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7/24/2019 Pediatric Physical Exam (C SU07)
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Pediatric Physical Exam
Adapted from Mosbys Guide to
Physical Examination, 6thEd.
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Age Descriptors
e!born birth to " months
#nfant $%& year
'oddler &%" years
(hild ") years
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*itals
Pulse
+espiration
lood pressure'emp
-eight
eight
infants and children
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Pulse
Apical pulse /thintercostal space in
the midcla0icular line
1emoral pulse use a point half!ay from
the pubic tubercle to A2#2
as a guide
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Pulse
Age eats per minute
e!born &"$%&3$
& year 4$%&6$
5 years 4$%&"$
6 years 3/%&&/&$ years 3$%&&$
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+espiration
#nfants rise and fall of the abdomen facilitatescounting
+ate, regularity and rhythm Depth +espiratory Effort
+etraction 7ribs, supracla0icular notch8 (ontraction of 2(Ms 1laring of nostrils Paradoxic breathing
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+espiration
Age +espirations per minute
e!born 5$%4$
& year "$%9$
5 years "$%5$
6 years &6%""&$ years &6%"$
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lood Pressure
(uff si:e 7children8 idth should co0er ;"
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'emperature
'ympanic thermometers are
becoming increasingly popular Accuracy depends on correct
techni=ue
Must read tympanic membrane 2hares blood supply !ith hypothalamus
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'emperature >oung #nfants
'raditional routes may be more
accurate
e!borns? axillary temp correlates
!ell !ith core temp due to the infants
small body mass and uniform s@inblood flo!
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-eight #nfant
irth to "9%56 months
#nfant measuring mat +
mar@ on a sheet of headrest paper Measure from the top of the head to the
heel 7foot dorsiflexed8
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&. 'ear a length of headrest paper
". Bay the child on top of the paper5. Mar@ the top of the childs head
9. As@ mother to hold child in place
/. Extend leg and mar@ under the heel
7foot dorsiflexed8
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-eight % (hild
(hild is able to stand !ithoutsupport 7"9%56 months old8
C2tature measuring de0ice -eels, buttoc@s and shoulders
against the !all Boo@ing straight ahead
uter canthus of the eye should line up !iththe external auditory canal
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eight
#nfant platform scale More accurate
7ounces or grams8
#nfant may sit or lie
Place paper or blan@ under the infant C!eigh it out
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-ead (ircumference
Done at e0ery Chealth 0isit
until " years of ageF yearly
from "%6 years of age
Measure the largest circumference !ith the
tape snug
ccipital protuberance to the supraorbital
prominence
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(hest (ircumference
Measure around the nipple line to the
nearest &
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+ecording Measurements
(hart on appropriate gro!th cur0e for
sex and age
#dentify the infants percentile ote any change or 0ariation from the
population standard or the childs norm
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At irth
A0erage !eight? / lb 4 o: 4 lb &5o:
A0erage length? &4%"" in 79/%//cm8
-ead circumference? &5%&9 in 755%5/ cm8
Most babies born to the same parents !eigh
!ithin 6o: of each other at birth Bo!er birth !eight? consider an undisclosed congenital
abnormality or intrauterine gro!th retardation
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Expected Gro!th
Bength increases by /$Hin the &st year of life
eight doubles by 6 months, triples by & year
-ead (hest (ircumference e!born to / months? -ead may be e=ual or
exceed the chest by " cm / months to " years? (hest should closely
approximate the head circumference I " years? (hest should exceed head
circumference
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Gro!th Patterns
#nfancy Gro!th of the trun@ predominates 1at increases until J months of age
(hildhood Begs are the fastest gro!ing body part eight is gained at a steady rate 1at increases slo!ly until 3 yrs of age !hen a prepubertal
fat spurt occurs before the true gro!th spurt
Adolescence 'run@ and legs elongate About /$H of the ideal !eight is gained 2@eletal mass and organ systems double in si:e
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Gender Differences
Maes !emaes
roader shoulders greater musculature
ider pel0ic outlet
2light increase in bodyfat during early
adolescence beforethe gain in lean tissue
Persistent increase infat throughout
adolescence, occuringafter the pea@ gro!thspurt
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(ommon (onditions
hat might you detect by recording height,!eight, head chest circumferenceK
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1ailure to 'hri0e
1ailure of an infant to gro! at Cnormal rates
May be related to? (hronic disease (ongenital disorder 7brain, heart, @idney8 #nade=uate calories and protein
#mproper feeding methods #ntrauterine gro!th retardation Emotional depri0ation
gro!th hormone le0els !ill be lo!
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hat ifK
-ead circumference increases rapidly orrises abo0e percentile cur0es
#ncreased intracranial pressuredDL? -ydrocephalus, etc.
-ead circumference gro!s slo!ly or falls off
percentile cur0es Microcephaly
dDx? (raniosynostosis, etc.
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(ongenital 2yndromes
Do!n 2yndrome 'urner 2yndrome associated !ith short stature
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2@in
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e!born Expected *ariants
'ransient puffiness of the hands, feet, eyelids, legs,pubis or sacrum occurs in some ne!borns
ot a concern if it disappears !ithin "%5 days
2ome ne!borns are bald !hile others are born !ithan inordinate amount of head hair
2heds !ithin "%5 months and replaced by more
permanent hair 7ne! texture and color8
Dar@%s@inned ne!borns do not al!ays manifest theintensity of melanosis that !ill be readily e0ident in"%5 months
Exceptions? nail beds and s@in of the scrotum
2@in may loo@ 0ery red the first fe! days of life
2@in color is partly determined by subcutaneous fat
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(utis marmorata 'ransient mottling !hen infant is exposed to
decreased temperature
Acrocyanosis (yanosis of hands feet A common response to cold
An underlying cardiac defect should be suspected ifacrocyanosis is persistent or more intense in the feetthan hands
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*ernix caseosa
hitish, moist, cheeseli@e substance Mixture of sebum and s@in cells
(o0ers the infants body at birth Protecti0e
""".#roo$sidepress.org/%roducts/&'()*_101/M+,ocume-ts4/et/*e"#or-/er-i.jpg
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Banugo
1ine, sil@y hair co0ering
the ne!born shoulders and bac@
2hed !ithin &$%&9 days
Banugo. 'his fine body hairresembling peach fu:: is present on
infants of "9 to 5" !ee@s gestation.
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'elangiectatic ne0i
a@a Cstor@ bites
1lat, deep pin@, locali:ed areas usually
seen in bac@ of nec@
2tor@ bite, or salmon patch.
A typical light red splotchy
area is seen at the nape of
the nec@.
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Mongolian spots
#rregular areas of deep blue
pigmentation usually in sacral and
gluteal regions
N2een predominantly in African, ati0e
American, Asian or Batin descent
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Erythema toxicum
Pin@ papular rash !ith 0esicles
superimposed thorax, bac@, buttoc@s, and abdomen
May appear "9%94 hrs after birth and
resol0es after se0eral days
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(ommon (onditions
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Milia
(ommon during the
first "%5 months
2mall !hite discrete papules on the
face and bridge of the nose Plugged sebaceous glands
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Miliaria
a@a C-eat rash
(aused by occlusion of s!eat ductsduring periods of heat and highhumidity
CPric@ly -eat
7crystaline8
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+ashes
Allergic rash (ontact dermatitis
Medications, supplements 1ood sensiti0ity
Diaper rash Acid urine output
>eastK
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Ec:ematous rash
>ounger children 1ace, elbo!, @nees
lder children adults -ands, nec@, inner elbo!s,
bac@ of @nees, an@les 1ace 7less often8
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2eborrheic Dermatitis
a@a C(radle (ap scalp Besions are scaling, adherent,
thic@, yello!, and crusted can spread o0er the ear and do!n the
nape of the nec@
N(an be also be seen on bac@,
intertriginous diaper areas
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#mpetigo
C-oney colored crusts
-ighly contagious 2taph. or 2trep.
infection (auses pruritis, burning, and regional
lymphadenpathy
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+ing !orm
'inea corporis
'inea capitis
M( 0ectorK
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2tra!berry hemangioma
Expected resolution?
