Physical Exam Flashcards
First thing you check with a child when you go into the room?
Say hello, smile, and introduce yourself.
See the general condition of the child (Are they healthy? Well fed? Good condition?)
Official temperature of a baby? Where do you check?
L
First you check the skin. What is a common skin lesion on infants? What two things do you check, where?
Look for skin lesions (especially hemangiomas) Prick test (infants belly button and forearm for toddler) Capillary refill test (less than 2 seconds on toddle and infants if it is done sternum because they have slower peripheral circulation)
Head and neck exam
- ) Check eye movements
- ) Sclera (color, can be blue in osteogenesis imperfecta and red, conjunctivitis)
- High carotene (pumpkin and carrots can’t cause eye color change but skin oranging) - ) We check lymph nodes (plus auxiliary [check bcg left lymph nodes] and femoral nodes and vessels), conjunctiva, and mouth
- ) Check the fontanelles for size and if it is even, protruding, and sunken in
Pulmonary system exam includes and what is seen on inspection
Inspection, percussion, palpation
-chest inspection (pectus excavatum, pigeon chest, scoliosis, asthma (under 4)=obstructive bronchitis until proven as asthma but some babies also just have barrel chest [barrel chest]
Breathing rate and cough/wheeze
Pediatric pulmonology inspection
Inspection
- Cyanosis (lips and peripheral limbs)
- irritability
- nasal flaring
- coughing or choking
- tripod position (use of accessory muscles to aid in breathing)
- grunting (kid tries to increase PEEP)
Percussion pulmonology treatment
Percussion (some institutes say it’s not valuable in pediatrics)
Done in cases where fluid is present
Pulmonology Auscultation steps
- compare the both sides like with adults (apex)
- start from below in kids and work your way up. Kids have pneumonia or bronchitis and are heard best at beginning before airways open with air in the examination
Two types of breath sounds
Bronchial and vesicular breathing
Which breath sound is the loudest
Bronchial breathing is heard over most of the back due the kids being so small
Do you hear bronchial and vesicular breathing on inspiration or expiration
Bronchial breathing is heard both on inspiration and expiration. Vesicular breathing is heard only on inspiration
What happens when bronchial breathing is increased?
Vesicular sounds decreased indicating pneumonia, with exudate inside alveoli or transudate edema due to right heart failure or tumor
What makes breathing sounds fainter in general?
Pneumonia, pneumothorax, tumor, pleural effusion, less chest movement (Pleuritis, phrenic nerve issue, dermatomyosisitis, duchenne, polymyotitis, emphysema)
Adventitious lung sounds
- Friction sound
- Crackle sound
- Rales
- Stridor
Friction sounds can be found in
Pleuritis and can be differentiated from pericardial issues by the patient holding their breath
Crackle sounds are due to? When is it heard? Causes?
Crackles sounds are caused by semi filled alveoli and when the patient inhales the alveoli collects some air and pops open. Only heard in inspiration. Caused by fluid from infection or arrhythmia.
Rales can be separated into 2 types
Wet type and dry type
What is wet type rales
wet type is when fluid or mucus in bronchioles and alveoli, heard in inspiration and expiration (moist bubbling sound)
What is dry type rales
Dry type is whistling due to dry mucus in the bronchi and lead to wheezing sounds best heard in expiration (asthma and obstructive bronchitis)
What is stridor and when can it be heard
Dry type is whistling due to dry mucus in the bronchi and lead to wheezing sounds best heard in expiration (asthma and obstructive bronchitis)
What can be heard in pneumonia? Obstructive bronchitis?
- ) diminished sounds, crackle, rales
2. ) Wheezing/rales
Abdomen exam order
- inspect abdomin (stomach is higher than chest is normal
- auscultate abdomen for 1 minute if they don’t have bowel sounds
- general palpation
- palpate and percuss spleen (in bigger kids)
- percussion of liver after asking patient to turn on side (liver dullness)
When to palpate bladder
During urinary retention you palpate bladder.
Causes include obstruction bph, neurologic damage, drugs, psychologic
Kidney palpation
Feel for costobertebral triangle, try to catch it after they breath in
Palpate deep to try to feel which two tumors developing
Wilma and neuroblastoma (retroperitoneal tumors)
Different lymph nodes and causes for reactiveness
Occipital lymph nodes-rubella, bartonella
Posterior auricular-
Preauricular-
Submandibular- tonsillitis (strep), mononucleosis (check spleen and liver, maculopapular rash due to amoxicillin on day 7)
Submental-
Posterior cervical-chronic otitis (not pathological if you feel many lymph nodes)
Superior cervical-
Supraclavicular- always pathological if palpated
Infraclavicular- always pathological if palpated
Jugular- always pathological if palpated (all three drain from mediastinum and gastric tumors)
Auxiliary (arm at 90 degree angle)- cat scratch, RA, any scratches in the limb
Femoral-
Inguinal-since whole leg drains to that area, kids fall all the time and get cuts. So it is normal to have reactive lymph nodes
What to check on head beside the lymph nodes
Check the mouth, normal color, normal sized tonsils
Pathological/malignant lymph nodes are described as
Not mobile, hard, larger than 1 cm (first test to do is US to see if reactive or pathological)
Meningeal tests include?
Brudzinski’s and Kernig test
For meningeal signs check what first?
Check neck stiffness (up, down, side to side)
Bruzinski sign
One hand behind the head and one on sternum will cause the knees to jerk if it is positive
(back can be painful if there is menigeal inflammation)
Kernig sign
Lift leg up to 40-60 degrees straight, a positive sign is that it’ll bend at the knee
Or
Lift knee in bent position 90 degrees
And try to straighten leg
What symptoms do you try to look for for systemic signs of meningitis
With children you look for system signs Fever Bulging fontanelle Bent back (optistotimus) meningitis and tetanus Crying or lethargy (high pitched) Extended limbs, don’t respond to pain stimuli Hypertension plus bradycardia Sunset eyes
Causes of Meningeal sign
Meningeal sign
Encephalitis, meningitis, muscle rigidity (torticolis, or cervical spine inflammation like ankylosing spondylitis)
And dehydration (edema of brain)
Hydrochephalus, hemorrhage (AV malformation), tumor
How to differentiate between dehydration and meningitis?
To differentiate between dehydration and meningitis give iv bolus, wait an hour, see if nuchal rigidity improves
If not treat with ceftriaxone
Signs of dyspnea
Signs of dyspnea
- nasal flaring
- intercostal retraction (see the ribs)
- subcostal retraction
- jugular retraction
- paradoxical breathing
- difficulty with expiration (prolonged)
Shape of chest in pulmonary disease
Shape of chest
- shape of chest of newborn-barrel shaped chest
- as they grow their chest becomes flatter (2/3 back to front to the length in front of chest)
- if barrel chest continues there is chronic bronchitis
Causes of Tachypnea
Tachypnea
- infection (sepsis)
- anemia
- circulatory problem
- respiratory distress
