Pediatric Exam Flashcards
newborn
first 28 days of life
infancy
0-12 months
toddler/early childhood
1-4 years
school-aged/middle childhood
5-10 years
adolescent
11-20 years
APGAR
Appearance, Pulse, Grimace, Activity, Resipiratory Effort
1 minute response:
0-4: severe depression
5-7 some nervous system depression
8-10 normal
5 minute response:
0-7: high risk for subsequent CNS and other organ system dysfunction
8-10: normal
Appearance
0: blue, pale
1: pink body, blue ext.
2. Pink all over
Pulse
0: absent
1: 100
Grimace
“reflex irritability”
0: no response
1: grimace
2: crying vigorously, sneeze or cough
Activity
0: flaccid
1: some flexion of arms/legs
2. active movement
Resp. Effort
0: absent
1. slow and irregular
2: good and strong
What does erythromycin ointment do? Vit K?
Erthyromycin ointment: in eyes to prevent infection
vitamin K injection to prevent bleeding
Gestational Age
- Based on neuromuscular sign and physical characteristics that change with gestational maturation
- Ballard scoring system
Gestation Age
Preterm 42 weeks
Birth Weight
extremely low birth weight < 1000 grams
very low birth weight <2500 grams
normal birth weight: above 2500 grams
SGA, AGA, LGA
SGA = lower 10th%, small for gestation age AGA = 10-90th, appropriate for gestational age LGA = large for gestation age >90th
Neonate feeding
- every 3 hours
- breastfeeding: initially small volumes of colostrum, milk will “come in” after 2-3 days and larger volumes will be taken
- formula: 15-30 ml (0.5-1oz)
Voiding after birth
3-4 voids in first 1-3 days is normal.
By day 4-5 should see 6-8 voids per 24 hours period.
Stooling
- Initial stools are meconium (should stool within first 24 hours of life - dark,black, tarry)
- By day 4-5 stools should change (Breast: yellow,seedy) (Formula: green/yellow)
Jaundice in newborns
- elevated levels prior to first 24 hours indicate more than physiologic jaundice:
- ABO incompatibility/Rh
- Cephalohematoma
- infection
- Hemoglobinopathies: ie. thalassemia
- enzyme deficiencies: G6PD
Hospital discharge
Vaginal delivery: 2 days after birth
C-Section: 3 days after birth
Prior to discharge:
- Hep B immunization
- hearing screen
- blood test
- circumcision
Well child Visits
Items discussed in HPI:
Feeding/eating, Stooling/voiding, Sleeping, Development, Safety, Additional parental concerns
PMHx
Medical problems, Injuries, Hospitalizations, Surgery, Meds, Allergies
Fmhx
Social hx: Family structure, Pets/guns/daycare, etc.
3-4 days of life: check growth 2 weeks: check growth and development and newborn screen #2 1, 2, 4, 6 months: check G&D 9 mos: check G&D and Hgb 12 months: check G&D
Growth in the first year: birth weight is tripled and height increased by 50%
Neurologic physical development
- neurological deveopment progresses centrally to peripherally (gross –> fine motor)
- head control, trunk control, use of arms, use of legs, use of hands then fingers
Language/Cognitive development
2 mos: cooing
6 mos: babbling
1 year: 1-3 words
Cognitive: learn cause/effect, object permanence and use of tools
- By 9 mos. should recognize strangers, seek comfort from parent during exam, actively manipulate objects
Gross Motor
using large groups of muscles to sit, stand, walk, run, etc., keeping balance, and changing positions.
Fine Motor
- using hands to be able to eat, draw, dress, play, write, and do many other things.
Language
- speaking, using body language and gestures, communicating, and understanding what others say.
Cognitive
- Thinking skills: including learning, understanding, problem-solving, reasoning, and remembering.
Social milestones
- Interacting with others, having relationships with family, friends, and teachers, cooperating, and responding to the feelings of others.
Exam guidelinees
- can do on table until nine months, after nine months, should do exam on parents lap because stranger anxiety develops at this age.
Head Circumference
Measure at each visit until 36 months of age
Observe for head shape, symmetry, tilt, lesions, hair abnormalities
Gen/Resp/CV/Abd Exams
Observation: Observe general appearance, comfort, wellbeing, activity level, grooming, temperament, body habitus, nutritional status
Respiratory: Observe breathing pattern, skin color, signs of distress & use of accessory muscles
Auscultate lung fields (ant./post.)
Cardiovascular: Compare brachial & femoral pulses B/L, Palpate PMI, Auscultate with bell & diaphragm
BP not routinely measure in child <3 yrs.
