Notes
prepared by Dr.N.S.Mani
The history is obtained
from parents or care taker
Firstly, informant
is to give a spontaneous account of a child’s illness
secondly you can ask
specific questions to clarify the informant’s description.
Older children can
provide history
Children can be
divided into age groups:
Neonatal 1st
4 weeks of life
Infant 1st year
Preschool 2 to
4 years
School 5
to 15 years
Childhood 1to
15 years
Adolescent 13
to 19 years
Age and sex. Note
date of birth.
Symptoms complained
of and their duration in chronological order. Maximum 3 complaints. The rest
you describe in history of preset illness.
The precise order of symptoms including any repeated episodes (e.g. asthma or epilepsy or
respiratory infection).
Changes noted since the onset of illness contrasting present with previous condition.
Activity or apathy may
be gauged by the child’s movements in cradle or cot, performance in normal household
activities, interest in people and things, willingness to walk to school or
shops, tiring easily or returning early from play.
Feeding and appetite. Temporarily
or persistently impaired (this may lead to an assessment of daily caloric
intake , food fads (certain religious belief e.g.- feeding rice to infant) or
dislikes; unusual parental ideas regarding diet; daily intake of vitamin
supplements?
Difficulty in swallowing is commonly functional rather than organic and related to
attempts to persuade the child to eat against his will with resultant choking
and gagging. The child with organic dysphagia may swallow food but will
regurgitate it shortly thereafter.
Thirst. If
present, assess the total daily intake of fluid and output of urine.
Vomiting. Amount;
frequency; duration; effortless or projectile; nature of vomitus (e.g. stained
with bile or blood); an isolated symptom or associated with abdominal pain
(e.g. constipation), fever or impairment of consciousness? In a baby the
possibility of rumination necessitates questions regarding observed movements
of the mouth and glottis prior to vomiting.
Abdominal pain is
probably thought to occur much more frequently than it actually does in babies
due to their propensity for drawing up their legs and crying as a result of
pain wherever it occurs. Toddlers, asked frequently if they have pain abdomen in
the presence of any upset, may come to use this term for pain at any site. With
abdominal pain ascertain its nature; timing; duration; constancy or intermittence;
site; aggravation by breathing or movement; relationship to food, bowel
movement or micturition; association with anorexia, diarrhea, melena,
constipation, vomiting, sore throat, cough or purpura. Always elicit the
sequence of symptoms evolution e.g.- in appendicitis it is painàvomitingàfever. In
Dysentery it is feveràpainàloose stool
Abdominal distention. Generalized
or localized; distended abdominal veins; past or present only; duration;
associated pain?
State of bowels and character of the stools. Breast fed infants normally
pass several semisolid golden yellow-colored stools per day. Ascertain the
frequency of bowel movement, character of the stools (hard or soft, watery,
accompanied by mucus, blood-streaked or mixed with blood, bulky, dark or pale,
floating on water, malodorous), presence of involuntary fecal soiling
(encopresis), pain or crying on defecation (e.g. anal fissure)?
Loss of, or gain in, weight. Has the child become thinner or fatter judged by general
appearance, recent looseness or tightness of clothing, wasting, swelling or
puffiness?
Discharge from eyes, ears, nose or other sites. Purulent, watery or bloodstained, profuse or
scanty, continuous or intermittent?
Sore throat. Babies
and toddlers do not complain of sore throat although parents
often assume this to be present (e.g. when there is refusal of food).
Older children can localize pain.
Cough. Ascertain
duration; character; dry or moist; paroxysmal; more severe by day or night;
disturbing of sleep; associated with pain, whoop, vomiting, chest pain, wheeze,
nasal discharge; accompanied by sputum (swallowed or expectorated, watery,
mucoid, mucopurulent or bloodstained).
Breathlessness. Present
only on activity (exercise tolerance) or at rest; persistent or intermittent;
of gradual or sudden onset; exercise induced; nocturnal or diurnal; associated
with cough, cyanosis or breath holding?
Cry or voice. Any
change?
Mouth breathing. Mouth
habitually open or shut, snores?
Stridor. Continuous
or intermittent, inspiratory or expiratory, duration?
Wheeze. Inspiratory
or expiratory; continuous or intermittent; precipitating factors; duration?
Abnormalities of the breath. Sweet smell (acetone) or foul?
Other localized pain. Extent,
nature, degree of severity, intermittent or continuous, duration and direction
of radiation?
Localized swellings. Site,
size, color, consistency, presence or absence of local pain, tenderness,
duration?
Rashes or other skin lesions. Site, color, number and size of lesions; vesicles, ulcers,
papules, macules, petechiae, itch?
Jaundice. Time
of onset, duration, any abnormality in the stools or urine, vomiting?
Cyanosis. Peripheral
or central, persistent or intermittent, affected by environmental temperature?
When appeared first, increase in intensity on crying.
Pallor. Intermittent
or persistent (many children are naturally fair in color but pallor tends to
cause anxiety in parents)?
State of the musculature. Normal active movements or not? Does the mother feel the limbs
to be stiff (hypertonicity or spasticity), or ‘floppy’, slipping through her
hands on lifting (hypotonicity)?
Changes in posture or in walk. Of long duration or recently developed;
holding the body in any unusual way (e.g. torticollis or scoliosis);
abnormality in gait (examine sole of shoes); falling frequently?
Coordination. Dropping
things, spilling from a cup, impairment of fine movement (e.g. writing or
buttoning clothing)?
Involuntary movements. Nature
of these; the same movement repeated or different movements; any injury suffered
as a result of the movements; aggravated by emotional stress?
States of reduced consciousness. Degree; premonitory symptoms or aura;
duration; subsequent awareness of events; injury sustained; response to
stimuli?
Convulsions and fits. State
of the child prior to the convulsion, any precipitating factor (e.g. fever),
any premonitory symptoms, type of movement observed (e.g. tonic or clonic);
duration of various stages, state of consciousness, loss of posture,
incontinence; uprolling of the eyes, biting of the tongue or other injury;
sleep or headache afterwards?
Speech. Delay
in onset or loss of speech, nature of speech (e.g. hoarse, aphonic, slurred),
change in character, difficulty in comprehension or expression?
Defects in vision. Able
to follow a moving object with eyes, difficulty in reading or in distance
vision, colliding with objects, color blindness?
Headache. Site,
manner of onset, severity, and accompanying symptoms (e.g. vomiting), aura
(e.g. migraine)? Younger children seldom complain of headache. Grandmother
often touches the forehead, feels warmth and reports it as head ache. Baby
should say, “I have head ache”
Hearing. Parental
or teacher appreciation of hearing loss; unresponsiveness or inattentiveness;
any evidence of mental retardation, behavior disorder or circumstance
suggesting organic or functional deafness?
Dysuria. Pain,
burning or cry related to micturition? It is during the flow of urine that the child
should cry if it is dysuria, not before or after micturition.
Frequency of micturition. How frequent, any recent change in pattern?
