pediatrics Flashcards
areas of assessment
Physical development -Assessed in depth at each visit Cognitive development -Assessed generally at each visit Social and emotional development -Assessed generally at each visit
principles of child development
- Child development proceeds along a predictable pathway
- The range of normal development is wide
- Various physical, social, environmental factors, as well as disease, can affect child development and health
- The child’s developmental level affects how you conduct the medical history and physical exam
stages of development
- Newborn (birth to 1 month)
- Infancy (1 to 12 months)
- Early childhood / Toddler (1 to 4 years)
- Middle childhood (5 to 10 years)
- Adolescence (11 to 20 years)
- -Early
- -Middle
- -Late
pediatric physical exam components
- Age-appropriate development
- Health supervision visits (well child visits)
- Integration of PE findings with healthy lifestyles
- Immunizations
- Screening procedures
- Anticipatory guidance
- Partnership with healthcare provider, child, family, caregivers, teachers
Sequence of newborn examination
- Careful observation of activity
- Head, neck, heart, lungs, abdomen, genitourinary system
- Lower extremities, back
- Ears, mouth
- Eyes whenever they open spontaneously
- Skin (throughout the exam)
- -Vernix caseosa: present at birth
- -Lanugo: shed within the first few weeks of life
- Nervous system
- Hips
newborn initial assessment
- Apgar scores: 1 and 5 minutes
- Gestational age and birth weight
- -Neonatal maturity
- Physical activity
- Congenital abnormalities
- Birth injury: clavicular fracture or brachial plexus injury
- Screenings: newborn screen, hearing
vital signs throughout development
- Height – every visit; plot on growth chart
- Weight – every visit; plot on growth chart
- -Calculate BMI (body mass index) starting at age 2
- Head circumference – up to 36 months; growth chart
- Blood pressure – start measuring at age 2
- Pulse – higher in infancy; slows down with aging
- Respiratory rate – higher in infancy; slows with aging
- Temperature
- -<2 months of age: rectal temperature
- -≥ 2 months of age: tympanic temperature
infancy
- 0-12 months
- Most rapid rate of growth
- -Birth weight triples, height increases by 50% by the end of year one
- Sequence of examination
- -Perform non-disturbing maneuvers early
- -Perform potentially distressing maneuvers near the end (ears, mouth, abdomen)
infant exam techniques
- Approach the baby gradually
- Speak softly, addressing the parent first
- Perform the majority of the exam with the child on parent’s lap
- Distract baby with a toy
infancy: head exam
- Inspect for symmetry
- Palpate:
- -Anterior fontanelle – closes between 4 and 26 months of age
- -Posterior fontanelle – closes by 2 months of age
infancy: eye exam
Inspect sclerae, pupils, irides, extraocular movements, and presence of red reflex
infancy: ear exam
- Inspect position, shape, landmarks, patency of ear canal
- Acoustic blink reflex
infancy: nose and paranasal sinuses
- Infants are obligate nasal breathers for first the 2 months of life
- Only the ethmoid sinuses are present at birth
- Inspect for position of nasal septum
infancy: mouth/pharynx
- Inspect mucosa, tongue, gums, palate, tonsils, and posterior pharynx
- Palpate gums and teeth
- -Teeth: 6 to 26 months of age, 1 tooth per month
- -Central and lateral incisors erupt first, molars last
infancy: neck
- Inspect for masses
- Palpate for presence of adenopathy: unusual in infancy
- Assess mobility of neck
infancy: thorax
- Inspect respiratory rate, color, nasal component of breathing, and listen for audible breath sounds
- Palpate tactile fremitus if infant is crying or making noise
- Percussion is not helpful in infants
- -Thorax is more rounded in infants than in older children and adults
infancy: lungs - auscultation
- Generally, sounds are louder and harsher
- Distinguish between upper and lower airway sounds
- -Upper airway: loud, symmetric transmission throughout the chest - loudest as stethoscope is moved upward; coarse during inspiratory phase
- -Lower airway: loudest over site of pathology; asymmetric; often has an expiratory phase
infancy: heart
- Inspect for cyanosis
- Palpate:
- -Peripheral pulses, especially brachial
- -PMI is not always palpable; 1 interspace higher than in adults
- -Thrills
- Auscultate:
- -S1, S2 (split is normal but fuse together as single sound during deep expiration)
- -S3 is frequently heard and is normal
- -Murmurs – functional murmurs vs. pathologic
infancy: breasts
- Inspect – enlarged in newborns secondary to maternal estrogen
- Palpate for masses
infancy: male genitalia
- Inspect
- Palpate for descent of testes into scrotal sac
infancy: female genitalia
-inspect
infancy: abdomen
- Inspect – umbilical cord remnant is gone by 2 weeks of age
- Auscultate bowel sounds
- Palpate - liver edge 1-2 cm below costal margin is normal; palpable spleen tip is normal
- Rectal – generally not done
infancy: musculoskeletal
- Inspect the spine
- -Spina bifida occulta
- Palpate the clavicle, hips, legs, and feet
- -Bowlegged growth to age 18 months is normal
Barlow Maneuver
- Test for ability to sublux or dislocate an intact but unstable hip
- If you feel the head of the femur slipping out onto the posterior lip of the acetabulum, this is a positive Barlow sign
- Concerning for hip dysplasia from laxity at hip joint
