Downstate Medical Center NRMS 5190/ NMRS5190: Health Assessment and Differential Diagnosis Exam 2, A+ guide.

Downstate Medical Center NRMS 5190/ NMRS5190: Health Assessment and Differential Diagnosis Exam 2, A+ guide. Exam: Preform less invasive manuevers early and potentially distressing manuevers near the nd of the examination If child reports pain in one area examine that area last Four Principles of Child Development: 1. Child development proceeds along a predictable pathway 2. The range of normal development is wide 3. Various physical, social and environmental factors as well as disease can affect child development and health 4. The childs developmental level affects how you conduct the H&P exam Five Critcal Domains of Development 1. Physical – gross and fine motor sills 2. Cognitive – problem solving through intuition, perception, verbal and nonverbal reasoning. Retain information and apply when appropriate 3. Language – communication – articulate, receive, and express information. 4. Social & 5 Emotional – form and maintain relationships Developmental Quotient = Developmental age/Chronological age x 100 85 Normal 70-85 Possibly delayed followup needed 70 Delayed PHYSICAL DEVELOPMENT Newborns have surprising abilities = fixing upon and following human faces. Neurological development progresses Centrally to Peripherally = Ex : ⟶ Head control before Trunk control ⟶ Control of Arms and Legs before Hands and Fingers Physical Growth : Infants Birth weight – By 6 months 2x, By 1 year 3x Height – increased by 50% from birth Cognitive and language development • Exploration fosters increased understanding • Learn cause and effect • Recognize strangers • Seek comfort from parents • Actively manipulate reachable objects • Language development from cooing at 2 months to 1 to 3 words by 1 year • Consider testing for hearing deficit if not making appropriate sounds and language Social and emotional development • Understanding of self and family • Social tasks • Attachment to individuals • Temperaments • Response to new stimuli varies • Observe interactions with caregivers Health History Birth History • Problems during pregnancy? • Gestational age? Pre,Late,Postterm? • Problems during labor or birth? • Vaginal or C-section birth? Past History • Allergies? • Medications, supplements, vitamins? • Illnesses? Family History • Hereditary disease patterns? • Age and health of first- and second-line relatives? • Family structure at home? Health Maintence • Immunizations • Safety measures • Risk factors • Tobacco • Alcohol • Substance abuse • Environmental hazards Health Maintence: Review of systems & Development status Infants: Tips for examining infants • Approach infant gradually, using toy or object for distraction • Perform much of exam in parent’s lap • Speak softly or mimic infant’s sounds to attract attention • Make sure infant is well-fed before proceeding- avoid being cranky/fussy • Ask about infant’s strengths to obtain useful developmental and parenting information • Do not expect head-to-toe examination in specific order • Save potential distressing parts of exam for last- e.g. mouth and ear General guidelines • Start with infant sitting or lying-in parent’s lap. • Hungry infants may need to be fed first. • Observe parent–infant interactions. • Note parent interaction with child • Leave diaper in place until ready to examine genitals, rectum, lower spine, and hips. PHYSICAL EXAM : General Survey and Vital Signs Measure infant’s body size Vital signs Compare with age-specific norms Assess pain regularly Variations beyond 2 standard deviations for age, 5th percentile, 95th percentile —indications for more detailed evaluation* Somatic Growth ⟶ Measure growth parameters carefully ⟶ Growth charts • Birth to 36 months • 2 to 18 years • Height, • weight, head circumference for age, body mass index Length - Younger than 2 years, supine On Measuring board or in Measuring tray Weight - Infant scale Dry diaper or naked Head circumference: First 2 years: Reflects the rate of growth of the cranium and the brain Vital signs ⟶ Blood pressure • Performed at least once during infancy • Systolic blood pressure gradually increases • Should routinely perform after age 3 years ⟶ Pulse – • More sensitive to illness, exercise, emotion than adults • Auscultate heart, palpate femoral or brachial artery ⟶ Heart Rates From Birth to 1 Year Age Average Heart Rate Range Birth–1 month 140 90–165 1–6 months 130 80–175 6–12 months 115 90-170 Respiratory rate ⟶ Ranges between 30 and 68 per minute in newborns; 25 to 60/min 6mos to 1 year ⟶ More responsive to illness, exercise, and emotion ⟶ Sleeping respiratory rate most reliable ⟶ Tachypnea: birth to 2 months, 60/min; 2 to 12 months, 50/min ⟶ Observe for a full 60 secs at minimum Temperature Fever common - Rectal temperature Higher in infancy and early childhood, 99.0˚F (37.2˚C) Temp 38C in infant less than 3 mos is considered a fever Temperature may fluctuate during day up to 101˚F (38.3˚Cespecially after vigorous activity Skin: Inspection Color: ⟶ Skin markings ⟶ Birthmarks Dark or bluish pigmentation ⟶ Vascular marking ⟶ Congenital dermal melandocytosis- document findings Palpation: ⟶ Turgor ⟶ Abdominal wall “Tenting” Sign of dehydration HEAD Sutures-Membranous tissue spaces separate bones of the skull Fontanelle- major sutures intersect • Feel like soft concavities • Soft and flat, pulsations normal • Anterior: closes by 22 months • Posterior: closes by 2 months Skull Symmetry and Head Circumference – A