Pediatrics Immersion Flashcards
Red reflex
Use an opthalmoscope and visualize the retina in the back of the eye. There should be red coloration due to red blood vessels.
If you don’t see a red reflex, it may suggest a mass or something blocking the view of the retina, or cataracts.
Signs of respiratory distress in a baby
- Cyanosis
- Grunting
- Nasal flaring
- Tachypnea (>60 bpm)
- Subcostal or intercostal retractions (highly visible ribs)
Normal RR for an infant
40-60 breaths/min
Normal HR for an infant
Varys w/ age, but anywhere from 80-170 bpm
Acrocyanosis
A normal finding
Lips are not cyanosed, so this is not dangerous. May persist for several months, particularly in colder areas.
Scaphoid abdomen
Often suggests diaphragmatic hernia
Abdomen does not contain as many organs! You can hear bowel sounds over the chest where herniated intestines are.
Requires immediate surgery.
Syndactyly
Kleinodactyly
Babinski reflex presence is normal until age __.
Babinski reflex presence is normal until age 2.
Nephrotic syndrome is often mistaken for ___ in pediatrics.
Nephrotic syndrome is often mistaken for allergy in pediatrics.
The eyes become puffy first, and it tends to occur around the same time seasonally (since it can be triggered by a URI)
When an infant is relaxed, you can take advantage for the purposes of your physical exam by. . .
- Reviewing facial features when facial muscles are not contracted
- Look at exposed skin
- Examine breathing (rate/pattern)
- Listen for murmur/breath sounds
- Assess red reflex if eyes are open
Anterior fontanelle
If an infant has high intracranial pressure, this fontanelle will be very wide.
In older children, it will be bulging.
When you are examining an infant, especially when you are removing coverings to look at skin, it is very easy for the baby to become. . .
. . . cold!!!!
Whenever possible, use warming lights overhead to keep the infant warm, and keep this in mind throughout your exam.
Moulding of sutures
May cause bumps along the cranial suture lines on an infant’s head.
Usually due to pressure during delivery. Resolves over time.
Completely benign.
Neonatal extracranial and intracranial birth injuries
Caput
Edema under the skin, but above the fascia and periosteum. Causes swelling/bulging. Crosses suture lines. Usually present at birth.
Totally benign. Resolves usually within 48 hours. Just put a hat on the baby.
What to ask when examining an infant’s head bulge
- Does it cross suture lines?
- Is there pitting edema?
- Is there fluid wave?
Cephalhematoma
Major risk factor is vacuum-assisted deliveries.
Presents 12-24 hours after delivery. Does NOT cross suture lines. No fluid wave.
Not serious, but may cause some jaundice within ~ 1 week of appearance. Monitor carefully for jaundice development.
Subgaleal hemorrhage
Above the skull, but beneath the periosteum. Blood witihn the external periosteal space. Presents soon after birth and does NOT cross suture lines. Fluid wave is PRESENT.
Potentially serious. Can be so much blood loss into this space that the baby loses significant circulating volume. This requires transfer to NICU and administration of plasma or cryoprecipitate to facilitate clotting.
Subdural hematoma
Not visually apparent on exam, but may present as seizures. Quite serious.
Why is it important to check for cleft lips and palate on infantile exam?
Babies with cleft lips or palates may have difficulty feeding due to muscle coordination, and so they must be fed with specialized nipples that are designed to make this easier for them.
Otherwise, it could lead to malnutrition/failure to thrive.
Clefts may also be found in certain syndromes and may be an early clue to identifying a more serious pathology.
Why do babies grunt when they are in respiratory distress?
Babies “grunt” (Ehhh, ehhh, ehhh) reflexively by constricting their larynx. This maintains a positive end expiratory pressure in their lungs, holding the alveoli open, much like PEEP on a ventilator.
If you see this with a newborn, you should think of a surfactant problem.
Where is the best place to look for significant cyanosis on an infant?
The tongue!!!
All newborns have __ in the first couple minutes of life.
All newborns have low oxygen saturation (~65%) in the first couple minutes of life.
What is going on in this picture?
An umbilical hernia.
No treatment needed. This will resolve on its own.
What’s going on in this picture?
Diaphragmatic hernia
Contents of abdomen are in the chest. Very rare, but quite serious. Bowel sounds may be heard in chest.
Male newborn genitourinary exam
Female newborn and anal genitourinary exam
What is going on in this image?
Classic hydroceles. Fluid collection in the scrotal sac.
Not pathological necessarily, will go away over time. But, if it persists or if it dramatically increases, intervention will be made. Families should be informed to let physicians know if this happens.
Types of hydrocele
Non-communicating hydroceles are benign, frequently present at birth, and go away over time on their own.
Communicating hydroceles will not resorb on their own, and the fluid can back up into the abdomen. Smaller early in the day, larger in the evening if child is upright all day.
What is going on in this image?
Testicular torsion.
Note the slight blue discoloration and decreased volume of the right scrotal sac. Often occurs in utero.
A flow-resolved ultrasound should be performed right away to establish whether or not there is good perfusion. This is an emergency and the infant should be transferred to the operating room ASAP.
Barlow test
Ortolani test
Performed after Barlow test (dislocation test)
Hypotonia
Hypotonia is indicative of serious pathology and these infants should be brought to the NICU.
Plantar grasp reflex
If you stroke up the middle of the foot (not the side, which would trigger the babinski reflex), the infant should curl their toes inward as if to grasp your fingers.
Very similar to palmar grasp reflex.
Babinski reflex
Moro reflex
Asymmetric tonic neck reflex
Aka the Fencer reflex
Congenital dermal melanocytosis
What is going on in this picture?
Infantile jaundice
May or may not be concerning. Concerning if it is just only hours after birth, as the placenta should have removed all bilirubin.
However, if this occurs days after birth and is not present on lower extremities, it is not concerning.
Nevus simplex
Erythema toxicum
Pustules of all eosinophils. Comes and goes within minutes. Most common in term infants.
Hemangioma
Generally benign, but large ones may be dysfiguring or cause mass effect, which indicates treatment.
What is going on in these individuals?
Measles!
Reddened conjuncitvae and red spots that also appear on the hands, as well as in the oral mucosa.
What is going on in these individuals?
Neisseria meningitidis.
Neisseria often affects older, sexually active young adults, however it can present in children as well and is very serious. Presents with significant skin manifestations as well as, of course, meningitis in some cases.
What is going on in these individuals?
Epiglottitis, in this case caused by Haemophilus influenzae B.
Used to be a common cause of childhood ER visits, but nowadays preventable by vaccination.
What is going on in this infant?
Turner’s syndrome (45, X)
Look at the neck! Extra neck skin is a typical congenital presentation.
Vital signs vs age (neonate, 3, 12)
What is going on in this throat x-ray?
Croup
Also known as laryngotracheobronchiti. A type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of “barking” cough, stridor, and a hoarse voice.
Fetal alcohol syndrome
What is going on in this individual’s iris?
Lisch nodules
Dome-shaped gelatinous masses developing on the surface of the iris. Gold-tan to brown in color, they may grow up to 2 mm in diameter and attain variable sizes on the same iris. The presence of Lisch nodules is the most common clinical sign of neurofibromatosis type I (NF-1)