irth? often not present or noticeable
&%" months? becomes noticeable&%6 months? gro!s most rapidly
&"%&4 months? begins to shrin@
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'richotillomania
May be related to? Excessi0e emotional stress
1amily circumstances, hospitali:ation, etc.
bsessi0e (ompulsi0e Disorder
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External (lues to #nternal
Problems
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1aun tail ne0us
'uft of hair o0erlying the spinal columnusually in the lumbosacral area
Associated !ith spina bifida occulta
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(afO au lait spots
E0enly pigmented patches light, dar@ bro!n, or blac@ in dar@ s@in
Present at birth or shortly thereafter
May be related to?
eurofibromatosis Pulmonary stenosis 'emporal lobe dysrhythmia 'uberous sclerosis
Suspect
neurofibromatosis if
you note >5 patcheswith diameters >1cm in
a child under 5
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Axillary 1rec@ling or
#nguinal 1rec@ling
May occur in conunction
!ith cafO au lait spots
Associated !ith neurofibromatosis
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1acial port%!ine stain
hen it in0ol0es the opthalmic di0ision
of the trigeminal ner0e it may be
associated !ith? 2turge%eber syndrome
sei:ures
ccular defects
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2upernumerary nipples
Especially in the presence of other
minor abnormalities
associated !ith renal abnormalities
E i i th b f
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Examining the e!born for
-yperbilirubinemia
Natural daylight is preferred
Examine the oral mucosa and sclera
#nspect the !hole body for Cdermal icterus 2tarts on the face and descends
ilirubin le0el is not high if only the face
7/mg
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+is@ 1actors
reast feeding
b%glucuronidase
(ephalhematoma or other cutaneous
or subcutaneous bleeds
-emolytic disease #nfection
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Physiologic Qaundice
Present in /$H of ne!borns appears to be an inability of the li0er to
conugate the bilirubin present in the blood
2tarts after the first day of life Rsually disappears in 4%&$ days May persist for 5%9 !ee@s
'reatment Cili lamp Cili lan@et 7blue lights8, or direct
sunlight 7conugate the bilirubin8 2eldom rises abo0e the "$mg
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Pathological Qaundice
If jaundice is present in the first 24 hours or it isintense and/or persistent, you must considerpathological jaundice
+( abnormalities sensiti0ity -emorrhage #mpaired hepatic function #nfections
'oxoplasmosis +ubella -erpes 2yphilis
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#nspection
(areful inspection of all s@in De0elop a pattern
Dont o0erloo@ body parts
Examine s@in creases Assymetrical creases on thighs
Possible hip dysplasia 2imian Bine 7hands feet8
possible Do!n syndrome
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2chamroth 'echni=ue
Place nail surfaces of
corresponding fingers
together
A. ormal? diamond shaped
!indo!
. (lubbed? angle bet!een
distal tips increases
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(lubbing of the ails
Associated !ith? +espiratory disease
(ardio0ascular disease 'hyroid disease
(irrhosis
(olitis
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2@in 'urgor
est e0aluated by gently pinching a
fold of the abdominal s@in
C'enting indicates? Dehydration Malnutrition
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#mmune and Bymphatic
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#mmune Bymphatic 2ystem
Bymph nodes in the neonate react =uic@ly to
any mild stimulus especially cer0ical and postauricular chains
'heory? compensate for lac@ of antibodies
by increased filtration and phagocytosis
Ability to produce antibodies is still immature atbirth but lymphoid tissue is plentiful
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Palatine 'onsils
Much larger during early childhood
than after puberty
Enlargement of the tonsils in children is
not necessarily an indication of a
problem may obstruct nasopharynx ;I sleep apnea
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bstructi0e 2leep Apnea
Periodic cessation of breathing during
sleep d
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Bymph Exam
It is not uncommon to find enlarge lymph nodes
that may e!en be !isible from a distance
Cormal 1irm, discrete, mo0eable, S/mm
Rp to &cm in cer0ical or inguinal regions
#n0estigate further if? Gro!ing rapidly or suspiciously large 7I"%5 cm8
1ixed and immo0eable
Expected +egions of
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Expected +egions of
Bymph ode Enlargement
S& year S" years I" years
postauricularand occipital common common uncommon
cer0ical andsubmandibular
uncommon common
It is NEVER normal forsupraclavicular lymph nodes to be
enlarged!
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(ommon (onditions
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#nfectious Mononucleosis
Epstein%arr 0irus
NMay occur at any age 7M( in teens8 #nitial symptoms?
Pharyngitis, fe0er, fatigue, malaise
Exam 1indings? Enlarged anterior and posterior cer0ical chains 2plenomegaly, hepatomegaly, and
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2trep Pharyngitis
2ymptoms? 2ore throat and runny nose
-eadache, fatigue,
abdominal pain
Exam 1indings?
Palatal petichiae Enlarged anterior cer0ical nodes
"#hroat culture needed to confirm
f f ( 2 2
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Mc#saac Modification of the (entor 2trep 2core
Likelihood:
%&
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-ead and ec@
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#nspect the -ead
2caling, crusting 7seborheic dermatitis8
Dilated 0eins 7increased #(P8
Excessi0e hair or unusual hairline
ote symmetry of shape, bulging or
s!elling
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(ranial Molding During a 0aginal birth the cranial
bones shift and o0erlap
Expect the s@ull to resume a Cnormalshape and si:e !ithin & !ee@
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(aput succedaneum (ephalhematoma
2ubcutaneous edema 2ubperiosteal bleed
(rosses suture lines Does not cross suturesM( occiput M( parietal
2oft, poorly defined margins 1irm, !ell%defined edges
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Rnusual contour may be related to a
0ariety of causes?
#rregular closing of suture lines7craniosynostosis8
Positional head deformity 7P-D8
Preterm infants? soft cranial bones flatten
!ith the positioning and !eight of the
head
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#nspect the 1ace
2pacing of features
2ymmetry
2@in color 'exture
Paralysis
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bser0e
-ead controlK PositionK
Mo0ementK
ote any?
Qer@ing 'remors #nability to mo0e head in one direction
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Palpate the -ead
ote any tenderness o0er the scalp
2uture lines
slight groo0e up to 6 months 1ontanels
should feel slightly depressedF some pulsation isexpected
Post. fontanel closes ;" months
Ant. fontanel closes by "9 months
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ulgingK #nfection
#ncreased intracranial pressure
DepressedK Dehydration
Measure the 1ontanels Anterior fontanel should
not exceed 9%/ cm
7S6 months8
ot a
sensiti0e
indicator
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'ransilluminate
Dar@ room
'ransilluminator firm against scalp
egin at the midline frontal region and inch
o0er the entire head bser0e the ring of illuminationF note
asymmetry
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A ring S" cm is expected on all regions of
the head except the occiput 7should be S&
cm8 #llumination beyond these parameters suggest
Excess fluid
Decreased brain tissue in the s@ull
#ransillumination should be done on e!ery
infant and on an older child if there is a
suspected intracranial lesion or rapidly
increasing head circumference
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#nspect the ec@
2ymmetry, si:e, shape
Edema
Distended 0eins Pulsations
Masses
ebbing
Excess s@in
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'o inspect the ne!borns nec@
Place the infant supine
Ele0ate the upper bac@ and let the
head fall bac@ into extension
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Palpate the ec@
2ternocleidomastoid ote toneF hematoma
'rachea
'hyroid Difficult to palpate unless its enlarged
Goiter #ntrauterine depri0ation of thyroid hormone
May cause respiratory distress
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(ommon (onditions
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'orticollis 7Cry ec@8
irth inury -ematoma
May be palpated shortly after
birth 1irm fibrous mass "%5 !ee@s
later
lder children +esult of trauma, muscle
spasm, 0iral infection, drug
ingestion, VVVVVVVVVV
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Management
1irst, consider the underlying cause 2pinal cord tumor or congenital spinal anomolyK
irth traumaK 2ubluxationK
(hiropractic care
Mechanical adustments
#ncreased Ctummy time Exercises
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Plagiocephaly
%ositio-a 2ead,e3ormit+
ra-ios+-ostosis5am#doid6
o ridging Palpable ridge
Ear on flat side migratesfor!ard
Ears e0en or ear on flat sideappears to be more posterior
1orehead protrudes 7sameside as occipital flattening8 1orehead does not protrude
ald spot on side offlattening
o bald spot or central baldspot
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Positional
Parallelogram 1rontal bulging Ear migrates anterior
2ynostosis 7lambdoid8
'rape:oid o frontal bulging Ears e0en
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(raniosynostosis
Premature union of cranial sutures
2mall head circumference 7microcephaly8 +igid sutures Misshapen s@ull
Rsually not accompanied by mentalretardation
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Microcephaly
+elated to?
