peds PA exam 3 Flashcards
Neurodevelopment symptoms
vision problems hearing loss changes in weight persistent N/V headaches fainting, blackout, memory change hyperactivity weakness in one part of body clumsiness- (posterior fossa?) changes in bowel or bladder habbits
5 Important components to neuro History
1) health history
2) behavioral assessment
3) psychosocial assessment
4) school performance
5) development history
* must adjust neuro exam to developmental age of child*
types of neuro exams
neuro eval
neuropsychological eval (brain and nervous system effect way you behave- IEP is example)
and Neurodevelopment Eval* the best one
history problems, cont
attention problems memory behavior language/communication problems vision neck pain-occipital head pain-bad weakness/jerks gait, sensory changes diplopia, mother's projection
If there is a problem with thinking or remembering, where could the problem be?
the hemispheres
if there’s a problem with coordination, the problem is:
in cerebellum
Balance problems? + N/V
Infratantorium
problem with arms/legs with bladder/bowel control, the problem might:
be in spinal cord
if problem with speech, the problem might be in the
left hemisphere
if the child presents with multiple problems that do not localize to 1 area, and things don’t fit together, consider:
psychosocial realms
significant fall
3x the child’s height
9 parts of neuro exam
1) overall inspection
2) general cerebral function
3) Cranial Nerves
4) reflexes
5) motor strength
6) sensory
7) proprioceptive and cerebral fx
8) Soft sign
Overall inspection: what do i Look for?
neurocutaneous lesions? muscle atrophy, weakness in gait, abnormal positioning, hand dominance before 18months, skin
temors? tremors of tongue or hands when not crying
hypermobility
ash leaf:
tuberosclerosis
cafe au lait;
> 5 of them assoc with neurofibromatosis
flammeus nevus
on side of face, that side associated with glaucoma
large calves indicate possible:
muscular dystrophy (is there pelvic girdle weakness?)
Marie Charcot Tooth Syndrome
Thin, stork like legs high arches sensory loss decreased reflexes neuropathy will present with distal weakness before wasting
myopathies vs neuropathies
myop; present as central weakness ex) proximal girdle eakness
Neuropathy presents with distal weakness ex) stork like legs, wasting of marie charcot
Diastematomyelia
split cord malformation; longitudinal split in spinal cord
multiple leasions + glutteal fold–>abnormality
-may be minimally affected or entirely asymptomatic; present as leg weakness, low back pain, scoliosis, incontinence
Cerebral Function, part II
JOMAC
*consider dev. milestones Judgement, problem solving Orientation to time/space Memory Affective disturbances Calculation disturbances
pre school child- cerebral function, assess:
comon objects? know family members, where you buy food, name something in refrigerator, knows if they have pets, can count 3 objects, draw a picture, 3 wishes
2 year old developmental tasks
- Gains 5-6 pounds and 5 inches HC 2cm
- Kicks ball forward
- Removes article of clothing (not Hat)
- Combines two words
- Mild lordosis with protuberant abdomen
- 8 more teeth to total 14-16
- Tower of 7 cubes
- Imitate circular strokes
- May draw a horizontal line
- Empties trash cans and drawers
- Parallel play
- Speech should be understood
- Rotary chewing refined
3-5 year dev tasks
• 3-5 YEARS PRESCHOOL—Initiative-vs.-Guilt • Gain 4-5 pounds and 2.5 - 3.5 inches • 3 years – Throws ball overhand – Names 4 animal pictures – Pedals tricycle – Puts on an article of clothing – Names one animal picture – Jumps up and down – Draws a person upon request with sticks – State age, sex – Involve other in play – Can count fingers – Hand muscle developed – Wants to do things by themselves – Learning to share – Likes to help – Brushes teeth
4 year old tasks
• Lordosis and round abdomen starts to disappears • Plays games with other children • Says what to do when tired, cold, hungry, • Says first and last name when asked • Copies circle • Balances on each foot for 2 seconds • Can copy a + with demonstration • Finger muscles for tasks • Balance on 1 foot for 5 seconds
5 year old task
• Dresses without supervision • Copies a cross • Draws a Person • Puts object on, under, in front of and behind when asked • Hops on one foot 2 or more times
SCHOOL AGE—Industry-vs.-
Inferiority
• 6-12 years • Mastering skills that will be needed later as an adult • Winning approval from other adults, peers • Building self esteem, positive self concept • Taking place in a peer group • Adopting moral standards
first grade dev tasks
- Print 1st and last name
- Write #’s 1-10
- Draws a person-6 parts
- Copies a square
- Heel to toe walk
- Knows the letters of the alphabet
- Walk on alternate heels
- Play sports
- Friends
- Peers
CN 1
olfactory-not often done, do it when there’s a direct blow to forehead above nasal bridge
CN II
optic nerve;
VISION testing
after head trauma
shape of pupil
penny test-follow with eyes, cold sensation
optic fundus, visual acuity, pupillary reactions, size in mm. accommodation
Horner’s syndrome
decreased sweating on affected side of face can happen post op cardiac pts ptosis sinking eyeball into ace constricted pupil
CN III, IV, VI
oculomotor, trochlear, abducens
eyelids for droopng, size, 6 fields of gaze, reaction to light and accom
CN VI
longest subarachnoid course of all, dyunfunction of itcan result from lesions anywhere along its course btw 6th nerve nucleus in dorsal pons and alteral rectus muscle in the orbit
Increased ICP
result in downward displacement of brain stem, causing stretching of the 6th CN
can happen from: shunt failure (check EOMs), pseudotumor cerebri (6th nerve palsy)
posterior fossa tumors
neurosurgical trauma, venous sinus thrombosis, meningitis, lyme
6th nerve palsy, differential
thyroid eye disease
myasthenia gravis
duane’s synrdome
send to neuropthalmologist for:
spasm near reflex
delayed break in fusion, old fracture in orbit
Papilledema: Grades
Grade 1: c shaped halo of edema surrounding optic disk
Grade 2- halo of edema now surrounds optic disc, margin not well defined
Grade IV- SEVERE- more severe swelling + circumferential halo, edema covers major vessels as they leave disc (grade III) and vessels on disk (grade IV)
nystagmus-if recent onset, think
posterior fossa tumor?
