Genesys FP Residents - Resident Site

History

 

A sympathetic listener who addresses the parent and child by name frequently obtains more accurate information than does a harried, distracted interviewer. Careful observation during the interview will often uncover stresses and concerns that otherwise are not apparent.

 

The history usually is learned from the parent or the caretaker of a sick child. For the acutely ill child, a short, rapidly obtained report of the events of the immediate past may suffice temporarily, but as soon as the crisis is controlled, a more complete history is necessary.

 

A well-organized record facilitates the retrieval of information.

 

The following guidelines indicate the necessary information and the order of presentation.

 

General

Identifying data: age and birth date, sex, race, relationship of the child and informant, and some indication of the mental state or reliability of the informant.

 

Chief Complaint

Given in the informant or patient's own words. A brief statement of the reason why the patient was brought to be seen.

 

Expanding the question of "Why did you bring him?" to "What concerns you?" allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying.

 

History of Present Illness

The details of the present illness are recorded in chronologic order. For the sick child, it is helpful to begin: "The child was well until "X" number of days before this visit." This is followed by a daily documentation of events leading up to the present time, including signs, symptoms, and treatment, if any. Statements should be recorded in number of days before the visit or dates.

 

If the child is taking medicine, the amount being taken, the name of the medicine, the frequency of administration, and how well and how long it has been or is being taken are needed.

 

For the well child, a simple statement such as "No complaints" or "No illness" suffices. A question about school attendance may be pertinent.

 

If the past medical history is significant to the current illness, a brief summary may be included.

 

Past Medical History

Obtaining the past medical history serves not only to provide a record of data that may be significant either now or later to the well-being of the child, but also to provide evidence of children who are at risk for health or psychosocial problems.

 

Prenatal History

Question about the health of the mother during this pregnancy, especially in regard to any infections, other illnesses, vaginal bleeding, toxemia, or care of animals

 

The number of previous pregnancies and their results, radiographs or medications taken during the pregnancy, results of serology and blood typing of the mother and baby, and results of other tests such as amniocentesis should be recorded.

 

Mother's weight gain excessive or insufficient.

 

Neonatal History

Apgar scores at birth and at 5 minutes.

 

Any unusual appearance of the child such as cyanosis or respiratory distress, and any resuscitative efforts that took place and their duration

 

Jaundice, anemia, convulsions, dvsmorphic states, and congenital anomalies or infections in the mother or infant.

 

Feeding History

Note whether the baby was breast- or bottle-fed.

 

Poor sucking at the first feeding may be the result of sleepiness of the baby, but also is a warning sign of neurologic abnormality, which may not become manifest until much later in life. By the second or third feeding, even brain-damaged children usually nurse well.

 

If the infant has been bottle-fed, inquire about the type of formula used and the amount taken during a 24-hour period. At the same time, ask about the mother's initial reaction to her baby, the nature of bonding and eye-to-eye contact, and the patterns of crying, sleeping, urinating, and defecating. Requirements for supplemental feeding, vomiting, regurgitation, colic, diarrhea or other gastrointestinal or feeding problems should be noted.

 

Determine the ages at which solid foods were introduced and supplementation with vitamins or fluoride took place, as well as the age at which weaning.

 

If feeding difficulties are present, determine the onset of the problem, methods of feeding, reasons for changes, interval between feedings, amount taken at each feeding, vomiting, crying, and weight changes. With any feeding problem, evaluate the effect on the family by asking, "How did you manage the problem?"

 

For an older child, ask the informant to supply some breakfast, lunch, and dinner (supper) menus, likes and dislikes, and response of the family to eating problems.

 

Developmental History

Estimation of physical growth rate is important. These data are plotted on physical growth charts. Any sudden gain or loss in physical growth should be noted particularly, because its onset may correspond to the onset of organic or psychosocial illness. It may be helpful to compare the child's growth with the rate of growth of siblings or parents.