Bed wetting and incontinence. Always present or recently developed; any polyuria, dysuria,
frequency of micturition, or thirst; do particular circumstances produce the
symptoms and what is the parental reaction to them (e.g. punishment or
ridicule); unhappiness or bullying at school?
Volume of urine. Evidence
of actual volume passed (parents tend to overestimate the amount of urine
passed per day).
Character of the urine. Color (e.g. orange, red, smoky, like tea or cola drink),
abnormal smell?
Manipulative
ability. Ability to
handle objects, use spoon, dress and undress himself, tie shoe laces (at 6
years), write.
Behavior and mood (best discussed in the absence of the child). Active or hyperactive; quiet or lethargic; talkative
or silent: disobedient; aggressive; negative; reluctant to go to school;
refusing food; withdrawn; reluctant to social activities; resistance to
bedding; reluctant to sleep; fearful of the dark; frequent awakening during the
night; subject to nightmares or night terrors, temper tantrums, nail biting and
thumb-sucking; care-free or anxious; uninteresting, nagging, demanding
attention; hard to please or careless; ‘highly strung’ or placid; crying too
readily; jealous; hot-tempered or emotionless; speech disturbed? Relationship
with parents, siblings, schoolmates and teachers?
Treatment already
given must be
ascertained. DO NOT MAKE ANY COMMENTS ON TREATMENT GIVEN ALREADY>
Selectivity of
questioning. Not all
of the questions given above are asked in every caes; some will dependent on
positive answers to primary questions. Better to ask too many rather than too
few questions: the more extensive the questioning the more likely are forgotten
points of history to be uncovered.
Mostly a history about past illness in a
child has to be obtained from parents, guardians or others. Baby books,
photographs, health visitor and infant clinic records may help.
Previous illnesses
Diagnosis, dates of
occurrence, duration and severity? How many times hospitalized, any surgery,
blood transfusion.
Include contact with
animals.
Residence abroad
Country and any
particular hazards it holds?
Inoculations
received and any reaction to them?
Details of mother’s pregnancy and delivery is
a necessary part of history taking in the case of an infant or young child. Illnesses
which the mother had before or during pregnancy, exposure to drugs or
radiation, hydramnios, hypertension, edema, albuminuria, threatened abortion or
ante partum hemorrhage, length of gestation, duration of labor (prolonged or
precipitate), type of delivery (high forceps and breech carry particular risk).
Note the infant’s birth-weight, state at delivery (e.g. Apgar score), and
postnatal history regarding events such as convulsions, breathing difficulties,
cyanosis, jaundice, vomiting, infection, special or intensive care.
How she was feeding
before the illness
Parents’ ages,
present state of health, past health and possible consanguinity? Previous
stillbirths or miscarriages (mothers who have had difficulty in conceiving and
have had abortions, stillbirths, infant deaths or abnormal children are more
likely to have children who suffer from congenital abnormalities and cerebral
palsy)? Past or present illnesses or deaths (with cause of death) of siblings?
Illnesses of other relatives or occupants of the house? Hereditary traits
require inquiry regarding a much wider circle of relatives.
Draw
a pedigree chart.
This involves the
time of achievement of milestones of motor, vision/fine motor, social/adaptive
and hearing/language progress. Note any evidence of dissociated development
(e.g. delay in reaching linguistic compared with motor milestones would raise
the question of hearing impairment or speech disorder; standing holding on to
furniture before sitting, cerebral diplegia; normal manipulative ability
combined with retarded postural milestones, ataxic cerebral palsy). About 15%
of mentally retarded children reach normal motor milestones during infancy.
With most disorders
it is necessary
- to build up a picture of the child’s
social and cultural environment;
- to appreciate fears and stresses both
i. at home (e.g. parental attitudes, separation
and divorce, absence of a parent, illness or chronic disability in the family,
jealousy at the arrival of a new baby, the possible death of a near relative)
ii. at school (e.g. a change of school,
difficulty in meeting educational standards, over-rigid discipline or
bullying);
- to judge intelligence and ability as
they affect capacity to meet the demands of communal living and education;
- to ascertain the occupation of the
father, the size and condition of the child’s home.
- Inadequately explained injuries or
neglected appearance may raise the possibility of child abuse.
The child who enters
the consulting room or is ill in bed may be
- an irritable infant whom nothing will
pacify.
- a toddler clinging to his mother and
burying his face in her lap at the slightest movement of the examiner
towards him,
- a more child of early school age who resists
attempts to remove his clothing, particularly his trousers,
- a hyperactive child who moves rapidly
round the room shows his destructive interest against toys, instruments or
the examiner’s papers
- an apprehensive schoolgirl moves back in
terror at the sight of a BP apparatus or ophthalmoscope.
The child should be
placed where he wishes, be it on the parent’s lap or on a chair by himself.
Removal of clothing or a visit to the examination couch may come later. The doctor
must remain patient and confident even if provoked
Impatience will
deprive you of information, which might be available. Your behavior should be
friendly, sociable, tolerant, and good-natured and calm as you listen, observe and
assess. You should encourage the mother and child no matter how the latter
behaves. Loud talking tends to alarm children, a soft voice is more likely to
be effective. Conversation should be in tune to the intellectual and social
level of the child. Talk to him/her and explain what is being done. Disturbing
or painful procedures should be kept to the end like knee jerk, throat
examination.
Observe child’s
psychological makeup and intelligence. Is he nervous, excitable, distractible,
withdrawn, intelligent or stupid? What is his emotional relationship with his
parents?
HEAD TO FOOT
EXAMINATION
ANTHROPOMETRY
VITAL SIGNS
ANTHROPOMETRY
VITAL SIGNS
SYSTEM EXAMINATION
GENERAL EXAMINATION
Clinical examination
of a child begins from the moment of first meeting.
A glance will reveal the level of
consciousness.
Child’s appearance, behavior,
state of nutrition, reaction to the environment, relationship with parents,
conversation, speech, cry, size relative to age, state of nutrition, state of
activity, posture, overt deformity, injury or hemorrhage.
The facies may indicate pain or anxiety,
the blankness of mental retardation, wasting or the spasmodic movement of the
tic. Hollow cheeks and sunken eyes may reveal weight loss or dehydration, edema
by periorbital swelling
Mouth breathing, jaundice or cyanosis may
be present. Some disorders, e.g. mongolism, cretinism, gargoylism, de Lange
syndrome and sometimes tetanus may be diagnosed immediately by the
characteristic facies, which they exhibit.
Rashes – look for color, size, distribution
and nature. The skin may be dry and loose in dehydration with loss of
elasticity on lifting up skin folds, loose but not inelastic in weight loss,
ulcerated, infected, dry, ichthyotic, angiomatous, abnormal pigmentation,
sweating abnormally, shiny and tense, edematous pitting on pressure showing localized swellings or striae.
The nails may be
bitten and show abnormalities including deficient formation, ridging, abnormal
curving, infection.
Finger clubbing may be present.