(raniostenosis
(erebral dysgenesisAssociated !ith mental retardation and
failure of brain to de0elop normally
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-ydrocephalus
Enlarged head
ossing of the s@ull
idening of sutures and fontanels Bethargy, irritability, !ea@ness
2clera 0isible abo0e the iris
C2unsetting sign
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(raniotabes
2oftening of the s@ull
Demonstrated by pressing the bone along
the suture line bone pops in and out
Associated !ith? +ic@ets and hydrocephalus
(an be a Cnormal finding up to &
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ells palsy 7facial palsy8
Asymmetry of facial features
Eyelid !ill notclose completely
Drooping corner of
mouth Boss of labonasial fold
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Do!n 2yndrome
Depressed nasal bridge
Epicanthal folds
Mongolian slant of eyes Bo! set ears
Barge tongue
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1etal Alcohol 2yndrome 71A28
2mooth philtrum
idespread eyes
#nner epicanthal folds Mild ptosis
-irsute forhead
2hort nose 'hin upper lip
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Eyes
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De0elopment 'able &&%&7Mosby8
y "%5 months *oluntary control of eye muscles
y 4 months (an differentiate colors
y J months
Eye muscles coordinateF a single imageis percie0ed
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'ips #nfant Eye Exam
'o encourage the infant to open their
eyes
Rse a dimly lit room -old the infant upright, suspended under
its arms facing you
-a0e parent hold infant o0er a shoulder
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#nspect External Eye
2i:e of eyes 7symmetryK8
Distance bet!een the eyes
-ypertelorism 7!idely spaced eyes8 may be associated !ith mental retardation
2lant of palpebral fissures
Epicanthal folds Prominent in Asian populations, Do!n
syndromeK
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#nspect Eyelids
'o detect the C2etting 2un 2ign +apidly lo!er the infant from upright
to supine position
Boo@ for sclera abo0e the iris
Differentials include?
Expected 0ariant in ne!born -ydrocephalus
rainstem lesion
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(linical ote
e!born eyelids may be s!ollen or edematous,
accompanied by conuncti0al inflammation
and drainage as a conse=uence of routinelyadministered antibiotics
eyond the ne!born period
redness, hemorrhage, discharge, granularappearance may indicate infection, allergy,or trauma
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#nspect
2clera
Pupil
#ris (onuncti0a
(oloboma
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(oloboma
a@a CWeyhole pupil
Boss of functional pupil ften associated !ith other
congenital abnormalities
rushfield spots hite spec@s in a linear pattern around the
circumference of the iris
2uggests Do!n syndrome
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2trabismusK
Exoptropic 0s. Esotropic
'ests include? (orneal light reflex 7-irschbergs 'est8 (ross%(o0er 'est (o0er%Rnco0er 'est
(orneal Bight +eflex
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a@a -irschbergs 'est
(hild stares at a penlight about 5$ cma!ay
Doctor loo@s at the reflection fromeach cornea #n relationship to the pupil
ormal? symmetrical
2trabismus? asymmetrical
Pseudostrabismus
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Pseudostrabismus 2ymmetrical corneal light
reflex (ommon in Asian and
ati0e American
populations 7prominent
epicanthal folds8
Disappears by & yoa
2trabismus 7esotropic8 Asymmetrical light reflex
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(ross%(o0er 'est
Patient stares at penlight
Doctor co0ers one eye and obser0es
the unco0ered eye for mo0ement
ormal? no mo0ement
Exotropic eye? mo0es lateral to medialEsotropic eye? mo0es medial to lateral
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(o0er%Rnco0er 'est
Patient stares at the penlight Doctor co0ers one eye and then
obser0es as it is unco0ered
ormal? no mo0ement 7remains fixedon the light8
Exotropic eye? mo0es lateral
Esotropic eye? mo0es medial
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-elp to differentiate
Paralytic 2trabismus #mpairment of extraocular muscles or their ner0e
supply
onparalytic 2trabismus o primary muscle !ea@ness
(an focus !ith either eye but not bothsimultaneously concern of de0eloping amblyopia
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#nfant (ranial er0es 7##, ###, #*, *#8
&. Expect the infant to focus and trac@
through 6$ degrees
". ptical blin@ reflex 2hine a bright light at the infants eyes
ote the =uic@ closure of the eyes and
dorsiflexion of the head
5. (orneal light reflex 7-irschbergs8
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Extraocular Mo0ements % (hild
2ix cardinal fields of ga:e
Peripheral 0ision
Parent may hold the childs head still
Rse a teddy bear or toy
-a0e child sit on parents lap
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*isual Acuity
#nfant Grossly examined by obser0ing the the
infants preference for loo@ing at certain
obects
>ounger (hildren bser0e play !ith toys % stac@ing, building,
or placing obects inside of others #f tas@s are performed !ell, 0ision difficulties areunli@ely
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2nellen E (hartN
'ested !hen a child can
cooperate !ith the exam
Rsually ;5 years of age
As@ !hich !ay the Clegs are pointing
NAlso a0ailable !ith different shapes
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'ips 2nellen E (hart
&. Ma@e it a Cgame
". #nstruct the child to point finger in the
direction of the legs of the E5. Allo! the child to practice follo!ing
instructions before you administer the
test9. Parent may assist !ith co0ering eye
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2nellen E (hart
+emember?
'est each eye seperately
ith and !ithout correcti0e lenses
"$
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$%hen testing !isual acuity in the child,
any difference in the scores betweenthe eyes should be detected&'
A " line difference 7"$
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Anticipated *isual Acti0ity
Age *isual Acuity
5 years "$
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+ed +eflex
NPerformed from birth on should be
elicited in e0ery ne!bornX
bser0e for opacities, dar@ spots, or
!hite spots !ithin the circle of red
glo! (ongenital cataracts
+etinoblastoma
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(ongenital (ataracts
+e=uires a full metabolic, infectious,systemic, and genetic !or@up
(ommon causes? #nfectious diseases
'xoplasmosis, +ubella 7M(8, (ytomegalo0irus, -erpes
-ypoglycemia 'risomies Prematurity Etc.
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1 d i E i ti
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1undoscopic Examination
(ifficult to perform on a newborn or
young infantconsider referral
ften deferred until "%6 months unless
the patient presentation suggests a
needEg. premature infant 7retinopathy8
+ ti th f P t it
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+etinopathy of Prematurity
lood 0essels are straightened and
di0erted temporally
(icatricial changes may be se0ere
+etinal detachment
Glaucoma lindness
'i 1 d i E
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'ips 1undoscopic Exam
Do not hold the childs eyelid open forcibly Beads only to more resistance
ften unable to @eep eyes still and focused
on a distant obect Rse a toy, picture, etc.
+esults may be better if the child sits on theparents lap
May !ant to do the exam !ith the patientsupine
1 d i E 2 i
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1undoscopic Exam 2upine
(hild laying supine on the exam table !ithhead near the end
2tand at the end of the table
Rse +t. eye to examine the childs Bt.
'E? +etinal findings !ill appear Cupside do!n #nspect the optic disc, fo0ea, and 0essels as
they pass by
b 5 th
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e!born 5 months
2creening Method +e=uire 1urther E0aluation
+ed reflex AbnormalAsymmetric
(orneal light reflex Asymmetric
#nspection 2tructural abnormality
6 th &
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6 months & year
2creening Method +e=uire 1urther E0aluation
+ed reflex Abnormal or Asymmetric
(orneal light reflex Asymmetric
Differential occlusion1ailure to obect e=ually toco0ering each eye
1ix and follo! !itheach eye 1ailure to fix and follo!
