Physical Assessment Flashcards
routine examination of the newborn
within 24 hours of birth
Significant Congenital Anomalies
congenital heart disease, hypospadias, down syndrome
order of examination
The exact sequence in which the newborn is examined is flexible so long as the entire body is examined at some stage
general observation
weight, length, head circumference, GA, general observation, movement and tone
head and face
fontanelle, facial appearance, and dysmorphic features
eyes
cataract, red eye reflex
mouth
cleft lip and palate, central cyanosis
Upper limbs
digits, palmar creases
chest
RR, retraction, heart sounds and murmurs
pulses
femoral
genitalia and anus
hypospadias, undescended testes, ambiguous genitalia, anus-position and appearance
back
midline defects
abdomen
abdominal distention, enlarged liver, spleen, kidneys or mass
hips
developmental dysplasia of the hips
lower limbs
talipes-positional, equinovarus
CDC/WHO full term female weight
2.7-3.85kg
CDC/WHO full term male weight
2.8-4kg
head circumference female
32-35cm
head circumference male
33-36cm
central cyanosis
best observed on the tongue
asymmetric crying face
congenital absence of the depressor anguli oris muscle
neonatal urticaia
2-3 day of day, rash; white pinpoint papules at the center an erythematous base, EOSINOPHILS; migrates to other sites, resolved by day 5
neonatal pustular melanosis
birth; NEUTROPHILS; readily removed by wiping, can be mistakem for staphylococcal infection
Milia
bening white cyst; nose and cheeks; retention of keratin and sebaceous material
harlequin color change
reddening and blanching; last for few minutes, due to vasomotor instability
Mongolian blue spots
base of spine /buttocks
Cafe au lait spots
common, more than 6 underlying disorder
capillary hemangiomas/stork bites
pink macules, caused by distention of dermal capillaried; upper eyelids, mid forehead, nape of the neck; fade over teh first year
port-wine/nervus flammeus
unilateral or segmental, do not cross midline; do nto fade will grow with child and become darker; evaluate infant for glaucoma and brain lesions (intracranial vasular anormalities)
most common benigh tumor of infancy
strawberry nevus/infantile hemangiomas; RX: propranolol
tense fontanelle
increased intracranial pressure: HUS; meningitis: LP
caput succedaneum
bruising and edema of the presenting part of the head
cephalohematoma
bleeding between peristeum and skull bone, confine within margins of the skull sutures, parietal bone, does not cross midline
subgaleal hemorrhage
bleeding between galea aponeurosis and periosteum; vacuum extractions; “wave sign”; potencial for large blodo loss causing hypovolemic shock
craniosynostosis
premature fucion of one or more cranial sutures; might restrict brain growth
coloboms
defect in a normal eye tissue
CHARGE syndrome
normal ears
the top third of the ear is level with a line drawn from the inner to the outer canthus of the eye
preauricular tags
ear skin tag
webbed neck, lymphydema of the feet
Turner syndrome
normal periodic breathing
up to 10 sec
HR
120-160
heart murmur
reflect directly for ECHO
single umbilical artery
asymptomatic renal abnormalities
micropenis
less than 2cm, suggests congenital hypopitutarism
hypospadias
urethral meatus is in abnormal position
polydactyly
extra digits
syndactyly
fused gigits
clinodactyly
bend digits
Trisomy 21
single palmar transverse creases
Clavicle fractures
supportive care only, immobilization for comfort
talipes equinovarus
feet turned inward from intrauterine compression/clubfeet
Ortolani manouver
when the posteriorly dislocated femoral head can be returned to the acetabulum
Barlow manouver
when the femoral head is in the acetabulum at rest but is dislocatable posteriorly out of the acetabulum,
developmental reflexes
rooting, sucking, palmar grasp, moro responses
Ballard examination
GA, 6 neurological, and 6 physical
CCHD AAP recomendations
Any oxygen saturation (SpO2) is less than 90%.
Oxygen saturation is less than 95% in both extremities on three measures, each separated by 1 hour.
There is a greater than 3% absolute difference in oxygen saturation between the right hand and either foot on 3 measures, each separated by 1 hour.