Horizontal nystagmus
seen with labyrinthine, cerebellar or brainstem pathology
vertical nystagmus seen in
cerebellar or brainstem pathology
Medication toxicity can cause
horiz or vert nystagmus* ex) Dilantin
CN V
trigeminal facial muscle atrophy/tremors palpate jaw muscles- monster face test for touch and temp sensation 3 parts of CN V- test in all 3
CN VII
Facial Nerve
look for symmetry when face is clenched for CN V test, (monster), then do smile/frown, close eyes, puff cheeks
note- lyme presents with CN II
facial nerve palsy: central
forehead is unaffected
facial nerve palsy, peripheral
forehead has problem- eyes roll up when try to close
CN VIII
Acoustic
tuning fork-hard in young kids
use of audioscope or audiometer for routine screening
Weber test
for CN VIII
middle forhead place tuning fork
does patient hear it equaly or on one side louder? normal is same on both sides
unilateral conductive hearing loss, patient hears best in which ear?
the abnormal ear
Rinne Test
comparing Bone conduction-place fork on mastoid process behind ear–
Air conduction- assess by holding fork in air near front of ear
AC>BC
CN IX
Glossopharyngeal
swallow
gag reflex
CN X
Vagus
vocal quality
rise of soft palate a child says A AH
swallowing problems?
CN IX and X
do HA HA- rise of soft palate intact vagus , plus ulnar deviation is both
CN XI
accessory
head rotation gainst resistence to test STCLM
shrug shoulders to test trapezius
CN XII
hypoglossal
inspect tongue in mouth- symmetry, tremors, atrophy? lingual sounds like l, t, d, n
unilateral lesion: protruded tongue deviates toward affected weaker side
Reflexes- grading
0 abscent 1+ hypoactive 2+ normal 3+ hyperactive without clonus 4+ hyperactive with clonus
Reflexes;
biceps triceps patellar achilles tendon (ankle) abdominal babinski snouting
babinksi
after walking, normal is downward curl
before walking - curl upwar
an abnormal or positive sign is upward curling in a walking child
Chaddock
stroke with blunt point around side of foot from external malleous to small toe
positive test: if there is dorsiflexion of big toe
oppenheimer
firmly press down on shine and run thumb and knuckles upward along medial tibia]
positive test: if there is dorsiflexion of big toe
muscular dystrophy bloodowork
TSH
CK
Liver enzymes
a child should tandem walk by
earliest; 4
latest- 6
fine motor
tap hands on thigh, alternate, touch each finger to thumb, look for intentional tremors, gait abnormalities,
grading motor strength
0/5 No muscle movement 1/5 Visible muscle movement, but no movement at the joint 2/5 Movement at the joint, but not against gravity 3/5 Movement against gravity, but not against added resistance 4/5 Movement against resistance, but less than normal 5/5 Normal strength
duchenne muscular dystrophy
boys
difficulty w climbing stairs, running, jumping frmo standing position, falls, slow motor progression,
18 months start waling, clumsy age 2-3, difficulty keeping up w peers 3-5yo
calf muscle hypertrophy
weakness- proximal before distal* legs before arms weaken, extensors weaken before flexors
to walking, calf pseudohypertrophy, lumbar lordosis, multifocal contractures, trendelenburg gait, fatigue,
WALK LIKE DUCK
gower’s maneuver
to stand from sitting, they will walk their hands up their legs slowly and climb up them
pronator drift
pt stand for 20-30sec arms straight forward, palms up, eyes closed
pt will not be able to maintain extension and supination if they have upper motor neuron problem
graphesthesia
adolescent- with blunt end of pen draw large number in their palm
stereognosis
familiar object in child’s hand and have them tell you what it is
Dystonic posturing
• Dystonic posturing is stiffening of the
extremities during a stressed gait or
rhythmic movements.
– The child hops in place or heel toe walk
-hand goes up on the weak side
penny on nose test
proximal inhibitation
The inability to inhibit proximal musculature while
using distal muscles is a neurologic marker.
• *Screen for proximal inhibition by having the
child rapidly alternate opening and closing of
fists with arms extended, or by rapidly rotating
the wrist while holding the arm up and hand
above the head
simple skull fracture
linear
depressed skull fracture
- Hematoma at site
* Piece of bone depressed into brain
compound skull fracture
- Laceration and depressed skull fracture
- Dura usually pierced
- Skull fragment may be displaced into the brain tissue.
