GPE in paediatrics

General physical examination in newborn is paediatric general examination

1. Presented by : GUIDE : DR LEELADHAR Dr. LAXMAN SIR GENERAL PHYSICAL EXAMINATION

2. General Physical Examination Essential Tools : Stethoscope Thermometer Sphygmomanometer (with cuff of different sizes) Torch Percussion hammer Weighing machine Measuring tape Tongue depressor Stop watch

3. Position for Examination Age Position 0 – 4 months : Examination table 4 months – 18 months : Mother’s lap 18 months – 3 years : Standing or mother’s lap After 3 years : Examination table. Adolescent girl : Presence of female attendant Well lighted, warm, colourful, comfortable room and warm hands are essential When examining a child the head and the body need to be gently immobilised .This is best achieved with the child seated in the parent’s lap. The parent restrains the child by placing one hand firmly on the child’s forehead and holding the side of the child’s head against the chest, while the other arm is placed firmly around the child’s body and both arms.

4. Sequence of examination General appearance Vital signs General features & Head to toe examination Evidence of Deficiency states Skin and its appendages Anthropometry Developmental assessment

5. General appearance

6. By observing the child , the Health status may be assessed to some extend e.g. Happy, playful, alert and interested in surrounding-normal child Dull, not interested in surroundings, irritable-kwashiorkor Shy and timid -overprotected child Nutritional status : may indicate some chronic diseases or conditons that affect basal metabolic rate. BMI=weight(kg) / height or length(m²) Posture : e.g. Ophisthotonus seen in Tetanus Crossing of leg(scissoring position) seen in Spastic cerebral palsy Squatting position seen in cynotic spell Facies Peculiar odour GENERAL APPEARANCE

7. ODOUR

8. Consciousness is a persons self awareness of self and surrounding. Drowsy : Child is sleeping but respond by light stimulus, but goes to sleep again if left alone Stupor : The child respond only to a strong stimulus (painful), localizes pain and tries to remove the painful stimulus. Delirium : Same status as stupor, pt not fully oriented to time, place, person. Level of consciousness

9. Glasgow coma scale : EVM scale Total 15 score, < 5 score - poor prognosis. Modified coma scale for infants Coos and babbles (5), irritable (4), cries to pain (3), moans to pain (2), no response(1)

10. Vital Signs : signs of life

11. Temperature – clinician can make a rough estimate of body temperature by placing dorsum of his or her hand over the neck of the child. SITES : Axillary – Infants and small children Oral – Older children Rectal – only in malnourished or very ill child Rectal Temp > Oral Temp. >Axillary Temp. approximately by 0.7 F Normal diurnal variation is 1 F Other sites: Groin, ear canal Clinically significant fever is defined as RECTAL temp. >= 100.4 F (38 C ) or ORAL temp. >= 99.5 F (37.5 C ) or AXILLARY temp. >= 99 F (37.2 C )

12. Temperature ranges temperature Degree centigrade Degree fahrenheit normal 36.6-37.2 98-99 subnormal <36.6 <98 febrile >37.2 >99 hyperpyrexia >41.6 >107 hypothermia <35 <95

13. Pulse - The characteristics of Pulses are: Rate Rhythm Volume Character Radio-femoral delay Condition of the vessel wall

14. Main peripheral arterial pluses Radial :Radial pulse is felt with tips of the fingers compressing the vessel against the lower end of the radius. Patient’s forearm should be slightly pronated and the wrist slightly flexed. Carotid : Right carotid is the best examined with the left thumb and the left carotid with the right thumb. (Never examine both carotids simultaneously) Brachial : Brachial artery is compressed against the humerus just above the antecubital fossa. Femoral : The femoral arteries lie midway between the iliac crest and the pubic ramus.

15. Posterior tibial : The posterior tibial is found 1 cm behind the medial malleolus of the tibia. Popliteal : The patient’s knees flexed at an angle of 120 degrees. The finger tips of both hands are placed in the popliteal fossae with the thumbs resting on the patient’s patella. Dorsalis pedis : The dorsalis pedis pulse compressed against the tarsal bones.