 

Ages at which major developmental milestones were met aid in indicating deviations from normal. Some such milestones include following a person with the eyes, holding the head erect, smiling responsively, reaching for objects, transferring objects, sitting alone, walking with support and alone, speaking the first words and sentences, and experiencing tooth eruption. Ages of dressing self, tying own shoes, hopping, skipping, and riding a tricycle and bicycle should be noted, as well as grade in school and school performance.

 

In addition, note should be made of the age at which bowel and bladder control were achieved. If problems exist, the ages at which toilet teaching began also may indicate reasons for problems.

 

Behavior History

Amount of sleep and sleep problems, and habits such as pica, smoking, and use of alcohol or drugs should be questioned if age appropriate.

 

The informant should state whether the child is happy or difficult to manage, and should indicate the child's response to new situations, strangers, and school.

 

Temper tantrums, excessive or unprovoked crying, nail biting, and nightmares and night terrors should be recorded.

 

Immunization History

The types of immunizations received, with the number, dates, and reactions should be recorded as part of the history.

 

History of Past Illnesses

Specific inquiry of any history of roseola, rubeola, rubella, pertussis, mumps, varicella, scarlet fever, tuberculosis, anemia, recurrent tonsillitis, otitis media, pneumonia, meningitis, encephalitis or other nervous system disease, gastrointestinal tract disease, or any other illness, as well as specific treatment.

 

The history of each past illness should include dates of onset, course, and termination. If hospitalization or surgery was necessary, the diagnosis dates, and name of the hospital should he included.

 

Questions concerning allergies include the occurrence and type of any drug reactions, food allergies, hay fever, and asthma.

 

Accidents, injuries, and/or poisonings

 

Family History

The family history provides evidence for considering familial diseases as well as infections or contagious illnesses.

Family diseases, such as allergy; blood, heart, lung, venereal, or kidney disease; tuberculosis; diabetes; rheumatic fever; convulsions; skin, gastrointestinal, behavioral, or mental disorders; cancer; or other disease the informant mentions should be included. Pertinent negatives should be included also.

 

Social History

Details of the family unit include the number of people in the habitat and its size, the presence of grandparents, the marital status of the parents, the significant caretaker, the total family income and its source, and whether the mother and father work outside the home. If it is pertinent to the current problems of the child, inquire about the family's attitude toward the child and toward each other, the type of discipline used, and the major disciplinarian. If the problem is psychosocial and only one parent is the informant, it may be necessary to interview the other parent and to outline a typical day in the life of the child.

 

Review of Systems

Eyes

visual changes, crossed or tendency to cross, discharge, redness, puffiness, injuries, glasses

 

Ears

difficulty with hearing, pain, discharge, ear infections, myringotomy, ventilation tubes

 

Nose

discharge, watery or purulent, difficulty in breathing through nose, epistaxis

 

Mouth and throat

sore throat or tongue, difficulty in swallowing, dental defects

 

Neck

swollen glands, masses, stiffness, symmetry

 

Breasts

lumps, pain, symmetry, nipple discharge, embarrassment

 

Lungs

shortness of breath, ability to keep up with peers; cough with time of cough and character, hoarseness, wheezing, hemoptysis, pain in chest

 

Heart

cyanosis, edema, heart murmurs or "heart trouble," pain over heart

 

Gastrointestinal

appetite, nausea, vomiting with relation to feeding, amount, color, blood- or bile-stained, or projectile, bowel movements with number and character, abdominal pain or distention, jaundice

 

Genitourinary

dysuria, hematuria, frequency, oliguria, character of urinary stream, enuresis, urethral or vaginal discharge, menstrual history, attitude toward menses and opposite sex, sores, pain, intercourse, venereal disease, abortions, birth control method

 

Extremities

weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps

 

Neurologic

headaches, fainting, dizziness, incoordination, seizures, numbness, tremors

 

Skin

rashes, hives, itching, color change, hair and nail growth, color and distribution, easy bruising or bleeding

 

Psychiatric

usual mood, nervousness, tension, drug use or abuse

 

PHYSICAL EXAMINATION

 

Vital Signs

Temperature

Taken in the axilla or rectum in the young child and by mouth after 5 or 6 years of age.