Erythema and Abrasions
dystocia, forceps delivery; self resolving within several days
Petechiae
head, neck, upper portion of the chest, and lover portion of the back at birth after a difficult delivery, self resolving
Ecchymoses/bruising
traumatic or breech deliveries; may cause increase in bili; resolve in 1 week
subcutaneous fat necrosis
rare form of panniculitis seen mostly in term or post-term infants characterized by well-circumscribed, indurated lesions of the skin and underlying tissue; associated with perinatal asphyxia and may be associated with hypercalcemia
Lacerations
inflicted with a scalpel during cesarean section
caput succedaneum
frequently, vaquely demarcated area of edema over presenting portion of the scalp; serum or blood; may extend across the midline of the skull; diminished 48-72 hours post delivery; EXTERNAL to periosteum
cephalhematoma
infrequent subperiosteal collection of blood overlying a cranial bone; mechanical trauma, rupture of diploic blood vessels that traverse from skull to periosteum; limitation to one bone; no overlying discoloration; later swelling, longer time of resolution: 3-4 weeks; BENEATH the periosteum
subgaleal hemorrhage
collection of blood in soft tissue between the galea aponeurotica and periosteum of the skull; midforceps and vacuum extractions; fluctuating mass straddling cranial sutures, fontanelles, or both; signs of hypoperfusion and falling hematocrit; Prompt restoration of blood volume with fresh frozen plasma or blood is essential;
skull fractures
uncommon; forceps delivery(depressed fractures) or difficult; most fractures are linear; labor
linear fracture
soft tissue changes and cephalhematoma
depresses fractures
visible, palpable indentations in the smooth countour of the skull, ping-pong ball
Facial Nerve Palsy
spontaneous recovery; compression of the peripheral portion of the nerve by forceps or maternal sacral promontory; paralysis;
clavicle fracture
greenstick type, but occasionally the fracture are complete
liver rupture
most frequently injured abdominal organ during the birth process
maxilla, lacrimal bones, and nose fractures
may present with respiratory distress and warrant emergent surgical attention
Duchenne-Erb palsy
mechanical trauma to the spinal roots of the fifth cervical through the first thoracic nerves (D-E: 5th and 6th cervical roots)
congenital anomaly
an internal or external structural defect that is identifiable at birth
malformation
primary structural defect in tissue formation (neural tube defect, congenital heart defect); genetic or teratogenic factor
deformation
abnormal mechanical forces acting on otherwise morphologically normal tissues; clubfoot, altered head shape
disruption
destruction nor interruption of intrinsically normal tissue
single gene / mendelian
limb anomalities
chromosomal
Downs Syndrome
subconjunctival hemorrhage
blood absorbed in 1-2 weeks
phrenic nerve paralysis
injuries are unilateral and are associated with ipsilateral upper brachial plexus palsy; ultrasonographic examination; The infant should be positioned on the involved side, and oxygen should be administered for cyanosis or hypoxemia.
torticollis
more of inuretro positioning; shortened sternocleidomastoid muscle; The head tilts toward the involved side, and the chin is somewhat elevated and rotated toward the opposite shoulder. The head cannot be moved passively into normal position.
dysmorphisms
anomalous external physical features
association
multiple congenital anomalities: VATER, CHARGE
syndrome
recognized pattern of anomalities with specific, usually heritable cause: Holt-Oram syndrome, The Cornelia de Lange syndrome
etiology of malformations broad categories
genetic(multifactorial, single gene/Mendelian, or chromosomal), environmental/teratogenic, and unknown
genetic complex examples
congenital heart defects, neural tube defects, cleft lip and palate, clubfoot, congenital hip dysplasia; usually genetics and environmental
single gene/Mendelian examples
limb anomalities, Smith-Lemli-Opitz syndrome;
chromosomal examples
down syndrome/trisomy 21; trisomy 18, and trisomy 13; aneuplodidies of the sex chromosomes (Klinefelter syndrome or Turner syndrome)
chromosomal aberrations testing
karyotype, FISH, chromosomal microarray (SNP); WES
teratogen
anything external to the fetus that causes a structural or functional disability in prenatal or postnatal life
common teratogens
alcohol, anticonvulsants, some altered metabolic states in the mother, (DM, phenylketonuria), infections (TORCH(toxoplasmosis, syphilis, rubella, cytomegalovirus, and herpes simplex