Basilar fracture
• break in the posteroinferior portion of the skull occurs. • produces dural tears that result in leakage of cerebrospinal fluid (CSF). – meningitis early S&S -blood behind TM nerve palsies, deafness or ringing dizziness, NV battle sign raccoon sign
epidural hematoma
older kids more often
• Blood is between the dural surface and the skull and is
usually the result of a tearing of the meningeal artery.
• more common in older children than in toddlers and
infants, because before age two, the middle meningeal
artery is not yet embedded in the bony surface of the
skull.
• May not have loss of consciousness.
• Signs and symptoms
– Headache
– Decreased level of consciousness
– Fever
– Dilation of the pupil on the affected side of the brain
battle’s sign
bruising over temporal area- seen in basilar fracture
raccoon sign
bruising around eyes, basilar fracture, also seen in neuroblastomas
Meningitis History
progression, exposure, history of otitis media? uderlying health, immunodef, seizures?
focal seizure is common iniital pres
generalized- febrile
presentation of meningitis in newborns
– Fever – Nonspecific symptoms (eg, poor feeding, vomiting, diarrhea, rash) – Bulging fontanel – Irritable, restless, or lethargic.
presentation of meningitis in older kids
– Sudden fever – Headache, – Nausea, vomiting, – Confusion, stiff neck, photophobia • Meningitis can cause seizures, and decreased level of awareness.
• Brudzinski sign for meningitis
– Flexion of neck causes flexion of hips and knees
– Test for nuchal rigidity with head off table in your
hands.
– Gently flex the head at the neck until the chin touches
the chest
– Positive
• When both the knees and hips are flexed in
response to passive flexion of the neck towards
the chest.
• Reflex is due to exudate around the roots in the
lumbar region, inflammation of lumbar
Kernig’s sign
–Associated with meningeal irritation and hamstring spasm –Flex hip and knee, then straighten knee. –Excessive pain and resistance bilaterally suggests meningeal irritation
PATIENTS IWTH VP SHUNT and Meningitis–
present differently
inc risk of getting meningitis
sometimes dont get as high a fever
-they get low grade ventriculitis, headaches, n, malaise, low fever
viral meningitis
less toxic and acute in presentation
enterovirus
more common in summer
vomiting, headache, stiff neck
Signs & Symptoms of DMD
• Abnormal muscle function
– Delayed walking
– Frequent falls
– Difficulty with running and climbing stairs
– Calf pseudohypertrophy
• Progressive proximal musculature weakness
– Waddling gait 2° girdle muscle weakness
– Gower’s sign
• Increase in serum creatine kinase (CK) and
transaminases (aspartate aminotransferase and
alanine aminotransferase)
• Delays in attainment of developmental milestones
intoeing
normal for infant and toddler years
flat feet
normal infant and toddler years; 10% of population
only a problem if it is r/t tarsal coalition which is painful; check by raising toes/tip toes- if you see arch, there’s no torsal coaliation
metatarsus adductus
top half of foot in-toes
the top half of the upper 1/2 forehoot has deformity
skin crease may be located on medial aspect of longitudinal arch
benign
internal tibial torsion
causes in-toes
assoc w sitting on feet
associated with intrauterine positioning
femoral anteversion
can cause mild intoe-ing
peaks in late preschool, spontaneous correction by age 8
severe cases-need referral
W- sitting position
toddler years muscular dev
largest amount of growth during these years
- wide based gait “toddling”
- Genu Varum (bow leg) seen until child walks for one year
- *if geu varum has inc by age 3 and not resolved, could be blount disease** needs referall (medial growth of tibial bone)
- genu Valgum (knock knees) abnormal if child has been walking
genu valgum
knock knees; normal 3-5 years old
Developmental dislocation of hip
idiopathic- positive family history, breech presentation, dislocated and irreducible, subluxated to dislocated and reducible
teratogenic- more severe with germ plasma defect
sig. assoc w/ club foot, congenital torticollis, metatarsus adductus and scoliosis
Females > males *breech
unilateral more common
highest risk: female, first born, breech delivery- need u/s
Ortolani maneuver
hip held while thigh is tested and abducted and pulled anterior; anterior push up one side at a time
Barlow maneuver
adducting hip while pushing thigh posteriorly
if hip goes out of socket: “dislocatable” or positive
confirm dislocation by performing ortolani to reduce and relocate hip
Galeazzi sign
lower extremities- when hips and knees are 90 degrees in flexion; identifies unilateral hip dislocation– are the knees different heights? the shorter leg will stay posterior b/c its not in socket
good for 5-6 month olds b/c ortolani/barlow won’t work on them)
Evaluating DDH
ultrasound
trandelenberg gait
pelvis tils toward normal hip when weight is on affected side
when to worry for genu varum/ valgum
alignment in comparison to age is normal sharp curve lateral thrust (severe bow leg) asymmetry intercondylar distance of > 15cm or 6 in
Ricket’s
"fanning" at wrist test Vit d, phosphorous, calcium and parathyroid hormone frontal bossing protuberance on costochondral borders-rosary -widened ends of bone (fanning) -low phosphorous shrt stature abnormal Vit D
note- african americans absorb less nutrients from the sun, need vit d supplements
internal tibial torsion
nonpathologic variation of normal
patella faces anterior position
delayed correction wil usually self correct over time
femoral anteversion
normal variant max age 3 delayed correction can lead to persistent intoing b/l w no other disease process correcst w time
wind sign
measurement of thigh foot angle w patient in prone position and knees flexed;
normal external radiation: ten degrees
> 10- abnormal
clubfoot
positional- in utero
true- structurally abnormal, bones of leg or foot or muscles of calf often underdev.
