Pediatric Primary Care (10 page)

k.  Landau (present 3 months to 2 years of age).

3.  Test cranial nerves.

a.  I: Olfactory.

b.  II: Optic.

c.  III: Oculomotor.

d.  IV: Trochlear.

e.  V: Trigeminal.

f.  VI: Abducens.

g.  VII: Facial.

h.  VIII: Acoustic.

i.  IX: Glossopharyngeal.

j.  X: Vagus.

k.  XI: Spinal accessory.

l.  XII: Hypoglossal.

4.  Test cerebellar functioning: finger-to-nose test, heel-to-shin test, Romberg.

5.  Test deep tendon reflexes (grading 4-0): biceps, triceps, brachioradialis, patellar, Achilles.

6.  Check sensory functioning: pain, temperature, touch.

V.  Musculoskeletal.

1.  Inspect curvature and symmetry of spine.

2.  Test for scoliosis.

3.  Inspect all joints for size, temperature, color, tenderness, mobility.

4.  Test for developmental dysplasia of the hips (DDH).

a.  Ortolani maneuver (evaluate up to 12 months of age).

b.  Barlow's maneuver.

c.  Trendelenburg's test (used after child is walking).

5.  Examine tibiofemoral bones: knock knee, bow legs.

6.  Inspect gait: waddling gait (DDH), scissor (cerebral palsy [CP]), toeingin.

7.  Note flexibility and range of motion of joints.

8.  Elicit planter reflex.

9.  Test motor strength of arms, legs, hands, feet (grading 4-0).

W.  Breast.

1.  Pigmentation.

2.  Location.

3.  Tanner stages (sexual maturity rating).

X.  Genitalia.

1.  Male.

a.  Inspect size of penis.

b.  Inspect glands and shaft for swelling, skin lesions, inflammation.

c.  Inspect uncircumcised male: prepuce.

d.  Inspect location of urethral meatus, note any discharge.

e.  Inspect scrotum for size, location, skin, and hair distribution.

f.  Palpate each scrotal sac for testes.

g.  Tanner stages (sexual maturing rating).

2.  Female.

a.  Palpate genitalia for any masses, cysts.

b.  Observe for any venereal warts.

c.  Inspect for location of urethral meatus, Skene glands, mons pubis, Bartholin gland, clitoris, labia majora, labia minora.

d.  Note any discharge: color and odor.

e.  Tanner stages (sexual maturity rating).

Y.  Anus.

1.  Inspect anal area for firmness and condition of skin.

2.  Elicit anal reflex.

BIBLIOGRAPHY

Bickley L.
Bates' Physical Examination and History Taking.
10th ed. Philadelphia, PA: Lippincott; 2008. Duderstadt K.
Pediatric Physical Examination.
Philadelphia, PA: Elsevier; 2006.

CHAPTER 4

Making Newborn Rounds

Candace F. Zickler

I.  MAKING NEWBORN ROUNDS

A.  Determine number of newborns delivered in last 24 hours.

B.  Prioritize assessments by birth time and concerns of nurses.

C.  Evaluate each infant within 12-24 hours of age and daily until discharge.

II.  REVIEW OF THE INDIVIDUAL RECORDS

A.  Mother.

1.  Past obstetric history: infertility, spontaneous abortions, stillbirths/perinatal deaths, parity, gravity, length of pregnancy, congenital anomalies in other infants, assistive reproductive technology (ART) used, isoimmune disease (Rh, ABO), pregnancy-induced hypertension (PIH), Cesarean births, vaginal birth after Cesarean, gestational diabetes. Current pregnancy history: maternal age, overall health (asthma, sickle cell disease), estimated date of confinement (EDC), prenatal care, number of previous pregnancies, multiple or single fetus, presentation/position of fetus, amount of amniotic fluid, fetal growth/size (small, appropriate, or large for gestational age), nationality, public assistance.

2.  Results of prenatal lab work: blood type; rubella IgG level; hepatitis B immunization status; serologic tests; HIV status (elective); gonorrhea and chlamydia cultures; maternal alpha fetal protein; urinalysis (bacteria, blood, protein); glucose screen; exposure to drugs, alcohol, tobacco, or teratogenic medications (valproate, tetracycline); exposure to viruses (TORCH: toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus); sexually transmitted infections; Group B streptococcus status.

B.  Newborn.

1.  Prenatal history: vaginal or Cesarean delivery; length of labor and delivery; tocolytics used during labor; narcotics, anesthesia, or analgesics mother received; presentation; placental abnormalities (three-vessel cord); amniotic fluid color/volume; Apgar scores (heart rate, respirations, muscle tone, reflex irritability, color) with 5-minute Apgar > 7.

2.  Since birth: delivery weight/length/occipital frontal circumference (OFC), temperature, blood pressure, pulse, respirations, feeding/nursing with breast or bottle, voiding spontaneously, passage of meconium, infant contact with mother/parents.

III.  PHYSICAL ASSESSMENT OF THE NEWBORN

A.  General appearance.

1.  Current weight, length, OFC, color, heart rate, respirations, temperature, blood glucose at birth, response to stimuli, posture, determination of gestational age from the New Ballard Score (physical maturity and neuromuscular maturity).

B.  Full-term infant > 37 weeks but < 42 weeks, premature infant < 37 weeks, late preterm infant> 34 weeks to 36 weeks and 6 days, post-term infant> 42 weeks.

C.  Late preterm infants at greater risk for airway instability when upright, respiratory distress, apnea/bradycardia, excessive sleepiness, excessive weight loss, poor feeding, hyperbilirubinemia, hypoglycemia, hypothermia, sepsis, weak suck, and rehospitalization.

IV.  ABNORMAL PHYSICAL FINDINGS (CONSULT WITH STAFF PHYSICIAN AND/OR REFER FOR EVALUATION, AS INDICATED)

A.  Dysmorphic facies hyper- or hypotelorism, epicanthal folds, symmetrical facies and extremities.

1.  Skin and scalp with plethora, pallor, jaundice, cyanosis, bruising, abrasions, petechiae, hemangioma, port wine stain, café au lait spots.

2.  Shape of skull.

3.  Bruising, hematoma/caput succedaneum.

4.  Size and tone of anterior and posterior fontanels.

B.  Pupils without red reflex and unequal pupillary sizes, nares patent (choanal atresia), mouth with teeth, hypoglossia/macroglossia, palate high arched or missing. External ears with tags or pinhole openings. Neck short/masses (cystic hygroma) or webbing.

C.  More/less than five fingers/toes on each hand/foot.

D.  Check clavicles for fractures. Chest shape with pectus excavatum/carinatum, and supernumerary nipples. Breath sounds that are moist and grunting/ retractions after 4 hours of age, apnea/respirations < 30 or > 60 per minute.

E.  Heart rate with murmur (soft III/IV systolic murmur normal for first 1224 hours since patent ductus may not be closed), or an irregular rate/rhythm < 100 > or 180 bpm, a cuff blood pressure < 65 or > 95 mm Hg of systolic pressure, and diastolic < 30 or > 60 mm Hg. Absent or decreased femoral pulses (coarctation of aorta), slow capillary refill is indicative of poor perfusion.