#nspection 2tructural abnormality
5 ld
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;5 years old
2creening Method +e=uire 1urther E0aluation
*isual acuityS"$
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;/ years old
2creening Method +e=uire 1urther E0aluation
*isual acuity "$ # t t
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Modifying >our #nstruments
to
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Ears
De elopmental 1eat res
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De0elopmental 1eatures
External auditory canal shorter, has an
up!ard cur0e infant otoscopic exam Cpull do!n!ard
Eustachian tube relati0ely !ider, shorter
and more hori:ontal +eflux of nasopharyngeal secretions
Gro!th of adenoids may occlude theeustachian tube #nterferes !ith aeration of the middle ear
#nspect the Ear
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#nspect the Ear
ell formed all landmar@s present
1lexible should ha0e instant recoil after bending
Position the tip of the auricle should cross an imaginary
line bet!een the outer canthus of the eye and
the prominent portion of the occiput 7EP8 o s@in tags or preauricular pits should be
present
(linical ote
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(linical ote
Bo! or poorly shaped auricles
associated !ith renal disorders and
congenital abnormalities
Palpate
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Palpate
Bymph nodes Pinna 'ragus Mastoid
'endernessK armthK
N#f pain is noted !ith palpation of the
mastoid, suspect mastoiditis
toscopic Exam #nfant
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toscopic Exam #nfant
&. Bay the infant supine
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e!born *ariants
>ou may note Bimited mobility Dullness and opacity of a pin@ or red tympanic
membrane Bight reflex may appear diffuse 'ympanic membrane is not conical for se0eral months
Auditory canal may be obstructed !ith 0ernix
")toscopic e*am should be performedwithin the first few wee+s of life
toscopic Exam (hild
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toscopic Exam (hild
Pull auricle either do!n and bac@+ up and bac@ best 0ie! of the tympanic membrane
Postpone until the end of the 0isit est done on parents lap e prepared to use restraint if encouraging
the child fails As@ the parent to restrain the child
+estraining a (hild toscope
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+estraining a (hild % toscope
1ace the child side!ays !ith one arm
placed around parents !aist
Parent holds the child firmly againsthis
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(linical ote
C+ed reflex
#f the child is crying or has recently cried
0igorously dilation of blood 0essels in the
tympanic membrane can cause redness
ou cannot assume that redness of themembrane alone is a middle ear infection-
Pneumatic toscopy
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Pneumatic toscopy
Assesses mobility of the tympanic
membrane needed to differentiate
Crying
Red Reex
Red
Moveable
Infection Red
No mobility
'ympanometry
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'ympanometry
Accurate !ay to identify middle ear effusion Ear piece must be sealed in the canal to pro0ide
accurate reading
ax, ruptured membrane, tubes
Acoustic +eflectometry 7ne!er technology8 (heaper
Easier to get accurate results
Assessing -earing
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Assessing -earing
bser0e response to a !hispered 0oice, toys, etc. As they get older, as@ child to perform tas@s in a
soft 0oice Rse !ords that ha0e meaning for them May !ant to ha0e a parent do it Ma@e sure theyre not responding to air
mo0ement or 0isual stimulus
eber, +inne, and 2ch!abach tests Rsed only !hen a child understands directions
and can cooperate !ith the examiner Rsually 5%9 years of age
Expected -earing +esponse
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Expected -earing +esponse
Birt to !mont"
#tartle reex$ crying$ce""ation of breating ormovement in re"pon"e to
"udden noi"e% quiet" toparent&" voice
' to ( mont" )urn" ead to*ard "ourceof "ound but may not
al*ay" recogni+e locationof "ound% re"pond" toparent&" voice% en,oy""ound producing toy"
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( to -. mont" Re"pond" to o*n name$telepone ringing$ andper"on&" voice$ even if not
loud% begin" locali+ing"ound" above and belo*$turn" ead '/ degree"to*ard" "ound
-. to -0 mont" Recogni+e" and locali+e""ource of "ound% imitate""imple *ord" and "ound"
(ommon (onditions
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(ommon (onditions
titis Externa
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titis Externa
#nfection of the auditory canal
-istory of trauma or moist en0ironment #tching in the ear canal #ntense pain !ith mo0ement of pinnaF che!ing Discharge may be !atery at first, then purulent
thic@ mixed !ith pus and epithelial cells Musty, foul%smelling
(onducti0e hearing loss 7exudate and s!elling8 (anal is red, edematousF tympanic membrane
obscure
acterial titis Media
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acterial titis Media
#nfection of the middle ear M( infection in childhood ften follo!s or accompanies R+'#
1e0er, feeling of bloc@age, tugging earlobe,anorexia, irritability, di::iness, 0omiting diarrhea
Deep%seated earache
Discharge if tympanic membrane ruptures orthrough tympanostomy tubesF foul%smelling
(onducti0e hearing loss 7fills !ith pus8 'ympanic membrane may be red, thic@ened,
bulgingF full, limited, or no mo0ement
titis Media !ith Effusion
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titis Media !ith Effusion
(ollection of li=uid 7effusion8 in the
middle ear
Associated !ith?
Allergies
Enlarged lymph tissue bstructed or dysfunctional eustachian tube
titis Media !ith Effusion
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2tic@ing or crac@ing sound on ya!ning or
s!allo!ingF no signs of acute infection
Pain is uncommonF feeling of fullness
Discharge is uncommon (onducti0e hearing loss as middle ear fills !ith
fluid
#f chronic, may delay speech de0elopment
temporarily 'ympanic membrane is retracted, impaired
mobility, yello!ishF air fluid le0el and
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ose
De0elopment
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De0elopment
Maxillary and ethmoid sinuses present at birth, though 0ery small
2phenoid sinus tiny ca0ity at birth not fully de0eloped until puberty
1rontal sinus de0elops by 3%4 years
#nspection
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#nspection
2ymmetric appearance Positioned in the 0ertical midline on the face nly minimal mo0ement of the nares !ith
breathing should be apparent
Possible congenital abnormality if 2addle%shaped nose !ith a lo! bridge and
broad base 2hort small nose Barge nose
CAdenoidal or CAllergic 2alute
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Adenoidal or Allergic 2alute
'rans0erse crease at the
uncture bet!een the cartilage and
the bone of the nose
(hildren often !ipe their noses !ith an
up!ard s!eep of the palm of the hand #f repeated often enough, causes a crease
#nternal ose
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#nternal ose
Rsually ade=uate to tilt the nose tip
up!ard
#nspect by shining a light inside Bargest otoscopic speculum may be used
(linical note? some say that a Cgreyishmembrane may indicate chronic allergies
asal Patency
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asal Patency
Must be determined at the time of birth
Mouth closed, occlude one naris and then
the other bser0e the respiratory pattern
ith total obstruction, the infant !ill not be ableto inspire or expire through the noncompressednaris
dDx? 2eptal de0iation, choanal atresia
(hoanal Atresia
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(hoanal Atresia
(ongenital nasal obstruction
of the posterior nares Qunction bet!een nasal ca0ity and
nasopharynx
e!borns may experience respiratory
distress and difficulty feeding
bligatory nose breathers
Copyright 2006University of Washington.