will need serial casting, then bracing; need close follow up
congenital clubfoot/talipes equinovarus
male female
1/1000 births
multifactorial etiology; heel turned in, adducted and supinated
ponsetti method
serial casting for clubfoot
legg-calve-perthes disease
disorder of femoral head
(vascular necrosis decreases bloodflow to femoral head)
idiopathic ischemic necrosis, collapse and subseq repair, self limiting
residual deformity
healing w new bone growth in femoral head
won’t fit well into socket
assessment of legg-calve-perthes
pain localized to hip, thih or knee
dec ROM, limited internal rotation/abduction
limp- antalgic/ trandelenbrug gait
(antalgic gait- cant stand on leg)
Blount’s disease
isolated growth disturbance of medial tibia epiphysis
more common in AA
compression injury to medial growth plate
lteral thrust on effected side- extreme bow leg
no evidence of ligamentous laxity
Osgood Schlatter
swelling/ pain of anterior tibial tuberosity
avulsion injury tibial spine
ages 10-15
tanner III for girls
Tanner IV for boys
growth spurt of bone- but muscle has not caught up, muscle grinds against leg, bump
slipped capital femoral epiphysis, SCFE
ortho EMERGENCY
males 2:1 females
b/l 25-50%
onset of puberty often, males 10-16, males 10-14
underlying connective or endocrine disorder ex) marfan or hypothyroid
-femoral head “falls off” femur”
-displacement of femoral epiphysis on femoral neck
unknown cause, multifactorial, endocrine, trauma
symptoms of SCFE & assessment
painful lip obligate external rotation loss of internal rotation trandelenburg gait pain may be in knee flexion contracture possible referred pain classic sign: pt will rotate their leg outwards*
Assess- onset of symptoms, sudden or insidious
pain- deep in groin, thigh, and or knee, inc w activity
gait- ext rotation, antalgic limp
loss of in rotation
classifications of SCFE
Acute, chronic and degree of slip
acute SCFE
chronic SCFE
> 3 wks
acute on chronic SCFE
> 1 month, sudden inc pain
mild slip SCFE
less than 1/3 diameter of femoral neck
moderate slip
less than 1/2 diameter of fem neck
severe slip
greater than 1/2 diameter of femoral neck
faber test
specific for problems of sacroiliac joint FABER=hip flexion ab-duction external rotation
Osteogenic sarcoma
pain on pressing lower femur is a BAD sign
most common malignant primary bone tumor in children
“sunburst” appearance on xray
primary symptoms intermittent pain history and swelling over several weeks
Ewing sarcomas
peripheral primitive neuroectodermal tumor
2.5% of cases of childhood cancer
most in adolescence and young adulthood
uncommon in people of african and asian descent
2nd most common
moth eaten destructive lesion in shaft of long bone “onion skin periostitis”
slight male predilection (1.5: 1)
95% of cases occur btw 4-25 years)
Rare in AA
primary symptom; pain with possible fever, tenderness
scoliosis
presence of body asymmetries shoulder height- not level scapular prominences chest prominences unequal line at C7
the younger the child develops the cure, the mroe likely it is to progress
Adam’s forward bend test
pt bends forward at waist standing w feet together and knees straight
patients arms are dependent, hands held w palms opposed
should be c shaped
shoes off
scoliosis measurements
> 10 degrees is abnormal most most common pattern is right thoracic and left lumbar use of scoliometer > 7 degrees, refer
Painful scoliosis
underlying pathology like spondylolysis, intraspinal tumor, herniated disc, tethered cord etc often cause the pain
new onset painful scoliosis- benign osseus lesions
benign bone tumors cause pain
more male predominance while idiopathic is more female
kyphosis
excessive curvature in thoracic spine
hyperlordosis
increased swayback
Sheuermann’s
inc kyphosis > 45 degrees, with 3 adjacent vertebrae at apex
more rigid
tight hamstrings or contracted pectoral muslces
.5-.8%
autosomal dominant
refer to ortho
spondololysis
stress fracture of vertebrae
most common in 5th vertebra in lower back, in fourth lumbar vertebra (L5)
low back pian usually self limited & seldom lassts
persistent pain > 2-3 wks needs referral
do one leg hyperextension test for dx
often from repetitive use- recurring truama, flexion, hyperextension or twisting
spondylolisthesis
prereq is spondylolysis
- when 1 vertebra slips forward on adjacent vertebrae
gradual deformity of loewr sine, narrowing of vert. canal, assoc w pain
you see this in athletic kids,
lumbrosacral area most often
can involve gatigue gracture at pars interarticularis (this si spondylolysis)
symptom- discomfort localized one sided to paraspinous region above belt
tarsal coalition
flat feet, no arch on tip toes
sever’s disease
if you press at the heel, its painful
friction- when the heel is lower than the top of the foot; the achilles rubs against bone opothocitis
Sports physical history
history- fam history, personal, ROS, keep RECORD OF THIS, collection of data prior to exam
chest pain? syncope? chest pain during exercise ?
