describe the newborn exam
- ABCs
- weight, length, head circumference and plot
inspect–
- look for dysmorphic facies or limb abnormalities
- work of breathing
- pallor, plethora, jaundice or cyanosis (acrocyanosis is normal)
skin–
6. milia? pinpoint white papules on the face that resolve spontaneously
7. mongolian spots? blue patches, normal
8. birth marks? normal…
numerous or large birthmarks may need assessment
9. erythema toxicum–usually day two or three, resolves spontaneously
10. petechiae or bruising? –higher risk for neonatal jaundive
HEENT–
- palpate anterior fontanelle and coronal/sagittal and lambdoid sutures and posterior fontanelle
- caput saccudeam? swelling crossing suture lines
- cephalohematoma? does not cross suture lines
- sub-galeal hematoma? more worrying–fluctuant boggy mass moveable across whole scalp.
- red reflex
- dysmorphic features?
- if infant can breath on own with mouth closed, no choanal atresia–check nasal airways by occluding one nostril then the other
- check ears–floppy? large?
- palate inspected and palpated
- palpate SCM muscles and ROM of head
- palpate clavicles for fractures
- webbing or redundant skin in female? think turners
chest–
- look for asymmetry
- listen to air entry in lung fields
- heart sounds in murmur on both chest and back
- brachial and femoral pulses and compare strength and timing
abdo–
- inspect for defects
- 3 vessel umbilical cord–2 arteries and one vein (if not–renal US)
- palpate for internal organs–liver 2 cm below costal margin, maybe spleen tip. kidneys on deep palpation.
GU–
- inspect for ambiguous genitalia, clitoromegaly (larger than 1cm), both testes descended/scrotal swelling
- penile length of less than 2.5 cm suggests micropenis and should be investigated
- patent anus
- sacral dimple
MSK–
- spontaneous symmetric movements of extremities are good
- examine hands and feed for normal numbers of digits and single palmar creases and club foot
- examine hips–barlow and ortolani maneuvers
- spine–scoliosis? (run spine down back)
neuro–
- posture while supine–flexion at hips, knees and elbows is normal. hypotonia?
- assess tone in ventral position
- primitive reflexes–plantar, sucking, moro, gallant and grasp
absence of red reflex suggest?
neonatal cataracts or other pathology
when should all of the meconium have been passed by?
first day of life
what does it mean if meconium is passed beyond first day of life
investigate
describe the pediatric CV exam
- ABCs, stable?
- signs of acute distress–pallor, sweating, cyanosis, WOB
- history
- body habitus, dysmorphic features (turners, downs, digeorge)
- vitals (head circ under 5 weeks); if HR regular, take for 15 sec then multiply by 4; BP in all 4 limbs
inspection–
- hands and feet–clubbing (angle)? splinter hemorrhages or other nail problems?
- capillary refill less than 2 sec
- increased WOB: tachypnea, intercostal indrawing, tracheal tug, head bobbing, nasal flaring, abdo breathing in older child
- scleral icterus or pallor in eyes?
- central cyanosis in mouth?
- mucous membranes for volumes status
- chest shape
- precordial bulge?
- pectus carinatum or excavatum
- visible cardiac impulse–often normal
peripheral palpation–
- radial, brachial and femoral pulses–rate, rhythm, volume and contour
- brachial-femoral delay–coarct?
- dorsalis pedis and posterior tibialis
precordium palpation–
- palpate apex beat–5th intercostal space in mid clavicular line, less than 2cm, tapping quality, less than 2/3 of systole (left lateral decubitus if hard to feel)
- heaves–forceful lifts
- thrills–turbulent flow
- palpate all 4 auscultory areas
- palpate liver–indication of right sided heart function–normal liver is 2 cm below costal margin–around 7 cm is normal liver span (percuss)
- enlarged spleen is more than 2 cm below costal margin
- edema?
auscultation–
- listen in all four positions both sitting and supine with both bell (low pitched… gallops and s2 split) and diaphragm (high pitched… most murmurs, s1 an s2, pericardial rub)
- if murmur, listen for radiation
- listen to lungs–crackles?
symptoms of CV disease
cyanosis
seating during feeds
SOB
palpitations
edema
chest pain
syncope
whar drugs can be associated with cardiac lesions in the neonate (when used during pregnancy)
lithium
phenytoin
alcohol
what maternal diseases can cause cardiac defects in the child
SLE
rubella
diabetes
how big should the BP cuff/bladder be?
should cover 40-75% of the arm and should be able to encircle arm and close
what characteristics suggest a benign murmur
systolic
normal s1 and s2
soft less than 3/6
otherwise healthy
often position dependent
