Children usually visit doctor for/when?
primarily for common acute problems an some chronic illness issueHealth screenings
Cephalocaudal direction
the process of cephalocaudal direction from head down to tail. This means that improvement in structure and function come first in the head region, then in the trunk, and last in the leg region
Major concepts for assessment and health promotion
-Development -Medical Hx- Nutritional status-Growth and vital sign measurements-physical assessment -guidelines for well child supervision-anticipatory guidance-immunizations
Standard Measurements
Weight, HeightHead CircumferenceChest circumferenceVital signs: temp, heart rate, respirations, BP after age 3. Vision: Right eye (OD), left eye (OS), both (OU)Hearing: correlates w/ language development; localization requires both ears
Key points to assessment procedure
-Head to foot exam is most orderly-but you must vary some according to child's response-examine young children in parent's lap-do intrusive examinations last-Use play techniques for infants and young children. -Examine least intrusive areas first (hands, arms) and gain their trust)-Examine sensitive, painful or intrusive areas last (ears, nose, mouth)-Determine what exam you want to complete before possible crying.
Neonate/newborn age group
birth to 28 days
Pre-term
gestational age <37 weeks
term
gestational age 37-42 weeks
Post term
gestational age > 42 weeks
Infants age group
birth to 1 year -young, Immobile birth to 6 months-older, mobile 6 to 12 months
Toddler age range
1-3 years
pre-schooler
3-6 years
school age or older child
6-12 years
adolescent
13-18 or 21
assessment approach to infants - birth to 6 months
if baby is comfortable and stress free, exam can be conducted on table. Sensory methods such as voice, noise makers toys to see or touch, or skin touch attract babies. They like a smiling human face. Do quiet thinks first, then head to toe
Approach to infants 6-12 months
consider exam in parents lap due to separation or stranger anxiety (up to 4 years)Warm up more slowly with play techniques. Object permanence and ability to anticipate develops, so provide comfort measures after unpleasant procedures. Increased mobility leads to additional safety measures and a chance for parent teaching of safety.
assessment approach to toddlers
exam in parents lap due to need for parent security play games. do least intrusive things firstSave ears, nose, throat for last. Avoid "no" responses or choices they can not make. Offer simple acceptable choices. Let them touch equipment
Assessment approach to Pre-schoolers
-Keep parent close. Some will cooperate with exam on table. Protect modesty -use dolls, animals or parents to examine first-magical thinking may cause fearfulness or thinking equipment is alive-let them play with equipment. use familiar, safe, non-frightening words and approaches
Assessment approach to school age child
-do a head to toe exam. Respect modesty-Address questions more directly to child. Explain in concrete terms.-Medical diagrams or teaching dolls are helpful. Elicit their active participation in hx, exam and care plan. Answer questions honestly
assessment approach to adolescents
Confidentiality, privacy, protection of modesty are important. Explain confidentiality parameters. Offer to examine alone, w/o parent present. address questions to patient. More common concerns among girls include body image distortion, loss of appetite and weight and lack of satisfaction. More common concerns among boys include irritability, social withdrawl, an drop in school performance
General Assessment : Body
symmetry, nutrition, build, hygiene, breath, odor, posture, movement, coordination, facial expression
General Assessment: Behavior
development, attitude, affect, responsiveness/awareness, cooperation, speech, LOC (person, place, time), thought process, attention span, concentration, memory
General assessment: distress
posture, (flexion/extension), pain, facial grimace, respiration
Edema in infants
periorbital (crying, allergies, renal disease, juvenile hypothyroidism) or dependent (renal or cardiac disease)
Lanugo
downy hair, more prominent in prematureoriginal hair may shed in 4-8 weeks, and be replaced
acrocynosis
cyanotic, cool extremities; warm pink trunk
Cutis Marmorata
bluish mottling due to chilling or stress
erythema toxicum
papules or vesicles on erythematous base at 24-38
Harlequin color change
lower side of body red, upper side pale- change reverses it
Milia
white papular epidermal cysts with sebaceous retention
Miliaria
4 types (crystallina, rubra, pustulosa, profunda)obstruction of sweat ducts from head and humidity aka heat rash
Plethora
erythema flush, due to polycythemia
capillary hemangiomas
(telangiectasia or telangiectataic nevus or nevus simplex --- "stork bites," "angel kisses") --- usual fade quickly and may only show up when child is cold when older
stork bite
also known as a salmon patch, is a cluster of pink to reddish-purple blood vessels (capillaries) that appear on a newborn's skin on the back of their head or neck. A stork bite is a type of birthmark. Stork bites are harmless and may fade over time.You might notice reddish or pink patches at the back of your newborn's neck, on the eyelids, forehead or between your newborn's eyes. These marks — sometimes nicknamed stork bites or angel kisses — tend to get brighter during crying. Some marks disappear in a few months, while others fade over a few years or persist.