menstrual history, heat related illness? any red flags–>cardio consult
PE for sports exam
BP, ht, wt eyes- anisocoria? heart- listen sit, lay, squat chest abdomen- hepatosplenomegaly? genitalia-active lesions- ex) herpes simplex or glatiroium- wrestling etc
2 min musculoskeletal exam
1) inspect child- symmetry
2) forward flexion, ext, rotation and lateral flexion of neck- ROM of cervical spine
3) Resist shoulder shrug (strength of trapezius, test CN XI)
Differences in Pediatric
Anatomy l
More radiolucent cartilage
l Growth plates prone to separate before joint
ligament tear
l Bones more porous & less dense prone to bow
when bent
l Thicker periosteum – reduces fracture
displacement, produces more callus, rapid
healing
l Bone formation potential greater, non unions
are rare, potential for overgrowth in shafts of
long bones
l Ability to remodel bones
intramembranous dev
develops in connective tissue
Intracartilaginous dev
catilaginous mass precedes
ossification
– primary center of ossification- diaphysis
– secondary center of ossification- epiphysis
Epiphyseal plate
– cartilaginous tissue separates diaphysis & epiphysis
– at skeletal maturity epiphyseal plate closes
-consider tanner stage and sex of child. for instance if a 16 yo has fracture, if he is a male: his growth plate is tli up til 21, more likely to be a break
if 16 yo female w same injury and her menses began 3 yo, then she is more likely to have a sprain cause her growth plates are closed
Neurovascular exam
pain, parasthesias, puleslessness, purple or pale color, paralysis, painful passive motion
radial nerve test
thumbs up sign
median nerve
a ok sign
ulnar nerve
spread or cross fingers
Plastic Fracture
bowed beyond natural recall
buckle/ torus fracture
compression at metaphysis and diaphysis junction “bump in road”
greenstick fracture
disrupts but not completely broken cortext- “incomplete” fracture
Avulsion
tearing away part of the bone by ligament or tendon
common site- hip
complete fracture
complete through born- from force
physeal fractures
higher the salter harris number, the great risk of growth plate arrest and joint incongruity
Physeal fractures- TYPES
Type I- separation of physis only; not typically seen on xray- splint, forms callus in 7-10 days, needs f/u appt
type II- separation fo physis with triangle fragment of metaphysis
type III- separation of physis and passes through metaphysis
Type IV- fracture passes through metaphysis, physis, epiphysis and into joint
type V- compression injury of physis, diagnosed in retrospect
SALTER
S-slice through (type I) A-Angled up (II) L (going down (III) Totally through (IV) ERased growth plate- (V)
Ankle injury
lateral collateral compex most often involved (85%)
strain is injury to muscle tendon unit attached muscle to bone
sprain is injury to ligament-holds joint together
if there is pain on the outer part of the foot, ovr the ligament, it is usually a strain
if there is pain over the malleolus, may be fracture
Ottawa Ankle Rules
An xray is needed if: pt has pain in malleolar zone and either bone tenderness over areas of potential fracture OR cannot bear weight for 4 steps immed. post injury in ED or Office
differences in pediatric and adult airway
larger tongue
tonsils and adenoids are larger
narrower airway, shorter, mores oft tissue, soft laryngeal cartilage
epiglottis- floppy, omega shaped, inc secretions
differences in pulmonary
fewer and smaller alveoli
less supportive pulmonary elastic and collagen tissue
cartilaginous sternum ribs
porly dev intercostal and accessory muscles–>resp aarrest
thin chest wall
Tachypnea
> 60 breaths per min
tachypnea 2-12 months
> 50 breaths per min
tachypnea 1-5 years
> 40 breaths per min
tachypnea 5 years +
> 20 breaths per min
Inspection: what does a precordial bulge indicate?
cardiac defect, pneumothorax, or chronic localized chest disease, or CF
suprasternal retractions indicate
high obstruction, severe
infrasternal retractions indicate
low obstruction
harrison’s groove
flaring of the ribs (bottom of pectoral muscle) seen often in hispanic kids
Percussion, where you should hear flatness
over thigh
where you should hear dullness
over liver
where you should hear resonance
over lung
where you should hear hyperresonance
none is normally present
where you should hear tympany
gastric air bubble or puffed out cheek
increased areas of vibration with tactile fremitus indic
decreased virbration with:
lung consolidation
dec with or absent when bronchus is obstructed
normal vesicular lung sound
short expiration, long inspiration
tracheal breath sounds
heard at suprasternal notch or lateral neck
hollow
non musical
heard clearly in insp and exp cycle
rep intrapulmonary sounds but can be disturbed if upper airway patency is altered
*reps upper airway patency
insp and exp are equal
bronchial breath sounds
soft
nonmusical
heard on both phases of resp cycle, mimicing tracheal sounds
indicates patent airway surrounded by consolidated lung tissue) pneumonia, fibrosis
I = E
stridor
high pitched, musical
best heard upper airway or at distance without stethoscope
indicates: upper airway obstruction
assoc with extrathoracic lesions- laryngomalacia, vocal cord lesions
and assoc w intrathoracic lesions (tracheomalacia bronchomalaia, extrnsic compression on expiration
will hear w foreign bodies
vocal cord dysfunction & stridor
aka paradoxical vocal cord motion
resp condition characterized by:
inappropriate adduction of vocal cord
resultant airflow limitation at level of larynx, accomp by stridorous breathing
if a kid w “asthma” does not improve on asthma meds- consider this
wheeze
musical, high pitched
can be heard on insp and exp
localized wheeze: suggests airway narrowing or blockage (foreign body) if it is
Generalized wheeze: assoc. w airway narrowing and limit of airflow ex) COPD, asthma
monophonic wheeze
large airway obstruction
inhaled foreign body, endobronchial tuberculosis, bronchial adenoma, enlarged mediastinal nodes, malignant tumors
*pts with monophonic, localized wheezing- consider mass lesion
polyphonic/heterophonous wheezing
small airway obstruction
exp. wheezing is predominant pres.