Disturbance of rate
or pattern of breathing or dyspnea may be visible. Abnormal sounds such as high
pitched cry, cough, wheeze, stridor or whoop may be heard. Abnormal smells such
as acetone (usually in a child who is refusing food) or the mousy odor of Phenylketonuria
may be detected.
Posture may be
abnormal as in Opisthotonus, kyphosis or torticollis
HEAD TO FOOT EXAMINATION
Here mainly describe dysmorphic features, any marks like Mantoux
test, pleural/bone marrow aspiration, any IV-canula
PHYSICAL
MEASUREMENTS
Over the first few days of life physiological
weight loss of up to 15% of bodyweight with return to birth-weight (BW) by 7
to 10 days is common followed by weight gain of approximately 25 g per day
up to 3 months. Expected weight in kilograms can be calculated as follows:
First year: During 1st
4 months: BW + (age in months x 0.8)
During
2nd 4 months: BW + (age
in months x 0.7)
During
3rd 4 months: BW + (age
in months x 0.6)
(Infants normally
double their birth-weight by 5 months and treble it by 1 year)
Between 1 and 9
years add 4 to the age in years and multiply by 2.
e.g 2 yr = (2+4)x2= 12kg
e.g 2 yr = (2+4)x2= 12kg
Between 9 and 12
years multiply age in years with 3.
e.g.8 yr = 8x3 = 24kg
e.g.8 yr = 8x3 = 24kg
One standard deviation
from these figures 12 % of their value.
At birth, length is approximately 50 cm
at 6 months 68
cm
at 1 year 75
cm
at 2 years 85
cm
at 3 years 95
cm
at 4 years 100cm
Over the next 8 years = annual increase 5.5
cm
e.g 10 yr = 100+(5.5x6)=100+33 = 133cm
e.g 10 yr = 100+(5.5x6)=100+33 = 133cm
One standard deviation is = 4% of their value.
In infancy, because of the difficulty of
measuring crown—heel length accurately crown—rump length is the most useful
The mean crown—rump length
at birth is 34 cm
at 2 weeks 34.5 cm
at 6 months 43.5cm
The mean crown—rump length
at birth is 34 cm
at 2 weeks 34.5 cm
at 6 months 43.5cm
|
|
Body proportions and shape change with age
Measurement of the arms should be from the
tip of the acromion to the tip of the middle finger and of the legs from the
anterior superior iliac spine to the internal malleolus.
measurements of length and weight can be used
to calculate
‘weight
for length’ that may be of value in the diagnosis of certain diseases. E.g.
hypothyroidism, Marfan’s syndrome or, as nutrition indices.
Length
for age, weight for age or weight for length below the 5th centile would
indicate under-nutrition in the absence of any disease process.
At birth 35
cm
6 months 43.5 cm
1 year 46.5
cm
2 years 49
cm
Increases annually by half a centimeter from
2 to 7 years
e.g. at 5 yr = 49+1.5= 50.5 cms
e.g. at 5 yr = 49+1.5= 50.5 cms
By one-third of a centimeter from 8 to 12
years.
e.g.at 10 yr 49+2.5+1 = 52.5 cms
One standard deviation from these figures — 2
% of their value.
A cranial hemi-circumference less on one side
than the other may indicate hemiplegia on the contra-lateral side.
Fever is a common concomitant of disease in
the child but hypothermia may also be so, particularly in the newborn. The
infant’s temperature can be taken in the groin with the thigh flexed on the
abdomen (normal = 37deg C or 98.4 deg F) or in the rectum (normal = 37.50C
or 99.5 deg F. Rectal thermometer has rounded bulb, clinical thermometer has
elongated bulb.
In older children, the axilla is more
suitable.
Low reading thermometers covering the range
29—43 deg C (85—109 deg F) are necessary in assessing hypothermia and should be
used routinely in pediatric practice. Premature infants have temperatures 10 F or so lower than full-term infants.
The normal auscultatorv method can be
carried out over the age of 3 years but is more difficult in younger children
in whom sedation may be necessary. The cuff width should be two-thirds of the upper arm
(cuffs of 5 cm and 7.5 cm are available). Auscultatory blood pressure
determination in the legs is difficult. The palpatory method (systolic
pressure) may be employed with babies and toddlers and where neither of these
methods is possible the flush method may be used. A suitably sized cuff
is applied loosely round the upper arm or thigh, the limb below the elbow or
knee is blanched by manual compression and the cuff inflated to 150 mmHg. The
compression is then released and the cuff pressure lowered slowly, the point at
which the blanched area flushes being noted. This flush pressure is midway
between systolic and diastolic pressures.
Noninvasive automatic methods of measuring blood pressure utilize the
Doppler principle and oscillometry and are valuable for monitoring (e.g. in
intensive care).
Average blood
pressures (mmHg) are:
Newborn (range of flush method) 35/85
Infancy (systolic /diastolic) 80/55
Preschool child (systolic / diastolic) 85/60
School child (systolic / diastolic) 90/60
Individual systems can be examined in a
standard sequence but in practice, this is seldom appropriate. It is better to
begin with the system which is likely to reveal the most information and to
leave to the last disturbing procedures and systems likely to yield least
information.
Pathological cranial
shapes are (a)Oxycephaly or
turricephaly. (b) Caput succedaneum (c) Microcephaly. (d) Scaphocephaly. (e)
Hydrocephaly.
Note color,
quantity and character of the hair and level of the hair line.
The anterior fontanel measures
approximately 2.5 cm x 2.5 cm at birth and does not close until 18 months
(delay may be seen in rickets, increased intracranial tension or abnormal
development of cranial bones, malnutrition, Down syndrome). Assess tension
(bulging or sunken) visually and by palpation.
The posterior fontanel measures 0.5 cm
in diameter at birth and closes shortly thereafter (by 3 months)
Cranial sutures such as the sagittal and coronal are easily
palpable at birth but the edges are not widely separated (e.g. as in raised
intracranial pressure). Sutures may be prematurely closed and the edges heaped
up in cranial synostosis.
Scalp veins may be distended
Craniotabes (seen in prematurity and rickets)
is a reduction in the rigidity of the cranial bones, which can be indented by
finger pressure over the parieto-occipital region. Structural defects such as
lacunae or areas of thickening may be detected by palpation.
Cranial bruits may be audible on auscultation over the
vertex, occipital or temporal regions.
After the fontanel has closed a ‘cracked
pot’ sign (raised intracranial pressure) may be elicited by a sharp tap
over the cranium.
The external auricle may be deformed, the
meatus narrowed or absent or the ears low set (one-third of the external
auricle should be above a horizontal line at eye level). Low-set ears are often
associated with other congenital abnormalities
Autoscopic
examination (the speculum should be appropriate to the size of the infant) may
reveal wax or purulent discharge (if necessary clear with a metal loop or
cotton wool on an orange stick), a tympanic membrane (eardrum) which is dusky,
bulging, retracted or perforated.