Nevus flammeus
port wine stains"), nevus vasculosis ---not likely to fade. Can be associated with Sturge-Weber Syndrome. Capillary malformation that is a congenital malformation of the superficial dermal blood vessels and grows in size as the child grows. It remains present for life and has no tendency toward involution like a hemangioma does.
strawberry hemangioma
bright red, lobulated tumor. Most growth of tumor in first 6 months. 60% are on the head and neck, 25% on the trunk, and 15% extremities.will slowly resolve (easy way to remember). Majority resolve without need for any kind of intervention.50% by age 5 years70% by age 7 years90% by age 9 years.Despite resolution of the vascular component, residual skin changes are observed in roughly 50% of cases.If started to resolve (called involution) before age 6 then less chances of scar formation, telangiectasia, or redundant or anetodermic (wrinkled) skin. (38% will have some skin changes).If longer to involute then there is a higher incidence of permanent cutaneous residua.80% that complete involution after age 6 years may exhibit significant cosmetic deformities especially if they involve the lip, nasal tip, eyelid, and ear.If they cause problems with one of the senses, with breathing, or future cosmetic problems may occur (on face, etc.) then may need intervention and referral to a pediatric dermatologist.
treatment for strawberry hemangioma
MedicationsPropranolol has become the treatment of choice for disfiguring or functionally significant hemangiomas - Propranolol hydrochloride (Hemangeol)Oral SteroidsLaser SurgerySurgical removal
cavernous hemangioma
bluish red, more vascular than strawberry A cavernous hemangioma happens when capillaries - small blood vessels that connect arteries and veins - swell and form a noncancerous mass called an angioma. These masses often occur in multiples in your brain, and almost always on one side only. The condition is relatively common.
Mongolian Spots
in darker pigmented infantsCongenital dermal melanocytosis. Dermal melanocytosis is the name of a kind of birthmark that is flat, blue, or blue-gray. They appear at birth or in the first few weeks of life.
Cafe Au Lait
<3cm and <6 in # are WNL-- larger size or more spots associated w/ Neurofibromatosis, or Von Recklinghausen disease-- an autosomal dominant disorder, with tumors on peripheral and cranial nerves.
Jaundice
Observed in sclera, skin, fingernails, soles, palms & oral mucosa.Does not blanche with pressure over chest or nose areasIs associated with liver disease, hepatitis, red cell hemolysis, biliary obstruction & sever infection during infancy.
Carotenemia
Observed in palms, soles, face, skin (not in sclera or mucous membranes)Blanches easily to pressure over chest or noseOccurs in older infants, with eating yellow vegetables ·
Hemolytic Jaundice of Newborn
Bilirubin above 5ml/dl
Pathologic Jaundice
Occurs first 24 hrs of life.Bilirubin increases faster than 5ml/dl/day
Physiologic Jaundice
Onset after 24 hrs, with peak from 72-90 hrs.Declines at 4 to 7 days
Breast Feeding Jaundice
Early onset: Onset at 2 to 4 days. Peak at 3 to 5 daysLate onset: Onset at 5-7 days. Peak at 10 to 15 days.May remain jaundiced for 3 to 12 weeks
nail clubbing may indicate
chronic hypoxia (respiratory or cardiac disease)
Spoon nails may indicate
iron deficiency anemia
splinter hemorrhages under nails may indicate
trauma or endocarditis
Head: Key points
Head Circumference (HC): Frontal Occipital Circumference (FOC)Fontannels/sutures: Anterior closes at 9 - 18 months, posterior by 2 monthsSymmetry & shape: Face & skullBruits: Temporal bruits may be significant after 5 yrsHair: Patterns, loss, hygiene, pediculosis in school aged childSinuses: Palpate for tenderness in older childrenFacial expression: Saddness, signs of abuse, allergy, fatigueAbnormal facies: "Diagnostic facies" of common syndromes or illnesses
Frontal Occipital circumference (FOC)
measured over the most prominent part on the back of the head (occiput) and just above the eyebrows (supraorbital ridges). This can be translated to mean the largest circumference of the head.