asthma, bronchiolitis
Transient Earlier Wheezing-TEW
usually disappear in early toddlerhood, patients will freq rattle as a wheeze, rattles get misdiagnosed in young children as a wheeze
rhonchus
musical and similar to snoring
lower in pitch then wheeze
may be heard on inspiration, expiration or both
assoc w fluid films and abnormal airway collapsibility
often clears with coughing–suggesting large airway involvement
soudns like snoring
clears with coughing vs. crackles which won’t
lower pitched than qheeze
fine crackles
nonmusical
short, explosive
heard on mid-late inspiration and occasionally on expiration
unaffected by cough, gravity dependent
you won’t necessarily always hear these in kids!
coarse crackles
nonmusical, short and explosive heard on early insp and throughout exp transmitted to mouth affected by cough indicates intermittent airway opening
croup
history is consist w URI w/ or w/o low grade fever
barking cough- often starts late in evening after child has been asleep
child can be progressively worse by 2nd/3rd night
mild: just expiratory stridor
severe: exp and insp stridor
steeple sign on lateral neck film
steeple sign is associated with
croup, lateral neck film
asthma history
time of onset, triggers
severity of symptoms, esp compared with current exacerbations
treatments given before ED? response?
all current meds, time of doses, hospitalizations, PICU?
Asthma Vitals
unusual fever
pulsus paradoxus- drop in systolic BP of 10 mmhg or more with inspiration- hard to measure and not as useful as we thought
increase in RR initially bu with fatigue in severe asthma it can slow
Asthma PE- Lungs
wheezing can be diffuse; first on exp then both insp and exp
localized initially
shifting in location as degree of obstruction varies
can be oconfused as pneumonia with persistent cough and localized rales
accessory muscle use indicates obstruction
presence of air leak may occur and present as subcut emphysema, deviated trach
C-ACT
childhood asthma control test- how well controlled is the asthma?
PASS
pediatric asthma severity score ** she likes this one better; mild/mod/severe/ resp arrest
wheeze, work of breathing, prolonged expiration, breah sounds aeration, breathlessness
PRAM
pediatric resp assessment measure
asthma diagnostics
Chest xray- not routine use, maybe for first time wheezer
spirometry- degree of resp compromise, peak exp flow rate over 6 but not likely practicle under 8 year old
30-50% of predicted or patient’s personal best–severe obstruction
Oximetry
Blood Gases in severe exacerbation- PCO2 is dec initially then may elevate as sign of muscle fatigue, hypoxia or hypercapnia–>acidosis
Pertussis
can happen even w immunization- 15% failure rate
cough up to 6months after acute illness
often from adult
infants might not have whoop but have paraoxysmal coughs and turn red or blue
3 phases of Pertussis
1) Catarrhal- 2 weeks, URI S/S w conjunctival injection, fever, mild cough
2) Paroxysmal- frequency and sev of cough inc 2-4 weeks
may have whoop, posttusive emesis, apnea
3) convalescent- les freq cough, dec severity 1-2 weeks
pertussis cough variations by age
older children, adolescents, adutls- milder symptoms, bronchitis like
infants- do not have enough diaphragmatic pressur to whoop–paroxysmal cough, post-tussive vomiting, cyanosis, apnea
1 reason for chronic abdominal pain in children
constipation
1 finger test
can child point to localize pain
LUQ organs
pancreas, spleen
RUQ
liver, gallbladder
LLQ
colon, intestine, L ovary
RLQ
intestine, appendix, R ovary
scratch test**
non touching maneuver
help to identify hepatosplenomagaly and avoid rupture
CVA tenderness
pt seated upright, place palm of left hand over CVA strike with left hand
tenderness indicates: pyelnephritis (inflamm of kidney substance and pelvis, or perinephric abscess
Red flags for abd assessment PE
guarding- peritonitis, appendticitis, cholecystitis
point tenderness- appendicitis, cholecystitis at McGurney’s point
Asymmetry- appendiceal abscess, tumor
No bowel sounds- peritonitis, infarcted bowels
Palpable mass- tumor, cyst, intussusception
Nutritional status- weight, height, edema, anemia
extra intestinal features- arthritis, skin, ciliary injection of uveitis is seen with crohn’s and JRA
Abd distention- peritonitis, obstruction
visible bowel loops- intussuseption, obstruction
high pitched bowel sounds- obstruction
Acute abdominal pain
slow or rapid onset of pain in abd; usually steadily builds; can relate to an event, can hve v/d, fever, anorexia, guarding is usually present
Subacute abdominal pain
won’t localize with 1 finger test
onset is more difficult to pinpoint
not acutely ill
allows exam of abd, may be vague in location and tenderness, hard to localize
chronic abdominal pain
onset assoc w an event that child doesnt want- test, gym, recess, not localized, does not waken child, can resolve spontaneously, pain is out of proprtion to PE, labs normal
“hyperresponsive” gut
Causes of epigastric pain
peptic ulcer disease (h pylori) GERD gallbladder trauma idiopathic
causes of periumbilical pain
functional abd pain, abd migraine, strept pharyngitis, gastroenteritis, appendicitis, carb or lactose deficiency
CAUSES OF RLQ PAIN
OVARIAN TORSION, APPENDICITIS, PID, ECTOPIC PREG, MITTELSHMERZ (MID MENSTRUAL CYCLE), RIGHT LOWER LOBE PNEUMONIA, inguinal hernia, iliopsoas abscess
LLQ pain cuase