Distortion
of the cone of light, which normally extends forward from the tip of the handle
of the malleus usually indicates infection, undue prominence of the malleus
retraction of the drum.
Perforations are most
likely in the upper part of the drum.
General aspects of facial appearance
mentioned already
Eyes
Age
and racial differences can be offset by using the canthal index (100 x inner
canthal distance divided by the outer canthal distance) which is 38 (SD 2.4)
for boys and 38.5 (SD 2.4) for girls.
The
eyes are wide apart = telecanthus
They
may be close spaced (e.g. Down syndrome)
Displaced
downwards (the sunset sign) in hydrocephalus.
Colour of the mucous membrane of the lower
eyelid may give some indication of anemia.If child cries it may squeeze the eye
, hence red.
The eyeballs may be prominent = exopbthalmos
sunken = enophthalmos)
enlarged = buphthalmos
may exhibit nystagmus, squint (strabismus),
Conjunctivitis,
icterus, hemorrhage, congenital defects (e.g. colobomata or aniridia), abnormal
iris pigmentation, Brushfield’s spots (small whitish inclusions in the iris often present in Down syndrome), opacities
of the cornea, lens or intraocular chambers.
The
pupils may be different in size (e.g. contracted (miosis) due to
unopposed action of the 3rd nerve in Homer’s syndrome or larger than normal in
an amblyopic eye);
they should react to light and accommodation.
Vision
in babies can be tested by
observing whether they follow, an object held 50cm in front of the face and
moved from side to side through an arc of 3O degree.
Ophthalmoscopic examination is best carried out in a dim room. The
examiner’s eye should be as near as possible to the ophthalmoscope and his head
placed so that it does not obstruct the gaze of the child’s other eye. If
observer and patient each have normal vision no lens (~O’) is necessary. The
need to use a plus (+) lens indicates hypermetropia, a minus (—) lens
myopia. An examiner with a refractive error should correct this with a lens of
the ophthalmoscope.
To get the young child to look in a fixed
direction get him to look with some expectancy in the required direction and
periodically fulfill his expectations. e.g. ‘tell me when the torch flashes’ —
a helper being prepared to flash the torch at the appropriate moment. Babies
looking backwards over the mother’s shoulder tend to open their eyes.
Dilatation of the pupils is not usually necessary routinely but for full
examination 1% homatropine may be used.
Ophthalmoscopy may reveal opacities of the media,
refractive errors, retinal hemorrhage, venous engorgement, Papilloedema with
blurring of the disc edges or filling of the optic cup with vessels coming into
focus in front of the disc, pallor of the disc, exudate, choreoretinitis,
abnormal pigmentation, cherry-red spots or choroid tubercles.
In older children, it is usually possible to
map visual fields against the examiner’s fields, each looking straight
at the other’s pupil 50 cm apart, the examiner frequently moving a cotton wool on
the end of an red stick midway between himself and the patient who indicates
each time when the cotton wool enters his visual field.
The nose may show evidence of infection or
allergy in the form of a purulent or watery discharge. Movement of the alae
nasi may indicate respiratory difficulty. The nasal mucosa may be pale,
congested, watery or dry; the septum may be deflected; polyps may be present.
By closing off the mouth, blockage of the nasal passages may be demonstrated.
The lips may show edema, pallor,
cyanosis or ulceration.
The mouth may be examined with the
cooperation of the child or without it .
Mucosae may be moist, dry, pink or pale, ulcerated, blistered, bleeding
or purpuric, exhibiting the white curd-like plaques of thrush, which will not
easily scrape off, or Koplik’s spots (measles) on the buccal mucosa. The gums
may be ulcerated or hypertrophied (e.g. phenytoin). The teeth can be
observed for number, whether primary or secondary, size and shape,
pigmentation, caries and enamel defect
The average times of eruption of the teeth
are as follows:
Deciduous (primary) teeth Eruption
Shedding
- central incisors lower upper 7th
month 75 months
- lateral incisors upper lower 9th month 86 months
C. first molars 12th month 100
months
D. canines 18th
month 122 months
E. second molars 24th
month 109 months
The teeth in the lower jaw are shed earlier
than those in the upper and girls’ teeth earlier than boys’ teeth.
Permanent
dentition Eruption
Age
in years
1. first molars 6
2. central incisors 6
3. lateral incisors 7
4. canines 10
5. first premolars 10
6. second premolars 11
7. second molars 12
8. third molars 20
Tongue: size,
shape, colour, appearance fo surface
Palate:
cleft or high arched any
abnormality of the uvula. If the child is willing to say ‘ah’ examination of
the posterior pharynx is easy; otherwise induce the gag reflex by
touching the posterior pharyngeal wall with a spatula and take advantage of the
few brief moments during which the posterior pharynx is revealed on gagging
Tonsils:
size, presence of infection,
exudate, pitting, peritonsillar swelling?
Posterior
pharyngeal wall: inflammation,
postnasal discharge, presence of lymphoid tissue?
Neck
Examine from front and back noting any
shortening, webbing, torticollis, head retraction or neck stiffness (by passive
flexion), limitation of flexion (ask child to put nose on knees while sitting
with knees drawn up), abnormal swellings (e.g. lymph glands, thyroid, cystic
hygroma . A sterno-mastoid tumor (early infancy) is a hard visible nodule
within the body of the steno-mastoid muscle
Enlargement
may occur in the anterior and posterior cervical triangles, occipital and
submental (lateral to salivary glands) regions — as well as axillary,
epitrochlear and inguinal regions. Ascertain tenderness, inflammation,
fluctuation and size.
CHEST
AND LUNGS
The cross-section of the infant’s chest is
circular compared with elliptical for the older child or adult. This imposes
limitations on expansion so that respiration is diaphragmatic and abdominal and
dyspnoea is reflected in both respiratory and abdominal movements. In infancy
over-inflation of the chest (e.g. in bronchiolitis) is most evident in the
upper half of the chest anteriorly. Chronic emphysema can cause an increase in
the antero-posterior diameter of the chest (pigeon chest) which is normally
less than the lateral diameter.
Chest circumference ranges from 32 ± 5 cm at birth to 75 ± 16 cm
at 14 years.CC is less than HC before 1 year.
Chest expansion measured at the nipple line between full
inspiration and expiration can be measured in cooperative older children. It
should be 4 cm or more. Asymmetry is
best detected by watching chest movement on taking a deep breath.
Visible deformities of the chest include
pectus excavatum,
Harrison’s sulcus (at insertion of
diaphragm),
precordial bulging,
thickening of the costochondral junctions
(rickety rosary),
the dinner fork deformity of the
costochondral junction (scurvy)
and anterior prominence of the ribs on one
side with frontal skull prominence on the same side (the ‘squint baby’
syndrome).
The respiratory rate must be measured
when the infant is at peace, not crying, struggling or feeding. Upper limits of
normal for various ages are as follows:
0 to 2 years 40
per minute
2 to 6 years 30
per minute
6 to 10 years 25
per minute
over
10 years 20
per minute
Respiratory rhythm may be disturbed in time and amplitude
particularly in premature and asphyxiated babies.
