Pediatrics Flashcards
(93 cards)
Neonatal period.
1st 28 days.
Remainder of infancy is
29 days to 1 year.
Infant exam highlights.
Parents present. Provide comfort when possible. Observe feeding. Suggested sequence: -Careful observation -Head, neck, heart, lungs, abdomen, GU -Lower extremities, back -Ears, mouth -Eyes when open -Skin as you go -Neurologic system -Hips Comfort – swaddle, then undress throughout exam; dim lights to encourage newborn to open eyes.
Assess for skin findings. Infant.
Newborn skin soft, smooth, thin.
10 min after birth, cyanosis → pink (flush).
Acrocyanosis (blue cast to hands & feet when exposed to cold) – if persists > 8 hrs or doesn’t disappear with warming, suspect congenital heart disease.
Central cyanosis – tongue, oral mucosa → suspect congenital heart disease.
Jaundice:
Physiologic – appears 2nd or 3rd day, peaks 5th day, resolves ≈ 1 week.
If seen in < 24 hrs, may be hemolytic ds of newborn
If lasts > 2-3 wks, suspect liver ds.
Need to know time of birth.
Common skin findings for newborns.
Erythema toxicum – appears 2-3 days after birth, red macules with central pinpoint vesicles scattered over body – disappears within a wk.
Pustular melanosis – small vesiculopustules over brown base – may last several mos, more common in black infants.
Milia – pinhead-sized smooth white raised area without erythema on nose, chin, forehead – due to retention of sebum in openings of sebaceous glands.
Usu. appears within 1st few wks – disappears over several wks.
Assessing the sutures and Fontanelles. Infant.
Sutures – membranous tissue spaces that separate the bones of the skull.
Fontanelles – areas where major sutures intersect.
Sutures:
Ridges on palpation.
Fontanelles:
Soft concavities.
Ant. fontanelle 4-6cm at birth, closes in 4-26 mos.
Post. fontanelle 1-2cm at birth, closes in 2 mos.
Fullness or bulging – suspect ↑ intracranial pressure (e.g. due to CNS infection).
Depressed fontanelle may be due to dehydration.
Child exam.
General principles.
Knock on door before entering room.
Determine everyone’s relationship to the child.
Learn to avoid assumptions.
Maximize child’s comfort – he/she may sit on a parent or caregiver’s lap whenever it does not interfere with the examination.
Clinician’s approach should be cautious & non-threatening.
Remain at child’s level whenever possible.
Maintain a comfortable distance.
Avoid interruptions (e.g. taking notes).
Children older than 4 may begin to provide some of their own history:
Up to age 12, clinician must still rely primarily on the caregiver.
Interview adolescents in absence of caregivers when appropriate:
Speak directly to child as much as possible.
Begin asking parent/caregiver to leave room for portion of the visit at age 10-11.
Be mindful of patient’s privacy:
If he/she objects to being unclothed or wearing a gown, allow him/her to remain clothed until that portion of the exam.
Child exam.
General principles continued.
Explain as you go but do not request permission:
Be honest.
Perform non-disturbing maneuvers early & potentially distressing maneuvers last*:
Examine painful areas last.
Perform portions of the exam that require cooperation 1st.
BP, lung & heart auscultation, eye, & neurologic exams.
Bothersome parts of the exam last.
Ear, throat, abdomen, head circumference.
Documentation follows same order as adult exam.
Can make “make a game” of some aspects of the physical exam.
Overall goals of pediatric visits.
Promoting health.
Detecting disease & abuse.
Counseling to prevent injury & future health problems.
Every interaction with a child is an opportunity for health promotion.
Note – at least one study has shown that physical exam in asymptomatic, school-aged children very rarely detects a significant abnormality.
Possible order of examination of young children.
General inspection Skin Eye Neurologic exam Lungs & heart Nose, throat, neck Musculoskeletal Abdomen Ear Genitals (if indicated) Older children (e.g. 5 & up) – order of exam may be head to toe (painful areas last).
Child exam.
History.
Prenatal: -Pregnancy complications (e.g. maternal tobacco use, infections). Birth history: -Vaginal vs C-section, prematurity, complications. Developmental history: -Pre-visit questionnaire useful. Preventive care*: -Incl. detailed immunization history. -Dental care.
Approach to the child exam.
Maintain rapport & trust while gathering data
Talk to the child
Be flexible!
