H and P

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H and P
2012-04-23 00:18:15
Pediatric physical exam

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  1. Children __ mo old and less are easily managed on an examing table while _ mo to _ years are usally better handled in moms lap
    • 6 mo examining table
    • 8mo to 3 yrs in moms lap
  2. In a young child what exams do you perform first
    • Heart
    • Lungs
    • Abdomen
  3. What exams do you perform last in a young child
    throat and ears
  4. If a portion of your exam is going to be painful or uncomfortable for the child do you tell them
    yes! be warm honest and tell them that it is necesary
  5. What are the 5 areas of which developemental milestones are assessed
    • Physical
    • Motor
    • Cognitive
    • Emotional
    • Social
  6. On a quick head to toe exam of a child what do you vitals/general is important
    • HR 120-160
    • Resp 30-60
    • temp under 100.4
    • BP 70/50
    • Consider environmental risk factors
  7. On a quick head to toe exam of a child what do you Head charactristics are important
    • Note shape lacs, bulges, bruising
    • Fontanelles
    • Size
    • Bulge
    • Enlarged more than 4cm hypothyroidism
    • Closed = craniosynostosis
  8. On a quick head to toe exam of a child what do you ENT findings are important
    • Note patency
    • ear tags
    • cleft lip
    • suck reflex
    • bilateral red reflex
  9. On a quick head to toe exam of a child what do you Neck things are important
    • Ensure no ducts, cysts bulges
    • Midline= thyroid disorder
    • Ant to SCM look for brachial cleft cysts
    • Posterior to SCM loof for cystic hygroma
    • Ensure no marks on the back of the head
  10. On a quick head to toe exam of a child what do you Chest findings are important
    • Ensure no clavical fracture
    • Ensure breathing without distress
    • auscultate the heart and lungs
    • most congenital heart disorders present with systemic symptoms
    • murmures not heard initially
  11. On a quick head to toe exam of a child what Abdominal findings are important too look for
    • Ensure soft and round
    • scaphoid = diaphragmatic hernia
    • ensure no masses
    • examine umbilical cord for anatomy
  12. On a quick head to toe exam of a child what Hip findings are important too look for
    • Barlow: click when hip dislocates posteriorly
    • Ortalani: clunk when hip relocates posteriorly
    • These tests are specific but not sensitive and should be repeated at follow up visits
    • Lower extremity pulses
    • Elevated pulse pressrue = PDA
    • Decreased pulse pressure = coarctation of the aorta
  13. In an infant/baby a decreased lower extremity pulse pressure indicates
    coarctation of the aorta
  14. In an infant/baby increased lower extremity pulse pressure indicates
  15. On a quick head to toe exam of a child what GU findings are important too look for
    • Note testes are decended bilaterally
    • Ensure no hernia, hydrocele, hypospadias etc
    • Ensure anus patent, no tracts
  16. On a quick head to toe exam of a child what Extremities findings are important too look for
    • count digits
    • check cap refil
    • check for deformity or asymetry
  17. On a quick head to toe exam of a child what Back findings are important to look for
    • Ensure spine symmetry
    • Note lumbosacral hair tuft (spina bifida)
    • Note gluteal pit in fold
  18. On a quick head to toe exam of a child what Skin findings are important to look for
    • Identify bruising, marks
    • Jaundice
    • Notice vernix caseosa
    • Lanugo in preterm
  19. On a quick head to toe exam of a child what Neuro findings are important to look for
    • General tone
    • Reflexes: suck, rooting (gone by 2mo), Fencer (gone by 4 mo), Moro (gone by 4 mo), Grasp (gone by 4 mo)
  20. The first year of life is...
    A. Preterm
    B. Infancy
    C. Toddler
    D. Neonate
    B. Infancy
    (this multiple choice question has been scrambled)
