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9. Curs Examin

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9. Curs Examin

  1. 1. Teaching Files: Detailed Newborn Examination
  2. 2. <ul><li>General </li></ul><ul><li>Measure and record height, weight, and head circumference. If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid). The exam is divided into two parts: an external characteristics score, which is best done at birth, and a neuromuscular score, which should be done within 24 hours after birth. </li></ul>
  3. 6. <ul><li>Small for gestational age (SGA) </li></ul><ul><li>Symmetric (HC = Wt = Len, all <10 %ile) -- 33% of SGA infants </li></ul><ul><li>Genetic </li></ul><ul><ul><li>Small maternal size </li></ul></ul><ul><ul><li>Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome) </li></ul></ul><ul><ul><li>Congenital abnormalities </li></ul></ul><ul><li>Intrauterine infections </li></ul><ul><ul><li>Viruses (rubella, CMV, ?varicella, ?HIV) </li></ul></ul><ul><ul><li>Bacteria (tuberculosis) </li></ul></ul><ul><ul><li>Spirochete (syphilis) </li></ul></ul><ul><ul><li>Protozoan (toxoplasmosis, malaria) </li></ul></ul><ul><li>Inborn errors of metabolism </li></ul><ul><ul><li>Hypophosphatasia </li></ul></ul><ul><ul><li>Some amino acidurias </li></ul></ul><ul><li>Environmental </li></ul><ul><ul><li>Drugs (heroin, methadone, ethanol, diphenylhydantoin) </li></ul></ul><ul><ul><li>X-rays (therapeutic) </li></ul></ul><ul><ul><li>Smoking </li></ul></ul>
  4. 7. <ul><li>Asymmetric (HC = Len > Wt, Wt <10 %ile) -- 55% of SGA infants </li></ul><ul><li>Uteroplacental insufficiency -- onset usually after 24 weeks </li></ul><ul><ul><li>Chronic hypertension </li></ul></ul><ul><ul><li>Preeclampsia </li></ul></ul><ul><ul><li>Renal disease </li></ul></ul><ul><ul><li>Cyanotic heart disease </li></ul></ul><ul><ul><li>Hemoglobinopathies </li></ul></ul><ul><ul><li>Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation. </li></ul></ul><ul><ul><li>Altitude </li></ul></ul>
  5. 8. <ul><li>Combined (symmetric or assymetric) -- 12% of SGA infants </li></ul><ul><li>Environmental </li></ul><ul><ul><li>Drugs (including ethanol) </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><li>Placental unit insufficiency </li></ul><ul><ul><li>Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation. </li></ul></ul>
  6. 9. <ul><li>Large for gestational age (LGA) </li></ul><ul><li>Infants of diabetic mothers </li></ul><ul><li>Beckwith-Wiedemann syndrome </li></ul><ul><li>Hydrops fetalis </li></ul><ul><li>Large mother </li></ul>
  7. 10. Preterm infants
  8. 11. Preterm infants
  9. 12. Preterm infants
  10. 13. <ul><li>Skin </li></ul><ul><li>Color </li></ul><ul><li>Pallor - associated with low hemoglobin </li></ul><ul><li>Cyanosis - associated with hypoxemia </li></ul><ul><li>Plethora - associated with polycythemia </li></ul><ul><li>Jaundice - Elevated bilirubin </li></ul><ul><li>Slate grey colour - associated with methemoglobinemia </li></ul>
  11. 14. <ul><li>Lesions </li></ul><ul><li>Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last several weeks. </li></ul><ul><li>Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear within 1 week. </li></ul><ul><li>Transient neonatal pustular melanosis - small vesicopustules, generally present at birth, containing WBCs and no organisms. The intact versicle ruptures to reveal a pigmented macule surrounded by a thin skin ring. </li></ul><ul><li>Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few days. Wright's Stain shows sheets of eosinophils. </li></ul><ul><li>Cafe au lait spots - suspect neurofibromatosis if there are many large spots. </li></ul><ul><li>Junctional nevi - if large numbers, suspect tuberous sclerosis, xeroderma pigmentosus, generalized neurofibromatosis </li></ul>
