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Pediatrics > The Newborn Physical Exam > Flashcards

The Newborn Physical Exam Flashcards

1
Q

The Prenatal Interview: Occur about 4 weeks before the date of birth
Key questions:
5

A
  1. Social circumstances
  2. Health of mother & father, including meds & allergies
  3. Genetic history
  4. Alcohol and smoking history
  5. Pregnancy history
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2
Q

The Prenatal Interview: What should we try and accomplish?

9

A
  1. Breast feeding vs. bottle feeding
  2. Safety/general concerns:
  3. Car seat usage
  4. SIDS
  5. Exposure to cigarette smoke
  6. Crib safety
  7. Work plans/child care plans
  8. Social support
  9. Opportunity to establish relationship
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3
Q

Pediatric or neonatal providers usually NOT present for uncomplicated births
DO attend when greater chance that the infant will need resuscitation:
5

A
  1. Cesarean sections
  2. Multiple births
  3. Premature births
  4. Fetal distress has been noted
  5. High risk pregnancy
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4
Q

Immediately after delivery
1. What should be accomplished?
5

A
  1. Airway cleared of secretions
  2. If baby not in distress may be placed on mother and even allowed to nurse
  3. Still dried and covered to keep warm
  4. If in distress or after mother has had the baby, infant is assessed
  5. APGAR scores are obtained
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5
Q

Temperature Regulation

3

A
  1. Newborn heat regulation not well developed
  2. Sensitive to excess heat loss (hypothermia) & heat retention (hyperthermia)
  3. Temperature is monitored closely after delivery
    Immediately after birth:
    -The infant is dried
    -Radiant heat is provided—also when infant is undressed for physical exam
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6
Q

Assess the integrity of the cardiopulmonary system:

5

A
  1. Heart rate
  2. Respiratory effort
  3. Muscle tone
  4. Reflex irritability
  5. Skin color
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7
Q

APGAR Scores
Obtained at 1 and 5 minutes: range 0-10
3

Timeline if the APGAR score is below 7?
Remains low?

A
  1. 7-10: no vigorous resuscitation required
  2. 4-6: requires stimulation and O2
  3. 0-3: requires assisted ventilation & possible cardiopulmonary support

Scores of 7-10 at one and five minutes indicates stable infant

  1. If scoring less than 7, scoring again done at 10 and 20 minutes
  2. If score remains low, observation of infant in intensive care warranted
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8
Q

Newborn Prophylaxis
In the US it is standard of care for the following routine procedures to be performed after birth to prevent serious disorders:
5

A
  1. Prophylactic eye care to prevent neonatal gonococcal ophthalmia (erythormycin)
  2. Administration of vitamin K1 to prevent vitamin K deficient bleeding (VKDB)
  3. Hepatitis B vaccination
  4. Umbilical cord care to prevent infection (aseptic clamping/cutting dry cord care)
  5. Monitoring for hyperbilirubinemia and hypoglycemia
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9
Q

Routine screening
In the US, universal newborn screening is performed for:
4

A
  1. hearing loss
  2. metabolic and genetic disorders
  3. congenitally acquired infectious disorders
  4. Critical congenital heart disease
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10
Q

What kind of metabolic and genetic disorders do we screen for?
4

A
  1. phenylketonuria,
  2. congenital hypothyroidism,
  3. galactosemia
  4. hemoglobinopathies
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11
Q

The Initial Newborn Exam

  1. Occurs when?
  2. Done where?
  3. Tools?
  4. State of infant?
A
  1. Can occur immediately or within 24 hours of birth
  2. Usually done in nursery/in infant bed at mothers side
    • Use warming light
    • May use a pacifier to quiet a crying infant
  4. Infant completely unclothed
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12
Q

