Head to foot examination in Paediatrics

Head to foot examination in Paediatrics

1. Head Hair Scalp Fontanelle Face Eyes Mouth Tongue Ears Nose Neck Limbs Chest Spine Abdomen Genitalia Skin

2. Flat or prominent occiput ? ( in trisomy 21 and 18 resp ) Shape of skull Fontanels Size of head

3. Microcephaly When HC is 3SD below normal two types Primary secondary

4. Macrocephaly HC >2SD above normal Familial macrocephaly Hydrocephalus – congenital or acquired Achondroplasia Cerebral giantism Fragile X syndrome Widening of suture in rickets, thalassemia

5. 6 at birth Only anterior and posterior palpable Anterior fontanelle -size 2.5 X 2.5 cm, AP direction upto 4cm Soon after delivery AF narrow( moulding ) and then increases in size Examined with child quiet and upright Closes by age 9-18 months Pulsation of AF normal

6. examination Closed/open ? Pulsatile / non pulsatile Normal /depressed / bulging ?

7. Sunken fontanelle

8. Bulging fontanelle

9. Asymmetry of head shape Types Dolychocephaly Brachycephaly Cephalic index = head width x 100 head length <76 dolichocephaly 76-80 normal ≥ 81 Brachycephaly

10. Dolichocephaly Increased AP diameter Sagittal suture close early Skull cannot grow laterally Growth only in AP diameter Also called Scaphocephaly

11. Brachycephaly Premature fusion of coronary suture Head cannot grow in AP diameter Transverse diameter is more Occiput flat as in down’s syndrome

12. Scalp swellings Dermoid Histiocytosis Osteoma Organized cephalhaematoma Secondary deposits Traumatic Seborrhoeic dermatitis of the scalp Yellow crusted plaques in the scalp

13. Cephalhaematoma Sub periosteal collection of blood Elevated periosteum Does not cross suture line unlike caput succedaneum Maximum size by third day Parietal bone commonly involved Disappears by 3-6 weeks or may get calcified

14. Caput succedaneum Diffuse soft bogy swelling of scalp Loose areolar layer of scalp Seen at birth Crosses suture line Disappears by 1-2 days

15. Cranial bossing Prominence of central parts of frontal and parietal bones Early manifestation of rickets Hydrocephalus Congenital syphilis Frontal Bossing

16. Craniotabes Ability of indentation under pressure of skull bones near suture and springing back to normal Normal in new born In rickets- elicited beyond newborn period

17. Head tilt and torticollis Due to Local painful reasons Compensation for visual defect Herniation or cerebellar tonsil Torticollis-Occiput tilted to one side and chin deviated to opposite side Head tilt-Both occiput and chin deviated to same side

18. Scalp hair White hair- as in albinism S parse, straight thin easily pluckable – as in malnutrition Alternately pigmented and depigmented hair called flag sign indicates alternate periods of abnormal and normal nutrition – seen in kwashiorkor Alopecia Congenital ectodermal dysplasia Treatment for malignancy Alopecia areata- autoimmune Trichotillomania- localized hair loss

19. Alopecia areata

20. Hypertrichosis Cushing's syndrome Precocious puberty Drugs like minoxydil, androgens Can be familial Low hair line Extending below spine c4 Low hair line in the back – turners, Klippel feil syndrome, due to short neck Low hairline in the Front – hypothyroidism

21. Moon face Cushing's syndrome or due to prolonged use of steroids Puffy face Nephrotic syndrome Hypothyroidism

22. Coarse facies Does not look cute Bloated cheeks and protruding tongue Seen in Hypothyroidism Mucopolysaccharidosis gangliosidosis

23. Mask like facies Wilsons disease or other disease affecting extrapyramidal system Tranquilizer overdose bilateral facial nerve palsy (GBS) Potter’s facies Small lower jaw Depressed nose

24. Mongoloid facies

25. Depressed nasal ridge Downs syndrome Congenital syphilis Late stage leprosy Micrognathia Cri-du-chat syndrome Di George syndrome Foetal alcohol syndrome Russell silver syndrome

26. Prognathism Angelman syndrome Acromegaly Fragile X syndrome

27. Lid oedema Nephritic Nephrotic syndrome Cardiac failure Kwashiorkor Severe cough Conjunctivitis stye Angioedema Hypothyroidism IM Microphthalmos Congenital infections like- CMV, Rubella, toxoplasmosis Cornea Megalocornea- glaucoma Cloudy cornea- Mucopolysaccharidosis

28. Colaboma Developmental defect in some portion of the eye Eyelash, iris, lens, retina affected Red eye Bacterial blepharoconjunctivitis Circum corneal congestion- as in acute uveitis Ptosis Congenital ptosis Occulomotor palsy Horner's syndrome Myasthenia gravis Oedema of the lid

29. Proptosis Malignancies- neuroblastoma, leukemia, retinoblastoma Non-malignancies- Cavernous hemangioma, Optic nerve glioma Hyperthyroidism- exopthalmos