constip, right ovarian or testicular pain
causes of suprapubic pain
UTI, const, urinary ret, hydrometrocolpos`
non abdominal causes of abdominal pain
pneumonia, strept pharyngitis ( not known why), reproductive tract disease (STD, ovarian cyst, ectopic preg), DKA- serum amylase elevated btu pt doesnt have pancreatitis, sickle cell disease- vasoocclusive crisis, gallstone formation, gallstones,
*any hemolytic anemia can cause gallstones**
factors suggesting acute abdomen
bilious vomiting (green) abd tenderness distension abd mass obstipation (severe const) feeding intolerance edema of abd wall crying, irritability, fever, hypotheremia, omphaltiis, severe pain
appendicitis clinical hx
pain precedes vomiting** n.v tenderness at McBurney's Point fever Leukocytosis
clinical pres of appendicitis - Toddler age
toddler: fever, vomiting, pain intermittent and refrred to right hip with limp; localized or gen abd pain
clinical pres of appendicitis- school aged child
abd pain and vom, pain with walking or movement is very specific, fever, abd wall tenderness tends to focal to RLQ, involuntary guarding present, sensitive
Appendicitis Signs and Symptoms: MANTREL
Migration of pain Anorexia Nausea and Vomiting Tenderness on RLQ Rebound tenderness Elevated temp Leukocytosis
Physical Assessment Tools for APpendicitis** 7 things
Mid abd pain to RLQ Anorexia Positive Psoas Sign Obturator sign heel strike Rovsing Sign Markle Jar Heel test
Psoas sign
lie child supine, place righ hand above r knee, direct child to raise leg against pressure, have child drop right leg over exam table–Positive if painful
Obturator Sign
pain occurs when theres internala nd external rotation of the flexed thigh
1) flex child’s R thigh at hip w knee bent
2) rotate leg internally at hip
Rovsing’s
pain in RLQ with left sided pressure
markle jar heel test
up on toes, down hard on heels “bunny rabbit” test, have pt jump up and down
Rebound tenderness
only do if there is no other positive other test, not on young child- firmly and slowly push in, hold, quickly withdraw- the pain is when you withdraw and remove hand
Murphy’s sign
temporary inspiratory arrest with palpation of Right subcostal margin- pain at gallbladder
indicates cholecystitis
Mneumonic for causes of Pancreatitis
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Spider/scorpion Mumps/malig Autoimmune Steroids Hyperlip/hypercalcemia/hyperparathyroid E-ERCP D-drugs, (hiv meds, furoesmide, methanol, salicylates etc0
Pancreatitis
most common from trauma
upper abd pain, periumbilical pain and radiation to back
lipase and amylase elevation
ileus, distension, ascites, hypercalcemia
Nonalcoholic Steatophepatitis (NASH) and nonaloholic fatty liver disease (NAFLD)
strong assoc w obesity, elev of liver enzymes
AST & ALT
NASH- fat in liver, along w inflammation and damage, leads to cirrhosis
NAFLD- fat in liver without inflamation
Bile colored vomit suggests
obstruction, midgut volvus (when get twists and cuts of BF)= URGENT
coffee ground colored vomitus
esophagitis, gastritis, gastric ulcer
bright red, small amount vomitus
esophagitis, gastritis
bright red blood, large amount
esophogeal tear (Mallory Weis tear) gastric ulcer, duodenal ulcer, esophageal varices (less likely in kids)
food or gastric content vomitus
infectious gastroenteritis, obstruction
assessing hydration status
HR**
level of activity
esp important w d, v or dec intake
voiding pattern
mallory weis tear
tear in mucosal layer at junction of esophagus and stomach
Eosinophillic esophagitis- EE
chronic, immune mediated esophageal disease characterized by symptoms r/t esophageal dysf and histologically by eosinophil predom inflam.
isolated to esophagus, and other causes of esophageal eosinophilia should be excluded, spec. PPI- responsive esophageal eosinopiia
S and S of EE
recurrent v, abd pain, dysphagia, pain w swallowing, vomiting happens not always with eating, intense discomfort as swallowed food moves down, episodes last for a few sec, or longer, sometimes food gets stuck in esoph- weight loss if its severe and chronic
heartburn, cough, chest pain –>endoscopy
Rome III criteria for functional abdominal pain
must include these 3 for at least once a week for at least 2 months prior to dx
1) continuous or episodic abd pain
2) insufficient criteria for other functional GI disorders
3) No evidence of inflammatory, anatomic, metabolic, neoplastic process that can explain it
* dx of exclusion*
ROME III DX Criteria for IBS
1) must include both if the following criteria, at least 1/week for 2months prior to dx. Abd discomfort or pain assoc w 2 or more of the following at leats 25% of time
1) improvement with defecation
2) onset assoc w change in freq of stool
3) onset assoc w change in form of the stool
no evidence of any inflammatory process
Dx criteria for Functional Dyspepsia
1) persistent or recurrent pain or discomfort centered in upper abd
2) not relieved by defecation or assoc w onset of change in stool freq or form
3) no evidence of inflamm, anatomic, metabolic or neoplastic process to explain symtpoms
Pyloric Stenosis
not a mechanical osbtruction
familial
5:1 male
non bilious, projectile vomiting
hungry after
hypochloremic metabolic alkalosis (they vomit out the chlorids–>alkalotic;
often presents at 3-6 weeks of lfie w nonbilious projectile vomiting
infant dyschezia
normal!