  12. 34. <ul><li>Neurological Exam </li></ul><ul><li>State of alertness </li></ul><ul><li>Check for persistent lethargy or irritability. </li></ul><ul><li>Posture </li></ul><ul><li>In term infant, normal position is one with hips abducted and partially flexed and with knees flexed. Arms are adducted and flexed at the elbow. The fists are often clenched, with fingers covering the thumb. </li></ul><ul><li>Tone </li></ul><ul><li>Support the infant with one hand under his chest. The neck extensors should be able to hold the head in line for 3 seconds. Should not have more than 10% head lag when moving from supine to sitting position. </li></ul><ul><li>Reflexes </li></ul><ul><li>Reflexes must be symmetrical. Biceps jerk test C5 and C6, Knee jerk tests L2-L4, Ankle jerk tests S1, S2. Truncal incurvation reflex tests T2 through S1. Anal wink test S4, S5. Other primitive reflexes include the Moro, palmer and planter grasps, sucking and rooting reflexes, and the asymmetric tonic neck reflex (ATNR). Asymmetric tonic neck reflex (seen in ventral suspension with arms rigidly extended and fists clenched) is abnormal. </li></ul>
  13. 35. <ul><li>When reflexes appear and disappear: </li></ul><ul><li>Reflex Appears Disappears </li></ul><ul><li>Moro Newborn 3 months </li></ul><ul><li>Grasp Newborn 3 months </li></ul><ul><li>Extensor plantar Newborn 8-12 months </li></ul><ul><li>Placing/stepping Birth 1-2 months </li></ul><ul><li>ATNR Newborn 3 months </li></ul>
  14. 36. <ul><li>Head and Neck </li></ul><ul><li>Head </li></ul><ul><li>Check for overriding sutures, the number of fontanelles and their size. Check for abnormal shape of head. Check for encephalocoeles. Measure the head circumference. </li></ul><ul><li>Eyes </li></ul><ul><li>Check for colobomas, heterochromia. </li></ul><ul><li>Cornea - Check for cloudiness. </li></ul><ul><li>Conjunctiva - Inspect for erythema, exudate, edema, jaundice and hemorrhage. Silver nitrate prophylaxis can cause a chemical conjunctivitis. Check for pupillary size and reactivity to light. </li></ul><ul><li>Red Reflex - Hold the ophthalmoscope 6-8&quot; from the eye. Use the +10 diopter lens. The normal newborn transmits a clear red colour back to the observer. Black dots may represent cataracts. A whitish color may be suggestive of retinoblastoma. </li></ul><ul><li>Ears </li></ul><ul><li>Check for asymmetry, irregular shapes. Look for auricular or pre-auricular pits, fleshy appendages, lipomas, or skin tags. </li></ul>
  15. 39. <ul><li>Nose </li></ul><ul><li>Look for flaring of the alae nasi as a sign of increased respiratory effort. Look for hyper- or hypo-telorism. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate nose breathers). A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected. </li></ul><ul><li>Palate </li></ul><ul><li>Check for cleft lip and palate. </li></ul><ul><li>Mouth </li></ul><ul><li>Observe the size and shape of the mouth. </li></ul><ul><li>Microstomia - seen in Trisomy 18 and 21. </li></ul><ul><li>Macrostomia - seen in mucopolysaccharidoses. </li></ul><ul><li>Fish mouth - seen in fetal alcohol syndrome. </li></ul><ul><li>Epstein pearls - small white cysts which contain keratin, frequently found oneither side of the median raphe of the palate. </li></ul><ul><li>Ranulas - small bluish white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts. </li></ul><ul><li>Tongue </li></ul><ul><li>Macroglossia - Hypothyroidism, mucopolysaccharidoses </li></ul><ul><li>Teeth </li></ul><ul><li>Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached. </li></ul>