 

Elevated temperature occurs with infection, excitement, anxiety, exercise, hyperthyroidism, collagen-vascular disease, or tumor.

 

Decreased temperature occurs with chilling, shock, hypothyroidism, or inactivity. Temperature may be decreased after taking certain drugs, with hypocortisolism, or with overwhelming infection.

 

Pulse

The normal rate varies from 70 to 170 beats per minute at birth to 120 to 140 shortly after birth, and ranges from 80 to 140 at 1 to 2 years, from 80 to 120 at 3 years, and from 70 to 115 after 3 years.

 

For each degree of temperature rise, the pulse rate increases about 10 beats per minute.

 

The pulse rate is elevated with excitement, exercise, or hypermetabolic states, and is decreased with hypometabolic states, hypertension, or increased intracranial pressure.

 

Absence of the femoral pulse is a cardinal sign of postductal coarctation of the aorta.

 

Respiratory Rate

The respiratory rate should be determined by observing the movement of the chest or abdomen or by auscultating the chest. The normal newborn rate is 30 to 80 breaths per minute; the rate decreases to 20 to 40 in early infancy and childhood and then to 15 to 25 in late childhood and adolescence.

 

Exercise, anxiety, infection, and hypermetabolic states increase the rate.

 

Central nervous system lesions, metabolic abnormalities, alkalosis, depressants, and other poisons decrease the rate.

 

Blood Pressure

The blood pressure should be measured with a cuff, with the bladder completely encircling the extremity and the width covering one half to two thirds of the length of the upper arm or upper leg. The pressure should be recorded and compared with normal readings.

 

High systolic pressure occurs with excitement, anxiety, and hypermetabolic states.

 

High systolic and diastolic pressures occur with renal diseases, pheochromocytoma, adrenal disease, arteritis, or coarctation of the aorta.

 

Height, Weight, Head Circumference

To obtain height and weight recordings, measure the infant supine up to the age of 2 years, and standing thereafter.

 

Measure head circumference in all infants less than 2 years of age and in those with misshapen heads.

 

General Appearance

A statement should be recorded about the alertness, distress, general development, and nutrition of the child. Mental status, activity, unusual positions, or apprehension or cooperativeness may direct one to consider an acute or chronic illness or no illness at all.

 

The child who lies quietly, staring into space, may be gravely ill. The child who lies quietly but becomes irritable when held by his mother (paradoxic irritability) might have meningitis or pain in motion.

 

Skin

Normal color of the skin is the result of the presence of melanin; depigmented areas are vitiligo: absence of pigment occurs in albinism. Cyanosis is caused by unsaturation of or abnormal forms of hemoglobin; jaundice is caused by excessive bilirubin deposited in the adipose tissue. Note the size and borders of nevi, which usually are darkly pigmented areas, and café-au-lait spots, which are brownish areas that may signal neurofibromatosis. White spots shaped like a leaf suggest tuberous sclerosis. Ecchymoses or petechiae and scars may indicate abuse.

 

Swelling may be caused by edema. Lack of turgor occurs with dehydration or recent weight loss. Describe any rashes, many of which are characteristic of viral or bacterial infection.

 

HEENT

Head and Face

Record the shape, symmetry, and any defects of the head; the distribution of hair; and the size and tension of fontanelles. A large head may be an early sign of hydrocephalus or an intracranial mass. A small head may be a result of early closure of sutures or lack of brain development. For any deviation from normal head size, frequent measurements are necessary. The fontanelles normally are flat. The posterior fontanelle closes by 2 months of age, and the anterior fontanelle closes by 12 to 18 months of age. Unusual hair whorls are associated with severe intracranial abnormalities.

The face may appear distinctive for a number of syndromes. For example, unilateral facial paralysis may be associated with congenital heart disease. Coarse facies occur with storage diseases. Epicanthal folds occur in a number of syndromes, including Down (5trisomy 21.)