Infection can cause respiratory inversion — the respiratory cycle
changing from
Inspiration / expiration / pause to
expiration / inspiration / pause,
often described by the mother as a ‘catch’ in
the infant’s breathing.
The normally longer inspiratory phase of
respiration may be exceeded by a lengthened expiratory phase (e.g. in asthma).
The pliable chest wall of the infant readily
reflects changes in intrathoracic pressure, increased inspiratory effort or
obstruction of airflow resulting in intercostal indrawing and costal margin
recession. Lower chest indrawing(in pneumonia), subcostal retraction (in
asthma)and deep breath of metabolic acidosis may look alike unless you
carefully observe.
Abnormal respiratory noises include
inspiratory and expiratory stridor, wheeze, cough and grunting respiration.
Palpation with the palm of the hand may
reveal a cardiac thrill, palpable rhonchi, the crepitant sensation of
subcutaneous emphysema, local tenderness or swelling. Due to the mobility of
the trachea in infancy and childhood tracheal displacement is not a reliable
sign. Axillary lymph nodes should be examined by abducting the arm from
the trunk, inserting the fingers into the axilla and palpating, with the arm
replaced beside the trunk.
The percussion note is more resonant in the
child than in the adult and percussion should be lighter( You “feel” it rather
than “ hear” it): significant impairment usually means extensive consolidation
or fluid in the chest. Hyperresonance occurs in overinflation, emphysema or
pneumothorax; reduced cardiac dullness is a valuable sign in these
situations.
The breath sounds in infants and
children are harsh (bronchovesicular). The inspiratory sound is normally two to
three times longer than the expiratory and followed by a pause. Breath sound
intensity may be reduced in conditions such as bronchiolitis, emphysema,
pneumothorax and pleural effusion and increased with consolidation or collapse
where an affected lobe or segment collapses against a bronchus giving rise to
bronchial breathing (sounds similar to those heard on auscultation over the
trachea).
Rhonchi and coarse crepitations are usually
associated with infection or bronchospasm, fine crepitations with infection.
The wheezing sounds associated with asthma are high pitched and musical.
Pleural friction is a rough sound.
Vocal resonance, heard on auscultation of the chest when the
patient speaks (e.g. says ‘one two three’), may be diminished (e.g. pleural
effusion) or increased (e.g. consolidation). If whispering is easily audible on
auscultation - whispering pectoriloqui
(associated with lung consolidation) is present.
Abnormal signs in the cardiovascular system
such as displacement of the apex beat may be due to respiratory disease.
Cardiovascular
disease may be accompanied by a range of general signs such as
poor
physical development,
squatting,
dyspnea,
tachypnea,
central
cyanosis,
edema,
finger
clubbing
distention
of superficial veins.
Cardiac
enlargement may be
associated with precordial bulging and abnormal pulsation — right
ventricular hypertrophy causing increased pulsation in the central and superior
parts of the precordium, left ventricular hypertrophy increased pulsation and
visible lifting of the apical precordium. Bulge is due to RV dilatation, LPH
(left parasternal heave) is due to RVH.
The
position of the apex beat displaced down and out means LV dilatation
Jugular
venous pressure (increased
if above the level of the manubrium sterni) can be assessed in older children but
this is rarely practicable in infants due to their shortness of the neck,
mobility and lack of cooperation.
Applying the palm of the hand to the chest,
thrills, increased precordial pulsation (apical in left ventricular hypertrophy
and basal and right sided in right ventricular hypertrophy) and diastolic shock
(in the pulmonary area in pulmonary hypertension) may be felt. The apex
beat, normally in the fourth or fifth intercostal space within the
mid-clavicular line, can be identified at the point of maximum impulse.
The pulse can be examined at the wrist
(radial) or inguinal region (femoral). Sinus arrhythmia (increase in rate on inspiration
with decrease on expiration) is common in most children.
A bounding pulse is usually associated with lesions
causing shunting (e.g. VSD or PDA),
a weak pulse with restriction of left-sided
cardiac outflow (e.g. aortic stenosis),
a collapsing (water hammer) pulse with wide
pulse pressure — difference between systolic and diastolic pressures — (e.g.
aortic regurgitation). The latter is best felt with four fingers laid across
the pulse with the patient’s arm elevated.
In Coarctation of the aorta the femoral
pulses may be absent, or delayed compared with the radial, and in older
children pulsating collateral vessels may be detected in the scapular region.
The thin chest wall of the child makes
cardiac percussion of more value than in the adult. The right cardiac border
does not normally extend beyond the right sternal edge: the upper border is at
the level of the second intercostal space
In conjunction with the position of the apex
beat (and the character of precordial pulsation) these assessments are of some
value in determining cardiac size and/or displacement. Diminished or absent
cardiac dullness is found in emphysema and pneumothorax.
Auscultaition
The ranges for heart rate in infancy
and childhood are:
|
Newborn
|
Infant
|
Preschool child
|
School child
|
|
70/120
|
80/160
|
75/120
|
70/110
|
Auscultation should be carried out over the
areas mitral, tricuspid, pulmonary, aortic, 3rd & 4th
left intercostal spaces,below left clavicle.
Auscultatory assessment concerns cardiac rhythm,
heart sounds, and murmurs.
Sinus arrhythmia (see above) is normal in
children: triple or gallop rhythm is usually associated with cardiac failure:
irregular irregularity (e.g. due to extra systoles or, rarely in childhood,
atrial fibrillation) may occur.
Close splitting of the second heart sound in
the pulmonic area (often present on inspiration and absent on expiration) is
common in normal children: pathological splitting is wider and does not vary
with respiration.
Third heart sound is differentiated from a
split second sound by being heard best at the apex, widely separated from the
second heart sound and of lesser intensity.
An ejection click may be associated with
stenosis of a valve.
There is diminished intensity of heart sounds
in cardiac failure or pericardial effusion; and of the pulmonic second sound in
pulmonary stenosis and aortic second sound in aortic stenosis.
Cardiac hypertrophy accentuates heart sounds.
Description of murmurs should include
1) site,
2) intensity (graded 0—6) with point of maximum intensity,
3) timing (systolic: pan, early or late; or diastolic: early diastolic,
mid-diastolic or presystolic,
4) propagation (mitral systolic murmurs radiate to the left
axilla, aortic systolic to the neck, aortic regurgitant down the left sternal
edge) and
5) variation with position. Coarctation of the aorta may produce a murmur
audible over the back.
6) Variation
with respiration
A venous
hum is a continuous loud murmur at the root of the neck abolished by
pressure over the jugular vein or placing the child in the head-down position.
A
pericardial friction rub is a to and fro leathery sound heard by the examiner,
on auscultation, as if close to his ear.
Cardiovascular disorder may also be revealed
in other systems, e.g. by hepatic enlargement in cardiac failure.
When you are asked to examine GIT start from
upper GIT.
