Initials Child Medical History Made Easy

Initials child medical history

[Music] in this lecture I'm going to discuss the newborn physical exam so before I even start I want to say two things about the newborn exam one is it can be tricky from the standpoint of making sure that the child is adequately warm so sometimes you have to be a little bit quick because if you light leave the child unexposed for a period of time they can start getting cold you'll notice that the skin starts to model or look like marble a little bit and let's assign that infinite getting cold if you can you can do a very careful exam under a warmer the other thing about the new more exam is it can be frustrated it's frustrating especially with auscultation and the reason is newborn infants might cry and make it hard to hear what's going on it's okay if you leave an infant and then come back to them later when they're sleeping to get the rest of your exam but let's go through the normal new born exam really carefully here so we can understand not only for an exam that might happen but also for your general practice on the pediatric wards so first let's review vital signs and growth parameters it's important that you have the height the weight and the head circumference on every infant new exam and it's important we review the vital signs the heart rate should be usually between 90 and 160 and a healthy newborn child the respiratory rate is usually high between 30 or 60 that's fine from the standpoint of blood pressure we often don't have one this is because it's a bit challenging to make we will use it in infants who are ill but if an infant as well the blood pressure is not a critical measurement and remember pulse ox is abnormal in the first day of life and very abnormal in the first 10 minutes so during the first 10 minutes it's normal for infant to go from 60% at birth to 90 percent then it can take the rest of the day to go up to a hundred percent but expect abnormalities in the pulse ox early in the second day of life that pulse ox should pretty much be normal in fact many centers use that pulse ox as a screen for congenital heart disease okay now you've got the vitals you've got the height the weight and the head circumference and you've plotted them so you have percentiles now we're going to do an exam and we're gonna start at the head and work our way down the first thing you're going to do on the head is feel the sutures early in birth sometimes they are slightly overriding and elevated but that should stabilize out relatively quickly also you should feel a fontanel in the anterior portion of the skull as is pictured here and a very small sort of finger large posterior fontanelle you should feel both of those and you should feel all those sutures and if you feel any asymmetries or abnormalities those should be noted this could be a partial craniosynostosis for example next we're going to check the eyes and we absolutely are going to a do a red reflex the red reflex is useful is because when you're looking and you're seeing not only the red reflex but also the possibility of slipped lenses which can happen with a variety of infant diseases also the red reflex may be absent in a patient with retinal blastoma so it's crucial to check those eyes also look at the irises if a coloboma is press present this might be charged syndrome now take a look at the ears as you draw a line backward from the eye it should intersect the top third of that ear also you should note any abnormalities of the year is it posterior placed but is it rotated are there pits are there tags abnormalities of the year may be associated with syndromes or maybe even just associated with renal abnormalities for reasons I don't understand ears and kidneys can sometimes go together in so many different ways next we're going to check the mouth we're going to look for abnormalities of the lips but we're also going to put our finger into the mouth and palpate the top of the mouth if there's abnormalities in a cleft palate you may note them obviously on exam but a palate on the inside may be high arched or may be abnormal as well with a lack of patency on the inside and that should all be noted while we've got our finger in there check the babies suck it should be vigorous that's technically part of the neuro exam but I would absolutely do it also we're gonna check the nose in pretty much any infant at some point we may suck out both nares that usually is done in the resuscitating room but we're gonna check patency of the nose if a tube goes in but can't get through that patient may have Co anal atresia which can cause respiratory distress in an infant next we're gonna look at the neck the neck is important in infants because it can have abnormalities that are hard to see unless you really extend the neck and look at it examples are a firebug lhasa duct system it line or a bronchial cleft cyst which is lateral so we'll look for abnormalities next palpate the clavicles it's common for clavicular fractures to happen in large babies or with bad shoulder dystocia next listen to the heart and lungs remember that half of normal newborns will have a murmur in the first day of life okay we're moving down to the liver it's normal to feel a liver and a baby in fact if you examine a baby well and you don't feel a liver you probably didn't examine them well enough you should be able to palpate livers in most babies it's even normal to be able to palpate kidneys in babies so you're gonna feel that liver and it should be generally no larger than 3 centimeters below the costal margin 3 centimeters is a pretty big distance babies can have big livers the spleen and the kidneys may be palpable and that may be normal next checked for the paitent rectum don't forget to check during that first newborn exam because a in peyton rectum can be a real critical surgical emergency in an infant so take a look and make sure that rectum is present while you're down there inspect the genitalia here's an example of a sample of an abnormal genitalia this child has ambiguous genitalia which are probably associated with congenital adrenal hyperplasia this child is a girl with a very large clitoris and a fused labrum majorem okay we're done with the genitalia are gonna move on to the extremities check the stability of the hips do a little bit of an Ortolan iam Barlow to make sure that's okay next inspect the spine and look for sacral dimples or Tufts acrocyanosis or blue hands and feet is normal and common but syndactyly such as this patient has or polydactyly which is even more common with an accessory digit is very common we need to look and count fingers and toes in every patient and make sure they look normal even subtle findings like a polymer crease may be your sign that the patient has for example Down syndrome lastly we're gonna do our neurologic exam we've already done the suck reflex but we're gonna comment on it during the neurologic exam check for their overall tone babies should prefer to be all balled up they don't want to have their extremities relaxed if a child is relaxed and open something is wrong neurologically check the sutt the suck check for a rooting reflex where you stroke their chin and they move towards it to suck check their grasp these infants should want to hold your finger holding your finger is a normal reflex in infants it's nice to not tell the mother that this is a reflex let her think her child wants to hold her finger also check the Moro reflex the Muro which should be done carefully is when you suddenly lower the head and the infants arms will come out and spread they may shake a little bit and then come back in again if infants do that that is normal what we're looking for is a symmetry of the Muro reflex if only one arm comes out that could be a sign of nerve damage perhaps from a brachial plexus nerve injury as a result of birth lastly it is good to check the DTRS the deep tendon reflexes are easy to appreciate in the knees for example of infants and we can also check the heels for clonise a little bit of clonus might be okay early in infancy so that's my summary of the neurologic exam from head to toe in infants thanks for your time [Music] you