joints: Marfan syndrome —> Aortic root dilatation, AR, MVP
—> Syndactyly
—> IE signs: Splinter haemorrhage, Osler nodes - Dependent edema (less common ∵ not ventricular dysfunction but pressure and volume overload of heart in children)
- Pulse
- Rate, Rhythm, Character, Volume
—> Radio/Brachio-femoral delay (hard to detect in infant ∵ short aorta)
—> Weak femoral pulse: Coarctation, Interrupted aortic arch
—> All pulses weak: AS, Low cardiac output syndrome causing systemic hypotension - Precordial: Inspection, Palpation
- Respiratory distress (tachypnea, subcostal + suprasternal insucking, use of accessory muscles, flaring of nostrils) (∵ pulmonary arterial congestion due to pulmonary blood flow from L-R shunt)
- Chest deformities (Bulging precordium ∵ cardiomegaly (most prominent in dilated RV), Harrison sulcus, Pectus excavatum / carinatum in Marfan)
- Visible cardiac pulsation (Usually abnormal ∵ pressure / volume overload of ventricle, LV (apical impulse) vs RV (left parasternal pulsation))
- Surgical scars (Mid sternotomy scar, Lateral thoracotomy scar (e.g. systemic to pulmonary arterial shunt insertion, repair of coarctation))
- Impulse
—> LV pressure overload: AS, Coarctation, Systemic HT
—> LV volume overload: L-R shunt, AR, MR
—> RV pressure overload: PS, Pulmonary HT
—> RV volume overload: ASD, PR
- Thrills (Precordium, Suprasternal region (AS, PS, Coarctation, PDA), Carotid artery) - Auscultation
- Precordium
- Carotid artery
- Posterior chest wall (Stenotic branch pulmonary arteries radiation, Continuous murmurs of collaterals (in association with severe aortic coarctation / pulmonary atresia with VSD), PDA (left infraclavicular area, LUSB), Coarctation)
- 2nd heart sound
—> Wide fixed splitting: ASD
—> Soft P2: PS
—> Loud P2: Pulmonary HT
- Ejection click (opening of stenotic valve, follow immediately after S1) —> PS, AS - Chest (Basal crepitations, Cardiac wheeze) + Abdominal examination (Hepatomegaly)
- Basal crepitations: Pulmonary venous congestion
- Cardiac wheeze: Increased lung fluid in large L-R shunts ∵ increased pulmonary blood flow)
- Hepatomegaly: Systemic venous congestion
- Situs inversus
