2 - Examination and Practical Procedures Flashcards
When is a newborn examination carried out?
- In first 72 hours
- Secondly at 6-8 weeks old
What is the purpose of the Newborn Infant Physical Examination (NIPE) ?
- Screen for congenital abnormalities that will benefit from early intervention
- To make referrals for further tests or treatment as appropriate
- To provide reassurance to the parents
Where should you do a newborn examination?
- Private area which provides confidentiality for parents
- The room should be warm and well lit naturally
- Make sure that the parents are present for the newborn check as this is an ideal time to answer queries and provide reassurance
What oxygen saturations do you need to measure in the newborn and why?
- Pre-ductal and post-ductal (based on position of ductus arteriosus)
- Normal saturations are 96% or above. There should not be more than a 2% difference between the pre-ductal and post-ductal saturations
- Certain congenital heart conditions are duct-dependent, meaning they rely on the mixing of blood across the ductus arteriosus. When the ductus arteriosus closes there can be a rapid deterioration in symptoms. These duct-dependent conditions may be picked up by measuring the difference in pre-ductal and post-ductal saturations
How do you measure pre and post ductal oxygen saturations?
- Pre-ductal saturations: baby’s right hand. The right hand receives blood from the right subclavian artery, a branch of the brachiocephalic artery, which branches from the aorta before the ductus arteriosus
- Post-ductal saturations: in either foot. The feet receive blood traveling from the descending aorta, which occurs after the ductus arteriosus
What are the general points you need to cover in a newborn baby exam?
- General appearance
- Head
- Shoulders and Arms
- Chest
- Abdomen
- Genitals
- Legs
- Back
- Reflexes
- Any skin markings
What are we looking at in general appearance of baby in the newborn exam?
- Colour: jaundice, pallor, cyanosis
- Posture
- Tone
- Cry
What are we looking at when looking at the head of a baby in the newborn exam?
- Size: Head cirumference
- Shape
- Fontanelle: posterior and anterior palpation for dehydration and raised ICP
- Ears: skin tags, low set ears and asymmetry. Suggest hearing screening
- Eyes: slight squints are normal, epicanthic folds can indicate Down’s, purulent discharge could indicate infection
- Red reflex: Absent with congenital cataracts and retinoblastoma.
- Mouth: cleft lip or tongue tie. Put little finger in mouth to check palate and suckle reflex
What is the definition of the following head abnormalities you may find in a newborn?
- Caput succedaneum
- Cephalhaematoma
- Subgaleal haemorrhages
- Craniosynostosis
How can you tell the difference between caput succedaneum and cephalohematoma?
What are we looking at when looking at the shoulders and arms of a baby in the newborn exam?
- Neck lumps
- Shoulder symmetry: check for a clavicle fracture
- Arm movements: check for an Erbs palsy
- Brachial pulses
- Radial pulses
- Palmar creases: a single palmar crease is associated with Down’s, but can be normal
- Digits: number of digits and if fingers are straight or curved (clinodactyly)
- Sats probe on the right wrist for a pre-ductal reading
What are we looking at when looking at the chest of a baby in the newborn exam?
- Respiratory rate: look for respiration distress, symmetry and listen for stridor
- Heart sounds: listen for murmurs, heart sounds, heart rate and identify which side the heart is on. Work upwards
- Breath sounds: listen for symmetry, good air entry and added sounds
What is normal heart rate and respiratory rate in a newborn?
RR: 40-60
HR: 120-150
What are some signs of respiratory distress in a newborn?
What are we looking at when looking at the abdomen of a baby in the newborn exam?
- Inspect: umbilicus, groin for hernias, distension
- Palpate: liver, spleen, kidneys, bladder
What are we looking at when looking at the genitals of a baby in the newborn exam?
- Check sex and record any ambiguity
- Palpate testes and scrotum: check both are present and descended, check for hernias or hydroceles
- Inspect the penis for hypospadias, epispadias and urination
- Inspect the anus to check if it is patent
- Ask about meconium
What are we looking at when looking at the legs of a baby in the newborn exam?
- Observe the legs and hips for equal movements, skin creases, tone and talipes (club foot)
- Barlows and Ortolani manoeuvres
- Count the toes
How do we do Barlow’s test?
Adduct hip (bringing the thigh towards the midline) whilst applying light pressure on the knee with your thumb, directing force posteriorly
If hip unstable, the femoral head will slip over the posterior rim of the acetabulum, producing a palpable sensation of subluxation or dislocation.
If the hip is dislocatable the test is considered positive. The Ortolani manoeuvre is then used to confirm the positive finding
How do we do Ortolani’s test?
