Neonatal PE

Question 1

10 day old baby for a routine check-up. Weight, height, head circumference given.

Tasks:
1. History including pregnancy and delivery for 2 minutes
2. Explain PE to the medical student
3. Explain steps to the mother

Answer 1

Task 1: History
- Introduce yourself
- Congratulate mother for delivery
- Open-ended question: How may I help you today?
- Mother:
○ How is she coping with motherhood?
○ How is your mood? Sleep?
○ Normal or CS?
○ Abdominal pain, discharge, fever?
○ Tears, cuts during delivery, healing well?
○ Waterworks: leakage, incontinence
○ Bowel motions, constipation?
○ Breastfeeding? Cracked nipples, swelling, pain on breast?
○ Swelling in the legs? (DVT)
- Baby:
○ Baby drinking well?
○ Active and alert?
○ Wet nappies?
○ Bowel motions?
○ Any discoloration on the skin?

Task 3: Explain PE
- Explain steps: head to toe examination, examine hip joints
- Exposure: undress baby, nappies off

I. General Appearance
- Respiratory distress, cyanosis
- Jaundice
- Normal flexed position of the limbs (tone)

II. Auscultation
- Before the child starts crying, I'll start auscultation for murmurs on all 4 valvular areas, and listen for breath sounds looking for added sounds

III. Head
- I'm going to plot the head circumference, height and weight on the growth chart
- Inspection: 
	○ Skull:
		§ Cephalhematoma: bleeding under the scalp as a result of difficult delivery
		§ Fontanelles
			□ Anterior
			□ Posterior
		§ Shape: flat occiput, plagiocephaly
	○ Eyes:
		§ Strabismus
		§ Red reflex: use Ophthalmoscope, look from far away, expect a red circle in pupil; if whitish circle or absent reflex, it can be a sign of retinoblastoma/congenital cataract
	○ Mouth:
		§ Central canosis
		§ Cleft palate/lip, bifid uvula
		§ Rooting reflex: stroke the side of the mouth, and will see a deviation of the lips to the side of the stimulus
		§ Sucking reflex: while wearing gloves, I'll insert my little finger on the mouth to check for sucking
	○ Ears: 
		§ Tags, abnormality in external ear
		§ Otoscopy
	○ Dysmorphic features:
		§ Upward slanting eye
		§ Epicanthal folds
		§ Flat nasal bridge
		§ Low-set ears

IV. Neck
- Palpate for swelling: branchial cyst, thyroglossal cyst

V. Chest
- Inspection: chest wall deformity

VI. Arm
- Single palmar crease
- Polydactyly, syndactyly
- Nails: CRT, cyanosis
- Pulse: radio-radio delay, radio femoral delay (coarctation of aorta)
- Grasping reflex

VII. Abdomen
- Hepatomegaly (CHF)
- Umbilical hernia, inguinal hernia
- Umbilical stump: redness, discharge

VIII. Hip Examination (6 weeks)
- Inspection: symmetric skin folds in thighs, gluteal region
- Length of legs
- Barlow test: flex the hip and knee to 90 degrees, mild adduction of the hip and apply slight forward pressure to see if the femoral head slips over the posterior rim of the acetabulum
- Ortolani test: flex the hip and knee to 90 degrees, abduct the hip to hear/feel the characteristic clunk as the femoral head is reduced into the acetabulum

IX. Genitals
- Boy: undescended testes, epispadia, hypospadia
- Girl: labial fusion

X. Ventral Suspension (check for hypotonia)
- Hold the baby with one hand on the stomach
	○ Keep head up, hold limbs up
	○ Abnormal: floppy
- Check the spine: sacral dimple, spina bifida, patent anus
- Moro reflex: lie the child down on the bed, raise the head slightly, gently remove the support, sudden flexion of the limbs of the child