congenital anomalities goal of the physical examination
to determine whether an anomaly is isolated or to detect a recognizable pattern of malformation so that a specific etiologic determination can be made
genetics skin
trisomy 21, hypothyroidism, cornelia de Lange syndrome-marbling pattern called cutis marmorata; Cafe-au-lait spots_neurofibromatosis
genetics hair
sparse hair: ectodermal dysplasia; hirsutism: cornelia de lange syndrome, FAS
genetics head
macrocephaly, microcephaly
dolichocephaly
increase in anteriorposterior diameter
brachycephaly
decrease in anteriorposterior diameter
plagiocephaly
assymetric head shape
hypotelorism
eyes too close together
hypertelorism
eyes too far apart
holoprosencephaly
trisomy 13
epicanthal folds
normal, but also in trisomy 21
coloboma
defect in eyelid margins; CHARGE syndrome
synophrys
fusion of the eyebrowns in the midline
microstomia
small mouth
macrostomia
large mouth
omphalocele
abdominal contents protrude through the umbilical opening
gastroschisis
isolated disruption in which the abdominal contents protrude through the periumbilical abdominal wall
APGAR
heart rate, respiratory effort, muscle tone, reflex irritability, color
BALLARD neurological
posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear
BALLARD physical
skin, lanugo, plantar surface, breast, ear/eye, genitalia
sucking reflex
birth, develop 33-36 weeks GA
rooting reflex
stroke the cheek and the corner of mouth
palmar grasp
tighting grasp, apparent at 28 weeks, strong by 36 weeks
tonic neck reflex
supine, head to the side, upper extremity extended on the side head is turned, fencing position
moro reflex
response to the sensation of loss of support, spreading movement of arms and hands, appears at 24-26 weeks, evolves throught 38
stepping refles
neonate held upright, alternating stepping movements
truncal incurvation reflex
ventral suspension, pressure parallel to the spine and thoracic area
babinski reflex
sole of the foot, plantar flexion, positive is normal: extension of toes, up to 18 months
Alpha-Fetoprotien Level
15-18 weeks pregnancy; neural tube defects
Aminocentesis
for MOB with known hereditary disorders, over 35 years old, Rh disease for optical density; trisomy 21; 18-20 weeks; later for fetal lung maturity
Assessment of Fetal Activity
kick count by MOB; 28+ weeks; 4 fetal movements per hour
Biophysical Profile
US and nonstress test; includes: AF index, fetal breathing, gross and fine movement, fetal tone
Chorionic Villus Sampling
chromosomal or biochemical defects; transabdominal or transcervical; 10-12 weeks, results in 24 hours;
Contraction Stress Test
FHR to uterine contractions; positive test (needs follow up) shows late decelerations in FHR
Doppler Velocimetry
blood flow in the umbilical arteries during diastole; placental perfusion; used in twin to twin transfusion in utero
Fetal Fibronectin Levels
“glue” , positive predictor of preterm labor and impending birth
Human Placental Lactogen Levels
low levels indicate uteroplacental insufficiency in maternal HPT;
Lecithin-Sphingomyelin Ration
L/S ration determines fetal lung maturity is done on AF; ; risk for many false high levels: blood, mec, vaginal seccretions
Lung Profile
L/S ration and PG levels; increase PG indicate mature lungs;
Maternal Serum Estriol Levels
increase as pregnancy advances; sharp or progressive decrease indicates fetal compromise;
Noninvasive Prenatal Screening NIPS
cell-free DNA analysis; Trisomies; MOB blood testend of first trimester
Nonstress Test
tests placental function that assesses FHR acceleration and variability; monitor MOB for 20-60 minutes increase of FHR by 15 bpm
Shake Test
AF for lung maturity indicated by a complete ring of bubbles in dilution of AF and ethanol
Ultrasound
GA, altered or abnormal growth, malformations; Placenta GRADE 0-III; Amniotic fluid volume (AFV); trisomy 21 (nuchal fold)
Unconjugated Estriol and Human
Chorionic Gonadotropin Levels
trisomy 21 and 18;
Cord Blood Gases
for low apgar scores,
FHR monitoring
120-160 bpm normal; early decels: benign; variable decels: umbilical cord compressions; late decels: fetal hypoxemia
pH of umbilical and/or fetal Scalp Blood
compared with APGAR scores; 7.27-7.28
Brazelton Scale
“cost of attention” amount of energy the infant must expend to maintain interaction; evaluates baby reflexes, muscle tone, state changes, and responsiveness to physical and social stimuli
dolichocephaly
premature infant; flattened one side of the head without craniosynotosis
craniotabes
soft or thinning bone; “ping-pong ball”; vitamin D deficiency
ankyloglossia
tonge tie
cystic hygroma
neck mass