16. Normal pulses at various ages AGE BEATS/MIN <6months 120-160 6-12months 110-120 1-5years 95-110 6-12years 80-100 >12years 60-100

17. Respiratory rate : The breathing is mostly abdominal or abdomino thoracic in infants & in older children predominantly thoracic. NORMAL RESPIRATORY RATES AT VARIOUS AGES Age Normal Respiratory Rate (breaths / min) Tachypnea (breaths / min) Upto 2months 30-50 >60 2-12months 20-40 >50 12months-5years 20-30 >40 5-12years 15-20 >30 >12years 15-18 >30

18. Blood Pressure Separate cuffs should be used for children of different ages. Age Cuff Width Infant 5 to 7 cm Children 7 to 9 cm Adolescence 9 to 11 cm If cuff too wide : Underestimates BP If cuff too narrow : Overestimates BP

19. Blood pressure(cont...) Methods for measuring blood pressure: Auscultatory method Palpatory method Flush method Oscillatory method Doppler method

20. Normal blood pressure in children Age Systolic BP (mmHg) Diastolic BP (mmHg) Newborn 50-70 25-45 Upto 6months 60-80 30-50 6months-12months 60-90 50-70 1-6years 70-100 40-70 7-12years 90-110 50-70

21. FORMULAE TO CALCULATE EXPECTED BLOOD PRESSURE IN CHILDREN : Formula used for children > 1 yr (50th percentile) Systolic blood pressure= 90 + ( 2 X age in years) Diastolic blood presuure=55 + (2 X age in years) Lower limit of systolic pressure= 70 + (2 X age in years)

22. CAPILLARY FILLING TIME : It is the most sensitive indicator of poor peripheral tissue perfusion. The refill is determined by blanching in area of skin over the face, forehead or sternum or pulp of finger by firm compression with finger tip for 5 sec. Note the time for the blanching to disappear. If it take >3 sec to refill it is significant.

23. General features & Head to toe examination

24. General features In GENERAL FEATURES look for Anaemia Cyanosis Jaundice Edema Lymphadenopathy

25. Jaundice – examine patient under sunlight Yellowish discoloration of skin and sclera. Site:- Upper bulbar conjunctiva. Under surface of tongue, soft palate, Palms and soles General skin surface.

26. Cyanosis – Bluish discoloration of the nalis, lips and tongue due to increased amount of reduced hemoglobine in capillary blood. Central Cyanosis – Tongue (margins, under surface), Inner aspect of lip, mucous membrane of gums, soft palate, cheek, lower palpebral conjunctiva. Peripheral cyanosis-

27. Pallorness SITE- Palm, conjunctiva, tongue, nail bed, lips, oral cavity muacos

28. Clinical assessment of jaundice KRAMER STAGING Area of body Zones Bilirubin levels(mg/dl) Face 1 4-6 Upper trunk 2 6-8 Lower trunk & thighs 3 8-12 Arms and lower legs 4 12-14 Palms & soles 5 > 15

29. Oedema Accumulation of excessive amount of tissue fluid in the S.C tissue. It is assessed by applying firm pressure for 30 sec. over the area by the tip of Rt thumb. For OEDEMA – Seen in dependent areas In Ambulatory pt. - look just above medial malleolus , lower end of tibia , upper part of shin bone In Bed ridden pt. – look over sacrum Pitting / non pitting

30. Cardiac cause Renal cause Liver ds. Myxodema Elephantiasis PITTING NON PITTING

31. Lymphadenopathy Lymph nodes are palpated by the pads of index and middle fingers with gentle but firm pressure and moving the overlying skin in circular motion. Peripheral LN are looked in the neck, axillae, Epitrochlear , groins and popliteal fossa. LN should be examined for - Site, size, number, consistency, tenderness, mobility, matting, overlying skin If LN - Warm, tender gland-infection Soft fluctuant gland- suppuration. Matted gland- chronic inflammation ( T.B.) Firm LN- Malignancy Localised/generalised Significant/ non significant ( Cervical lymphadenopathy upto 1.5 cm diameter and LN discrete , mobile, and non tender )