Inspection
Disease may reveal itself by distention with
shiny tense abdominal skin and distended abdominal veins or a scaphoid abdomen with lax
wrinkled skin. Absent abdominal wall movement on respiration may indicate a
disorder such as peritonitis.
Visible peristalsis may be seen in obstruction (e.g. in the
epigastrium in pyloric stenosis : obstruction low down in the gut may cause a ladder
pattern. A distended bladder may show as a rounded swelling in the Suprapubic
region. Umbilical abnormalities include hernia, omphalocele, infection
or discharge. Other hernia may be present and inguinal lymph glands may
be enlarged.
Palpation
Should be carried out with warm hands usually
with the examiner seated beside the child lying recumbent or held on the
mother’s knee, head supported, knees and hips flexed. Crying children relax the
abdominal muscles during inspiration allowing the examiner a brief moment when
palpation is possible.
Tenderness should be sought using gentle palpation followed by deeper
palpation, while simultaneously looking for evidence of pain in the form of
facial grimacing. Rebound tenderness (sudden withdrawal of the hand on deep
palpation) may confirm doubtful tenderness. Guarding of the abdominal
wall may be localized or generalized and in severe degrees may amount to
boarding. Palpation of a pyloric tumor (start with the stomach empty and
give a feed) : the tumor may harden and relax intermittently and be impalpable
when relaxed.
The lower border of the liver is
normally 1 cm below the costal margin in infants and children and can be felt
rolling under the finger as it descends during inspiration
Liver
span, measured in the
mid-clavicular line, is the distance between the upper border of the liver
determined by percussion and the lower edge.
At a body weight of 20 kg the mean span (± 2
SD) is 8cm (± 1.8 cm), and at 60kg 10.2cm (± 2.0 cm).
An enlarged spleen is felt in the left
hypochondrium possibly extending into the left iliac fossa in infancy
and the right in older children. In lesser degrees of splenic
enlargement the tip can be felt descending superficially below the costal
margin on deep inspiration.
The kidneys can be palpated bimanually
at the end of forced expiration.
A distended bladder may reach the umbilicus.
Tumors (e.g. Wilms’ or neuroblastoma) may be felt, and the soft
sausage-shaped tumor of Intussusception be found in the right upper quadrant
during relaxation.
A strangulated hernia (e.g. inguinal)
may be hard, irreducible and very tender.
With ascites a fluid thrill may be
detected, the wave caused by flicking the abdominal wall on one side being
transmitted to a hand-held flat on the other side, with the hand (hypothenar
edge) of a second person placed on the abdomen in the longitudinal axis of the
patient to suppress any transmission of shock waves through the fat of the
abdominal wall.
Enlarged inguinal lymph glands may be
palpable.
When supine, dullness due to
free fluid may be present in both flanks but on turning the patient on to one
side disappears from the upper side while the level of dullness rises over the
lower side (shtfting dullness — allow half a minute for change to take
place). A distended bladder will cause increased dullness in the
suprapubic area. Intra-abdominal masses may impair percussion.
Tinkling, crackling bowel
sounds are normally audible intermittently over the abdomen, are accentuated
with increased peristalsis (e.g. obstruction) and absent with ileus (e.g.
peritonitis).
Note color, consistency and the presence of
abnormalities such as blood, mucus or pus. Bright red blood suggests bleeding
from the lower alimentary tract, melena from the upper while streaking suggests
local bleeding (e.g. anal fissure). Threadworms may be noted on the stool.
Anus
Examine
for normality of position and abnormalities such as stenosis, paralysis,
fissure, prolapse or evidence of trauma — as may occur in sexual
abuse.
Use
a finger appropriate to the size of the patient to detect the tone of the anal
sphincter; fecal masses, including their character:
gripping
of the finger (e.g. anal stenosis, or narrowed segment in Hirschsprung’s
disease), intrapelvic masses or undue pain. Note material on the withdrawn
finger (e.g. blood).
Genitalia
Female genitalia may show labial adhesions,
clitoral enlargement, abnormal discharge, abnormality of the vaginal introitus
(e.g. sexual abuse) or urethra,
In the male, note the size of the penis and
any developmental abnormality such as hypospadias, Phimosis or prepucial infection
(balanitis).
The testes should be examined for presence in
the scrotum (in a warm room with warm hands as cold will cause retraction),
abnormality in size and shape: if palpable in the inguinal canal see if they
can be maneuvered gently into the scrotum.
Transillumination may reveal the nature of a scrotal swelling
(e.g. hydrocele is transilluminable, solid tumor is not). Do assessment of
secondary sexual characteristics.
1. Higher function
2. Cranial Nerves
3. Motor System
4. Sensory System
5. Cerebellar signs
6. Autonomic system
7. Soft neurological Signs
8. Neonatal Reflexes
9. Meningeal Signs
10.Skull & Spine
The nervous system can be examined in the
older child with the same accuracy as in the adult but in the infant and young
child has not achieved the functional precision with which it operates later;
intelligent cooperation is also likely to be lacking.
Neurological deficits are often more easily
observed in the course of everyday activities than on formal examination: they
may reveal neglect of a limb (e.g. hemiplegia), strabismus, clumsiness, in-coordination,
intention tremor, ataxia and neglect of sound.
Developmental assessment is largely the assessment of the maturation
of the nervous system .
After infancy it is usually possible to test
specific aspects of neurological function and intelligence separately
During infancy neurological and intellectual
disorders tend to express themselves in terms of disturbed motor function. A
neurological lesion may be appreciated as impaired intelligence and vice versa.
Note state of consciousness, such as
degree of alertness, interest, memory for events, hyper-excitability, hyper-irritability,
unresponsiveness, drowsiness, stupor or coma.
Disorders of posture and movement may
result from neurological disease:
1) In recumbency is he too inactive and is
posture unduly affected by gravity (hypotonia)?
2) Are there normal limb, trunk and head
movements or abnormal movements (e.g. the writhing movements of choreo-athetosis,
intention tremor or the repetitive involuntary movement of tics or purposeless
roving movements of the eyes (blindness)?
3) Can he/she sit and stand?
4) Are there any convulsive movements, generalized,
localized, or the ‘salaam’ attacks of myoclonic epilepsy (in which the sitting
infant suddenly falls forward or drops his head)?
5) Is there any in-coordination, clumsiness,
abnormality of gait (e.g. the broad-based groping walk of ataxia;
stiff-legged scissoring gait of spasticity with difficulty in putting the heel
to the ground; the outward flinging and stiffness of one leg with adduction,
elbow flexion and limited swinging of the arm on the same side seen in hemiplegia;
the awkward gait and pes-cavus of Friedreich’s ataxia or the staggering gait of
cerebellar disturbance)?
Are
there any palsies (e.g. facial or Erb’s, or wrist drop).