Molding
suture overlap, resolve in 2 daysDuring a head first birth, pressure on the head caused by the tight birth canal may 'mold' the head into an oblong rather than round shape. Newborn head molding is a common occurrence that usually disappears after a few days.
capput succedaneum
scalp swelling resolve in 2 days It is most often brought on by pressure from the uterus or vaginal wall during a head-first (vertex) deliver
cephalohematoma
subperiosteal hemorrhage, resolve in weaks/months A cephalohematoma is an accumulation of blood under the scalp. During the birth process, small blood vessels on the head of the fetus are broken as a result of minor trauma
fontannels
Fontannels: Tense and bulging with increased intracranial pressure (ICP)Large HC/ICP: Increased HC due to increased ICP (before suture closure), tense & bulging fontannels, dilated head veins, "sunset sign."In older child, after cranial sutures close, ICP increases are more like adult signs ( headache, vomiting, BP increases, change in LOC)Depressed with dehydrationHead may tranilluminate.May indicate hydrocephalus, intraventricular hemorrhage, trauma, meningitis or tumors.Small HC- May indicate microcephaly or craniosynostosis
sunset sign
The "setting sun" sign is an ophthalmologic phenomenon where the eyes appear driven downward bilaterally. The inferior border of the pupil is often covered by the lower eyelid, creating the "sunset" appearance. This finding is classically associated with hydrocephalus in infants and children
craniosyntosis
Asymmetric head shape due to premature closure of sutures. Surgical separation corrects defect.
craniotables
Ping-pong" effect with pressure over temporo-parietal-occipital areas. May be WNL, or result of hydrocephaly, rickets or infection (syphalis)
Macewens sign
Cracked pot sign" sound with tapping over parietal bone. May be WNL in infants, or associated with ICP (increased intracranial tension) & suture separation (i.e. lead encephalopathy, tumor)A sign to detect hydrocephalus and brain abscess. Percussion (tapping) on the skull at a particular spot (near the junction of the frontal, temporal and parietal bones) yields an unusually resonant sound in the presence of hydrocephalus or a brain abscess.
Chevostek's sign
Spasm of facial muscle with percussion over zygomatic bone in front of ear. May be associated with hypocalcemic tetany and tetanus.
Flattened head areas
Especially occipital flattening with hair loss, may indicate persistent placement of baby in same position.
Eyes Key points
Vision: Red reflex & blink in neonateVisual following at 5-6 wks180 degree tracking at 4 monthsE chart & strabismus check for preschool childSnellen charts for older childrenPERRLAAmblyopia (lazy eye): Corneal light reflex, binocular vision, cover-uncover testEOMs: tracking 6 fields of visionFundoscopic exam of internal eye & retina
Eye Variations
Placement & symmetry:Wide set: hypertelorism - Down syndrome. Hypertelorism is a term used to describe an abnormally large distance between the eyes. It refers to the position of the bony orbits, the 'eye sockets,' in which the eyes lie, in the skull.Close set: hypotelorismEpicanthal folds or upward slants - ethnicity, Down's.Eyelids: Ptosis, lid lag, blepharitis (stye), swelling
dacryocystitis
blocked tear duck may cause redness, swelling and discharge
allergic shiners
dark circles may indicate allergy
periorbital edema
may indicate renal problems
sunken eyes
may indicate dehydration
conjunctiva possible findings
Inflammation, pallor (anemia),Cobblestone appearance may indicate allergy
Sclera possible findings
Jaundice (liver disease), injection (conjunctivitis),Hemorrhage, blue color (osteogenesis imperfecta)
cornea possible findings
Smooth, moist,clear (not injected with conjunctivitis red eye)
Brushfields spots are associated with ____
Down's syndromelight speckling of iris
Coloboma
notch at outer edge of iris, may indicate visual field defect congenital abnormality of the membranes of the eye Coloboma is an eye condition that people are born with. It happens when part of the tissue that makes up the eye is missing.