32. Head to toe examination Examination of Head & Face In Head LOOK for Size Shape Symmetery Bossing or prominencies Ant. Fontanel Sutures Macewen’s sign Auscultation Transillumination of Skull

33. Shape & Size of Head- Microcephaly <3 rd SD below mean Macrocephaly >2 SD above mean Brachycephaly –coronal suture fuses prematurely Dolichocephaly-anterior posterior length of the skull>width Plagiocephaly-skull is asymmetrical in shape

34. FONTANELLE There are 6 fontanels at birth. Ant. Fontanels: 2.5 X 2.5 cm. It closes by 9-18 month of age. Post. Fontanels: < 1 cm. It closes by about 2 month of age. ANTERIOR FONTANELS : normal / bulging / sunken open/ close Buldging fontanels – Crying / Coughing / vomiting Increased I.C.T  meningitis, intra cranial bleed, subdural hematoma, ICSOL , hydrocephalus, pseodotumor cerebri Sunken fontanels – Dehydration Early closure in craniosynostosis, primary microcephaly

35. Disorders Associated with a Large Anterior Fontanel - Hypothyroidism Achondroplasia Congenital rubella syndrome Hypophosphatasia Intrauterine growth restriction Osteogenesis imperfecta Prematurity Trisomies 13, 18, and 21 Vitamin D deficiency rickets

36. Caput succedaneum Cephalohematoma Diffuse, baggy, soft swelling of scalp. Seen at birth. Cross suture line. Disapper by 1-2 days. Sub periosteal collection of blood, Does not cross suture lines. Maxi. size 3 rd day Disapper by 3-6 week.

37. Macewan’s sign or Cracked pot sound: Percussion of skull with the finger & cracked pot sound is heard. It is indication of separated sutures ( due to Increased ICP) Physiologically present if ant. Fontanel is open. Transillumination of skull Done in all infants below 1 year of age. Done in dark room with a torch placed over the frontal region & occipital region & rim of translucency is looked for. When translucency extend > 2 -2.5 cm in frontal area & over 1 cm in occipital region, it abnormal, and indicate subdural effusion, hematoma, hydrocephalus.

38. Examination of Nose Look for- Discharge ( watery / purulent / yellow ), congestion or blockage, bleeding , polyps, DNS , foreign body Depressed nasal bridge- Down syndrome cong. Syphilis( saddle nose), late stages of leprosy,

39. Ear Should be examined in all Children with unexplained fever , URTI, ear ache or Discharging ear. Also look for – Preauricular sinuses Preauricular skin tags Partial or complete absence of pinna Microtia

40. Eyes Do not open eyes forcibly. Look for Anameia Xerosis Bitot spot (Vit. A deficiency ) Any developmental defect –cataract, corneal opacity Any bulging / proptosis of one or both eyes Puffiness and infection of eyelids Ptosis Size of pupils & pupillary reflexes Fundus examination Ptosis U/L in occulomotor nerve paralysis, Horner’s symdrome, tumors of eyelid and B/L in myasthenia gravis, myotonic dystrophy

41. Mouth & Throat LIPS : Angular Stomatitis & Cheilosis (Nutritional deficiency) Dry mouth / Dry mucosa : Dehydration, Mouth breathing, Antihistamine Trismus (Lock jaw)- Tetanus, part of dystonia Gums- Bleeding gums- Scurvy, gum hyperplasia Koplik spots – pinhead sizes, white spots (like sago) with a red margin in buccal mucosa, opposite the molar teeth in measles. Thrush- White patches seen in neonates, Immuno- suppressed child, prolonged antibiotic therapy, AIDS, steroids . Mouth Ulcers- Seen in Vit. B deficiency, children with Leukemia . Palate High arched, cleft, bifid uvula, position of uvula Throat For size of Tonsils, evidence of inflammatory memb.