Abdominal:
Observe shape, contour, & presence of hernias
Auscultate bowel sounds in all 4 quadrants
Percuss, Palpate & note size of liver & spleen (may be able to palpate kidneys), liver tip should be palpable 1-2 cm below costal margin.
Palmar grasp
place finger in hand and press against palmar surface –> grasp finger
B to 4m
Plantar grasp
touch sole at base/toes –> toes curl
B to 9m
Moro (startle reflex)
hold supine support head, back, legs; abruptly lower 2 feet –> arms abduct and extend, hands open and legs flex, +/- cry
B to 4 m
Asymmetric tonic neck
supine, turn head to one side, holding jaw over shoulder –> arm/leg on that side extend and opposite arm/leg flex
B to 4 m
Positive support
Hold around trunk and lower till feet touch surface –> hips/knees/ankles extend, partially bearing weight (sags after 20 sec)
B or 2m–> 6 m
Rooting
Storke perioral skin at corner of mouth –> mouth opens and turns head toward side stimulated
Trunk Incurvation (Galant’s reflex)
support in prone position, stroke one side of back 1 cm from midline from shoulder to buttocks –> spine curves toward the stimulated side.
B to 3m
Placing/Stepping
Hold upright, have one sole tough table –> hip and knee of that foot will flex and other foot will step forward
B (best after day 4) to variable
Landau
Suspended prone –> head lifts up and spine will straighten
- B to 6m
Parachute
suspend prone and slowly lower the head toward the surface –> arms/legs will extend in protective fashion
4-6m and does not disappear
Barlow maneuver
- physical examination tests for ability to sublux or dislocate intact but unstable hip
- Can indicate developmental hip dysplasia (DHD)
If B/O test positive, need imaging to diagnose DHD - adducting the hip (bringing the thigh towards the midline) while applying light pressure on the knee, directing the force posteriorly.[2] If the hip is dislocatable - that is, if the hip can be popped out of socket with this maneuver - the test is considered positive.
- The Ortolani maneuver is then used, to confirm the positive finding (i.e., that the hip actually dislocated).
Ortalani test
tests for presence of posteriorly dislocated hip
Galeazzi maneuver
have knees flexed, look at the position of the knees in relation to one another- the knee that is lower will have a posterior dislocation possibly at the acetabulum
anterior fontenele
- “frontal fontanel”
larger and usually closes later: 18m-2yr
posterior fontanele
“occipital fontanel”
smaller and closes earlier at 1-2 mos of age
anterior fontenele
larger and usually closes later: 18m-2yr
posterior fontanele
smaller and closes earlier at 1-2 mos of age
nose exam
obligate nose breather first 2 months, only ethmoid sinuses are present at birth
Teeth development
6-26 ms.
usually develop 1 tooth per month
central and lateral incisors develop at first, molars will develop last
Red reflex
- Reflection of light on retina, generally red in color
- Should be symmetrical reflection with light held 18 in away
- Abnormal could equal cataracts, glaucoma, retinoblastoma or other abnormalities of eye
Hemangioma
benign and usually self-involuting tumor (swelling or growth) of the endothelial cells that line blood vessels, and is characterised by increased number of normal or abnormal vessels filled with blood. It usually appears in the first weeks of life and grows most rapidly over the first six months.
Mongolian spots
seen when melanin did not migrate completely in skin - seen in darker skinned babies
Hemangioma
benign and usually self-involuting tumor (swelling or growth) of the endothelial cells that line blood vessels, and is characterised by increased number of normal or abnormal vessels filled with blood. It usually appears in the first weeks of life and grows most rapidly over the first six months.
Still’s Murmur
- sound made from blood flow as it crosses the valve. Since infants/children have less tissue between the heart and the stehoscope, these can be auscultated and are common children
- Grade II/VI, musical, vibratory midsystolic
- located left of sternum in 4th ICS
- can be heard better when laying down
Venous Hum
- heard on the right side of neck at Jugular vein
- sound caused by flow of venous blood from head and neck into thorax
- continuous sound while sitting
- soft, continuous, louder in diastole
- this is a common sound; all other diastolic murmurs are pathologic
Still’s Murmur
- Grade II/VI, musical, vibratory midsystolic
- located left of sternum in 4th ICS
- can be heard better when laying down
Venous Hum
- heard on the right side of neck at Jugular vein
- soft, continuous, louder in diastole
- sound of blood coming back through veins: normal to hear
Carotid Bruit
Heard at carotid arter bilaterally
- midsystolic, usually louder on left, eliminated by carotid compression
- normal to hear
Ear exam
- need to pull back
don’t need to pull up and back
Late adolescence
17-20 years old
Middle Adolescence
15-16 years old
- females will develop sooner, males feel awkward
Late adolescence
17-20 years old
Adrenarche
- activation of adrenal medulla for production of adrenal androgens
- occurs before the onset of puberty
Gonadarche: what hormones are stimulated when?