  21. The neonatal period is when?
    the first 28 days the post neonatal period is 29 days to 1 year
  22. When is a newborn most responsive to a physical exam
    1-2 hours after feeding b/c they are not too hungary or full
  23. If you are having trouble gettin a newborn to open their eyes what can you do
    dim the lights
  24. After birth the Apgar score is assessed at __ and __ mins
    1 and 5
  25. What does the Apgar score include? what is its max and min score?
    • Scoring is based on 0-2 for each category
    • Total scores range form 0-10
    • Heart rate: absent 0, less than 100= 1, >100 = 2
    • Respiratory effort: absent = 0, slow and irregular = 1, good =2
    • Muscle tone: Flaccid =0, some flesion of arms and legs = 1, active movement = 2
    • Reflex irritability: no responses = 0, Grimace = 1, crying vigorously sneeze or cough= 2
    • Color: Blue or pale = 0, pink body blue extremities = 1, pink all over 2

    • 8-10 at one min is normal
    • 5-7 at one min is some nervous sytem depression
    • 0-4 at one min is severe depression immediate rescesutation

    • 8-10 at 5 mins is normal
    • 0-7 at 5 mins is high risk for subsequent central nervous sytem and other organ system dysfunction
  26. If the apgar score is more than __ at 5 mins then proceed to a full exam
  27. What are the 5 components of apgar
    • Heart rate
    • Respiration
    • Color
    • Reflex/irritability
    • movement/muscle tone
  28. A preterm baby is a baby less than __ wks
  29. A term baby is a baby __-__ wks
  30. A post term baby is a baby less than __ wks
  31. Wt under 1,000gms is
    A. extremely low birthweight
    B. very low birth weight
    C. Low birth weight
    D. Normal birth weight
    A. extremely low birthweight
    (this multiple choice question has been scrambled)
  32. Wt under 1,500gms is
    A. Normal birth weight
    B. Low birth weight
    C. extremely low birthweight
    D. very low birth weight
    D. Very low birth weight
    (this multiple choice question has been scrambled)
  33. Wt under 2,500gms is
    A. extremely low birthweight
    B. very low birth weight
    C. Low birth weight
    D. Normal birth weight
    C. Low birth weight
    (this multiple choice question has been scrambled)
  34. Wt above or equal to 2,500gms is
    A. Low birth weight
    B. large for gestational age
    C. Large birth weight
    D. Normal birth weight
    D. Normal birth weight
    (this multiple choice question has been scrambled)
  35. Preterm AGA infants are prone to what conditions
    • RDS
    • Apnea
    • PDA
    • infection
  36. Preterm SGA infants are prone to what conditions
    • asphyxia
    • hypoglycemia
    • hypocalcemia
  37. Full term babies lie in what position
    symmetric position with limbs semiflexed and legs partially abducted
  38. Breech babies lie in what position
    legs and head are extended
  39. Frank breech babies lie in what postion
    legs are abducted and externally rotated
  40. In the first several hours after birth on your assessment of a child you note asymmetric movmetn of the arms and or legs what does this tell you?
    CNS of PCS deficits birth injuries or congenital anomalies it means you FURTHER INVESTIGATE
  41. T or F a new born should have a flexed tight fist with slow athetoid posturing movements
    • True (I just think jay will like the word athetoid)
    • Athetosis is a symptom characterized by involuntary convoluted, writhing movements of the fingers, arms, legs, and neck. If found in older children it is a sign of CP
  42. T or F tremor during vigorous crying and from 4 days after birth throught the rest of infancy is normal
    False, tremor is normal after vigorous crying, but is not normal after 4 days post birth. At this time a tremor indicates CNS disease
  43. When are well child exams done
    4 days, 2 wks, 2,3,6,(9), 12, (15), 18 months, 14 months then yearly
  44. When do you start measuring BP
    after 3 y.o.
  45. What is the formula for a childs systolic BP? what is the formual for normal diastolic BP?
    • SBP= 80 + age X2
    • DBP = 2/3 SBP
  46. What children should be in rear facing car seats
    less than 20 lbs or less than 12 mo
  47. What children should be in front facing car seats?
    children 20-40 lbs and 1-4 y.o
  48. what children should be in a booster seat
    4-8 y.o. and 40-80 lbs
  49. Is it recommended for infants to sleep supine or prone
  50. cooing occurs at __ months, babbling occurs at ___ mo and 1-3 words at ___ mo
    • Cooing = 2mo
    • Babbling = 6mo
    • 1-3 words = 12 mo
    • Interest in either the red sox, Bruins or Celtics occurs around the first 1-3 words in children born in Boston
  51. What are the 4 areas of assessment in the Denver Developmental Screening Tool
    • Personal-social
    • Fine motor adaptive
    • Language
    • Gross motor
  52. A DDQ score of > 85 is __
  53. a DDQ score of 70-85 is __
    possibly delayed and needs to be followed
  54. a DDQ score of less than 70 is __
  55. T or F it is normal to have a 10% loss of body weight during the 1st week of life, but they should be expected to gain it back by 2 wks
  56. a Baby's size doubles by _mo and triples by _ months
    4 and 12
  57. What are two signs that a child is falling off the growth curve and action should be taken
    • an infant less than 5% with no obvious cause
    • Infant that crosses two percentile lines or major channels consecutively without cause
  58. deviations greater thant __ standard deviations from normal for their age are reason for futher evaluation