Partial or dark red reflex indicates
pathology, various retinal anomalies or opacities of cornea, anterior chamber or lens (i.e. cataract)
White retinal reflex indicates
pathology (i.e., retinoblastoma, Retinal detachment chorioretinitis)
retinal hemorrhage
is pathological, associated with a variety of causes: Is a specific diagnostic criteria in "shaken baby" syndrome.
papilledema of increased ICP
more likely in older child, with closed cranial sutures
ear key points
MAKE SURE THEY PASSED THEIR HEARING EXAM AFTER BIRTH!!!!!!!!Exam last In younger childrenRestrain Young children in lap, head braced against parent's chestHearing: Especially if language delay or frequent otitis media
otoscope exam on infants/toddlers/preschoolers
pull auricle down
otoscope exam on school aged and adolescents
pull auricle up and back
tuning for w/ children
Weber & Rinne tests to differentiate conductive vs sensorineural hearing loss are not effective with younger children
otitis exeterna
Pain with movement of auricle or tragus, discharge in canal, occurs more often in summer ("swimmer's ear").
Otitis Media
middle ear infection
exam of TM
Dull, gray, retracted, loss of light reflex, landmarks may be more difficult to see, with possible superior injection near short process of malleus is associated with blocked or obstructed eustachian tubes.Dull, bulging, gray or with some injection is associated with pressure, fluid or pus accumulating in the middle ear.Red, dull/thick/bulging, with landmarks not visible is associated with acute otitis media.Orange-amber color, with/without bubbles/fluid lines is associated with serous otitis media with effusion, often associated with viral URIs, or pressure changes, such as diving or flying.
Nose Key points
Exam nose & mouth after ears (after crying from ear exam)....will be juicy....heheObserve shape & structural deviationsNares: ( check patency, mucous membranes, discharge, inferior turbinates, bleeding)Septum: (check for deviation)Remember:Infants are obligate nose breathersNasal flaring is associated with respiratory distress
Sinus pain location - age of development
Maxillary cheek & upper teeth present @ birth· Ethmoid medial & deep to eye present @ birth· Frontal forehead & above eyebrow approximately 7 years· Sphenoid deep behnd eye in occiput adolescence
Teeth
20 deciduous teeth, begin eruption at 6 months & continue adding approximately 1/month32 permanent teeth, erupt from 6 to 25 years, with molar eruption from 1to 25 years
gingival cysts
Newborn cysts: White retention epitheleal cysts occur in the newborn:Epstein's pearls occur along midline of palate.Bohn's nodules occur along gum line, resembling teeth.
vesicular eruptions in the the mouth
Can occur on lips, buccal mucosa & tongue, due to viral infections, such as herpes simplex cold sores or aphthous stomatitis.
fissure/cracked lips
May be due to harsh climate or vitamin deficiencies.
color variations/mouth
Central cyanosis can be observed in lips & mucosa. Pallor may indicate anemia. Cherry red coloration may be seen in acidosis.
white patches in mouth
White ulcerated sores on mucosa ae cankers, related to mild trauma, viral infection, mild trauma or local irritants.
Koplik's spots
small white, red rimmed eruptions on buccal mucosa next to first & second molars, appear and disappear before the onset of Measles (rubeola) rash.
a smooth red tongue may be r/t
vitamin deficiencies
strawberry and raspberry tongue are seen in
scarlet fever
A short frenulum with inability to touch tongue to upper gum ridge ("tongue tie" or ankyloglossia) may lead to
later speech problems.
With gag reflex, deviation of uvula to one side suggests either
glossopharyngeal or vagus nerve involvement or infection of peritonsillar or retropharyngeal abcess.
an absent or bifid (notched) uvula may indicate
submucosal or soft palate cleft.
tooth markings
Brown & black spots may indicate caries."Baby bottle" caries appear on teeth at gum line and are due to babies taking a bottle to bed, and milk pools around the teeth.Brown-white mottling may indicte excessive fluoride intake.Green & black staining may indicate oral iron intake contacting teethAn increase in tooth decay or evidence or eroded enamel may indicate frequent, self-induced vomiting, especially in adolescent girls. Callous marks on fingers/knuckles might also be observed
tonsils in school age children and adolescents
Large tonsils, due to developmental lymph tissue hypertrophy are common
streptococcal tonsilitis
Large red tonsils covered with white exudate are suggestive of streptococcal tonsillitis, especially if palatal petichiae & red uvula are present.
Diphtheric Tonsilitis
Thick, gray exudate
infectious mononucleosis
A gray, necrotic discoloration of tonsillar tissue
peritonsillar abscess
A unilateral, red, enlarged tonsil
Nasal voice quality
may indicate enlarged adenoids
Hoarse cry may indicate
croup, cretinism or tetany.