Nill breathe
!hen
crying
2inuses
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2inuses
#nfant Maxillary and ethmod sinuses are small 1e! problems arise in these areas and
examination is generally unnecessary
(hild Maxilary sinuses should be palpated 1e! sinus problems occur since the sinuses
are still de0eloping
#here is wide !ariation howe!er&&& do not ruleout sinusitis simply on the basis of age-
2inusitis
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2inusitis
#nfection of one or more paranasal sinuses May be a complication of a 0iral R+'#, dental infection,
allergies, or a structural defect of the nose
2igns in children include? upper respiratory symptoms nasal discharge lo!%grade fe0er daytime cough malodorous breath cer0ical adenopathy intermittent painless morning eye s!elling facial pain or headache
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Mouth 'hroat
De0elopmental 1eatures
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De0elopmental 1eatures
2ali0ation increases by 5 months
#nfant drools until s!allo!ing is learned
'eeth
"$ deciduous teeth appear 76%"9 months8
Eruption of permanent teeth begins about 6
years of age and is completed by &9%&/ yrs 5rdmolar 7C!isdom tooth8 ;&4 years old
#nspection
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#nspection
'ongue should fit !ell in the floor of the mouth
protrude beyond the al0eolar ridge
1renulum
usually attaches mid!ay bet!een the0entral surface of the tongue and its tip
Macroglossia
7 b ll l t 8
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7abnormally large tongue8
(ongenital hypothyroidism (ongenital abnormalities
Do!n 2yndrome
2hort 1renulum 1eeding problems
2peech difficulties
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atal 'eeth 'eeth or tooth buds in
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a ne!born
Potential for aspiration May be remo0ed
+etention (ysts7a@a Epstein Pearls8
Appear along the buccal
margins of the gums
Pearl%li@e retention cysts Disappear in &%" months
aby bottle syndrome Multiple bro!n caries on upper
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Multiple bro!n caries on upper
and lo!er incisors
d
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Palate 2hould be !ell%formed !ith no cleft
#nfant arro!, flat palate roof or a high, arched palateK
may result in feeding and speech problems associated !ith congenital anomolies
(hild -ighly arched palateK
seen in chronic mouth breathers
(left Bip and Palate
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p
(ongenital malformation 1issure in the upper lip and
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'onsils 2hould blend !ith the color of the pharynx Pea@ si:e bet!een " % 6 years
2hould retain unobstructed passage
Graded to describe their si:e
&) 0isible
") half!ay bet!een tonsillar
pillars and the u0ula
5) nearly touching the u0ula
9) touching each other
'onsillitis
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#nflammation or infection of the tonsils 1re=uently caused by streptococci
2ore throat, referred pain to the ears, dysphagia,
fe0er, fetid breath, and malaise
'onsils appear red and s!ollenF purulent exudate
yello! follicles are associated !ith strep.
Anterior cer0ical lymph nodes enlarged
Peritonsillar Abscess
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#nfection of the tissue bet!een the tonsil and
pharynx (omplication of tonsillitis
Dyphagia, drooling, se0ere sore throat !ith pain
radiating to the ear, muffled 0oice, fe0er
'onsil, tonsillar pillar and adacent soft palate
become red and s!ollen 'onsil may appear pushed for!ard or bac@!ard,
possibly displacing the u0ula
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Drooling ormal in infancy
#f it persists past &" months
consider a neurologic disorder
#f acute consider epiglotitis
Epiglottitis
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p g
2uspected !ith 2udden high fe0er Drooling (roupy cough 2ore throat Apprehension focus on breathing
'ripod position, nec@ extended
N#mpending air!ay obstruction d
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(rying pro0ides an opportunity to examine
the mouth
A0oid depressing the tongue 2timulates the C'ongue 'hrust +eflex Ma@es 0isuali:ation of the mouth difficult
#nsert your glo0ed finger into the infantsmouth fingerpad to the roof of the mouth
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mouth, fingerpad to the roof of the mouth
E0aluate the infants suc@ 2hould ha0e a strong suc@, tongue pushing
0igorously up!ard against the finger
Palpate the hard and soft palates Palatal arch should be dome shaped o palpable clefts 2oft palate should rise symmetrically !hen the
infant cries 2timulate a gag reflex by touching the
tonsillar pillars
'ips (hild Mouth Exam
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'o reduce fear, let the child hold andmanipulate the tongue blade and light
2tart by as@ing to see their teeth Rsually not threatening
As@ the child to protrude the tongue and sayCah, a tongue blade is often unnecessary
'o raise the palate, as@ the child to pantCli@e a puppy
#f child refuses to open mouth
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#nsert a tongue blade through the lips
to the bac@ molars
Gently but firmly insert the tongueblade bet!een the bac@ molars and
press the blade to the tongue
'his should stimulate the gag reflex Gi0es you a brief 0ie! of the mouth and
oropharynx
$.hildren of any age who are not too big to
sit on a parents lap are better e*amined there
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p p
than on the e*amining table&'
+estraining a (hild ral Exam
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2eated in the parents lap, bac@ to the
parent and legs bet!een the adults legs
Parent can reach around to restrain the
childs arms !ith one arm and control thechilds head !ith the other
(an usually be accomplished !ithout forcing 1orce only ma@es them more angry
+estraining a (hild % 2upine
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#f the child acti0ely resists
Place child supine on the exam table
Parent holds arms extended abo0e the head
and assists in restraining the head Doctor lies across the childs trun@ and
stabili:es the childs head
'hird person may need to hold the childslegs
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(hest and Bungs
e!born Apgar 2core
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A ctivity
P ulse
G rimaceA ppearance
R espirations
2ubecti0e =ualitati0e e0aluation done at & and / minutes
determine Csur0i0ability of the ne!born by
obser0ing the le0el of function of / components
Muscle tone
-eart rate
+eflex irritability (olor
+espiratory rate
Apgar 2core
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$ & "
-eart rate Absent S&$$ I&$$
+espiratoryeffort Absent 2lo!
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Maternal en0ironment during labor 2edati0es
(ompromised blood supply to the child
Mechanical obstruction by mucus
eurological damage 7birth trauma8K #nfants rely primarily on the diaphragm for
respiratory effort 7(5,9,/8
De0elopment
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ony structure is more prominent than
the adult d
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(hest is generally round A%P diameter approximately the same as
the trans0erse
#f the Croundness of a childs chest
persists past the "nd year, suspect a
possible chronic obstructi0e pulmonaryproblem
(ystic 1ibrosis
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Autosomal recessi0e
disorder of exocrine glands 2!eat glands
2alt loss in s!eat 7Ctaste salty8
Bungs 1re=uent and progressi0e pulmonary
infections 7thic@ mucus8 Pancreas
2tic@y, foul smelling stool
#ntrauterine gro!th retardation 2maller chest circumference compared to
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2maller chest circumference compared to
the head
Poorly controlled diabetes
+elati0ely larger chest circumference
ipples
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2ymmetry in si:e
2!elling
Discharge 2upernumerary
Measure distance bet!een the nipples 2hould be Y chest circumference
reast de0elopment in a
ne!born d
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(ount for & minute A0erage? 9$%6$ rpm 74$ rpm is not
uncommon8
#f room temp is 0ery !arm or cool,
0ariation in the rate occurs
Most often tachypnea 2ometimes bradypnea
+espiratory +hythm
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ote regularity of respiration Premature infants are more li@ely to ha0e
irregular respiratory patterns
Periodic breathing se=uence of relati0ely 0igorous respiratory
efforts follo!ed by apnea of as long as &$%&/seconds
Periodic reathing
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(ause for concern if Apneic episodes tend to be prolonged aby becomes centrally cyanotic
#n the term infant periodic breathing should!ane a fe! hours after birth
Persistence in preterm infants is relati0e to
gestational age Apneic periods should diminish in fre=uency
as they approach term status
bser0e (hest Expansion
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#f asymmetric, suspect inability to fill
one of the lungs
Pneumothorax Presence of air
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+ib cage and sternum Boss of symmetry
Rnusual masses
(repitus 1ractured cla0icle 7birth trauma8
May sho! no e0idence of pain
Liphoid Mobile and prominent
Auscultation #nfant
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Bocali:ation of breath sounds is