  16. 40. <ul><li>Chin </li></ul><ul><li>Micrognathia - occurs with Pierre-Robin syndrome, Treacher-Collins syndrome, Hallerman Streiff syndrome. </li></ul><ul><li>Neck </li></ul><ul><li>Palpate over all muscles, palpate clavicles for possible fractures. Web neck found in Turner's and Noonan's syndromes. Torticollis usually secondary to sternocleidomastoid hematoma. Cystic hygromas most common neck mass. Lymph nodes are unusual at birth and their presence usually indicates congenital infection. </li></ul><ul><li>Note : Suspect tracheo-esophageal fistula (TEF) if polyhydramnios is present. </li></ul>
  17. 41. <ul><li>Chest and Lungs </li></ul><ul><li>Observe respiratory rate, respiratory pattern (periodic breathing, periods of true apnea). Observe chest movements for symmetry and for retractions. Listen for stridor, grunting. Note that there may be some enlargement of the breasts secondary to maternal hormones. </li></ul><ul><li>Cardiovascular System </li></ul><ul><li>Measure heart rate, blood pressure in upper and lower extremities, respiratory rate. </li></ul><ul><li>Inspection </li></ul><ul><li>Check baby's color for pallor, cyanosis, plethora. </li></ul><ul><li>Palpation </li></ul><ul><li>Check capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready). Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, situs inversus, or other thoracic problem. </li></ul><ul><li>Auscultation </li></ul><ul><li>Note rhythm and presence of murmurs which may be pathologic. </li></ul>
  18. 42. <ul><li>Abdomen </li></ul><ul><li>Note shape of abdomen. Flat abdomens signify decreased tone, abdominal contents in chest, or abnormalities in abdominal musculature. Note abdominal distension. </li></ul><ul><li>Observe for diastasis recti. Observe for any obvious malformations e.g. omphalocoele. An omphalocoele has a membrane covering (unless it has been ruptured during the delivery) whereas a gastroschisis does not. </li></ul><ul><li>Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may be normal for the liver to be about 2 cm below the right costal margin. The spleen is not usually palpable; if the spleen is felt, be alert for congenital infection or extramedullary hematopoeisis. After locating these organs (checking for situs inversus), palpate for any abnormal masses. </li></ul><ul><li>Auscultate for bowel sounds. </li></ul><ul><li>Examine for hernias - umbilical or inguinal. </li></ul><ul><li>Inspect anal area for patency and/or presence of fistulas. </li></ul>
  19. 43. <ul><li>Genitourinary Exam </li></ul><ul><li>Kidneys </li></ul><ul><li>Examined by palpation. The kidneys should be about 4.5-5.0 cm vertical length in the full term newborn. The technique for palpation is either a) one hand with four fingers under the baby's back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney). </li></ul><ul><li>Male genitalia </li></ul><ul><li>Term normal penis is 3.6±0.7 cm stretched length. Inspect glans, urethral opening, prepuce and shaft. Normally difficult to completely retract foreskin. Observe for hypospadias, epispadias. Inspect circumcised penis for edema, incision, bleeding. Full term infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes. </li></ul><ul><li>Female genitalia </li></ul><ul><li>Inspect the labia, clitoris, urethral opening and external vaginal vault. Often a whitish discharge is present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal. Hymenal tags may be present normally. </li></ul>
  20. 44. <ul><li>Extremities and Skeletal System </li></ul><ul><li>Spine </li></ul><ul><li>Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles. </li></ul><ul><li>Upper extremity </li></ul><ul><li>Look for clavicular fracture, absence of radius or ulna. Inspect creases and fingers. </li></ul><ul><li>Lower extremity </li></ul><ul><li>See posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes. </li></ul>

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