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physical ASSESSMENT CHILDREN AND NEONATES.pptx
- 1. PHYSICAL ASSESSMENT OFA CHILD
- 2. APPROACH Pediatric Assessment: TheMajor Focus • Major differences between children and adults • Specific approaches and techniques to physical exam • Normal findings, variations and common pathological conditions • Interpretation of exam results
- 3. Major Concepts inPediatric Physical Assessment • Children are not little adults • Understanding differences from adults is important • Differences relate to both growth and development patterns • Differences exist in motor skills and coordination, and in physiologic, psychosocial, behavioral, temperamental, language, and cognition areas
- 4. Exam Settings • Outpatient(office, clinic emergency room) – Well child check – Illness visit • • Inpatient – Moderate to severe illness – Anxiety and stress • School setting or health office • – Children usually healthy – Illness visits primarily common acute problems and some chronic illness issues – Health screenings
- 5. Standard Measurements – Weight –Height – Head Circumference – Chest Circumference – Vital Signs • Temperature • Pulse, Heart Rate • Respiration • Blood Pressure – Gestational Age Assessment and Intrauterine Growth Charts
- 6. Sensory Issues – Smell:usually not tested; observe for unusual odors from child – Taste: usually not tested; infants often prefer sweet tasting foods – Touch: well developed in infant; if stimulated can invalidate other sensory tests – Vision: right eye (OD), left eye (OS), both eyes (OU) – Hearing: correlates with language development; localization requires both ears
- 7. Approach to PhysicalExam – Consider age and developmental level; observe for “readiness” clues – Take time to get “acquainted” – Use play techniques for infants and young children – Determine best exam place ( table, parent’s lap, examiner’s lap) – Use systematic approach; but be flexible to accommodate child’s behavior – Examine least intrusive areas first (i.e., hands, arms) – Examine sensitive, painful or intrusive areas last (i.e. ears, nose, mouth) – Determine what exam you want to complete before possible crying (i.e. heart, abdomen)
- 8. Age Groups – Neonate/NewbornBirth to 28 days • Pre-term Gestational age <37 weeks • Term Gestational age 37-42 weeks • Post-term Gestational age > 42 weeks – Infant Birth to 1 year • Young, Immobile Birth to 6 months • Older, Mobile 6 to 12 months – Young Child 1-5 years • Toddler 1-3 years • Pre Schooler 3-6 years – School Age or Older Child 6-12 years – Adolescent 13 to 18/21 years • Pre-Adolescent10-12 years
- 9. General Assessment: Body: Symmetry,nutrition, build, hygiene, breath, odor, posture, movement, coordination, facial expression Behavior: Development, attitude, affect, responsiveness/awareness, cooperation, speech, LOC (person, place, time), thought process, attention span, concentration, memory Distress: Posture, (flexion/extension), pain, facial grimace, respiration
- 10. Skin, Hair andNails: Skin – Key Points • Color:Jaundice, pallor, cyanosis, erythema, ecchymosis • Texture & Turgor: Degree of hydration or dehydration • Edema: Periorbital (crying, allergies, renal disease, juvenile hypothyroidism) Dependent (renal or cardiac disease) • Birth Marks • Pigmentations: Hyperpigmentation (endocrine, growth dis turbance); hypopigmentation • Infectious lesions: Viral, bacterial, fungal (erythema, macule, papule, vesicule, pustule) • Capillary bleeding: Petichiae and purpura usually indicate serious conditions • Infestations: Pediculosis, scabies, insect bites • Pruritis: Dry skin, allergy, eczema, contact dermatitis, hepatic, renal, lesions • Trauma: Scars, ecchymosis, signs of abuse • Hand:Dermatoglyphic variations associated with syndromes
- 11. Common Skin Variationsin Newborns and Infants • Thin, transparent skin, especially premature • Color Variations • Vascular Markings • Pigmentations • Lanugo (downy hair) more prominent in premature • Original hair may shed at 4-8 weeks, and be replaced
- 12. Skin Color Variations •Jaundice:Pathologic in first 24 hrs. physiologic after 24 hrs. • Acrocyanosis Cyanotic, cool extremities; warm, pink trunk • Cutis marmorata Bluish mottling due to chilling or stress • Erythema toxicum Papules, vesicles on erythematous base @24-48 hrs. • Harlequin color change Lower side of body red, upper side pale – change reverses it