Cry and speech may be affected
e.g.
the high-pitched cry of cerebral injury, the peculiarly specific cry of the
cri-du-chat syndrome, delayed speech with mental retardation and autism, lack
of speech intelligibility in mental retardation or cerebral palsy, aphonia in
chorea, stammering, monotony and lack of expression in deafness and certain
types of cerebral damage. Range of vocabulary, language and ideas give some
indication of intelligence.
With younger children, lack of cooperation
will diminish ability to test the cranial nerves although with practice
observation of the child’s movements may enable a limited examination to be
made.
1st (olfactory) nerve. Only older children have the experience and
ability to distinguish smells such as orange, lemon or chocolate.
2nd (optic) nerve. Can the infant and toddler see and follow
(later name) objects? For older children use Snellen types. Take newspaper
cutting of different sized letters both Malayalam and English, paste on white
paper and carry with your CNS kit. Also Blue, red, green colour strips.
Test visual fields
Ophthalmoscope examination.
3rd (oculomotor), 4th (trochlear) and 6th
(abducens) nerves.
Test eye movements in all directions (the common
abnormalities are inability to deviate the eyes fully upward or abduct the eyes
fully).
3rd nerve paralysis causes
1) ptosis,
2) lateral deviation of the eye (unopposed
action of 6th nerve) and
3) pupillary dilation;
4th nerve paralysis (often along with 3rd
nerve paralysis)
diplopia
on looking downwards and medially (e.g. going down stairs),
6th nerve paralysis (of lateral rectus
muscle)
loss of
abduction of the eyes (paralytic squint) on looking to the affected side.
Paralysis of the sympathetic innervation of
the pupil (usually damage to the cervical sympathetic chain) results in a
contracted pupil (myosis) still reacting to light and accommodation, along with
Ptosis, enophthalmos and loss of sweating (anhidrosis) on the affected side of
the face (Homers syndrome )
squint –make an assessment of eye movements. divergent squint in III
nerve, Convergent in IV nerve.
5th (trigeminal) nerve. Test sensation over the area supplied by the
sensory branch — forehead, cheek and lower jaw — and by the
corneal and jaw reflexes; motor function by palpating contraction in the
masseter muscle when the patient clenches the teeth.
7th (facial) nerve. Upper motor neuron lesions affect the lower
part only of one side of the face so that the teeth cannot be shown effectively
and the lips formed for whistling; lower motor neuron lesions affect the whole
of one side of the face so that, in addition to the above, eye closure,
forehead wrinkling and smiling are affected
8th (auditory) nerve. Damage to the auditory branch impairs hearing
damage to the vestibular branch may result in
impaired balance and positional nystagmus (following sudden rotating movement
of the head).
9th (.glossopharyngeal) and 10th (vagus)
nerves. Test their motor
function by asking the patient to say ‘ah’ — paralysis on the affected side
results in the palate being drawn to the healthy side or merely lack of
movement.
X-ray palatography may help.
For diagnosis of paralysis of the recurrent
laryngeal branch of the vagus do indirect laryngoscopy.
Enlarged adenoids may also limit palatal
movement.
11th (spinal accessory) nerve. Demonstrate trapezius weakness by exerting
downward pressure on the patient’s shoulders as he tries to shrug them.
12th (hypoglossal) nerve. Paralysis affects the same side of the tongue,
which deviates to the affected side on protrusion, or waggling shows limited
movement towards one side.
Handling of the child and passive movements
of limbs indicate muscle tone
Muscle softness, floppiness, excessive laxity
of joints (with hyperextensibility of the digits, elbows and knees) are the
features of hypotonia; excessive firmness of muscles, stiffness and
limited mobility on passive movement indicate hypertonia. Spasticity in
the upper limbs can be tested by extending the arm fully at the elbow,
supinating the forearm and seeing if there is a Pronator flick when the limb is
released. Hypertonia may be ‘clasp knife’ (stretching the muscle beyond a
certain range results in sudden relaxation of tone), generalized or regionalized
(e.g. adduction of the thighs and shortening of the tendo-Achillis with plantar
flexion of the foot — spastic diplegia (Little’s disease)).
Assessed by observing capacity for muscular
activity and ability to overcome resistance (by examiner) to various movements.
Specific tests such as the finger—nose test
or the picking up of small objects may examine this. Dysdiadochokinesis (inability
to carry out rapid repetitive movements such as patting the back of the hand or
asymmetry of footsteps heard on running) is a feature of ataxic cerebral palsy.
A tendency to run on the toes suggests cerebral diplegia. A hemiplegic
posturing of the limb on one side may be most obvious on running.
Pin prick, normally causing a withdrawal
response, can be used to test sensory loss.
In older children sensation can be tested by
light
touch (cotton wool),
two-point
discrimination (compass points normally recognized 2—3 cm apart),
temperature
appreciation (hot or cold water in test tubes),
positional
sense (ask the child to state the position of a joint passively moved and
screened from him, e.g. ‘is the toe pointing up or down’?),
rombergism
(ability to maintain balance with eyes shut),
vibration
sense (detection of vibration of a tuning fork applied to a bony point) and
astereognosis
(inability to tell by touch the nature of a familiar object such as a coin
placed in the hand).
Cutaneous nerve segments can be used to judge
levels of cord damage in respect of sensory loss.
In early infancy there are a number of primitive
reflexes peculiar to this period of life whose absence or persistence
beyond the time of normal disappearance often has pathological significance
After infancy the main superficial and
deep reflexes used in neurological examination, and their segmental
innervations, are:
Jaw
jerk pons
Biceps
jerk C5
Supinator
jerk C6
Triceps
jerk C6, C7
Abdominal
reflex Th8—12
Cremaster
reflex Ll
Knee
jerk L3, L4
Ankle
jerk L5, SI
Plantar
response S1
In Kernig‘s sign extension of the
flexed knee with the child supine and hips at a right angle is resisted or
impossible. In Brudzinski’s sign, flexion of the head produces flexion
of the knees and thighs. In impairment of straight leg raising, the leg,
with the knee fully extended, cannot be raised to a right angle with the
patient supine. Balancing’ movements reflect labyrinthine function
Past history, place in school, relationship
with peers and routine clinical examination may reveal much about higher
nervous function; accurate assessment will involve psychometric testing and
formal speech and language analysis.
Examination of the nervous system and of the
locomotor system may be closely interrelated.
Fractures may be visible or suspected because
of deformity, crepitus (which should not be actively elicited), pain on
movement and local tenderness — which could be due to other conditions such as
bruising or osteomyelitis.
Deformities of the trunk and neck
These may be spinal such as scoliosis (best
recognized when the child bends forward to touch his toes or suspected if skin
creases in the flanks are asymmetrical and fail to disappear when the spine is
passively flexed to the opposite side), kyphosis (anterior bowing) or lordosis
(posterior bowing). Ribs may be absent. With torticollis the head is
tilted towards the affected side, the chin points in the opposite direction and
rotation of the head away from the affected side may be limited.