- Earliest gonadal changes of puberty- GnRH released
- Boys: LH stimulates testosterone production and FSH stimulates sperma maturation
- Girls: FSH stimulates estrogen and follicle formation; LH stimulates corpus luteum after ovulation
Thelarche
- beginning of breast development at puberty
Pubarche
beginning of pubic hair
Tanner Stagings: Breast development
I: no glandular tissue, areola follows the skin of the chest (age 10 or younger)
II: breast bud forms, with small area of surrounding glandular tissue; areola begins to widen (10-11.5)
III. breast begins to become more elevated, and extends beyond the borders of the areola (11.5-13)
IV. increased breast size and elevation; areola and papilla form a secondary mound projecting form the contour to the surrounding breast (13-15)
V. breast reaches final adult size; areola returns to contour of the surrounding breast, with projecting central papilla (15+)
Tanner Stagings: Pubic hair
I. no pubic hair at all (below age 10)
II. small amount of down hair with slight pigmentation at base of penis and labia majora (10-11.5)
III. hair becomes more coarse and curly, begins to extend laterally (11.5-13)
IV. adult-like hair quality, extending across pubis but sparing medial thighs (13-15)
V: hair extends to medial surface of the thighs (15+)
Tanner Stagings: Breast development
I: no glandular tissue, areola follows the skin of the chest (age 10 or younger)
II: breast bud forms, with small area of surrounding glandular tissue; areola begins to widen (10-11.5)
III. breast begins to become more elevated, and extends beyond the borders of the areola (11.5-13)
IV. increased breast size and elevation; areola and papilla form a secondary mound projecting form the contour to the surrounding breast (13-15)
V. breast reaches final adult size; areola returns to contour of the surrounding breast, with projecting central papilla (15+)
Tanner Stagings: Pubic hair
I. no pubic hair at all (below age 10)
II. small amount of down hair with slight pigmentation at base of penis and labia majora (10-11.5)
III. hair becomes more coarse and curly, begins to extend laterally (11.5-13)
IV. adult-like hair quality, extending across pubis but sparing medial thighs (13-15)
V: hair extends to medial surface of the thighs (15+)
aortic sound
heard in URSB, at 2nd ICS
pulmonic sound
heard in ULSB (2nd ICS)
Tricuspid sound
heard in LLSB (4th ICS)
Mitral sound
apex: heard in LMCL (5th ICS)
Precordial activity
- Normal with innocent murmur
- increased in atrial septal defects
S1 sound
- normal with innocent murmur
- normal with atrial septal defect
S2 sound
- splits and moves with respiration in normal murmur
- widely split and fixed (does not move with inspiration) seen in atrial septal defect
systolic murmur (supine)
- crescendo/decrescndo and possibly vibratory at lower left sternal border for innocent murmur
- “flow” at upper left sternal border seen in atrial septal defect
Retractile testicle
= testicles that are not located within the inguinal canal and are able to be drawn in the scrotal sac
- not abnormal: testes will descend over time
Hymen
fold of mucous membrane that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia
- imperforate hymen = hymenal opening nonexistent; will require minor surgery if it has not corrected itself by puberty to allow menstrual fluids to escape
Retractile testicle
= testicles that are not located within the inguinal canal and are able to be drawn in the scrotal sac
- not abnormal: testes will descend over time
Hymen
fold of mucous membrane that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia
- imperforate hymen = hymenal opening nonexistent; will require minor surgery if it has not corrected itself by puberty to allow menstrual fluids to escape
Uvula inspection
- should be midline and without deviation
- aids in closing off the nasopharynx with swallowing
- use tongue depressor to iniate “gag” reflex which estimates CN IX/X
Corneal light reflex
“blink reflex”
- involuntary blinking of the eyelids elicited by stimulation such as toughing of the cornea or by bright light
Uvula inspection
- should be midline and without deviation
- aids in closing off the nasopharynx with swallowing
- use tongue depressor to iniate “gag” reflex which estimates CN IX/X
Babinski’s Sign
- stoke bottom of patient’s foot with tongue depressor
- when non-pathological it is called the plantar reflex and a downward response is elicited (while the positive “Babinski’s sign” indicates pathology and refers to an upward response)
+ sign can identify disease of the spinal cord and brain and also exists as a primitive reflex in infants (upward response)