The Newborn Exam
What to look for?
7

A
  1. If infant startles or stops with conversation or noise, probably can hear
  2. If blinks with bright light in eyes, probably can see
  3. If it urinates on you, the urethra is patent
  4. If it defecates on you, the anus is patent
  5. Infant’s response to being examined is a gross neurologic evaluation: crying, moving, fussing, etc
  6. Jitteriness can be a sign of low sugar, seizures, infection
  7. Nasal flaring is a sign of respiratory distress
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13
Q

General Impression

  1. General appearance? 3
  2. Normal hemoglobin?
  3. Plethoric in polycythemia we should suspect?
  4. Pallor associated with what? 2
  5. Whats the normal tone?
  6. Cyanotic associated with what? 2
A
  1. General Appearance
    - Distress?
    - Color?
    - Tone?
  2. Normal hemoglobin 16-17g/dl, therefore ruddy
  3. (suspect maternal diabetes)
    • anemia or
    • poor perfusion
  5. Normal: flexor tone greater than extensor tone
  6. -Cyanosis heart/lung disease
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14
Q

Etiologies of SGA Infants

8

A
  1. Congenital infections
  2. Chromosomal defects
  3. Cell toxins (e.g., alcohol, narcotics)
  4. Maternal malnutrition
  5. Multiple gestations
  6. Pre-eclampsia—asymmetric
  7. Placental abnormalities
  8. Maternal use of tobacco
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15
Q

Etiologies of LGA Infants

6

A
  1. Maternal diabetes
  2. Hydrops fetalis
  3. Genetic predisposition
  4. Male fetus
  5. Post-date gestation
  6. Multiparity
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16
Q
  1. Cutis Marmorata is what?

2. This finding is considered?

A
  1. is a mottled appearance that will disappear over time

2. normal

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17
Q
  1. What is Vernix Caseosa?

2. This finding is considered?

A
  1. white to yellow waxy covering in newborns, most abundant in the creases and flexor surfaces
  2. normal
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18
Q
  1. What is Lanugo?

2. This finding is considered?

A
  1. downy hair covering the body, more common with prematurity
  2. normal
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19
Q
  1. What is Erythema toxicum?
  2. Usually found where?
  3. Considered?
A
  1. Benign rash characterized by fleeting erythematous papules and pustules filled with eosinophils.
  2. Usually predominates on face and chest. Appears 1-14 days after birth and disappears over several days to weeks.
  3. normal
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20
Q
  1. What are Nevus Flammeus, Vascular Nevi, Salmon patches?
  2. Considered?
  3. What are they called on the back of the neck?
  4. Above eyes?
A

Usually benign flat red markings on upper eyelids, in the area above the nose sometimes extending to the forehead, and/or on the back of the neck (may change in intensity with crying)

  1. normal
  2. “Stork bites” when on back of neck
  3. “Crow’s nests” when above the eyes
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21
Q
  1. What is Port-Wine Stain?
  2. Occasionally associated with what?
  3. Considered?
A
  1. In the nevus flammeus family but are permanent discolorations of the skin
  2. On occasion are associated with arteriovenous malformations in other organs
  3. Normal
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22
Q

Definition of the following:

  1. Sebaceous gland hyperplasia?
  2. Milia?
  3. Acne Neonatorum?
  4. These are considered?
A
  1. small yellow papules that are often seen over the nose and cheek; these disappear spontaneously
  2. similar but white papules and smaller, again they disappear without treatment within a few weeks
  3. acne appearance likely from maternal hormonal influence, may take several months to disappear
  4. normal
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23
Q
  1. What are Mongolian spots?
  2. What are these not?
  3. Considered?
A
  1. bluish black macular lesions usually over lumbrosacral area. Seen in most native American, black, and Asian infants. This is 2. NOT a bruise!
  2. normal
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24
Q
  1. What are Strawberry or capillary hemangiomas?
  2. Grow for how long?
  3. Management?
  4. Considered?
A
  1. elevated collections of capillaries, variable appearance
  2. Grow for 3-7 months, stabilize, then at about one year begin to involute. Patient usually without scar or blemish by five years of age
  3. Leave these alone unless on the eyelid in which consult with ophthalmologist required
  4. Perhaps worrisome
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25
Q
  1. What is a Cavernous Hemangioma?
  2. How is it different than strawberry hemangiomas?
  3. When very large associated with what?
  4. Clinical course?
  5. Management? 2
  6. Considered?
A
  1. This is a collection of larger blood vessels, usually much larger than strawberry hemangiomas and bluish in color.
  2. much less common than strawberry hemangiomas and have less predictable course.
  3. thrombocytopenia
  4. Often, they mature and then disappear
  5. Sometimes requires
    - steroids or
    - radiation treatment in extreme cases
  6. Perhaps worrisome
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26
Q
  1. Head Exam: Measure the head where?
  2. What is normal?
  3. Increased head circumference > 2 SDs may indicate what?
A
  1. Measure head circumference at largest possible diameter (parietal bones, just above ears)and compare with standards (should be within 2 SDs of the mean for the gestational age), 2. normal is about 34-35cm.
  2. hydrocephalus
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27
Q
  1. What do we compare head size to?
A

Compare with chest circumference, in full-term infants, the chest circumference should be 1-2.5cm smaller than the head circumference. If not corresponding with these guidelines, consult with pediatric neurologist advisable

28
Q

Examining the Head

  1. Palpate what?
  2. Check for what marks on the head? 2
  3. Newborn skull malleable for what?
  4. May not be round because of birth canal. When is it?
A
  1. Palpate the anterior & posterior fontanelles
  2. Check for
    - molding and
    - forceps marks (if used)
  3. passage through the birth canal
  4. May not be round (if it is usually indicates C section)
29
Q

Inspect fontanelles

  1. What should be the largest? (juncture? 2)
  2. Usually closed by when?
  3. What is smaller? (juncture)
  4. Generally closed when?
A
  1. Anterior fontanelle should be larger
    - (juncture of two frontal and two parietal bones); should be flat
  2. Usually closes by 18-24 months of age
  3. Posterior fontanelle smaller -juncture of parietal and occipital bones; about fingertip in size,
  4. generally closed by six weeks of age
30
Q

What is Hydrocephalus?

A

increased volume of CSF usually due to obstruction of CSF into subarachnoid space.

31
Q

CLinical features of hydrocephalus

7

A
  1. Clinical features: macrocephaly, an excessive rate of head growth
  2. irritability
  3. vomiting
  4. loss of appetite
  5. impaired upgaze
  6. impaired extraocular movements
  7. hypertonia and hyperreflexia
32
Q

Examining the Head

  1. What is Caput succedaneum?
  2. reabsorbs when?
A
  1. (very common): boggy swelling in subcutaneous tissues which crosses the suture lines. Head compression against cervix impedes venous return,
  2. reabsorbs within 1 to 3 days
33
Q
  1. Cephalohematoma?
  2. Not typically apparent until when?
  3. Almost always results from what?
  4. Often lasts how long?
  5. Cephalohematoma in older infant who comes in for routine care should make examiner suspicious of what?
A

blood collected below the periosteum and therefore confined to a single bone, will NOT cross the suture line

  1. Not typically apparent until 24-48 hours after birth
  2. Almost always parietal bone, usually results from fracture
  3. more than 4 weeks
  4. child abuse
34
Q
  1. What is Craniosynostosis?
  2. Most common is the _____________, which leads to anteroposterior lengthening
  3. Fusion of coronal sutures would lead to what?
  4. To detect this, what should we do?
A
  1. abnormal premature closure of skull sutures
  2. sagittal suture
  3. lateral lengthening
  4. palpate sutures and see if they move up and down independent of one another
35
Q
  1. Craniotabes is what?
  2. What kind of condition?
  3. If persistant investigate for what?
    3
A
  1. Ping-pong ball feel of the skull
  2. Usually a benign condition that disappears over time
  3. If persistent, investigate for
    - marasmus,
    - rickets
    - syphilis
36
Q

Face exam: Very important to look at the face of the newborn

  1. Eyes too large may indicate what?
  2. Eyes too small?
  3. Small chin (micrognathia) in Pierre Robin syndrome may predispose infant to what?
A
  1. Eye(s) too large may indicate Glaucoma
  2. Eyes that appear too small may indicate Fetal Alcohol Syndrome, along with a wide, flat nasal bridge, lacking a groove between lip and nose, and a small jaw
  3. respiratory obstruction
37
Q

1, Asymmetry of face while crying? May indicate what?