difficult
reath sounds are easily transmittedfrom one segment to another
NDifficult to detect absence of breathsounds in any gi0en area
Auscultation (hild
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May not be able to gi0e enough of anexpiration to satisfy you 7S/ years old8 Especially !ith subtle !hee:ing
As@ them to Cblo! out your penlight As@ them to blo! a!ay a bit of tissue in
your hand Bisten after they run up and do!n thehall!ay
(hest !all is thinner and more resonantthan adults
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than adult s
reath sounds may sound louder, harsher,and more bronchial
-yperresonance is common Easy to miss the dullness of underlying
consolidation 7percussion8
$If you sense some loss of resonance, gi!e it as
much importance as you would gi!e fran+
dullness in the adult&'
'ips Bung Exam
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Percussion is usually unreliable in the infant Examiners fingers may be too large
A sob is fre=uently follo!ed by a deepbreath Allo!s the e0aluation of 0ocal resonance
1eel for tactile fremitus
hole hand, palm and fingers
(rac@les and +onchi ot uncommon immediately after birth 7fluid
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ot uncommon immediately after birth 7fluid
has not completely cleared8 #f asymmetric, a problem should be suspected
dDx? aspiration of meconium
+espiratory Grunting #nfant tries to expel trapped air or fetal lung
fluid !hile trying to retain air and increase
oxygen le0els #f persistent, cause for concern
2tridor -igh pitched, piercing sound
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(annot be dismissed as inconse=uentialespecially !hen inspiration is longer thanexpiration
1loppy epiglottis (ongenital defects (roup
Edematous response #nfection
Allergen
2mo@e
(hemicals
Aspirated foreignbody
#ncreased +espiratory Effort
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+etraction at the supracla0icular notch
(ontraction of the 2(Ms
1laring of the nostrils b0ious intercostal exertion
7retractions8
'achypnea
C2ee%sa! respirations
Does a loss of synchrony bet!een B and + occurduring the respiratory effortK #s there a lag inmo0ement of the chest on one sideK AtelectasisKDiaphragmatic herniaK
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Diaphragmatic herniaK
#s there stridorK (roupK EpiglottitisK
#s there retraction at the suprasternal notch,intercostally, or at the xiphoid processK
Do the nares dilate and flare !ith respiratory effortK #spneumonia presentK
#s there an audible expiratory gruntK #s it audible !iththe stethoscope only or !ithoutK #s there lo!er air!ay
obstructionK 1ocal atelectasisK
#s there paradoxic breathingK
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(ommon (onditions
'racheomalacia
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1loppiness of the trachea 'rachea changes in response to 0arying
pressures of inspiration and expiration resulting inCnoisy breathing hee:ing, inspiratory stridor
NGenerally benign and self%limiting !ith age
dDx? 0ascular lesion, tracheal stenosis, foreign body
Also? Baryngomalacia Baryngotracheomalacia
ronchiolitis
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*iral +2* 7respiratory syncytial 0irus8
Most common S6 months
Expiration becomes difficult due to
hyperinflation of lungs
Exam findings? #ncreased A%P diameter of thoracic cage
-yperresonant percussion
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(oughing (omes in Cfits and tends to be harsh
'achypnea
+apid, short breathsF expiratory phase prolonged Possible !hee:ing and crac@les
#nfant appears anxious
Generali:ed retraction Perioral cyanosis
#nfluen:a
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Generali:ed febrile illness 70iral8 Mild cases may ust seem li@e a cold R' the
0ery young are at higher ris@ +espiratory tract may be o0er%!helmed
7interstitial inflammation and necrosis8
(ough 1e0er
Malaise -eadache (ory:a Mild sore throat
(rac@les +honchi 'achypnea 2ubsternal pain
Pneumonia
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#nflammatory response of the
bronchioles and al0eolar space to an
infecti0e agent
acterial, fungal , or 0iral
Exudates lead to lung consolidation Dyspnea, tachypnea, and crac@les
Diminished breath soundsF dullness to
percussion
#2PE('# 'achypnea2hallo! breathing
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2hallo! breathing
1laring of nostrilsccasional cyanosis
Bimited mo0ementF splinting
PABPA'# #ncreased fremitus 7consolidation8PE+(R22# Dullness 7consolidation8
AR2(RB'A'# *ariety of crac@lesccasional rhochi
ronchial breath sounds
Egophony, bronchophony, !hisperedpectorilo=uy
ronchitis
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#nflammation of the mucusmembranes of the bronchial tubes
Acute #ro-chitis 1e0er and chest pain
hro-ic #ro-chitis *ariety of causes Excessi0e secretion of mucus
oth can sho! 0arying
degrees of in0ol0ement
bstruction Atelectasis
Most often =uite mild
#2PE('# ccasional tachypnea
ccasional shallo! breathing
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ccasional shallo! breathing
ften no de0iation from expectedfindings
PABPA'# 'actile fremitus undiminished
PE+(R22# +esonance
AR2(RB'A'# reath sounds may be prolonged
ccasional crac@les
ccasional expiratory !hee:es
Asthma
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(PD characteri:ed by air!ayinflammation mucosal edema
increased secretions bronchoconstriction
-yperreacti0ity to allergens, anxiety,R+'#, smo@e, exercise, cold air, etc.
#2PE('# 'achypnea
Dyspnea
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Dyspnea
PABPA'# 'achycardia
Diminished fremitus
PE+(R22# -yper%resonance
Bimited diaphragmatic descentFlo!er diaphragmatic le0el
AR2(RB'A'# Prolonged expiration
hee:esDiminished lung sounds
(roup
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*iral Particularly parainfluen:a 0iruses
Most commonly?
*ery young children 7& Z to 5 years old8 oys I girls
2ome are prone to recurrent episodes
dDx? epiglottitis, aspirated foreign body
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ften begins in the e0ening after the childhas gone to sleep A!a@ens suddenly, frightened
-arsh stridorous cough Car@ of a seal Babored breathing +etraction
#nspiratory stridor ' al!ays fe0er
Epiglottitis
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-aemophilus influen:ae type #ncidence appears to ha0e reduced
M(? 5%3 years old
Acute, life%threatening egins suddenly and progresses rapidly to full
obstruction of the air!ay
'reat this as a medical emergency
#nserting tongue blade may be deadlyX
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(hild sits straight up !ith
nec@ extended, head held
for!ard
Appears 0ery anxious and ill Rnable to s!allo!
Drooling from the open mouth
(ough is ' common
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-eart
1etal (irculation
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(ompensates for the non%functional fetal lung lood passes directly from the + to
B atrium through the 3orame-
o7ae +ight 0entricle pumps blood through the
ductus arteriosus
At birth... functional closure of forameno0ale and the ductus arteriosus closes!ithin "9%94 hours
Patent Ductus Arteriosus
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lood flo!s through the ductus duringsystole and diastole
#ncreases pressure in the pulmonary circulation
#ncreased !or@load for the right 0entricle
2mall shunt? may be asymptomatic
Barge shunt? may ha0e dyspnea on exertion
CMachinery murmer
-arsh, loud, continuous murmur &st % 5rd intercostal spaces lo!er sternal border
Rsually unaltered by postural changes
Patent 1oramen 0ale
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Allo!s blood to flo! bet!een the
right and left atria
Rsually asymptomatic May exhibit cyanosis !ith exertion 7especially if
other congenital heart defects are present8
-eart Exam
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Examine !ithin the first "9 hours and againat "%5 days of age (hanges from fetal to systemic and pulmonary
circulation
(omplete e0aluation of heart functionincludes s@in, lungs, li0er (ongesti0e heart failure in the infant may
present !ith a large, firm li0er 7hepatomegaly8 Rnli@e adults, this finding may be noted
before pulmonary crac@les
#nspection
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(olor? should be Cpin@
PurplishK
dDx? polycythemia
Ashy, !hiteK
dDx? shoc@
(entral cyanosisKdDx? congenital heart disease
Distribution intensityof discoloration.
Extent of change after
exertion.
2e0ere cyanosis e0ident at birth or shortly aftersuggests? 'ransposition of the great 0essels 'etralogy of 1allot 7blue8
Al!ays
cyanotic
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'etralogy of 1allot 7blue8 'ricuspid atresia
relies on A2D *2D for oxygenation of blood 2e0ere septal defect 2e0ere pulmonic stenosis
(yanosis that does not appear until after theneonatal period suggests? Pure pulmonic stenosis Eisenmenger complex % only de0elops in some cases
right%to%left shunting 7*2D is M(8 combined !ith pulmonaryhypertension
'etralogy of 1allot 7pin@8 2eptal defects
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ulgingK
Precordium tends to bulge o0er an
enlarged heart if the enlargement is
long%standing 'horacic cage is more cartilaginous and
yielding in children
(apillary +efill
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(apillary refill time is 0ery rapid up to " yrs
S & second 7normal8
Prolonged capillary refill time 7I " seconds8dDx?