Used to confirm posterior dislocation of the hip joint
1. Flex the hips and knees of a supine infant to 90°.
2. With your index fingers placing anterior pressure on the greater trochanters, gently and smoothly abduct the infant’s legs using your thumbs.
A positive sign is a distinctive ‘clunk’ which can be heard and felt as the femoral head relocates anteriorly into the acetabulum
What are we looking at when looking at the back of a baby in the newborn exam?
Inspect and palpate for:
- Scoliosis
- Hair tufts
- Naevi
- Birthmarks
- Sacral pits
What skin findings on a newborn exam do you need to note down?
- Haemangiomas
- Port wine stains
- Mongolian blue spot
- Cradle cap
- Desquamation
- Erythema toxicum
- Milia
- Acne
- Naevus simplex (“stork bite”)
- Moles
- Transient pustular melanosis
How do you perform a respiratory examination on a child?
- Intro, consent, PPE
- Inspection inc sounds and around the bed
- Hands: tremor, eczema as atopy and asthma, CRT, clubbing
- Pulse: femoral in babies
- Face
- Tracheal position
- Inspect chest
- Palpate apex beat
- Percuss
- Chest expansion (not in young/babies)
- Auscultate
- Same on posterior
- Lymph nodes
- Pedal or Sacral Oedema
What is normal respiratory rate in children?
What are some dysmorphisms you may look out for when doing paediatric cardiorespiratory exams?
What signs help demonstrate the work of breathing in children?
When has a child got hepatomegaly and what does this indicate?
- If liver edge felt 2cm below costal margins
- Sign of heart failure
Where do you feel the apex beat in a child?
How do you do an abdominal examination in a child?
Same as on adults
- ‘What did you last have to eat, let’s find it, if not I will have to listen for it’
- ‘Can you jump up and down’ - Not possible if guarding
How may the following masses present on an abdo exam of a child
- Neuroblastoma
- Wilm’s tumour
- Intussupection
- Faecal impaction
How do you report on a CXR?
Remember children usually AP
How can you assess the age of a child on a CXR?
Humeral heads physis present: child, ossification starts around 14 yrs
No humeral heads: preterm neonate as ossification occurs at term
Umbilical clips: less than 2 weeks old
How does an inhaled foreign body show on CXR of a child?
Hyperlucent thorax on the side foreign body is
What is vater syndrome?
What investigations should you do?
- Skeletal survey
- If under 1 with neurology or encephalopathy need CT head
Do a follow up skeletal surgery in 11-14 days
What are the four types of fractures in paediatrics?
Buckle: Compression fracture from axial loading. Usually at metaphysis of long bones
Greenstick: Fracture on one side of the cortex only, mid diaphyseal
How are fractures through the growth plate classified?
How do we measure peak expiratory flow in children?
- Stand upright
- Meter is level
- Fingers are not over the gauge
- Breathe out maximally
- Then take a deep breath
- Place mouth around the mouthpiece
- Ensure a tight seal
- Breath out as hard and as fast as they can
- Should make a huffing sound
- Repeat 3 times
- The highest recording from the 3 attempts
- Plot this against their height
What fractures in children are common in suspected physical abuse?
Buckle: Compression fracture from axial loading. Usually at metaphysis of long bones
Greenstick: Fracture on one side of the cortex only, mid diaphyseal
How do you explain to a parent how to give an inhaler with a facemask?
- Put two halves of spacer together and attach face mask
- Remove cap of inhaler and shake it
- Hold mask over mouth and nose in upright or 45 degree position to keep valve open
- Make sure child lying on back
- Press inhaler and let child take 5-6 breaths or 20 seconds
- If second dose take inhaler out and shake before second dose
LISTEN FOR CLICKS - if no clicks not adequate breaths
How do you explain to a teenager how to use their inhaler?
- Take cap off, shake and press to release test spray
- Check dose to check not empty
- Shake inhaler
- Sit or stand up straight and tilt chin up
- Breathe out completely until lungs feel empty
- Put lips around inhaler to make seal and start breathing in slowly
- Press and breathe in slowly until lungs full
- Hold breath for 10 seconds
- Shake before any second doses
- Rinse mouth if steroid inhaler
How can you explain to a parent how to use their child’s autoinjector?
- Lie child flat and elevate legs
- Remove the safety cap
- Place the tip of auto-injector against front or side of thigh, holding the auto-injector at right angles to the leg
- Press hard and steadily into the thigh and keep in place for 10 seconds after click
- Remove the auto-injector from the thigh, massage the injection site
- Give a second injection after 5-15 minutes
- Ensure an ambulance is on its way. Stay in position until medical assistance arrives
- Auto-injectors need to be discarded in a safe manner, give to hospital or ambulance
