01 - Newborn Physical Exam

 

Neonatal History should: 1.  Identify disabling diseases that are amenable to prompt preventive action or treatment (e.g. rds) 2.  anticipate condition that may be of late importance (e.g. gonococcal conjunctivitis) 3.  uncovers possible causative factors that may explain pathologic conditions regardless of their immediate future significance (e.g. metabolic diseases)

Eyes

     

         

Doll’s eye maneuver Subconjunctival/ retinal hemorrhages Red orange reflex: if you don’t have consider for retinoblastoma or cataract Leucokoria (white pupillary reflex): cataracts, tumors, rop Chemical irritation White sclerae Blue sclerae (osteogenesis imperfecta) Chorioretinitis

           

Anotia (treacher-collin’s syndrome) Microtia Preauricular tags and pits Dull gray tympanic membrane Low set ears Malformed ears

   

Broad in appearance Choanal atresia   Ngt need to be firm, insert it and ct scan   Can also put cotton to see ait   Babies are nose breathers   Babies are pinkish if mouth closed Flaring of the ala nasi

• • •

•

• • •

PHYSICAL EXAMINATION OF THE NEWBORN INFANT Three periods of examination: 1.  2.  3. 

•

Ears  Ears 

Immediately after delivery (focus on congenital problems and adaptation to extrauterine life, birth injuries) At 24 hours of life (more detailed examination) Upon discharge (if possible together with the mother)

Anthropometric measurements   Birth weight   Birth length: place head on the fixed part of the scale   Head circumference   Chest circumference   Abdominal circumference

• • • • • •

•

•

•

Nose 

•



•

Physical examination:   Pulse / cardiac rate : 120-160 bpm   Respiratory rate : 30- 60 breaths/min.   Blood Pressure : not routinely taken taken unless the baby is ill or with heart murmur







•

•

 

•

•

•

GENERAL APPEARANCE   Posture (flexion) – if flaccid, sedated or with neuromuscular problem   Physical Activity   Edema   Muscle tone   Level of alertness (18-20 hours sleep)   Color (cyanotic, acrocyanotic, pallor, plethoric, jaundice) •

•

•

•

•

•

REVIEW OF SYSTEMS

Mouth  Mouth    Natal teeth (lower incisors)   Bifid uvula   Cleft lip and palate   Sucking pads   Small tonsils   High-arched palate   Large tongue   Ankyloglossia – tongue tied   Retention cysts (ranula)   Epstein’s pearls   Micrognathia (pierre-robin syndrome   Excessive salivation   Macrostomia – big mouth •

•

•

•

•

•

•

•

•

•

•

Head / skull   Molding •

                 

• • • • • • • • •

Cephalhematoma (10-20% may have skull fractures) Caput succedaneum Skull defects (anencephaly) Anterior and posterior fontanels Craniosynostosis Craniotabes Micro/ macrocephaly /hydrocephaly Cutis aplasia congenita Bruits

•

•

Neck   Neck • • • • • • • • •

Face

 

•

   

• •

Dysmorphic features : epicanthal folds, widely spaced eyes, microphthalmia, asymmetry, long philtrum, low set ears Asymmetrical face (7th cn palsy) Moebius syndrome (hypoplasia of the 7th nerve nucleus)

•

                   

Short neck Hematoma on sternocleidomastoid muscle Cystic hygroma Branchial cleft cysts Thyroglossal duct cyst Webbing – turners syndrome  syndrome  Resistant neck to flexion (meningitis or sah) Bruits of thyroid gland Congenital torticollis Clavicular fracture in lga babies

Chest •

• • • • •

 

Breast hypertrophy with or without milk (witches’ milk) normal

        

Mastitis Supernumerary nipples Inverted nipples Widespread nipples Chest circumference : 2 cm < hc

 

  Anus Lungs

       

• • • •

       

• • • •

       

•

Breathing is predominantly abdominal Retractions, grunting Asymmetric breathing Stridor – obstruction above larynx, increased upon inspiration, urti Bronchovesicular breath sounds Apnea – 20 seconds stop breathing Periodic breathing Crackles or rales - lrti

• • •

Passage of meconium within the first 12 hours after birth Imperforate anus – make sure theres a hole Fistula in ano Meconium pearls

Musculoskeletal system   Unequal limbs due to lymphangiomas/ hemangiomas   Syndactyly / polydactyly / clinodactyly   Ortolani maneuver : congenital hip dislocation   Talipes equinovarus/ equinovalgus   Amelia / pocomelia   Rocker-bottom feet   Simian crease   Breech presentation   Brachial palsy   More premature less creases •

•

•

•

•

•

Cardiovascular system bpm    Normal resting heart rate: 90-160 bpm  th   Pmi at 4  ics th  ics    In adults its 5  ics    Characteristic of pulses: coarctation of aorta   Dextrocardia – heart is on the right, stronger pulse on the right   Benign / pathologic murmur   Sinus bradycardia   Blood pressure : systolic 40-80 mmhg   Diastolic 20-55 mmhg   Mean 25-60 mmhg •

•

•

•

•

•

•

•

•

Skin •

 

•

•

•

•

•





Abdomen   Palpable Liver palpable 2 cm brcm o  Palpable splenic tip o    Gas in rectum by 24 hours, should pass out meconium   Umbilical hernia – lump in umbilicus with skin   Masses   Scaphoid abdomen: diaphragmatic hernia, all intestines are the the chest, abdomen is empty   Omphalocoele – lump in umboilicus with no skin, but with thintransparent covering   Gastroschisis – intestines are outside the body   Omphalitis – redness, erythema, inflammation around the umbilicus arteries, 1 vein, wharton’s jelly   Umbilical cord : 2 arteries,   Tufts of hair

• •

       

•

•

•

•

•

•

•

•

•

 

Umbilical granuloma

Genitourinary system length, press down the fat to   Penis should at least be 2 cm in length, measure   Transitory hydrocoele – usually temporary, check through transillumination   Hypospadias – urethral openingis below, ventral   Tight prepuce – normal, but as they grow older may loosen   Ambiguous genitalia (cah)   Pseudomenses   Erection of the penis   Voiding within 24 hours testes    Undescended testes    Large labia majora •

•

•

•

•

•

•

•

•

•

• • • • •

         

Hymenal tags Testicular torsion More rugae if older, less if baby Inguinal hernia – looks like a third testes Prune belly syndrome

If not obvious, press on the skin ski n then let go. Check for yellowish discoloration. Vernix caseosa Erythema toxicum (eosinophils) Pustular melanosis (neutrophils) Milia – whitish, erythematous pustules on the tongue Miliaria Mongolian spots Capillary hemangioma – group of blood vessels, outpouching Mongolian spots – blue spots on the butt Meconium staining of skin, cord and nails Lanugo (preterm) Vellus hair (term) Gelatinous skin Parchment-like skin (post-term) Tuft of hair Amniotic band Stork’s bite Pigmented nevi Petechiae/purpura o

 

•

•

Vasomotor instability : mottling, acrocyanosis, harlequin color change Cyanosis Pallor Plethora Jaundice or icterus: if physiological not seen in the eyes, just in the skin.

• • • • • • • • • • • • • • • • • •