  59. What are the parameters for "failure to thrive"
    • Growth less than 5th percentile for age
    • Growth drop >2 quartiles in first 6 mo
    • Weight for height below the 5th percentile
  60. how many years from birth should you continue to measure head circumference
  61. Small head with premature closure of sutures is a condition know as
  62. A head circumference above teh 97th percentile or 2 STD above the mean is
  63. What are some causes for sustained hypertension in an infant?
    • Coarctation of the aorta
    • Congenital renal malformation
    • renal artery disease
  64. pulse of __ to __ in an infant is SVT
  65. Fever can raise a infants respiration rate __ breaths for every degree centigrade
  66. Rapid shallow RR in newborns is a sign of what pathology
    • cyanotic cardiac disease
    • Tetrology of Fallot and TGV right to left shunting and metabolic acidosis
  67. Tachypnea for birht -2 mo is ___ and tachypnea for 2-12mo is ___
    • >60 breaths /min
    • >50 breaths /min
  68. > __ degrees F is a fever for an infant and this is of greatest concern in a child less than 2-3 mo
  69. __ is a fine downy hair growth covering a newborn especially on the shoulders and the back prominent in premature infants
  70. ___ is a lattice like bluish mottled appearanc on the trunk arms and legs that may last for months after birth
    Cutis marmorata
  71. ____ is a blue cast to the hands and fee then exposed to cold very common in early infancy and the first few days of life. if it does not resolve within 8 hrs of warming you should be concerned for ____ check oral and mucosa of toung for signs of central cyanosis
    • Acrocyanosis
    • Cyanotic congenital heart disease
  72. ___ is a transient cyanosis of one half of the body or one extremity that occasionally occurs in newborns
    Harlequin Dyschromia
  73. ___ is a cheesy white material covering the infant at birth. it is composed of sebum and dequamated epithelial cells
    Vernix caseosa
  74. _____ is scattered vesicles on an erythematous base usually on the face and trunk. results from obstruction of sweat glands/ducts. Disappears spontaneously after a few weeks
    Miliaria rubra
  75. ___ may appear similar to HSV or S. aureus infection. Appears on 2-3 days of life. Erythematous macules/papules with central pinpoint vessicles on an erythematous base over the entire body. Microscopic evaluation reveals eosinophils. Appear similar to flea bites and dissapear within 1wk of birth
    Erythema toxicum
  76. May appear similar to HSV or S. aureus infection. Common in black infants. Small vesicopustules over a brown macular base taht are present at birth and located on the head, neck, back and extremities. Resolve in 24-48 hrs. Pigmented macules resolve in 1-3 moths. Microscopic examination of contents reveals neutrophils but lesions are sterile
    Pustular melanosis
  77. ___ are Pinhead, smooth white raised areas without surrounding erythema on the nose, chin and forehead. Result from retention of sebum in the openings of sebaceous glands. Usually appear within the first few weeks and disappear over several weeks
  78. What is a midline nevus flammeus, AKA an eyelid patch, AKA a salmon patch, AKA a stork bite, AKA angel kisses
    • A birthmark on the upper eyelid (eyelid patch) that fades in one year
    • Flat irregular light pink patches that can also be seen on the nape of the neck (stork bite) or forehead or upper lip (angel kisses)
    • Fades with age
    • Not true nevi they result from distended capillaries.