42. Tongue examine for colour / dry or wet /coating /papillae , tremors , symmetry , ulcer . Beefy Red smooth tongue ( due to atrophy of papillae ) Niacin deficiency Strawberry Tongue Scarlet fever, Kawasaki disease Coating of Tongue – Poor oral hygience , Typhoid fever ,Uremia. Macroglossia – Down’s syndrome, congenital hypothyroidism

43. NECK : LOO K for any Swelling Webbing Hair line JVP Arterial and venous pulsations Thyroid gland Lymphnodes Cysts Fistula Position of trachea Short neck – Turner , Down, Noonan Webbing - turner, noonan Neck stiffness- meningitis, SAH, tetanus Swelling of the neck- diphtheria, mumps or cellulitis.

44. Enlargement of neck veins- measure the JVP. JVP- Pt lies supine, propped up by 45 degree, head turned slightly away to the opposite side & neck relaxed in supine position the jugular veins will be distended normally, at 45 O jugular vein is just seen above the clavicles. The upper level of the vein is noted & a ruler is kept at that level , parallel to the ground. Another ruler is put perpendicular to the first ruler up to the angle of louis. The distance from the angle of louis to the first ruler give the jugular pressure normally 3-4 cm

45. BONES & JOINTS Look for Chest deformity Localized swelling Ends of long bones Joint inflammation Swelling Mobility Size & Symmetery of limbs Examine hands and feet for size , shape, length of fingers and toes

46. In septic & rheumatoid arthritis- Joint are red ,hot, swollen, tender & limited movement due to pain. In rheumatic arthritis( rheumatic fever)- there may be arthralgia (painful joints without any other sign of inflammation like heat or swelling). Arachnodactyly - unduly long fingers. Seen in marfan syndrome ,homocystinuria.

47. Spine LOOK for Any swelling (Pott’s spine), Tenderness (Fracture of vertebrae) or Curvature of spine (Kyphosis, Scoliosis, Lordosis etc.) Range of movements Kyphosis – Forward bending of vertebral column ( Post. Curvature). Scoliosis – Lat. bending of vertebral column. It may be primary that cannot be obliterated (poliomyelitis ,muscular dystrophy, osteogenesis imperfecta) and secondary that is obliterated by lying down (due to compensatory phenomenon). Lordosis – Excessive backward curvature of vertebral column

48. Evidence of Deficiency states

49. Evidence of Deficiency states

50. Vitamin Deficiency Vit. A : Night blindness , Bitot spots , Xeropthalmia ,keratomalacia , mucosal alteration leading to frequent respiratory and GIT infections. Vit. B : Bitot spots : Chalky grey spots on the temporal side of corneo-scleral junction. Thiamine B1 Beri-Beri Riboflavin B2 Glossitis , Cheilosis, keratitis Niacin B3 Pellagra ( diarrhoea, dermatitis , demetia ) Folic acid Megaloblastic anaemia,glossitis Cobalamine B12 Megaloblastic anaemia,Thrombocytopenia

51. Vit. C : Scurvy characterized by irritability, hemorrhages under periosteum of long bones ,gums , mucous membrane. Vit. D :Rickets Vit. E : Hemolytic anaemia in preterm babies Vit. K : Hemolytic ds. Of newborn with bleeding manifestations from different sites

52. Skin and its appendages

53. Skin examination should be done in well lighted room. In SKIN following abnormalities should be looked for; Colour changes- pallor, cynosis, jaundice Scratch marks –seen in cholestasis Rashes- measles , chickenpox Skin turgor- (by pinching the skin of abdomen or chest) increased in marasmus,hypernatraemic dehydration. Bed sore- over the sacrum, lateral malleolus, shoulder girdles, back of heel of foot ( due to loss of muscular action )

54. Skin lesions

55. Primary lesions due to vascular pathology Petechiae- small 1-2mm blood filled macular lesions due to minor haemorrhaes in skin. Purpura- 3mm-1cm maculopapular lesions due to subdermal bleed. Ecchymosis- subdermal bleed >1cm in size.

