Physical Exam

Question 1

First thing you check with a child when you go into the room?

Answer 1

Say hello, smile, and introduce yourself.

See the general condition of the child (Are they healthy? Well fed? Good condition?)

Question 2

Official temperature of a baby? Where do you check?

Answer 2

L

Question 3

First you check the skin. What is a common skin lesion on infants? What two things do you check, where?

Answer 3

Look for skin lesions (especially hemangiomas)
Prick test (infants belly button and forearm for toddler)
Capillary refill test (less than 2 seconds on toddle and infants if it is done sternum because they have slower peripheral circulation)

Question 4

Head and neck exam

Answer 4

1. ) Check eye movements
2. ) Sclera (color, can be blue in osteogenesis imperfecta and red, conjunctivitis)
   - High carotene (pumpkin and carrots can’t cause eye color change but skin oranging)
3. ) We check lymph nodes (plus auxiliary [check bcg left lymph nodes] and femoral nodes and vessels), conjunctiva, and mouth
4. ) Check the fontanelles for size and if it is even, protruding, and sunken in

Question 5

Pulmonary system exam includes and what is seen on inspection

Answer 5

Inspection, percussion, palpation
-chest inspection (pectus excavatum, pigeon chest, scoliosis, asthma (under 4)=obstructive bronchitis until proven as asthma but some babies also just have barrel chest [barrel chest]
Breathing rate and cough/wheeze

Question 6

Pediatric pulmonology inspection

Answer 6

Inspection

• Cyanosis (lips and peripheral limbs)
• irritability
• nasal flaring
• coughing or choking
• tripod position (use of accessory muscles to aid in breathing)
• grunting (kid tries to increase PEEP)

Question 7

Percussion pulmonology treatment

Answer 7

Percussion (some institutes say it’s not valuable in pediatrics)
Done in cases where fluid is present

Question 8

Pulmonology Auscultation steps

Answer 8

• compare the both sides like with adults (apex)
• start from below in kids and work your way up. Kids have pneumonia or bronchitis and are heard best at beginning before airways open with air in the examination

Question 9

Two types of breath sounds

Answer 9

Bronchial and vesicular breathing

Question 10

Which breath sound is the loudest

Answer 10

Bronchial breathing is heard over most of the back due the kids being so small

Question 11

Do you hear bronchial and vesicular breathing on inspiration or expiration

Answer 11

Bronchial breathing is heard both on inspiration and expiration. Vesicular breathing is heard only on inspiration

Question 12

What happens when bronchial breathing is increased?

Answer 12

Vesicular sounds decreased indicating pneumonia, with exudate inside alveoli or transudate edema due to right heart failure or tumor

Question 13

What makes breathing sounds fainter in general?

Answer 13

Pneumonia, pneumothorax, tumor, pleural effusion, less chest movement (Pleuritis, phrenic nerve issue, dermatomyosisitis, duchenne, polymyotitis, emphysema)

Question 14

Adventitious lung sounds

Answer 14

• Friction sound
• Crackle sound
• Rales
• Stridor

Question 15

Friction sounds can be found in

Answer 15

Pleuritis and can be differentiated from pericardial issues by the patient holding their breath

Question 16

Crackle sounds are due to? When is it heard? Causes?

Answer 16

Crackles sounds are caused by semi filled alveoli and when the patient inhales the alveoli collects some air and pops open. Only heard in inspiration. Caused by fluid from infection or arrhythmia.

Question 17

Rales can be separated into 2 types

Answer 17

Wet type and dry type

Question 18

What is wet type rales

Answer 18

wet type is when fluid or mucus in bronchioles and alveoli, heard in inspiration and expiration (moist bubbling sound)

Question 19

What is dry type rales

Answer 19

Dry type is whistling due to dry mucus in the bronchi and lead to wheezing sounds best heard in expiration (asthma and obstructive bronchitis)

Question 20

What is stridor and when can it be heard

Answer 20

Dry type is whistling due to dry mucus in the bronchi and lead to wheezing sounds best heard in expiration (asthma and obstructive bronchitis)

Question 21

What can be heard in pneumonia? Obstructive bronchitis?