 

Eyes

Test vision grossly in the young child with brightly colored objects. In the older child, test with Snellen's E chart. Evaluate for strabismus by noting the position of the reflection of light on the cornea from a distant source. Evaluate the range of eye movements and the presence of nystagmus. Both eyelids should open equally. Failure to open is ptosis and may be caused by neurologic or systemic diseases. Upward slanting of the palpebral fissures with covering of the inner canthus (epicanthal folds) is a sign of Down syndrome. The conjunctivae should be pink, but not inflamed; the sclera should be white. Examine the cornea for haziness (a sign of glaucoma) or opacities. Record the size and shape of the pupils, the color of the iris, and the response of the iris to light and accommodation. In the fundiscopic examination, use a zero lens and note the presence of a red reflex, or hemorrhages or pigmented areas, and the size of the veins compared to the arteries. Any obstruction, such as corneal or lenticular cataract will obliterate part of or the entire red reflex. The disc borders should be sharp. They are blurred with increased intracranial pressure. The macula may not be clear, which is a sign of degenerative diseases. Obtain the corneal reflex by lightly touching the cornea with a piece of cotton. Failure to blink indicates trigeminal or facial nerve injury.

 

Ears

Note the position of the ears and abnormalities of the external ear, the pinna. Low-set ears may suggest the presence of renal agenesis. Tags and deformities frequently are associated with other minor or major anomalies. Grossly evaluate hearing, and then proceed with examination of the inner ear. Pull the earlobe up and anteriorly. Grasp an otoscope equipped with a bright light so that the holding hand rests on the child's head and moves with any movement of the head, and use the largest speculum that will fit into the canal. The canal should be clear, and the drum should be pearly gray in color and concave. A cone of light, the malleus, and sometimes the incus will be identified. If the bones are not visualized, the drum is not gray in color or is infected, or the drum is not concave, fluid may be in the inner ear, which is diagnostic of otitis media.

 

Nose

Raise the tip of the nose and look up the nose with a bright light. Deformities of the septum, bleeding, or discharges should be recorded. The normal nasal mucosa is light pink in color. Tap on the maxillary and frontal sinuses for tenderness. Feel for air egress from both nares.

 

Mouth and Throat

Examination of the mouth and throat usually is the most resistant part of the examination and should be performed near the end of the examination. The child should be sitting so that the tongue is less likely to obstruct the pharynx. Deformities or infections around the lips are recorded. Count the number and note the condition of the teeth. Similarly, note the condition and color of the tongue, buccal mucosa, palate, tonsils, and posterior pharynx. Normally, these are pink in color. Exudate indicates infection by bacteria, viruses, or fungi, but etiology usually cannot be determined by physical examination alone. Note also the presence of the gag reflex and the voice or cry. If the child seems hoarse, question the parent concerning the normal voice. Laryngitis can lead to airway obstruction. After the age of 2 years, children should not drool. Chronic drooling may suggest mental deficiency, but acute onset of drooling is a grave sign of epiglottitis or poison ingestion.

 

Neck

Feel in the neck for lymph nodes, which normally are nontender and up to 1 cm in diameter in both the anterior and posterior cervical triangles. Larger or tender nodes occur with local or systemic infection or malignancies. Feel the trachea in the midline. The thyroid may not be palpable. Other masses may be present and are always abnormal. Flex the neck. Resistance to flexion is a cardinal sign of meningitis, except in infancy, but this also occurs with severe infections around the neck or dislocation of the cervical vertebrae.

 

Lymph Nodes

In addition to the lymph nodes in the neck, palpate inguinal, epitrochlear, supraclavicular, axillary, and posterior occipital nodes. Normally, inguinal nodes may be up to 1 cm in diameter: the others are nonpalpable or less than 5 mm. Larger or tender nodes hold significance similar to that described for abnormal cervical glands.

 

Chest

Observe the chest for shape and symmetry. The chest wall is almost round in infancy and in children with obstructive lung disease. Respirations are predominantly abdominal until about 6 years of age, when they become thoracic. Note suprasternal, intercostal, and subcostal retractions, which are signs of increased respiratory work. Swelling at the costochondral junctions is an indication of rickets. Edema of the chest wall occurs in children with superior vena cava obstruction. Asymmetry of expansion occurs with diaphragmatic paralysis, pneumothorax, or other intrathoracic abnormalities.