2ignificant dehydration
-ypo0olemic shoc@
Apical #mpulse
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9th % /th left intercostal space, medial
to the midcla0icular line Apex of the heart is higher, heart lies
more hori:ontal
NAdult heart position is reached by age 3
EnlargementK PositionK
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Pneumothorax 2hifts apical pulse a!ay from the area of
pneumothorax
Diaphragmatic hernia M( on the left side 2hifts the heart to the right
Dextrocardia Apical impulse on the right
Dextrocardia 2inus #n0ertus
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Dextrocardia +ight thoracic heart normally placed stomach
and li0er May be associated !ith other anomolies
2inus #n0ertus -eart and stomach are on the right, li0er on the
left ot 0ery common
Pulses
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rachial, radial, and femoral pulses arepalpable
ea@ or thin pulse dDx? Decreased cardiac output Peripheral 0asoconstriction
ounding pulse dDx? B to + shuntF PDA 7patent ductus arteriosus8
Difference in pulse amplitude bet!een femoral andradial pulses dDx? (oarctation of the Aorta
-eart +ate
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-eart rate is more 0ariable #nfants? eating, sleeping, and !a@ing (hildren? exercise, tension, fe0er
-+ &$%"$ beats for each degree temp.
2inus arrhythmia is common in children +ate 0aries in a cyclical pattern
1aster on inspiration
2lo!er on expiration1ixed tachycardia may indicate difficulty
-eart +ate
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Age eats per minute
e!born &"$%&3$
& year 4$%&6$
5 years 4$%&"$
6 years 3/%&&/
&$ years 3$%&&$
Auscultation
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Murmers +elati0ely fre=uent in the first 94 hours Most are innocentF transition from fetal to
pulmonic circulation
89--oce-t mumers: Disappear !ithin "%5 days 7Cshort8 Grade # or ## intensity 7Csoft8
2ystolic Rnaccompanied by other signs and
symptoms
C2
A murmur is usually ' a significant
congenital anomaly. Paradoxically, a
significant congenital anomaly may be
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g g y y
unaccompanied by a murmur
Must in0estigate if
persists beyond "nd or 5rd day of life is intense
fills systole
occupies diastole to any extent almost al!ays significant
radiates !idely
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*enous hum
(aused by turbulence of blood flo! in the
internal ugular 0ein (ontinuous lo!%pitched sound
Bouder during diastole (ommon in children Rsually has no pathologic significance
As@ child to sit !ith head turned a!ay tilted slightly up!ard Auscultate supracla0icular space
lood Pressure
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1lush 'echni=ue 7#nfant8 Place cuff on upper arm 7or leg8 Ele0ate and !rap the arm firmly !ith an elastic
bandage from fingers to antecubital space
Empty 0eins and capillaries #nflate cuff to a pressure abo0e the systolic
reading you expect Bo!er the arm and remo0e the bandage
Arm !ill be pale
Diminish pressure gradually until you see asudden Cflush and return to usual color
lood Pressure
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lood pressure is measured the same as in
the adult after " years
'o facilitate the exam Explain the process
Bet them explore the sphygmomanometer
Ma@e sure to use the correct cuff si:eX (o0er "
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A sustained increase in P is almost al!ays
significant in the ne!born 2tenosis of renal artery
(oarctation of the aorta (ystic disease of the @idney
euroblastoma
ilms tumor
-ydronephrosis Adrenal hyperplasia
(2 disease
-ypertension (hild
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Do not ma@e the diagnosis of hypertension basedon one reading
An ele0ated systolic but normal diastolic may be d
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'a@e careful note of? eight gain 7or loss8 De0elopmental delay (yanosis
(ongenital heart defects that impedeoxygenation
(lubbing fingers and toes
(ongenital Defects
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Atrial 2eptal Defect
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Allo!s oxygenated blood to lea@ from the
left atrium into the right
Minor cases may be asymptomatic
Barger defects may re=uire surgery
NMay not sound particularly impressi0e
7especially in an o0er!eight child8
More apt to be significant if Palpable thrust
+adiation through to the bac@
(oarctation of the Aorta
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arro!ing in a portion of the aorta M(? descending aortic arch near the
origin of the left subcla0ian artery andligamentum arteriosum
(an cause se0eral life%threatening complications 2e0ere hypertension Aortic aneurysm, dissection or rupture Endocarditis rain hemorrhage
2tro@e -eart failure and premature coronary artery disease
N+epair is typically recommended before age &$
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(ompare radial and femoral pulses ormal? pea@ at the same time 7or femoral
slightly earlier8 (oarctation? delay and
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#nfants may ha0e C'et spells, central cyanosis Paroxysmal dyspnea !ith loss of consciousness
As they get older (lubbing of fingers and toes
Exam findings? Parasternal hea0e
Precordial prominence 2ystolic eection murmur heard o0er the 5rd
intercostal space 2ometimes radiating to the left side of the nec@
(ommon (onditions
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Acute +heumatic 1e0er
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(omplication of strep. pharangitis 7or s@in
infection8 ;I connecti0e tissue disease May result in serious cardiac 0al0e in0ol0ement
M( mitral or aortic 0al0es
M( children bet!een /%&/ years of age
Pre0ention is the best therapy i.e. ade=uate treatment for strep. infections
+ecent strep infection 1e0er Migratory polyarthritis
E th i t
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Erythema marginatum Pin@ margins, pale centers (horea 7er@y body mo0ements8 1irm, painless subcutaneous nodules
Elbo!s, @nees, !rists
Murmur Mitral regurgitationF aortic insufficiency
1riction rub 7pericarditis8 (ongesti0e heart failure (ardiomegaly
Qones (riteria Diagnosis of +heumatic 1e0er " maor manifestations or & maor ) " minor manifestations
-igh probability of acute rheumatic fe0er
N#f th id f di t i f ti
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N#f theres e0idence of a preceding strep infection
Major Ma-i3estatio-s Mi-or Ma-i3estatio-s
(arditis
Polyarthritis(horea
Erythema marginatum
2ubcutaneous nodules
.linical
%Pre0ious rheumatic fe0er orrheumatic heart disease
%Arthralgia
%1e0er
0aboratory
%Acute phase reactions? E2+, (%reacti0e protein, leu@ocytosis
%Prolonged P%+ inter0al on E(-
Wa!asa@i Disease
A t ill 7f 8
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Acute illness 7fe0er8 Etiology un@no!n
#nfectiousK (arpet cleanersK
M( children under /F males I females
(an be self%limiting, reco0er in a fe! days (omplications? 0asculitis ;I aneurysms
(ritical concern? cardiac in0ol0ement 70asculitisof the coronary artery8
2igns symptoms? 1e0er 7fe! days 5 !ee@s8
(onuncti0itis 7red eyes8
+ash 7stomach, chest, genitals8
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Des=uamation
2tra!berry tongue
(happed lips
Byphadenopathy
Edema of hands and feet
2ystemic 0asculitis
Medical Management? Gamma globulin, Aspirin
1bd
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1bdomen
'ips Abdomen Exam
+ l ti d i t
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+elaxation and =uiet ottle
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'enderness and pain can be difficult todetect and locali:e Distract the child !ith a toy 2tart a!ay from the area suspected bser0e for changes as you mo0e to identify
the area of greatest pain (hange in pitch of crying +eection of the opportunity to suc@ Dra!ing the @nees to the abdomen 1acial expression (onstriction of pupils
#nspection
M t ith i ti
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Mo0ement !ith respiration
2hape
(ontour
Pulsations
Pulsations? common in infants Distended 0eins dDx? 0ascular obstruction,
abdominal distension or abdominal obstruction 2pider ne0i dDx? li0er disease
#nfant
Abdomen should be rounded and dome
shaped
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Distended abdomenK 1eces, mass, organ enlargement
2caphoid abdomenK Abdominal contents are displaced
Abdominal and chest mo0ements should be
synchronous
slight bulge of the abdomen at the beginning ofrespiration
'oddler Abdomen protrudes slightly
Cpot%bellied
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After age / Abdomen may become conca0e
!hen laying supine