56. Shape of Skin lesion Linear Lesion - contact dermatitis , incontinentia pigmenti Annular lesion – Ring worm Distribution of Rashes If symmetrical lesions – endogenous cause If asymmetrical lesions – exogenous cause Skin pigmentation Brown or blue-black pigmentation of buccal mucosa and exposed parts of skin-in Addison’s disease Greyish bronze coloured skin- haemochromatosis Generalised hypopigmentation due to congenital absence of melanin-albinism Depigmented patches in skin without any known cause-vitiligo Symmeterical Flexor distribution of lesion – Atopic dermatitis ( A nterior – A topic ) Symmeterical Extensor distribution of lesion – Psoriasis ( P osterior – P soriasis )

57. HAIR AND NAIL Examine Scalp for– Seborrhea Alopecia (zinc deficincy, candidiasis, tinea capitis, polyendocrine deficiency syndrome) Pediculosis Flag sign (sparse, straight, thin, easily pluckable, lusterless, gray or red or alternate depigmentation and Pigment)

58. NAILS Nails examined to determine for pallor, cyanosis, Clubbing- grades 1 to 4, NAIL LESION SEEN IN Platynychia iron defi. Anemia. Koilonychia or spooning of nails iron defi. Anemia. brittleness of nails PEM Half & half nail(Terry’s nail) CRF White nail anemia, hypoalbuminemea Splinter hemorrhages infective endocarditis, trauma Pitted nails psoriasis,eczema

59. Clubbing – Bulbous swelling of the terminal part of the finger and the toes with increase AP as well as transverse diameter of nail. Schamroth’s windows test Grades I to IV Causes- cardiac, pulmonary, GIT, idiopathic

60. Anthropometry

61. WEIGHT Age Weight Gain 0-3 months 20-40 gm /day Till 1 Year of age 400 gm / month 3 to 7 years of age 2 kg / year Till Puberty 3 kg/ year Age Wt. approx. (of birth weight ) At 6 months doubles At 1 year triples At 2 year 4 times At 3 year 5 times At 7 year 7 times

62. Length & Height Up to 2 year -length by infantometer. Older children -standing height by stadiometer. Age Height gain At birth 50 cm at 1 year 75cm at 2 year 82.5cm 2-12 year 6x+77 Adolescence Girls during 12-16 years Boys during 14-18 years 8 cm/year 10 cm/year

63. Growth Velocity and Other Growth Characteristics by Age INFANCY CHILDHOOD ADOLESCENCE Birth-12 month : 24 cm/year 12-24 month : 10 cm/year 24-36 month : 8 cm/year 6 cm/year Slowly decelerates before pubertal onset Height typically does not cross percentile lines Sigmoid-shaped growth Adolescent growth spurt accounts for about 15% of adult height Peak height velocity Girls: 8 cm/yr Boys: 10 cm/yr

64. In new born done after 1 st day of birth (when caput succedanem and over riding of sutures would have disappeared) Head circumference is measured with a flexible tape measure starting at the supraorbital ridge around to the occipital prominence in the back of the head, locating the maximal circumference . Head circumference Age Head circumference At birth 33-35cm Till 3 months 2 cm /month 4 to 6 months 1cm /month 7 to 12 months 0.5 cm /month

65. MEAN Head circumference Age Mean HC At birth 33-35cm 3 months 40 cm 6 months 43 cm 1 year 46-47 cm 2 years 48 cm 12 years 52 cm Adult size 55-56 cm

66. Chest circumference The chest circumference is measured at the level of the nipples, midway between inspiration and expiration. The circumference of chest is about 3 cm less than the head circumference at birth. The circumference of head and chest are almost equal by the age of 1 year.

67. Mid arm circumference Over the left triceps, with the arm hanging by the side, a non stretchable tape is passed around the circumference of the arm.( mid point of left arm, midway between acromian and olecranon process with arm hanging loosely ) >13.5 cm Normal 12.5 to 13.5 cm Moderate malnutrition <12.5 cm Severe malnutrition

68. Upper segment / Lower segment ratio Age US/LS ratio Birth 1.7: 1 3 years 1.3: 1 6 years 1.1: 1 1 year 1 Adult 0.9 Increase Decrease Rickets, Achondroplasia, Untreated Congenital hypothyroidism. Kyphoscoliosis Mucopolysaccharidosis, Klinefelter syndrome.

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