    • Diasappear in 1 yr
  79. ___ is a light brown pigmented lesion. It usually has boarders that are uniform. it is noted in more than 10% of black infants. If more than 5 of these are present then it is concerning for neruofibromatosus
    Cafe au lait spots
  80. __ are common dark bluish spots in dark skinned infants
    mongolian spots
  81. ___ is a bluish purple or deep magenta lesion. that can be large or small
    Port wine stain
  82. A port wine stain found in the V1 branch of the trigeminal nerve could indicate what
    sturge weber syndrome
  83. Physiologic jaundice occurs in half of all newborns is appears on the _ or __ day and peaks on the __ day and usually disappears within a __ it is best noted in the natural sunlight and can be autmented by stretching the skin taught
    • 2nd or third day
    • 5th day
    • dissapears in a week
  84. Significant edema is noted in teh hands and feet of newborn girls with __ syndrome
  85. Where is the meotopic suture located
    it is the suture that comes down the front of the forehead and makes up the center spindle of the peace sign that the anterior fontanel makes
  86. the posterior fontanelle sloses by __ months
  87. a __ can cause a loud cranial bruit in an infant
    AV fistula
  88. ___ is an asymmetric head swelling that crosses the suture lines over the occipitoparietal region. Caused by capillary distention and extravasation of blood and fluid from vacuume assisted birth. Disappears in 1-2 days
    Caput secundum
  89. found in premature infants. The head is long in the ocipito frontal diameter but narrow in the bitemporal diameter. The skull usually normalizes in 2 days
  90. asymmetry of the cranial vault caused by caused by mostly lying on one side usually shows flattenign of the parieto-occipital region on the dependent side and a prominent of the frontal region on the oposite side evens out as teh baby becomes more active. Back sleeping has increased the prevalence of plagiocephaly
  91. Dandy walker malformation
    • Dandy–Walker syndrome (DWS), or Dandy–Walker complex, is a congenital brain malformation involving the cerebellum
    • and the fluid filled spaces around it. A key feature of this syndrome
    • is the partial or even complete absence of the part of the brain located
    • between the two cerebellar hemispheres (cerebellar vermis).[1] The Dandy–Walker complex is a genetically sporadic disorder that occurs one in every 25,000 live births, mostly in females.[2]
  92. What is a blue dot sign
    • The appearance of a small dark blue spot on transillumination in
    • patients with torsion of the testicular appendage or epididymis,
    • accompanied by intense pain at or near the head of the epididymis or
    • testis, and an isolated tender palpable nodule
  93. premature closure of of cranial sutures leaves a raised bony ridge at the suture line and an abnormally shaped skull
  94. spongy springy feeling of cranial bones. Can be caused by increased intracranial pressure, metabolic disturbances and infections
  95. hydrocephalus
    also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, tunnel vision, and mental disability. Hydrocephalus can also cause death.
  96. __ is a shortened chin caused by the head flexed on the sternum in utero
  97. Upslanting of the palpebral fissures indicates
    Down Syndrome
  98. Down Slanting of the palpebral fissures indicates
    Noonan's syndrome
  99. Short palpebral fissures indicates
    Fetal alcohol Syndrome
  100. Epicanthic fold
  101. If a newborn cannot open their eyes what does it suggest
    congenital ptosis, occulomotor palsy or mechanical issue
  102. Dolls eyes reflex
    Seen during the first 10 days of life. The eyes remain fixed in one direction if the head is turned without the body.
  103. Colobamas
    • Key shaped iris
    • may be seen with naked eye in babies
  104. Brushfield's spots
    • ring of white spots on the iris.
    • Strongly suggests Down syndrome
  105. What are the visual milestones
    • Birth: blinks and may reguard face
    • 1 month; fixes on objects
    • 1.5-2 months: coordinated eye movements
    • 3 months: eyes converge baby reaches
    • 12 months: acutity around 20/50
  106. Small deformed or low set ears suggests congenital defects especially ___ disease
    renal (weird right?)
  107. T or F the TM is not visible for the first few days of life on otoscopic exam
  108. Acoustic Blink Reflex
    blinking of the pts eyes in response to sudden sharp sound. snap your fingers or use a bell or beeper from about 1 ft away. Hard to produce wthin the first few days of life after repeated testing in a short period of time b/c habituation occurs
  109. Give some milestones/Signs of a hearing child at..
    0-2 mo
    2-3 mo
    • 0-2 mo: startle response and blink to sudden nosie, calming down with soothing music or voice
    • 2-3 mo: change in body movement s in response to music. change in facial expression to familiar sounds
    • 3-4mo: turing eyes and head to sound
    • 6-7mo: turing to listen ot voices and conversation
  110. ___ is a congenital disorder where the back of the nasal passage is blocked, usually by abnormal bony or soft tissue formed during fetal development
    Choanal atresia
  111. At birth the ___ are the only sinuses developed
    ethmoid sinuses
  112. When does pneumatization of the frontal sinus take place? when do the first sinus infections occur
    • 2-4 pneumatization of frontal
    • 6-10 y.o. sinus infection
    • sphenioid sinus present at birth but does not become significant until 5th to 8th year
  113. Enanthem
    are medical terms for a rash (small spots) on the mucous membranes.[1] These are characteristic of patients with smallpox, measles, and chicken pox.