Deformities of limbs
Normally children are mildly bow-legged
before the age of 2 years and knock-kneed between the ages of 2 and 12 years: thereafter
the legs straighten spontaneously. Deformities may consist of absence of bones
(e.g. radius with severe flexion and lateral twisting of the hand and wrist, or
phocomelia), shortening or deformity of bones, increased carrying angle at the
elbow (Turner’s syndrome, incurving of the little finger (Down syndrome), the
‘dinner fork’ deformity of the wrists with the hands outstretched (chorea and
flexion deformities (e.g. arthrogryposis multiplex congenita
Lower limb deformities include genu valgum
and genu varum. talipes equinovarus (club foot), talipes calaneo-valgus,
metatarsus varus, absence of part of a limb, shortening or unequal development
(e.g. hemiatrophy or hemihypertrophy). Excessive joint mobility is seen in
hypotonia, Eblers—Danlos syndrome and diastrophic dwarfism.
Measurement of limb length. Finger shortening
(brachydactyly; e.g. Down and the Ellis—van Creveld syndrome) or lengthening
(arachnodactyly; e.g. Marfan’s syndrome) may be expressed in terms of finger
length relative to palm length — the middle finger length (tip to proximal
crease) is 43% of the total hand length (tip of the middle finger to the distal
palmar crease).
Muscles
May be wasted, hypertrophied (e.g.
pseudohypertrophic muscular dystrophy Fig. 2.6h) or absent (e.g. Poland’s
syndrome). Fasciculation or fibrillary movements may be noted in the tongue,
thenar eminence or elsewhere. Muscle tone — see page 35.
Joints
Examination
will include assessment of joint temperature relative to other body areas,
range of movement, swelling, local lenderness or pain on active or passive
movement. Dislocation may cause gross deformity. In the knee, synovial effusion
is likely to give rise to patellar tap — with the knee joint extended
and the thigh gripped just above the patella, the patella, on being sharply
depressed, is felt to tap against the underlying bone. Dislocation may cause
gross deformity.
Congenital dislocation of the hips (CDH) should be diagnosed as soon as possible
after birth, not after the child begins to walk when the classical late signs
(shortening, external rotation of the limb, asymmetry of thigh folds and
limited abduction) have developed. Ortolani’s test is used in diagnosis: the
thighs are abducted while the middle finger of each hand presses the greater
trochanter forward if the hip is
dislocated the femoral head during abduction can be felt to slip forward with a
‘clunk’ (similar to the sensation of changing gear in a car and to be
differentiated from the common non-significant minor muscular clicks). An
extension of the test (Barlow maneuver) consists in applying pressure backwards
and outwards with the thumb on the inner side of the thigh as abduction is
commenced. If the femoral head slips out over the posterior lip of the
acetabulum and returns when pressure is released and abduction continues the
hip is unstable. These tests should not be repeated more than necessary.
Dislocation may be confirmed by radiology or ultrasound. In anteroposterior
radiographs, with the hips and knees extended, thighs medially rotated and
abducted from the midline, a line
along the center of the femoral shaft lies outside the upper lip of the
acetabulum
EXAMINATION OF THE NEWBORN
Gross physical abnormalities are obvious at
birth but other manifestations of disease tend to be less specific. Examination
has a threefold purpose — recognizing (1) physical defects, (2) disease and (3)
establishing a baseline to which later clinical assessments can relate.
MEDICAL HISTORY OF PARENTS, SIBLINGS AND
OTHER RELATIVES
The mother’s previous pregnancies may
indicate factors such as prolonged involuntary infertility, habitual abortion
or frequent fetal loss implying higher risk of congenital abnormality. Parents,
siblings or other relatives may suffer, or have suffered, from disorders which
carry hereditary risks. Certain maternal diseases may have profound influence
on the fetus. The social history may imply disadvantage.
BIRTH HISTORY
Note birth rank and maturity, evidence of
fetal distress, early rupture of the membranes, induction of labor, prolonged
or rapid labor, type of delivery, obstetric estimate of gestation, birthweight,
Apgar score, apnea, need for resuscitation, special or intensive care.
GESTATIONAL AGE
Important in making judgments concerning
diagnosis and management, this may be assessed by (1) mother’s ~dates’ (p. 79),
(2) obstetric examination (p. 80), (3) ultrasound measurements of fetal growth
(p. 80), (4) clinical examination of the infant. Gestation age may be assessed
using external characteristics, muscle tone and primitive reflexes (Table 2.2).
Dubowitz & Dubowitz (1977) have derived a score based on (a) neurological
criteria and (b) external criteria convertible into gestation age (Fig. 2.17).
A more rapid method relies on skin color and texture, breast development and
ear firmness (Parkin et al
1976).
Behavioral characteristics: was breathing established spontaneously at
birth or intubation required? What is the state of consciousness, response
to stimuli, amount of spontaneous movement (or lack of it)? Have there been convulsions
(localized or generalized). Are sucking and swallowing impaired
(e.g. in bulbar palsy) necessitating tube feeding? Are there normal crying responses
to hunger and pain? Is there a normal state of alertness, or apathy? Does
sleep occupy the normal 20 out of 24 hours?
Posture in the newborn is one of flexion; the arm will remain flexed at
the elbow on ~pulling to sit’, the popliteal angle remains at 90~ on straight
leg raising (in contrast dorsiflexion of the foot against the tibia reveals the
diminished extensor tone — Table 9.1), sudden passive extension (stretch) and
then release of the elbow will result in forearm recoil; in the prone position
the lower limbs are flexed under the abdomen, the arms flexed at the elbows and
adducted beside the trunk (Fig. 9.1); on ventral suspension the dangling limbs
remain flexed (Table 9.1). Disturbance of the normal postural flexiort is
likely to indicate neurological dysfunction. In generalized hypotonia the
infant is ‘floppy’ with a ~flat’ posture in recumbency. Regional hypotonia is
seen for instance in the bilateral lower limb paresis of spina bifida or in
Erb’s palsy. In generalized hvpertonia (extensor hypertonus) the legs
are usually more affected than the arms, the trunk tends to be opisthotonic and
the extensor tone in the neck results in seemingly good head control in ventral
suspension but poor head control on pulling to sit’ (Fig. 2.18a). In more
severe cases, the arms are also involved, the position being one of decerebrate
rigidity. In hypertonia static postures may be interrupted by ‘cycling’
movements of the lower limbs, ‘doggy paddling’ of the upper and generalized
‘jitteriness’: tendon reflexes are usually exaggerated. Transient or persistent
hemisyndromes may occur in which one side of the body may show increased
or diminished tone relative to the other (tonic hemisyndrome); reflexes,
particularly the extensor reflexes, such as the asymmetrical tonic neck reflex
(Fig. 2.1 8b), may be accentuated unilaterally (reflex hemisyndrome) or one
side may be paralyzed (paralytic hemisyndrome).
Spontaneous movements exhibited by the newborn infant include
rotation of the head, movement of the arms, sucking the thumb, movement of the
lower limbs (more than the arms).
The primitive and tendon reflexes which
can be used in neurological assessment
No comments:
Post a Comment