Ortolani Maneuver
- Test for posteriorly dislocated hip
- With hip dysplasia you feel a “clunk” as the femoral head enters the acetabulm; palpable movement of the femoral head back into place is a positive Ortolani sign
infancy: nervous system
Inspect motor tone
Palpate motor tone through passive ROM of major joints
Normal reflexes
Normal reflexes: newborn
Palmar grasp, plantar grasp, moro reflex, asymmetric tonic neck reflex, positive support reflex, anal reflex, positive Babinski
Normal reflexes: infancy
- Tonic neck
- Step
- Grasp
- Crawl
- Triceps, brachioradialis, and abdominal reflexes present starting at age 6 months
moro reflex
- The Moro reflex is an infantile reflex normally present in all infants/newborns up to 3 or 4 months of age as a response to a sudden loss of support, when the infant feels as if it is falling. It involves three distinct components:
- spreading out the arms (abduction)
- unspreading the arms (adduction)
- crying (usually)
Early Childhood (1-4 years)
- Rate of growth slows to 50% of that of infancy
- Tips for examination sequence:
- -Start with the child seated – examine the eyes, palpate neck, percuss/auscultate
- -Move child to supine position – examine abdomen, musculoskeletal, nervous system; examine genitalia last
- -End the examination with the patient upright; look at the throat and ears
tips for examining young children
- Use a reassuring voice throughout the examination
- Let the child see and touch the examination tools you will be using
- Avoid asking permission to examine a body part because you will do the examination anyway; instead, ask the child which body part he or she would like to have examined first
- Examine the child in the parent’s lap; allow the parent to undress the child
- If unable to console the child, allow a short break
- Make a game out of the examination
early childhood: vital signs
Measure blood pressure starting at age 2
early childhood: neck
Palpate for lymph nodes; adenopathy is common
early childhood: eyes
- Cover and uncover test
- Red reflex
- Cataract: black/absent red reflex
- Retinoblastoma: white ocular reflex (leukocoria)
early childhood: ears
Visualization of tympanic membrane is the greatest challenge
early childhood: nose/sinuses
Maxillary sinuses present by age 4
cover-uncover test
Check for alignment and strabismus
Monocular and intermittent strabismus demonstrated in figure
cover-uncover test with alternating cover test
In the cover-uncover test, the child first focuses on an object about 10 ft (3 m) away, although this may be impractical in a small examining room. An interesting object such as a small toy usually holds the child’s attention. The examiner covers one eye with a hand-held occluder or cupped hand, while watching the other eye for any movement of fixation. The examiner then removes the cover to see if the first eye has deviated.
If no movement is elicited on the cover-uncover test, the alternating cover test is performed. Again with the child focused on a distant object, each eye is covered in sequence, while the examiner looks for ocular deviation. If misalignment of either eye occurs during these provocative maneuvers, referral for treatment of strabismus is indicated. With practice, the entire ocular alignment screening examination can be accomplished in about 60 seconds.
early childhood: heart
Brachial pulses still easier to feel than radial
early childhood: abdomen
- Protuberant abdomen still normal
- Liver span 1-2 cm below costal margin is still normal
- -Use the scratch test to palpate for the liver size
- Spleen edge 1-2 cm below costal margin is normal
Liver scratch test
After placing a stethoscope over the approximate location of a patient’s liver, scratch the skin of the patient’s abdomen lightly, moving laterally along the liver border. When the liver is encountered, the scratching sound heard in the stethoscope will increase significantly. In this manner, the size and shape of a patient’s liver can be ascertained.
early childhood: male genitalia
Testes undescended in scrotal sac by age 1 is abnormal and need to refer
early childhood: muscluloskeletal system
- Knock-knees from 18 months to 4 years of age
- Inspect spine for scoliosis in any child who can stand
middle childhood (5-10 years)
Physical examination is more straightforward; the same sequence that is used in adults can be used starting in this age group
middle childhood: nose and paranasal sinuses
- sphenoid sinuses present by age 8
- frontal sinuses present by age 6-7
middle childhood: tonsils
peak growth is between ages 8-16 years
middle childhood: breasts
development in girls is the first sign of puberty; may start as early as age 6
middle childhood: musculoskeletal system
- inspect legs and feet
- inspect spine for scoliosis
adolescence: unique features
- Scoliosis
- Sexual health
- Testicular self exam
- Sports screening
adolescence: male puberty
Tanner stages to determine stage of puberty
adolescence: female puberty
Tanner stages to determine stage of puberty
well child visits: schedule
- Neonates
- -Initial birth assessment
- -2 weeks of life
- Infants
- -2, 4, 6, 9, 12 months old
- -Combine with immunization schedule
- Children
- -15 & 18 mos
- -Annually from 2-5 years
- -Every 1-2 years from 6-10 years
- Adolescents
- -Every 1-2 years
- -11-12 yo visit is important for vaccines