Answer 21

1. ) diminished sounds, crackle, rales

2. ) Wheezing/rales

Question 22

Abdomen exam order

Answer 22

• inspect abdomin (stomach is higher than chest is normal
• auscultate abdomen for 1 minute if they don’t have bowel sounds
• general palpation
• palpate and percuss spleen (in bigger kids)
• percussion of liver after asking patient to turn on side (liver dullness)

Question 23

When to palpate bladder

Answer 23

During urinary retention you palpate bladder.

Causes include obstruction bph, neurologic damage, drugs, psychologic

Question 24

Kidney palpation

Answer 24

Feel for costobertebral triangle, try to catch it after they breath in

Question 25

Palpate deep to try to feel which two tumors developing

Answer 25

Wilma and neuroblastoma (retroperitoneal tumors)

Question 26

Different lymph nodes and causes for reactiveness

Answer 26

Occipital lymph nodes-rubella, bartonella Posterior auricular- Preauricular- Submandibular- tonsillitis (strep), mononucleosis (check spleen and liver, maculopapular rash due to amoxicillin on day 7) Submental- Posterior cervical-chronic otitis (not pathological if you feel many lymph nodes) Superior cervical- Supraclavicular- always pathological if palpated Infraclavicular- always pathological if palpated Jugular- always pathological if palpated (all three drain from mediastinum and gastric tumors) Auxiliary (arm at 90 degree angle)- cat scratch, RA, any scratches in the limb Femoral- Inguinal-since whole leg drains to that area, kids fall all the time and get cuts. So it is normal to have reactive lymph nodes

Question 27

What to check on head beside the lymph nodes

Answer 27

Check the mouth, normal color, normal sized tonsils

Question 28

Pathological/malignant lymph nodes are described as

Answer 28

Not mobile, hard, larger than 1 cm (first test to do is US to see if reactive or pathological)

Question 29

Meningeal tests include?

Answer 29

Brudzinski’s and Kernig test

Question 30

For meningeal signs check what first?

Answer 30

Check neck stiffness (up, down, side to side)

Question 31

Bruzinski sign

Answer 31

One hand behind the head and one on sternum will cause the knees to jerk if it is positive (back can be painful if there is menigeal inflammation)

Question 32

Kernig sign

Answer 32

Lift leg up to 40-60 degrees straight, a positive sign is that it’ll bend at the knee Or Lift knee in bent position 90 degrees And try to straighten leg

Question 33

What symptoms do you try to look for for systemic signs of meningitis

Answer 33

``` With children you look for system signs Fever Bulging fontanelle Bent back (optistotimus) meningitis and tetanus Crying or lethargy (high pitched) Extended limbs, don’t respond to pain stimuli Hypertension plus bradycardia Sunset eyes ```

Question 34

Causes of Meningeal sign

Answer 34

Meningeal sign Encephalitis, meningitis, muscle rigidity (torticolis, or cervical spine inflammation like ankylosing spondylitis) And dehydration (edema of brain) Hydrochephalus, hemorrhage (AV malformation), tumor

Question 35

How to differentiate between dehydration and meningitis?

Answer 35

To differentiate between dehydration and meningitis give iv bolus, wait an hour, see if nuchal rigidity improves If not treat with ceftriaxone

Question 36

Signs of dyspnea

Answer 36

Signs of dyspnea - nasal flaring - intercostal retraction (see the ribs) - subcostal retraction - jugular retraction - paradoxical breathing - difficulty with expiration (prolonged)

Question 37

Shape of chest in pulmonary disease

Answer 37

Shape of chest - shape of chest of newborn-barrel shaped chest - as they grow their chest becomes flatter (2/3 back to front to the length in front of chest) - if barrel chest continues there is chronic bronchitis

Question 38

Causes of Tachypnea

Answer 38

Tachypnea - infection (sepsis) - anemia - circulatory problem - respiratory distress