+espirations continue to be abdominal until6%3 years of age
#n young children, restricted abdominalrespiration may be related to peritoneal irritation
Rmbilical stump
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Rmbilical stump should be dry and odorless
#nspect all s@in folds for? Discharge +edness #nduration
2@in !armth Granulomatous tissue
Granuloma
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2erous or serosanguinous discharge
once the stump has separated
o other signs of infection
Rmbilicus is usually in0erted
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Rmbilicus is usually in0erted ften e0erts !ith increased abdominal
pressure
ote any protrusion through theumbilicus or rectus abdominus muscle -ernia Diastasis recti
Rmbilical -ernia
Protrusion of omentum and
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Protrusion of omentum andintestine through theumbilical opening
(ommon in infants +each maximum si:e by & month Generally close spontaneously by &%" years
'o determine si:e, measure the diameter of
the opening 7not the protruding contents8 2hould Creduce !ith light pressure
Diastasis +ecti
Midline separation 7& 9 cm8
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Midline separation 7&%9 cm8
of the rectus abdominus bet!een the xiphoid and umbilicus
o need to repair in most cases herniation through the rectus abdominus
does re=uire surgery
Rsually resol0es by 6 years of age
Peristaltic a0es
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Peristaltic a0es Rse tangential lighting bser0e abdomen at eye le0el
Rsually not 0isible 2ometimes seen in thin, malnourished
babies 2uggests intestinal obstruction
Auscultation
Peristalsis 7Cmetalic tin@ling8
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Peristalsis 7 metalic tin@ling 8 -eard e0ery &$%5$ seconds
o!el sounds should be present &%"
hours after birth
o bruits or 0enous hum should be
detected
Bight Palpation
Wnees flexed
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Wnees flexed Place your hand gently on the abdomen
'humb at the right upper =uadrant
#ndex finger at the left upper =uadrant Press 0ery gently at first, only gradually
increasing pressure
#dentify the spleen, li0er, and masses
close to the surface
2pleen
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2pleen Palpable &%" cm belo! the left costal margin
for the first fe! !ee@s after birth
A detectable spleen tip is common in !ellinfants but increase in spleen si:e mayindicate?
blood dyscrasias septicemia
Bi0er 7lo!er border8 Bi0er 2cratch test
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Bi0er 7lo!er border8 e!born? ust belo! the right costal margin
#nfants toddlers? &%5cm belo!
(hildren? &%"cm belo!
-epatomegaly? lo!er border I5 cm belo!
the right costal margin
#nfection (ardiac failure
Bi0er disease
Bi0er 2cratch test
Deep Palpation
Palpate all =uadrants for masses
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Palpate all =uadrants for masses Bocation
2i:e
2hape
'enderness
(onsistency
'ransillumination can be used to distinguishcystic from solid masses
1ixed masses should be in0estigated !ith
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1ixed masses should be in0estigated !ithspecial studies if Baterally mobile Pulsatile
Palpate the aorta for signs of enlargement Bocated along 0ertebral column
#f any suspicion of neoplasm exists, limit
palpation of the mass May cause inury or spread of malignancyX
ephroblastoma 7ilms 'umor8
M( intraabdominal tumor of childhood
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M( intraabdominal tumor of childhood7"%5 years of age8
Malignant
1irm, non%tender mass deep !ithin the flan@ nly slightly mo0eable
ot usually crossing the midlineF sometimes
bilateral
Possibly? Bo!%grade fe0er
-ypertension
euroblastoma
1re=uently appears as a mass in the
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1re=uently appears as a mass in theadrenal medulla
Malignancy in early childhood
1irm, fixed, non%tender, irregular and nodularabdominal mass Malaise Boss of appetite eight loss
Protrusion of eye7s8 ther symptoms may occur !ith?
compression of the mass or metastasis to adacent organs
Percussion
May be more tympanic 70s adults8
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May be more tympanic 70s. adults8 2!allo! air !hen feeding crying
'ympany !ith distended abdomenK Gas
Dullness !ith distended abdomenK
1luid, solid mass
Examine the ladder
Palpate and percuss o0er the
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Palpate and percuss o0er thesuprapubic area
Determine si:e
DistentionK
+ebound 'enderness
bser0e childs facial expression and
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bser0e child s facial expression andpupils
e cautious
)nce a child has e*perienced palpation
that is too intense, a subseuent e*aminer
has little chance for easy access to theabdomen
(ommon (onditions
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(ommon (onditions
hat if you find K
2ausage%shaped mass in the left lo!er
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2ausage shaped mass in the left lo!er=uadrant
1eces in the sigmoid colon
(onstipation
Midline, suprapubic mass
1eces in the rectosigmoid colon-irschsprung disease
-irschsprung Disease a@a(ongenital Aganglionic Megacolon
Absence of parasympathetic ganglion cells
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Absence of parasympathetic ganglion cellsin a segment of the colon no peristalsis
e!born? May fail to pass meconium in the first "9%94 hrs
lder infants and young children? #ntestinal obstruction or se0ere constipation 1ailure to thri0e Abdominal distention Episodes of 0omiting and diarrhea
hat if you find K
2ausage%shaped mass in the left or
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2ausage shaped mass in the left orright upper =uadrant
#ntussusception
#ntussusception
Prolapse of one segmentof intestine into another
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Prolapse of one segmentof intestine into anotherresulting in intestinal obstruction
M( 5%&" months oldF cause is un@no!n
Acute intermittent abdominal pain Abdominal distention *omiting 2tools mixed !ith blood and mucus
+ed current elly appearance 2ausage%shaped mass in + or B upper =uadrant + lo!er =uadrant feels empty 7Dance sign8
#ntussusception CA(DE1
A bdominal or anal Csausage
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A bdominal or anal sausage
lood from the rectum
( olic? babies dra! up their legs
D istention, dehydration, and shoc@
E mesis
1 ace pale
hat if you find K
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li0e%shaped mass in the right upper
=uadrant 7deep palpation8 immediately
after the infant 0omitsPyloric stenosis
Pyloric 2tenosis
-ypertrophy of the circular
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-ypertrophy of the circularmuscle of the pylorus orobstruction of the pyloric sphincter
+egurgitation ;I proectile 0omiting 1eeding eagerly 7e0en after 0omiting8 1ailure to gain !eight 2igns of dehydration
2mall, rounded mass palpable in the + upper=uadrant especially after the child 0omits
Gastroesophageal +eflux 7GE+8
+elaxation or incompetence of the lo!er
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+elaxation or incompetence of the lo!eresophagus persisting beyond the ne!born
period
+egurgitation and 0omiting
eight loss and failure to thri0e
+espiratory problems
aspiration leeding from esophagitis
iliary Atresia
(ongenital obstruction or absence of some
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gor all of the bile duct system
Qaundice
ecomes apparent at "%5 !ee@s -epatomegaly
Abdominal distention
Poor !eight gain
Pruritis 2tools become lighter in color
Rrine dar@ens
Meconium #leus
'hic@ening and hardening of meconium in
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g gthe lo!er intestine ;I intestinal obstruction
1ailure to pass meconium &st "9 hrs after birth
Abdominal distention
NMust consider cystic fibrosis
Mec@el Di0erticulum
utpouching of the ileum
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p g M( congenital anomaly of
the G# tract *aries in si:e presentation
May be asymptomatic #ntestinal obstructionK Di0erticulitisK
right or dar@ red rectal bleeding
Bittle abdominal pain 2ymptoms li@e those of acute appendicitis
mphalocele
#ntestine present in the umbilical cord or
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pprotruding from the umbilical area *isible through a thic@ transparent membrane
ecroti:ing Enterocolitis
#nflammatory disease of the gastrointestinal
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y gmucosa Associated !ith prematurity
#mmaturity of the G# tract
Abd i l di t ti
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