A shrill, high-pitched cry in a newborn may indicate:
increased ICP such as head injury or meningitis
neck assessment key points
Check for position, lymph nodes, masses, cysts or fistulas/cleftsSuppleness & Range of Motion (ROM)Check clavicle in newbornHead control in infantTrachea & thyroid in midlineCarotid arteries (bruits)TorticollisWebbingMeningeal irritation
head lag, significant lag after 6 months may indicate
cerebral palsy
torticollis
Stiff neck" with resistance to lateral head turn as result of injury to sternocleidomastoid muscle, more often seen in newborn
webbing
feature of "Turners Syndrome" or other congenital abnormalities.
assess clavicle in newborn
Check for fracture in newborn, associated with shortening, break in contour, crepitus at fracture site, and decreased motion of arm
lymph node size in children & adolescents vs elderly
Nodes are proportionately large in older children & adolescents, and smaller in the elderly.
AP diameter during infancy
round chest 1:1 ratio
AP diameter during school age years
1:2
Pectus Carniatum
or pigeon breast: concavity of sternum
Pectus excavatum
or funnel chest protrusive sternum
Harrison's Groove
horizontal ression groove of lower ribs with lower rib flaring, may indicate vitamin D deficiency (richets)The Harrison sulcus or Harrison groove refers to a groove at the lower end of the rib cage seen in young children/infants with abnormally weak bones (e.g. rickets) or chronic respiratory disease (e.g. severe asthma).
Beading or richitic rosary
protrusive deformities along costochondral junctions, may indicate vitamin D defenciency (richets)The terms "rachitic rosary" or "beading of the ribs" refers to the prominent bony knobs that develop at the costochondral joints of rachitic patients.
Tanner stages for Female (breast)
I Prepubertal, elevation of papilla onlyII Breast bud, elevation of breast & papilla as small mount, enlargement of areolaIII Further enlargement of breast & areola, no separation of contoursIV Areola projected as secondary moundV Mature, recession of areolar mound to breast contour, projection of papilla only
Vitals for newborn
HR 100-180RR >50 abnormal leukocyte count >34
vitals for 1month to 1 yr
HR 90-180 RR >34Abnormal leukocyte count > 17.5 or <5
Vitals 2-5
HR 80-140RR >22Abnormal leukocyte count >15.5 or < 6
Vitals for 6-12 yrs
HR 60-130RR >18Abnormal leukocyte count >13.5 or <4.5
Vitals for >13yr old
HR 60-100RR >14Abnormal leukocyte count >11 or < 4.5
Location and size of heart in infant... Which intercostal space>
midclavicular 4th ICS.
friction rubs before age 3
usually congenital
friction rubs after 3
often acquired
review Male and Female Tanner Stages
0
scoliosis
pre-adolescent growthlateral curvaturecontralateral hip humpprominent scapulaasymmetry: shoulder, arms, hips
Congenital hip dislocation or dysplasia
check hip abduction & symmetryasymmetrical hip abductionasymmetrical thigh & gluteal foldsOrtolani's clickBarlow's test
ortolani's click
a click is heard or felt as dislocation is reduced For the Ortalani manuever, the hip is abducted and gentle pressure is applied to the proximal thigh from behind. Here, the examiner attempts to relocate an already dislocated femoral head back into the acetabulum. If the joint is dislocated, a palpable "clunk" is noticed as the head slides back into place.
Barlows test
hip flexed and thigh adducted while pushing posteriorly -> femoral head dislocates posteriorlyTx of congenital - harness/braceThe examiner grasps the infant's thigh near the hip and with gentle posterior/lateral pressure, attempts to dislocate the femoral head from the acetabulum. Normally, there is no motion in this direction. If the hip is dislocatable, a distinct "clunk" may be felt as the femoral heads pops out of joint.
varus
feet turning in
valgus
feet turning out
genu varum
bowleg -- knees 2 inches apart
Genu valgum
knock knees -- ankles 3 inches apart
pes equinus
weight bearing on toes -- CP or other muscular diseases
cerebellar functions for peds
Balance, gait & leg coordination, ataxia, posture, tremors· Finger to nose (fingers to thumb) 3-4 yrs· Finger to examiner's finger 4-6 yrs· Ability to stand with eyes closed (Romberg) 3-4 yrs· Rapid alternations of hands (prone, supine) school age· Tandum walk 4-6 yrs· Walk on toes, heels school age· Stand on one foot 3-6 yrs