infant grunts and groans while stooling, soft stool,
this is a failure to coordinate relaation of pelvic floor and sphincter
its normal
Malrotation with Volvulus
abnormal fixation of bowel mesentary with twisting around mesenteric artery painful distended abd bilious vomiting blood in stool abd pain
bilious emesis is…
mechanical obstruction unless proven otherwise!
intussusception
invaginating or telescoping one portion of the bowel into itself; produces obsrtuction and vascular compromise
most freq cause of mechanical obstruction in infants and toddlers
cuts off BF–>mechanical obstruction
males- 5-1- months, 2x > females
Jelly stool is classic sign, vomiting, and intermittent abd pain with palpable sausage shaped mass “Dance’s Sign”
palpable mass most often seen in RUQ
ileocolic insus.- telescoping pulls bowel structures upward in abd
fever, diarrhea, bloody stool takes longer to dev
Dance’s Sign
assoc w intussusception- concavity in RLQ due to abscence of underlying bowel
Dx and Tx for intussusception
Barium enema is 100% Diagnostic
pneumatic reduction - less sedation, pain, less morbid and 80-90% success
hydrostatic reduction is effective in 60-80%
operative reduction if others fail
recurrence rate 8-12%
Hirschprung’s
no stool within 48 hours of birth; constip from birth, FTT, marked distention, abnormal rectal anatomy
aganglionic megacolon- won’t stimulate expulsion
pungent odor`
Hirschprung’s presentation in newborn
more distended without peritoneal signs unless perf, react minimally to exam, lethargic, fever, tachycardia, ominous hypotension
rectal exam- slight pressure on examining finger with no stenosis or obstruction
ampulla empty- on removal, explosive evacuation of stool or gas
Hirschprung’s presentation in infant and kids
chronically distended, nt abd, large fecal masses on left
rectal exam-ampulla empty
anal tone is normal
explosive stool will also occur post exam
constipation and decreased height may indicate
hypothyroidism
hematemesis
vomiting of blood or blood per rectum- coffee grounds, or bright red
melena
dark or black tarry stools when bleeding is from upper tract
hematochezia
maroon stools which indic distal GI source of short transit time from briskly bleeding proximal source
juvenile polyps- lower GI bleeding
prox to transv colon, uncommon in infants
bleeding with sloughing of polyps
painless, rarely massive
gardner’s syndrome: malignant potential
anal fissures- older children we are concerned about Crohn’s
Meckel diverticuli
found in 2% of pop
most common source of significant GI bleeding in kids*
preschool- bleeding is a result of HCL secreted from gastric mucosa in the diverticulum-forms an ulcer on ileal mucosa
diff btw ulcerative colitis and Crohn’s
UC: colon only, Crohn’s: anywhere mouth->anus dig track
UC- diffuse, continuous superficial inflam, edema and shallow ulceration in small pseudopolps in rectum desc colon as far as ileocecal junciton
Crohn’s= focal asymmetrical inflamm anywhere along GI, most common in terminal ileum prox to colon and ileocecal jx
Ulcerative colitis hx
15-30 years old dx
acute bloody diarrhea
cramping, tenesmusm pallow, growth retardation
extraintestinal manifestations of UC
arthralgia (knees, ankle, wrist), uveitis, oral ulcerations (aphthous ulcers), growth retardation, liver diseased , erythema nodusum , pyoderma granulosum (skin)
Crohn’s
weight loss 90%, abd pain, typically RLQ, diarrhea, fever, bloody diarrhea, anal skin tag, perianal ulcerations
same extraintestinal manigestation
neuroblastoma
most common tumor under 1 year
pres signs vary w primary site: 2/3 are adrenal, remainder are in sympathetic paraspinous ganglia; posterior mediastinum, less than 5% in head neck
vasoactive intestinal peptide, watery D, distention, electrolyte imb, opsoclonus-myoclonus- dancing eyes with myoclonic jerks w or wo cerebellar atxia, catecholamine excess: flushing, tachy, headache, HTN (renal origin);
Neuroblastoma-PE
Head and Neck- visual changes, exopthalmos, horner’s- (ptosis, meiosis, anhydrosis), cerebellar ataxia
thoracic- neuro abnorm, cough, SOB
Raccoon eye
Heterochromia Iridis
child presents sick (unlike wilms where child presents well);
hard, fixed, firm w irreg border
wilm’s tumor
abd mass firm flank, nt, not usually crossing midline,
DO NOT TOUCH BELLY if you are considering Wilm’s
younger kids (mean: 30months)
well appearing, most common abd malig, asymptomatic, rarely pain, HTN, Microhamturia