 

Breasts

Breasts normally are hypertrophied at birth; they regress within 6 months and develop with the onset of puberty. Development during adolescence is staged. Breast development in both boys and girls usually begins asymmetrically. Palpate for nodules, which may be cysts or tumors. Redness, heat, and tenderness usually indicate infection.

 

Lungs

Examination of the lungs includes observation, palpation, percussion, auscultation, and, if indicated, transillumination.

 

Observation

Note the type and rate of the child's breathing. The rate of respiration varies, as described previously. Rapid rates, known as tachypnea, are associated with infection, fever, excitement, exercise, heart failure, or intoxicants. Slower rates are characteristic of intracranial lesions, depression caused by sedative drugs, heart block, or alkalosis. Cheyne-Stokes breathing, which is characterized by periods of deep, rapid respirations followed by slow, shallow respirations, is common in premature and newborn infants, and in those with intracranial or metabolic abnormalities. Dyspnea, or distress during breathing, is associated with flaring of the intercostal spaces and nares. Inspiratory dyspnea is more common with obstruction high in the respiratory system and expiratory dyspnea is more common with lower respiratory diseases.

 

Palpation

Feel the entire chest with the palms and fingertips. Note masses or areas of tenderness. Tactile fremitus, a vibratory sensation during crying or speaking, normally is felt over the entire chest. Fremitus is absent if the airway is obstructed.

 

Percussion

Either direct percussion (tapping the chest wall directly with either the index or middle fingers) or indirect percussion (placing a finger of one hand firmly on the chest wall and tapping that finger with the index or middle finger of the opposite hand) may be used in children. The entire chest wall is percussed anteriorly, posteriorly, and along the midaxillary line. A resonant sound will be obtained over most of the chest except over the scapulae, diaphragm, liver, and heart, where dullness is elicited. Dullness detects consolidation in the lungs, as well as the size and position of the liver and heart. Scratch percussion, which involves tapping the chest wall with a finger while listening with a bell stethoscope over the heart and liver, is especially useful in determining heart and liver size. Increased resonance is found with increased trapped air, emphysema, or air in the pleural space (pneumothorax).

 

Auscultation

To auscultate the lungs in children, listen with a small bell in small children and with the diaphragm in older children. Normal breath sounds are bronchovesicular and inspiration is twice as long as expiration in young children; breath sounds are vesicular and inspiration is three times as long as expiration in older children. Breath sounds are decreased with consolidation or pleural fluid in the young child and increased with pneumonia in the older child. Fine crackles either in inspiration or expiration (rales) indicate foreign substances, usually fluid, in the alveoli or smaller bronchi, as occurs in bronchitis, pneumonia, or heart failure. Coarse extraneous sounds (rhonchi) are the result of foreign substances in the larger airways, as in crying or upper respiratory infection. Musical extraneous sounds (wheezes) are caused by airflow through compromised larger airways, as in asthma.

 

Transillumination

If pneumothorax is present, the chest will transilluminate. This is especially useful in the newborn.

 

Heart

In addition to the heart's rate (pulse) and rhythm, and the blood pressure, note the size, shape, sound quality, and presence of murmurs when examining the heart.

 