  114. Bohn's Nodule
    • are smooth whitish bumps or cysts which are sometimes found in the mouths of newborns. They are found at the junction of the hard and soft palate, and along lingual and buccal parts of the dental ridges, away from the midline. These nodules are 1-3 mm in size, and filled with keratin.
    • The nodes are a result of cystic degeneration of epithelial rests of
    • the dental lamina (rests of Serres). They are benign, and usually
    • disappear within the first three months of life. Bohn's nodules are
    • similar in appearance to Epstein's pearls, which develop on the roof of the mouth.
  115. Epsteins pearls
    white or yellow rounded mucosal retention cysts seen on the alveolar ridge and posterior midline of the hard palate. They disappear within 1-2 months
  116. Prominent toung in a newborn could mean
    • congenital hypothyroidism
    • Downs syndrome
  117. Shrill high pitched cry of a newborn means
    high intracranial pressure and in infants born to narcotic addicted moms
  118. Hoarse cry in an infant means
    • hypocalcemic tetany or
    • congenital hypothyroidism
  119. Continout inspiratory and expeiratory stridor in an infant
    upper airway obstruction, small larynx, delay of development of the cartilage in the tracheal rings
  120. Absense of cry in a newborn
    • severe illness
    • vocal cord paralysis
    • profound brain damage
  121. Tooth eruption what isthe rule of thumb
    1 tooth for every month of age between 6 and 26 mo
  122. small dimplings or openings anterior to the midportion of the SCM + or minus a sinus tract
    Brachial cleft cysts
  123. Periaruicular cysts and sinuses
    common pinhole size pits uusally anterior to the helix often bilateral with or without hearing defects
  124. cyst just above the thyroid. small firm mobile mass that moves upward with tounge protrusion detected after 2 yrs
    thyroglossal duct cysts
  125. "wry neck" from bleeding into the SCM from stretching at birth. A firm mass is felt within 2-3 wks after birth and diasappears after months
    Congenital torticolis
  126. Pectus excavatum
    funnel chest
  127. pectus carinatum
    pigeon chest
  128. Apnea in a newborn greater than 20 seconds and accompanied by bradycardia is concering for
  129. Thoracoabdominal paradox
    inward movement of the chest and outward movement of the abdomen during breathing. normal in newborns. Concern for muscle weakness in older children
  130. Rasberry red toung in a an infant suggests
    oxygen desaturation
  131. An infant presents with tachypnea, tachycardia, and hepatomegaly with no increased work of breathing what do you suspect
  132. abnormally weak pulses in the lower extremities or the femoral arteries in children is
    coarctation of the aorta
  133. full pulses in the dorsalis pedis and posterior tibial pulses are
    • PDA OR
    • truncus arteriosus
  134. when the breast tissue developse in the first 6-24 months in the absense of other pubertal signs it is called
    premature thelarche
  135. The umbilcal cord should have what vessels
    • 3 vessels
    • 2 deoxy arteries
    • and 1 large oxygenated vein
  136. Diastasis recti
    separateion of the two rectus muscles. resolves in early childhood
  137. an Olive type mass on palpation of the RUQ with peristaltic wave and projectile vomiting suggest
    pyloric stenosis
  138. Newborn stool is this color ___ but progresses to ___ over a few days
    black and tarry and progresses to tan peachy honey colored
  139. This tests for prescence of a posteriorly dislocated hip
    Infant is supine. Flex the knees at the place where the index finger ov the greater trochanters then abduct the hip simultanously until the legs touch the table
  140. ability to dislocate an intact but unstable hip (what is the test)
  141. how do you perform a Barlow test
    flex the knees and place the index finger over the greater trochanters press down and attempt to put your thumbs to the table
  142. Galeazzi test
    • flexed the knees and place feet up on the table and look for varying knee height
    • Tibial torsion corrects itself during the second year of life it is pathologic only in associated with foot deformities
  143. __ clubfoot is due to uterine molding. able to reduce to nl on postion exam and may follow or treat with serial casting if severe
    Extrinsic (supple)
  144. ___ clubfoot is idiopathic and causes resulting in abnormal bone structures not able to be reduced on exam serial casting and may need surgery
    Intrinsic or rigid
  145. Metatarsus adductus
    adduction of the forefoot withotu inverions
  146. What is state regulation?
    ability to modulate the level of arousal in response ti different degrees of stimulation