child with abnormal shape of length of palpebral fissure: Upslanting- Down syndrome Downslanting – Noon syndrome Short – Fecal Alcohol • Asymmetric head swelling? • Plagiocephaly? head to have a flattened appearance Measure circumference – Palpate carefully • Macrocephaly? • Microcephaly? Facial symmetry Inspect face for Micrognathia? when your lower jaw is underdeveloped or smaller than usual. Compare facies with face of parents. Abnormal-appearing facies can identify specific syndromes • Upslanting (Down syndrome) • Downslanting (Noonan syndrome) • Short (fetal alcohol effects) Eyes: Inspection Use subdued lighting, Use tricks, small colorful toys, or light Eye movements ⟶ Esotropia- intermittent alternating convergent strabismus – turns inward ⟶ Exotropia- intermittent alternating divergent strabismus – turns outward ⟶ Pupillary reaction ⟶ Irises Conjunctiva : Swelling? Redness? Visual acuity cannot be measured Abnormalities: Brushfield spots – Little white spots that(are)slightly elevated on the surface of the iris and are arranged in a ring concentric with the pupil. These spots occur in normal children but are far more frequent in Down's syndrome Strabismus - misalignment of the eyes, causing one eye to deviate inward while the other eye remains focused. Ears • Ear canal directed downward from the outside , Position , Shape, Features of ear Detect abnormalities, Kidney problems and hearing problems are often found together because both kidneys and the inner ears develop at the same time. • Light reflex is diffuse Patency of nasal passage • Gently occlude each nostril alternately while holding mouth closed • Obligate nasal breathers - infants • Do not occlude both nares simultaneously Mouth Equipment: Tongue blade, Flashlight Edentulous, Mucosa smooth Epstein pearls - tiny white or yellow, rounded mucous retention cysts, are located along the posterior midline of the hard palate. They disappear within months. Amount of saliva – little during first 3 months, older infants produce a lot of saliva and drool frequently Tongue Frenulum Ankyloglossia (tongue tie)- short frenulum. Limits protrusion of tongue • Inspect pharynx during crying • Do not expect to visualize tonsils Inspection : Crying Normal: lusty, strong ⟶ Teeth eruption ⟶ One tooth for each month of age between 6 and 26 months up to maximum of 20 primary teeth Inspection - Assess respirations and breathing patterns Periodic breathing- alternating pattern of slow and rapid breathing Observe carefully: Three aspects of the infant’s breathing: respiratory rate (i.e., tachypnea), audible breath sounds and work of breathing. • Nasal flaring? • Grunting? • Audible wheezing? • Lack of breath sounds? HEART Breasts : Inspection • Undeveloped • Flush with chest wall • Residual enlargement from maternal estrogen may be present for several months after birth • Can be engorged with white liquid- lasts 1 to 2 weeks Abdomen Inspection • Lying supine • Protuberant due to poorly developed abdominal musculature • Blood vessels and peristalsis easily noted • Umbilicus • Inspect for redness or swelling • Herniation? • Diastasis recti - separation of the two rectus abdominis muscles. Benign condition in most cases, it resolves during early childhood. Pelvis Rectal exam is generally not performed on infants or children unless question patency of anus or abdominal mass Referral to pediatrician or pediatric nurse practitioner if imperforate anus found Focus on detection of congenital abnormalities. • Hands, spine, hips, legs, feet Combine musculoskeletal examination with neurologic and developmental examination - IPROMS Inspection, Palpation of bony structures and related joint and soft tissue structures, assessment of Range of Motion, and Special maneuvers to test specific movements. Palpate clavicle, Inspect spine, Palpate spine MSK Examine legs and feet • Symmetry? • Bowing? • Torsion of legs- twisting of the tibia inward or outward • Leg length? • Galeazzi or Allis test* used to assess for hip dislocation, primarily in order to test for developmental dysplasia of the hip. It is performed by flexing an infant's knees when they are lying down so that the feet touch the surface and the ankles touch the buttocks. • Torsion of tibia? Neuro = Techniques are highly specific to age Abnormalities often present as developmental abnormalities – failure to do age-appropriate tasks Screening includes: • Mental status • Gross and fine motor function • Tone • Cry Deep tendon and primitive reflexes • Variable due to undeveloped corticospinal pathways • Maybe difficult to elicit • Same technique as adult, except use finger instead of hammer Babinski response? When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age. Ankle clonus? a sign of spasticity in which involuntary shaking or jerking of the leg occurs when the toe is placed on the floor with the knee slightly bent Infant periodicity schedule • Recommended health supervision visits at: • Birth • At 3–5 days • 1, 2, 4, 6, 9, 12 months Assess infant’s growth and development Perform comprehensive physical examination Provide anticipatory guidance Growth After 2 years, toddlers gain about 3 kg and grow 5cm/year Gross and fine motor skills develop quickly Abnormalities detected during play • Behavioral problems • Developmental Delay • Social or Environmental problems • Neurologic problems Assessing older children • Provide gown and leave underwear in place • Parents of children younger than 11 years should stay with child .................Continued,