Precordial bulging is a sign of right-sided enlargement. A cardiac impulse may not be noted in a young child, but in a thin, active child, it may suggest the size and position of the heart. An apex beat outside the midclavicular line in the fifth interspace indicates cardiomegaly, which is a significant sign of heart disease or heart failure. Palpation and percussion are described above. Auscultate both in the sitting and the supine position. Determine the heart rate and rhythm if this was not done previously. Auscultate initially over the apex (mitral area), then over the lower right sternal border (tricuspid area), the second left intercostal space at the sternal edge (pulmonary area), and the second right intercostal space at the sternal edge (aortic area). Next, proceed to the remainder of the precordium, the axillae, back, and neck. Note heart sounds and any arrhythmia. A loud first sound at the apex occurs with mitral stenosis, a loud second sound at the pulmonary area occurs with pulmonary hypertension, and a fixed split-second sound in the pulmonary area occurs with an atrial septal defect. Innocent murmurs are systolic, musical, or vibratory and of low intensity, and usually are heard at the second left Interspace, just inside the apex, or beneath either clavicle. The latter is a venous hum that may be continuous and that disappears when the patient is supine. Diastolic murmurs are almost always significant. Significant systolic murmurs may be stenotic and are loudest in mid-systole over the aortic or pulmonary areas. Regurgitant murmurs begin immediately after the first sound. Over the mitral or tricuspid area, they indicate valvular insufficiency. A continuous or uneven systolic murmur along the upper left sternal border indicates patent ductus arteriosus.

 

Abdomen

Observe the shape of the abdomen. A flat abdomen may indicate diaphragmatic hernia; a distended abdomen may indicate intestinal obstruction or ascites. Auscultate before percussing or palpating. Normally, peristaltic sounds are heard every 10 to 30 seconds. High-pitched frequent sounds occur with obstruction or peritonitis; absent sounds indicate ileus. Next, palpate gently, beginning in the left lower quadrant and proceeding to the left upper, right upper, right lower, and midline areas. Then palpate more deeply in the same areas and follow with palpation in the same areas with the unused hand, pushing toward the front hand from the child's back. Feel especially for the liver in the right upper quadrant and the spleen in the left upper quadrant, and estimate their size. Any other masses are abnormal. Determine tenderness and attempt to locate the maximum point of any tenderness, which may indicate intra-abdominal infection such as peritonitis, cystitis, or appendicitis, or rapid enlargement of organs, as occurs with enlargement of the liver in heart failure. Percuss to verify findings. Feel in the costovertebral angles to determine kidney size. Tenderness usually indicates pyelonephritis.

 

Genitalia

 

Average adolescent development in girls proceeds as follows:

·         breast development at 10.5 years of age,

·         pubic hair at 11 years of age,

·         increase in height velocity at 12 years of age,

·         menarche at 12.5 years of age

·         axillary hair at 13 years of age.

 

Average development in boys proceeds as follows:

·         testicular enlargement at 11.5 years of age,

·         pubic hair at 12.5 years of age,

·         increase in height velocity at 14 years of age,

·         facial and axillary hair at 14.5 years of age.

 

Variations in order of development suggest hormonal abnormalities. Modesty of the child should be respected during the examination, especially of the genitalia.

 

Inspect the genitalia for urethral discharges, which are always pathologic and indicate infection anywhere in the genitourinary systems.

 

In a girl, vaginal bleeding after the newborn period and before puberty may be the result of injury or foreign body. Fused labia minora usually part with hygiene. Imperforate hymen causes hydrocolpos before puberty and hematocolpos after menarche. Vaginal discharge may be the result of injury or foreign body in a young girl, usually is normal at the start of puberty, and suggests infection in an older girl. Adolescents with vaginal discharge, dysuria, lower abdominal pain, irregular bleeding, or sexual activity require a complete vaginal examination. The uterus in a younger child is palpated for size, shape, and tenderness with one hand over the lower abdomen and a finger of the other hand in the rectum. For an older child, the cervix is visualized with a vaginoscope or small speculum, and cultures are obtained.

 

In boys, testes should be in the scrotum after birth, although active cremasteric reflexes may empty the scrotum temporarily. The meatal opening should be slit-like and the urinary stream should be strong. Hydroceles, which do not reduce and do transilluminate, and hernias, which reduce but do not transilluminate, enlarge the scrotum. Testicular tenderness suggests torsion of the testis or epididymitis.

 

Rectal

Inspect the anus for fissures, inflammation, or lack of tone. The latter may indicate child abuse. The rectum is not examined routinely, but is examined in all children with abdominal or gastrointestinal complaints, including diarrhea, constipation, or bleeding from the rectum.