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- 16. • Milia Whitepapular epidermal cysts with sebaceous retention • Miliaria (4 types) Obstruction of sweat ducts from head and humidity • Neonatal acne, prickly head Miliaria – crystallina, rubra, pustulosa, profunda • Pallor Anemia or anoxia • Plethora Erythematous flush, due to polycythemia
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- 19. Skin Vascular Markings Capillaryhemangiomas (telangiectasia or telangiectataic nevus or nevus simplex --- “stork bites,” “angel kisses”) --- usually fade Nevus flammeus (“port wine stains”), nevus vasculosis ---not likely to fade Can be associated with Sturge-Weber Syndrome Strawberry hemangioma: bright red, lobulated tumor
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- 23. Skin Pigmentations • Mongolianspots in darker pigmented infants • Pigmented nevi, • Café au Lait (<3cm and <6 in # are WNL – larger size or more spots associated with Neurofibromatosis , or Von Recklinghausen Disease) – an autosomal-dominant disorder, with tumors on peripheral or cranial nerves
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- 25. Yellow Skin Color Jaundice:Observed in sclera, skin, fingernails, soles, palms & oral mucosa . Does not blanche with pressure over chest or nose areas Is associated with liver disease, hepatitis, red cell hemolysis, biliary Obstruction & sever infection during infancy. Carotenemia: Observed in palms, soles, face, skin (not in sclera or mucous membranes) Blanches easily to pressure over chest or nose Occurs in older infants, with eating yellow vegetables Renal Disease: Yellowing of exposed skin areas (not sclera or mucous membranes) May be associated with chronic renal disease
- 26. Hemolytic Jaundice ofNewborn: Biirubin above 5ml/dl • Pathologic: Occurs first 24 hrs of life. Bilirubin increases faster than 5ml/dl/day • Physiologic: Onset after 24 hrs, with peak from 72- 90 hrs. Declines at 4 to 7 days Breast Feeding: Early onset: Onset at 2 to 4 days. Peak at 3 to 5 days • Late onset: Onset at 5-7 days. Peak at 10 to 15 days. • May remain jaundiced for 3 to 12 weeks
- 27. Hair: Key Points •Assess for distribution, color, texture, amount, quality and for infestations • Coarse, dry, brittle or depigmented hair may indicate nutrition deficiency or thyroid disorder • Alopecia may be related to tinea capitus, hair pulling or persistent positioning • White eggs (nits) attached to hair shafts indicate pediculosis • Hair tufts on spine or buttocks may indicate spina bifida
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- 29. Nails: Key Points •Inspect for color, shape, condition, nail biting and infection • Clubbing may indicate chronic hypoxia (respiratory or cardiac dis ease) • “Spoon” nails may indicate iron deficiency anemia • Pitted nails may indicate psoriasis • Splinter hemorrhages under nails may indicate trauma or endocarditis
- 34. HEENT: Head &Neck: Eyes: Ears: Nose, Face, Mouth & Throat • Head: Symmetry of skull and face • Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes • Eyes: Vision, placement, external and internal fundoscopic exam • Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane • Nose: Exam of nose and sinuses • Mouth: Structures of mouth, teeth and pharynx
- 35. • Head Circumference(HC): Frontal Occipital Circumference (FOC) • Fontannels/sutures: Anterior closes at 10-18 months, posterior by 2 months • Symmetry & shape: Face & skull • Bruits: Temporal bruits may be significant after 5 yrs • Hair: Patterns, loss, hygiene, pediculosis in school aged child • Sinuses: Palpate for tenderness in older children • Facial expression: Saddness, signs of abuse, allergy, fatigue • Abnormal facies: “Diagnostic facies” of common syndromes or illnesses
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- 41. Macewen’s sign:“Cracked pot”sound with tapping over parietal bone. • May be WNL in infants, or associated with ICP & suture separation (i.e. lead encephalopathy, tumor)
- 43. Flattened head areas:Especially occipital flattening with hair loss, may indicate persistent placement of baby in same position.