  1. May also be what?
  2. How can you differentiate?
A
  1. aortic valve abnormalities
  2. May also be facial nerve palsy secondary to pressure on facial nerve during birth process
  3. (usually appreciated even when baby is not crying and is temporary)
38
Q

The Eye Exam of a newborn consists of?

5

A
  1. Positioning and symmetry
  2. Trauma
  3. Reflex eye opening present
  4. Cornea clear
  5. Fundoscopic: check for red reflex only
  6. Erythromycin ointment is applied to the eyes routinely
39
Q
  1. What can appear with trauma from birth process, disappears by end of first week of life?
  2. What is not usually seen in the first 24 hours?
  3. If you dont see a red reflex what could this be? 2
A
  1. Subconjunctival hemorrhage
  2. Conjunctivitis: usually not seen in first 24 hours
  3. If not, something blocking light path such as
    - cataract,
    - or tumor, such as retinoblastoma, need ophthalmologist consult
40
Q

Nose exam:

  1. Asymmetry of the nares may indicate what?
  2. Patency? If no secretions and unsure if patent, attempt to do what?
  3. If this is not possible what is the Dx?
A
  1. septal deviation from birth trauma
  2. pass 5 French catheter through the nostril.
  3. If not passing, choanal atresia.
41
Q

What direction do we pull the pinna in an infant exam?

A

down because its more horizontal

42
Q

The mouth exam:

Hard palate masses in midline?

A

Epstein pearls

43
Q
  1. Whats the normal respiratory rate for newborns?
  2. Grunting and retractions indicate what?
  3. Why would we check the nipples?
  4. Chest deformaties? 2
A
  1. 40
  2. Grunting and retractions indicate distress
  3. Check nipples—may be some breast tissue from mother’s hormones
  4. Deformities:
    - Pectus carinatum (out)
    - Pecturs excavatum (depressed in)
44
Q
  1. If abnormality in pattern of breathing,

2. Unusual to hear what in the lungs on auscultation?

A
  1. order CXR
  2. rales, rhonchi, wheezes,
    even with severe respiratory distress
45
Q

Cardio:

  1. Normal pulse?
  2. What pulses should we check? 4
  3. If the femoral pulses are dimished what is possible?
  4. What do we need to check if they are?
A
  1. Pulse: 120-180
  2. Check
    - radial,
    - femoral,
    - brachial pulses and
    - compare femoral to UE pulses
  3. If femoral pulses diminished—possible coarctation of the aorta
  4. Need to check BPs before coarctation and after coarctation
46
Q

What is the normal appearance of the abdomen in the newborn?

A

full, protruding, and round. It should not be flat or sunken (scaphoid), nor should it appear tense

47
Q
  1. Tense abdomen could be associated with what?

2. Causes could include what? 5

A
  1. intestinal obstruction
    • imperforate anus,
    • Hirschsprung disease, and
    • meconium ileus (which is seen in cystic fibrosis)
    • perforated viscus
    • peritonitis
48
Q
  1. Inspect the umbilical cord: Hoe many umbilical arteries and veins should their be in the cord?
  2. If not what could this be associated with?
A
  1. there should be two umbilical arteries and one umbilical vein (only one umbilical artery may be associated with renal malformations)
49
Q

An appreciable mass is usually a what?

A

a kidney, often resulting from obstructive lesions of the urinary tract.