30. Epicanthic fold Crescent shaped fold of skin originating below eye and sweeps upwards to blend with upper lid Inner canthus covered Classic of down’s syndrome Seen in Chinese race Mongoloid slant Upward slant= slanting from medial to lateral Racial, down’s syndrome, prader willi syndrome

31. Antimongoloid slant Downward slanting Turner’s syndrome Edward syndrome ( trisomy 18)

32. Hypertelorism Distance b/w medial canthi of 2 eyes more than width of each eye Turner’s syndrome. Down’s syndrome Canthal index= distance b/w inner canthi/ distance outer canthi >0.38  hypertelorism

33. Conjunctiva Xerosis- dryness, wrinkled appearance Bitot spots- grey, rough dry areas on temporal side of conjunctiva

34. Cataract Congenital cataract- transmitted as autosomal dominant, recessive or X linked Intrauterine infections- rubella Metabolism cause- galactosemia( oil drop cataract), Wilson's disease (sunflower cataract) Chromosomal anomalies- trisomy 13, 18, 21 Trauma, radiation, drugs( long term steroids)

35. Buphthalmos Congenital glaucoma Cornea usually cloudy cornea due to corneal oedema Enlarged orbital globe (bulging eyeballs) Blepharospasm Epiphora Strabismus Non parallelism of visual axes Due to Refractory error Medial rectus stronger than lateral rectus Concomitant – constant deviation In paralytic type deviation is not constant

36. Kiesel fiescher ring Periphery of cornea as golden yellow, greenish or brownish ring Deposition of copper There is no space between limbus and ring Wilsons disease

37. Low set ears Superior attachment of pinna to the side of head must be at or above line joining 2 inner canthi in normal child Below- low set ears Downs syndrome Di George syndrome Turners Examine from front with child’s head erect and eyes facing directly forward large prominent ears Fragile X syndrome, marfan’s

38. Deformed pinna Down’s syndrome Treacher Collin's syndrome Bat ear Protruding ear with poorly formed fold of helix Tragus sign Otitis externa Pressing of tragus causes pain Deafness Sequelae of neonatal kernicterus Intrauterine rubella infection Recurrent otitis media Aminoglycosides Ear wax Tympanic membrane trauma

39. Outer edge of lips should fall on a perpendicular line drawn from centre of either pupil with eyes When edge of lip falls outside- macrostomia. inside- microstomia Large mouth Goldenhar syndrome William syndrome Angular stomatitis Riboflavin deficiency congenital syphilis

40. Philtrum Long nose leads to short philtrum and a short nose leads to wide philtrum Long philtrum – William's syndrome Short philtrum- cohen syndrome Smooth philtrum- foetal alcohol syndrome Uvula Bifid uvula Apert syndrome Di George syndrome Treacher’s syndrome

41. Palate Cleft palate Trisomy 13,18 Pierre robin syndrome Foetal hydantoin syndrome

42. Painful ulcer of hard palate- herpes zoster Painful ulcer of oropharynx, soft palate- herpangina Rash in mucous membrane due to exanthematous fever Drooling Normal during teething Stomatitis Acute epiglottitis/ diphtheria Pseudobulbar palsy Dry mouth Dehydration Mouth breathing antihistamine

43. Oral thrush AIDS Antibiotics Steroids Hypoparathyroidism Look for enlarged salivary glands

44. Delayed dentition No teeth beyond 13 th month Hypothyroidism Hypopituitarism Rickets PEM Discoloured teeth Poor oral hygiene Tetracycline therapy( brown) Enamel hypoplasia ( brown) Kernicterus (brown) Porphyria(reddish) Iron therapy(black) Chalky white patches(Fluorosis)

45. Macroglossia Congenital hypothyroidism Down’s syndrome Cystic hygroma Hemangioma Foote’s sign Rhythmic protrusion of tongue in new born may suggest intracranial haemorrhage or cerebral oedema - Coating of tongue- poor oral hygiene, typhoid fever, uremia - Smooth bald tongue without papillae- vit B12 deficiency

46. Short neck Turner’s syndrome Down’s syndrome Klippel feil deformity Noonan’s syndrome Hypothyroidism Goiter Puberty Hashimoto’s thyroiditis Iodine deficiency Grave’s disease

47. Thyroid gland best appreciated when child extends neck or when child swallows Thyroglossal cyst- moves with protrusion of tongue Webbed neck Turner’s syndrome Noonan’s syndrome Lymphadenopathy Localized- any infection in draining area Generalized- >2 non contiguous lymphnodes Viral infection- IM, HIV, Rubella Bacterial-TB Malignancy- lymphoma, leukemia Drugs- phenytoin

48. Warm tender gland- infection Soft fluctuant gland- suppuration Matted gland- chronic inflammation(TB) Hard nodes- malignancy Neck stiffness Meningitis (stiffness on flexing neck but not on lateral movement) Sub arachnoid haemorrhage Meningism- upper lobe pneumonia, tonsillitis Herniation of brain as in Space Occupying Lesion Local causes- retropharyngeal abscess, painful cervical adenitis