- 44. Eyes: Key Points •Vision: Red reflex & blink in neonate • Visual following at 5-6 wks • 180 degree tracking at 4 months • E chart & strabismus check for preschool child Snellen charts for older children • Irritations & infections • PERRLA • Amblyopia (lazy eye): Corneal light reflex, cover-uncover test • EOMs: tracking 6 fields of vision • Fundoscopic exam of internal eye & retina
- 47. Eyes: Variations • Placement& symmetry: Wide set: hypertelorism – Down syndrome • Close set: hypotelorism • Epicanthal folds or upward slants – ethnicity, Down s. Character of eyebrows
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- 52. Conjunctive: Inflammation, pallor(anemia), • Cobblestone appearance may indicate allergy
- 53. • Sclera: Jaundice(liver disease), injection (conjunctivitis), Hemorrhage, blue color (osteogenesis imperfecta) • Cornea: Smooth, moist,clear (not injected with conjunctivitis red eye) • Pupil & Iris:Brushfield’s spots (light speckling of iris) seen in Down s. • Coloboma (notch at outer edge or iris) may indicate visual field defect.
- 54. • Othalmoscope: Partialor dark red reflex indicates pathology, various retinal anomalies or opacities of cornea, anterior chamber or lens (i.e. cataract) • Glabellar/blinking reflex
- 55. Ears: Variations • External:Malformed auricle/pinna, or low-set or obliquely-set ears may be Associated with many syndromes, or genitourinary & chromosomal abnormalities. • Otitis externa: Pain with movement of auricle or tragus, discharge in canal, occurs More often in summer (“swimmer’s ear”) • Otitis media: Proper position & holding of otoscope facilitates comfortable . As middle ear pressure or fluid increases, the tympanic membrane (TM) becomes less mobile with pneumatic otoscopy.
- 58. • Exam nose& mouth after ears (after crying from ear exam) • Observe shape & structural deviations • Nares: ( check patency, mucous membranes, discharge, bleeding) • Septum: (check for deviation) • Infants are obligate nose breathers • Nasal flaring is associated with respiratory distress
- 59. Nose: Variations Allergy: Pale,boggy mucous membranes & interior turbinates , watery discharge, mouth breathing & “allergic salute” line across nose. Infection: Erythematous, edematous mucous membranes, with purulent yellow or green nasal discharge Foreign body: Foul odor or unilateral discharge Excoriation: Irritating discharge, frequent wiping or nose picking Asymmetry of nasolabial folds may indicate facial nerve impairment or Bell’s palsy.
- 60. Sinuses: Key Points •Palpate maxillary & frontal sinus areas for tenderness of sinusitis in older children • Development of facial sinuses and location of sinus pain is listed below: Sinus Pain Location Age of Development · Maxillary cheek & upper teeth present @ birth · Ethmoid medial & deep to eye present @ birth · Frontal forehead & above eyebrow approximately 7 years · Sphenoid deep behind eye in occiput adolescence
- 62. Mouth & Pharynx:Key Points • Inspect lips for color, symmetry, moisture, swelling, sores, fissures • Inspect buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding, lesions. • Inspect tongue & frenulum for movement, size & texture • Count teeth & inspect for caries, malocclusion and loose teeth. • 20 deciduous teeth, begin eruption at 6 months & continue adding approximately 1/month 32 permanent teeth, erupt from 6 to 25 years, with molar eruption from 1to 25 years • Observe for quality of voice • Observe infants for rooting and sucking reflexes, Epstein pearls & thrush • Observe breath for halitosis
- 64. Variations • Newborn cysts:Epstein’s pearls occur along midline of palate. • Fissure/cracked lips: May be due to harsh climate or vitamin deficiencies. • Color variations: Central cyanosis can be observed in lips & mucosa.. Pallor may indicate anemia. • Cherry red coloration may be seen in acidosis. • Koplik’s spots, small white, red rimmed eruptions on buccal mucosa next to first & second molars, appear and disappear before the onset of Measles (rubeola) rash.