50
Q

Genitalia: Inspection/palpation
Females?
3

A
  1. Labia majora/minora full and puffy
  2. Examine labia/gently separate to inspect clitoris
  3. Influence of maternal hormones may cause withdrawal bleeding from vagina
51
Q

Genitalia: Inspection/palpation
Males?
4

A
  1. Examine for presence of both testes in the scrotum (may require “milking”), shape and size of penis, foreskin and location of the urethral meatus.
  2. Inability to palpate testes could indicate cryptorchidism
    Hard testis is not normal, suspect congenital torsion or tumor, consult with pediatric urologist
  3. Penis should be straight, if bent ventrally a chordae of the penis may be present and this is associated with:
  4. :
52
Q
  1. What is Hypospadias?

2. What do we have to do to repair this?

A
  1. a condition where the urethral meatus is displaced proximally on ventral aspect of penis
  2. (Do NOT circumcise! Foreskin will be used to repair this)
53
Q

What is anal atresia?

A

atresia—imperforate anus (surgical emergency)

54
Q

Musculoskeletal

  1. first thing to do?
  2. Clinodactyly is what?
A
  1. Count the fingers and toes

2. is an inturning of a finger, usually the fifth, which can be seen with Down syndrome

55
Q

What tests do you have to do for the hip?

3

A
  1. Ortolani’s & Barlow’s tests/full abduction
  2. Leg length—check for discrepancy
  3. Buttocks: symmetrical creases
56
Q
  1. What is Metatarsus Adductus?

2. What is the key with this diagnosis?

A
  1. forefoot adduction, usually from intrauterine crowding (*intrauterine crowding causes an increased risk for Developmental Dysplasia of hip).
  2. The key with this is whether the foot can be straightened easily. If so, no treatment necessary. If rigid, requires ortho consult for surgery.
57
Q
  1. Internal tibial torsion: often seen in conjunction with what?
  2. Usually improves with what?
A
  1. often seen in conjunction with metatarsus adductus, again from intrauterine crowding (which is important because?);
  2. usually improves without treatment over a period of months, but may take years
58
Q

Talipes Equinovarus (Clubfoot) is what?

Treatment?

A
  1. combination of metatarsus adductus, varus deformity, and shortening of the Achilles tendon
  2. Treatment should begin while newborn is in the nursery
59
Q
  1. Make sure to inspect hips for what?
  2. Hip abduction should be how many degrees at birth? and then for subsequent exams?
  3. Risk factors? 3
A
  1. Developmental Dysplasia of the Hips (DDH)
  2. Hip abduction should be 180 degrees at birth, and at least 120 degrees in subsequent exams
    • family history,
    • breech presentation
    • female to male (9:1 ratio)
60
Q

What is pilonidal sinus?

In general, any abnormalities of the spine other than Pilonidal sinus, such as other sinuses, cysts, fatty tumors, or tufts of hair warrants what?

A

An abnormal skin growth located at the tailbone that contains hair and skin.

consultation with pediatric neurologist.

61
Q

Babinski sign is POSITIVE! This is normal in infants at what ages?

A

less than 6 months of age

62
Q

What is stronger flexor or extensor tone?

A

Flexor tone > extensor tone is normal. When supine and at rest, the normal infant is flexed at the elbows, hips, and knees.

63
Q

A “floppy” baby (extensor tone > flexor tone) requires immediate investigation. The cause may be:
3

A
  1. Insult to CNS such as intracranial bleeding or infection
  2. Congenital disorder of nervous system or muscles
  3. Sepsis
64
Q

What is Brachial plexus palsies (also known as Erb’s palsy):

What is the prognosis?

A

one of the upper extremities flaccid (usually secondary to difficult delivery with injury to brachial plexus [C5, C6]).

Often good prognosis but consultation with pediatric neurologist necessary

65
Q

Moro reflex: Dropping baby down (while supporting head and neck) symmetric abduction and extension
This is absent on the side of a what?

A

Brachial Plexus Palsy

Pediatrics (18 decks)

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