physicals

Question 1

describe the newborn exam

Answer 1

1. ABCs
2. weight, length, head circumference and plot

inspect–

3. look for dysmorphic facies or limb abnormalities
4. work of breathing
5. pallor, plethora, jaundice or cyanosis (acrocyanosis is normal)

skin–
6. milia? pinpoint white papules on the face that resolve spontaneously
7. mongolian spots? blue patches, normal
8. birth marks? normal…
numerous or large birthmarks may need assessment
9. erythema toxicum–usually day two or three, resolves spontaneously
10. petechiae or bruising? –higher risk for neonatal jaundive

HEENT–

11. palpate anterior fontanelle and coronal/sagittal and lambdoid sutures and posterior fontanelle
12. caput saccudeam? swelling crossing suture lines
13. cephalohematoma? does not cross suture lines
14. sub-galeal hematoma? more worrying–fluctuant boggy mass moveable across whole scalp.
15. red reflex
16. dysmorphic features?
17. if infant can breath on own with mouth closed, no choanal atresia–check nasal airways by occluding one nostril then the other
18. check ears–floppy? large?
19. palate inspected and palpated
20. palpate SCM muscles and ROM of head
21. palpate clavicles for fractures
22. webbing or redundant skin in female? think turners

chest–

23. look for asymmetry
24. listen to air entry in lung fields
25. heart sounds in murmur on both chest and back
26. brachial and femoral pulses and compare strength and timing

abdo–

27. inspect for defects
28. 3 vessel umbilical cord–2 arteries and one vein (if not–renal US)
29. palpate for internal organs–liver 2 cm below costal margin, maybe spleen tip. kidneys on deep palpation.

GU–

30. inspect for ambiguous genitalia, clitoromegaly (larger than 1cm), both testes descended/scrotal swelling
31. penile length of less than 2.5 cm suggests micropenis and should be investigated
32. patent anus
33. sacral dimple

MSK–

34. spontaneous symmetric movements of extremities are good
35. examine hands and feed for normal numbers of digits and single palmar creases and club foot
36. examine hips–barlow and ortolani maneuvers
37. spine–scoliosis? (run spine down back)

neuro–

38. posture while supine–flexion at hips, knees and elbows is normal. hypotonia?
39. assess tone in ventral position
40. primitive reflexes–plantar, sucking, moro, gallant and grasp

Question 2

absence of red reflex suggest?

Answer 2

neonatal cataracts or other pathology

Question 3

when should all of the meconium have been passed by?

Answer 3

first day of life

Question 4

what does it mean if meconium is passed beyond first day of life

Answer 4

investigate

Question 5

describe the pediatric CV exam

Answer 5

1. ABCs, stable?
2. signs of acute distress–pallor, sweating, cyanosis, WOB
3. history
4. body habitus, dysmorphic features (turners, downs, digeorge)
5. vitals (head circ under 5 weeks); if HR regular, take for 15 sec then multiply by 4; BP in all 4 limbs

inspection–

6. hands and feet–clubbing (angle)? splinter hemorrhages or other nail problems?
7. capillary refill less than 2 sec
8. increased WOB: tachypnea, intercostal indrawing, tracheal tug, head bobbing, nasal flaring, abdo breathing in older child
9. scleral icterus or pallor in eyes?
10. central cyanosis in mouth?
11. mucous membranes for volumes status
12. chest shape
13. precordial bulge?
14. pectus carinatum or excavatum
15. visible cardiac impulse–often normal

peripheral palpation–

16. radial, brachial and femoral pulses–rate, rhythm, volume and contour
17. brachial-femoral delay–coarct?
18. dorsalis pedis and posterior tibialis

precordium palpation–

19. palpate apex beat–5th intercostal space in mid clavicular line, less than 2cm, tapping quality, less than 2/3 of systole (left lateral decubitus if hard to feel)
20. heaves–forceful lifts
21. thrills–turbulent flow
22. palpate all 4 auscultory areas
23. palpate liver–indication of right sided heart function–normal liver is 2 cm below costal margin–around 7 cm is normal liver span (percuss)
24. enlarged spleen is more than 2 cm below costal margin
25. edema?

auscultation–

26. listen in all four positions both sitting and supine with both bell (low pitched… gallops and s2 split) and diaphragm (high pitched… most murmurs, s1 an s2, pericardial rub)
27. if murmur, listen for radiation
28. listen to lungs–crackles?

Question 6

symptoms of CV disease

Answer 6

cyanosis

seating during feeds

SOB

palpitations

edema

chest pain

syncope

Question 7

whar drugs can be associated with cardiac lesions in the neonate (when used during pregnancy)

Answer 7

lithium

phenytoin

alcohol

Question 8

what maternal diseases can cause cardiac defects in the child

Answer 8

SLE

rubella

diabetes

Question 9

how big should the BP cuff/bladder be?

Answer 9

should cover 40-75% of the arm and should be able to encircle arm and close

Question 10

what characteristics suggest a benign murmur

Answer 10

systolic

normal s1 and s2

soft less than 3/6

otherwise healthy

often position dependent