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- 69. • Tongue variations:A smooth, red tongue may be related to vitamin deficiencies, • “Baby bottle” caries • Brown-white mottling may indicate excessive fluoride intake. • Green & black staining may indicate oral iron intake contacting teeth
- 72. Neck: Variations • Headlag: Significant lag after 6 months may indicate cerebral palsy • Torticollis: “Stiff neck” with resistance to lateral head turn as result of injury to sternocleidomastoid muscle, more often seen in newborn • Clavicle: Check for fracture in newborn, associated with shortening, break in contour, Crepitus at fracture site, and decreased motion of arm • Webbing: Feature of “Turner’s syndrome” or other congenital abnormalities • Meningeal: Irritation indicated by nuchal rigidiy, opisthotonos, tripod position with sitting, Positive Brudzinski’s sign (with patient supine, neck flexion produces pain and flexion of hips and knees). • Positive Kernig’s sign (with patient supine, hip & knee flexed, extension of knee Produces pain & resistance • Nodes: Lymphadenopathy common with infection in older children, upper neck areas, and below angle of jaw, usually bilateral. Should not be deep cervical or clavicular.
- 78. Thorax & Lungs:Key Points • Structure: Observe for shape, symmetry & posture – AP diameter: round chest or 1:1 ratio during infancy, with transverse diameter increasing, with AP:lateral ration 1:2 during school age years.
- 79. Pectus carinatum orpigeon breast: concavity of sternum
- 80. Pectus excavatum orfunnel chest protrusive sternum
- 82. Breast: Key Points •Inspection: size, color, symmetry, color, nipples/accessory nipples, dimpling • Palpation: masses, consistency, elasticity, nipple discharge • Male gynecomastia • Self Exam
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- 86. Lungs & RespiratoryStatus: Key Points • Symmetry of expansion, decreased expansion (pneumonia, pneumothorax, FB) • Prolonged expiratory phase • Resp irate (>40 at rest, after neonate period = respiratory distress) • Color: cyanosis or mottling • Clubbing • Nasal flaring • Grunting (expiratory) • Stridor (inspiratory): croup • Snoring (expiratory): upper airway obstruction, allergy, enlarged lymph tissue • Retractions • Respiratory movement: males abdominal, females thoracic-costal, • elderly shallow, infants abdominal • Dyspnea • Orthopnea
- 87. • Dullness topercussion: fluid or mass • Quality: vesicular (bronchioles, alveoli) • bronchovesicular (bronchi) bronchial (trachea) • Adventitious (adventitious) sounds – Crackles (rales) – Rhonchi (course breath sounds) – Wheeze • Pleural friction rub
- 88. Cardiovascular: Key Points •Vital signs: compare with normal/age values • Peripheral pulses: apical, carotid, radial/brachial, femoral, pedal • Rate, rhythm: compare cardiac rhythm with pulse • Peripheral vascular: color, temperature, edema, skin texture/changes • Capillary refill: immediate • Peripheral pulses: femoral pulses absent or diminished in aortic stenosis • Deep vein thrombosis: Homan's sign • Skin: pallor, cyanosis (lips, nail beds, ear lobes) • Clubbing • Pulsating neck vessels (JVD)
- 89. • Heart • – Rate,rhythm, heart sounds – Auscultation: sitting, lying, left recumbent & bending forward – location & size of heart: midclavicular 5th intercostal space (4th/infant) • Murmurs:may be systolic, diastolic or continuous (timing, location, quality (course, harsh, blowing, high pitched)
- 91. Abdomen: Key Points –Contour – Peristalsis – Skin: color, veins – Umbilicus – Tenderness – Ridigity – Hernias: umbilical, inguinal, femoral – Masses - size, shape, dullness, position, mobility – Liver – Spleen – Kidneys – Bladder
- 92. Female Genitalia – Externalgenitalia: Pelvic 16-18 years or when sexually active – Mons pubic, prepuce (clitoral hood), clitoris, labia minora/majora, vagina, Skene's & Bartholin's ducts, anus – Size, color, skin integrity, masses – Redness, swelling, labial adhesions/fusion, lesions, discharge (foul-smelling)
- 93. Male Genitalia – Penis:Size, color, skin integrity, circumcision – Urethral meatus: Shape, placement, discharge, ulceration, discharge meatal stenosis, hypospadias, epispadias – Scrotum: Color, size, symmetry, edema, masses, lesions, tenderness, – testes descended bilaterally – Pubic hair
- 95. Musculoskeletal: Key Points –Alignment, contour, strength, weakness & symmetry – Limb, joint mobility: ROM, stiffness, contractures - Neck, shoulder, elbow, wrist, hip, knee, ankle, foot – Digits – Dermatoglyphics
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