Allow patient to sit on parent/caregiver’s lap
Observe interaction between caregiver & child
No eye contact between caregiver & child suggests possibility of neglect
After 1st year of life – techniques of examination similar to those for adults.
Vitals.
Pulse. Respiration. -In a child older than 1 year, tachypnea defined as >40 breaths per minute (bpm). Blood pressure. Temp. Height. Weight.
Pulse. Child exam.
Determined by direct auscultation or palpation of heart:
-Or by palpation of peripheral arteries (e.g. brachial or radial pulse).
Rate is faster, more variable:
-E.g. fever – for each degree ↑, HR is 10-20 beats faster.
Sinus arrhythmia is common in children:
-Rate varies in a cyclical pattern.
-Faster on inspiration.
-Slower on expiration.
Respirations. Child Exam.
For infants – rise & fall of the abdomen facilitates counting.
Rate, regularity & rhythm:
-Observe for 2, 30 second intervals or for 1 full minute.
Depth.
Respiratory Effort (important to visualize):
-Retraction (ribs, supraclavicular notch).
-Contraction of SCM’s
-Flaring of nostrils
-Paradoxical breathing – sign of respiratory distress.
Blood pressure. Child Exam.
Routine measurement begins at 3 y/o.
Cuff size (children):
-Width should cover ~2/3 of the upper arm or thigh.
Too wide - underestimate BP.
Too narrow - artificially high BP.
Interpretation based on standards for sex, age, height.
Do not make diagnosis of hypertension based on one reading:
-An elevated systolic but normal diastolic may be due to transient anxiety.
Significant 90th percentile
Severe 95th percentile
*If consistently above the 95th percentile, DDx include:
Kidney disease (incl. renal artery ds).
Coarctation of the aorta.
Temperature. Child Exam.
Routine temp not always necessary.
Tympanic thermometers very popular.
-Accuracy depends on correct technique.
-Wait until your baby is at least 6 months old to use a digital ear thermometer.
-Must read tympanic membrane.
–TM shares blood supply with hypothalamus (measures core body temp). Reading approx. 1.40F (or 10F) higher than oral temp.
Rectal temp preferred for infants & young children.
Axillary acceptable.
100.4 or greater is considered a fever.
Height. Child Exam.
Birth to 24-36 months.
-Infant measuring mat OR mark on a sheet of exam table paper.
–Measure from the top of the head to the heel (foot dorsiflexed).
Child is able to stand without support (24-36 months old):
-Heels, buttocks & shoulders against the wall.
-Looking straight ahead
–Outer canthus of the eye should line up with the external auditory canal.
Weight. Child Exam.
Infant platform scale
-More accurate (ounces or grams).
-Infant may sit or lie – should be weighed naked or wearing only a dry diaper.
BMI beginning at age 2.
Head circumference. Child Exam.
Done at every “health visit” until 2 years of age.
Measure the largest circumference with the tape snug:
-Occipital protuberance to the supraorbital prominence.
Recording measurements.
Child Exam.
Chart on appropriate growth curve for sex and age.
- Identify the infant’s percentile.
- Follow over time (benefit of EHR).
- Note any change or variation from the population standard or the child’s norm.
Growth patterns. Child Exam.
Infancy:
-Growth of trunk predominates.
-Fat increases until 9 months of age.
Childhood:
-Legs are fastest growing body part.
-Weight is gained at a steady rate.
-Fat increases slowly until 7 yrs of age when a prepubertal fat spurt occurs before the true growth spurt.
-Lengthwise, widthwise, lengthwise, widthwise.
Adolescence:
-Trunk and legs elongate.
-About 50% of the ideal weight is gained.
-Skeletal mass and organ systems double in size.
Skin. Child Exam.
Careful inspection of all skin:
-Develop a pattern.
-Don’t overlook body parts.
Examine skin creases:
-Single line that runs across the palm of the hand.
-May be assoc. with abnormal medical conditions.
E.g. Down syndrome, fetal alcohol syndrome.
Common Rashes. Child Exam.
Allergic rash: -Contact dermatitis -Medications, supplements -Food sensitivity. Diaper rash: Yeast?
Eczematous Rash:
Eczema (aka atopic dermatitis):
-Younger children: Face, elbow, knees (extensor surfaces).
-Older children & adults: Hands, neck, elbows, knees (flexor surfaces), ankles
Face (less often).