49. Opisthotonus Tetanus Meningitis Kernicterus And local causes- retropharyngeal abscess

50. Absence of clavicle- cleidocranial dystosis Pre sternal oedema- mumps Widely spread nipple- turners Shield chest- turners Absence of pectoralis muscle- polland’s syndrome

51. Pectus excavatum

52. Pectus carinatum

53. Gynaecomastia Transient during puberty Obesity Cirrhosis liver digitalis Oestrogen secreting tumour Klinefelter’s syndrome

54. Loss of normal curvature in cervical region is seen in Juvenile rheumatoid arthritis Loss of curvature in Lumbar region- ankylosing spondylitis Scoliosis Lateral curvature of spine Non fixed- corrected on lifting axilla or bending down Fixed- not corrected on bending Gibbus Prominent at apex of kyphosis Due to underlying collapsing vertebrae Commonest cause- TB spine

55. Cubitus valgus Forearm distal to elbow directed away from the body Cubitus varus Forearm distal to elbow directed towards the body

56. Clinodactyly Shortened middle phalanx of little finger More pronounced in radial aspect Little finger curved inwards Down’s syndrome and some normal children

57. Camptodactyly flexion deformity of 5 th finger seen in downs syndrome Bifid thumb due to chromosomal anomaly

58. Arachnodactyly unduly long fingers seen in marfan's syndrome and homocystinuria Thumbs sign: thumb protrudes the ulnar border when it is brought across the palm. Present in marfan's syndrome, absent in homocystinuria.

59. Trident sign – Achondroplasia Divergence of 3 rd and 4 th fingers. Thumb and 1 st two fingers & the last two fingers stand out as separate giving a trident appearance Polydactyly congenital with no apparent reason occasionally familial

60. Syndactyly fused fingers trisomy 13 Absent thumb fanconii anaemia Osler's Nodes transient, small, pea sized, tender nodule in pulp of finger and toes infective endocarditis, vasculitis syndrome

61. Janeway lesions painless erythematous patches over palms and soles Phocomelia congenital absence of limbs due to use of thalidomide in 1 st trimester

62. Koilonychia soft , thin, brittle, flattened, concave nails. Seen in iron deficiency anaemia White nail anaemia hypoalbuminemia Red nail – polycythemia Black nail – addisons disease Splinter haemorrhage – infective endocarditis

63. Splinter haemorrhage

64. Clubbing normal angle between nail and nailbed is lost Normally there is a gap when nails are placed in opposition, which is lost in clubbing  shamroths window test causes: Cardiac- cyanotic heart disease, IE, TOF, Eisenmenger syndrome Pulmonary- bronchiectasis, lung abscess, empyema GIT – Inflammatory Bowel Disease, cirrhosis

65. Cyanosis -bluish discolouration when reduced Hb more than 5gm% causes: Cardiac- congenital cyanotic heart disease, Eisenmenger syndrome Pulmonary- interstitial pneumonia, severe pneumonia, ARDS Methaemoglobinemia

66. Palmar crease – Simian crease seen in downs syndrome is a transverse palmar crease

67. Coxa valga- angulated away from the hip joint Coxa vara- angulated towards the hip joint Genu valgum (knock knees)- commonly seen in rickets and congenitally. Distance between the medial malleoli is more than 5cms G enu varus (bow legs) – seen in achondroplasia and rickets. distance between medial condyle is more than 5cms

68. both genu varum and genu valgus are physiological in children of 1 ½ to 2 yrs of age genu recurvatum seen in poliomyelitis There is hyper extension of the knees pes planus- flat foot, seen physiologically in 1 ½ to 2yrs pes cavus-claw foot, seen in poliomyelitis talipus equino varus- foot adducted downwards, inwards and with medial concavity

69. Look for abdominal masses to exclude hepatosplenomegaly kidney mass(hydronephrosis) faecal mass intussusceptions malignancy umbilical hernia(imperfect closure of the umbilical ring, protrudes during straining)

70. Hernia Undescended testes Precocious puberty Hydrocele Micropenis length less than 1.5cm normal length of penis- 4cms. Seen in hypopituitarism, Klinefelter's syndrome , noonans syndrome Micro orchidism- seen in hypopituitarism, hypothalamic disorders, Lawrence moon beidl syndrome Macro orchidism- seen in testicular tumours, fragile x syndrome

71. Look for changes suggestive of PEM Flaky paint dermatosis Crazy pavement dermatosis Keratomalacia

72. Neurocutaneous markers Hypopigmentation/hyper Molluscum contagiosum Pyoderma Scabies Fungal infections Skin turgor Rash Mongolian spots Haemangioma Spider naevus Port wine stain

73. Molluscum contagiosum

74. Mongolian blue spots Grey blue pigmented macule over lumbosacral region Benign & it fades in months to years

75. Haemangioma Salmon patches- pale pink macule Site – neck eyelid face Present at birth Spider naevus Main vessel is an arteriole Seen in chronic liver disease

76. Port wine stain Present at birth Fade with age but does not disappear Associated with surge weber syndrome It can be masked by cosmetics