Inspect the anus for fissures, inflammation, or lack of tone. The latter may indicate child abuse. The rectum is not examined routinely, but is examined in all children with abdominal or gastrointestinal complaints, including diarrhea, constipation, or bleeding from the rectum.

 

Extremities and Back

Asymmetry, anomalies, unusual size, pain, tenderness, heat, and swelling deformities of the extremities and back must be distinguished from congenital malformations, osteomyelitis, cellulitis, myositis, or, rarely, rickets and scurvy. Joint heat, tenderness, swelling, effusion, redness, and limitation or pain on motion may indicate arthritis, arthralgia, synovitis or injury, or septic arthritis (which is a medical emergency). Observe as the child walks for the presence of a limp. Clubbing of the fingers is a sign of chronic hypoxemia, as in congenital heart or chronic pulmonary diseases.

 

The spine should be straight with mild lumbar lordosis. Kyphosis, scoliosis, masses, tenderness, limitation of motion, spina bifida, pilonidal dimples, or cysts may be caused by injury, malformation, infections, or tumors.

 

Weakness, tenderness, or paresis of the muscles suggests inflammatory muscle disease, congenital or metabolic neuromuscular diseases, or central nervous system abnormalities.

 

Neurologic Examination

Mental status and orientation help determine the acuteness of a child's illness, depending on the environmental conditions. Position at rest and abnormal movements such as tremors, twitchings, choreiform movements, and athetosis are characteristic of hyperirritability of the central nervous system. Incoordination of gait usually indicates cerebellar dysfunction. Kernig's sign (inability to extend the leg with the hip flexed) and Brudzinski's sign (flexing the neck with resultant flexion of the hip or knee) are indications of meningeal irritation.

 

Examination of tendon reflexes (biceps, triceps, patellar, and Achilles) is less important than is observation of general activity. Hyperactive reflexes indicate an upper motor neuron lesion or hypocalcemia. Decreased reflexes are seen in lower motor neuron lesions or the muscular dystrophies.

 

 

ASSESSMENT

 

The Assessment should be a brief statement of what diagnostic possibilities seem most likely.  It may include a general statement of your approach to the diagnostic plan. 

 

The History and Physical findings do not need to be reviewed here; however, your diagnostic thinking should be outlined and certainly will be evident in more detail in your plans for problem evaluation. 

 

A discussion of the most probable cause and important alternative possibilities should be included. 

 

PLANS

 

Plans for each problem should be divided into a) a diagnostic plan, b) a treatment plan and c) a patient education plan.  The diagnostic plan should include a rationale for each test, showing how it can be expected to further define the nature of the problem.

 

An appropriate initial treatment plan should be presented.  It should include the following aspects: 1) activity level; 2) diet; 3) medications; 4) other therapy (respiratory, PT/OT, etc) and 5) IV orders.  The risks and benefits of procedures and treatments should be discussed.

 

The treatment plan should include patient education and should state what the patient was told.  In addition, the resident should present any pertinent long-term implications of the major problems in terms of the patient’s 1) expected course; 2) self-image; 3) role in the family and the community: and 4) financial situation.  The utilization of family and community resources in the patient’s ongoing care should be discussed.

 

Diagnostic tests that are planned should each be connected to the diagnosis being evaluated by that test.

 

Treatment should include all medications, surgery, physical therapy or other treatments being directed towards the problems at hand.

 

FORMAT FOR A WRITTEN NEWBORN HISTORY & PHYSICAL

 

Newborn Exam - Delivery Room

 

The purpose of the delivery room history and examination is to identify major congenital malformations or other risk factors that would mandate transfer to the Neonatal Intensive Care Unit (NICU) rather than the Newborn Nursery.

 

Inquire about high risk factors which may be associated with respiratory depression, such as: antepartum fetal bradycardia or tachycardia, meconium-stained amniotic fluid, maternal fever, placental abnormalities, premature or prolonged rupture of membranes (PROM), administration of narcotics, preeclampsia or eclampsia, diabetes, multiparity, use of recreational drugs, abnormal presentation of the fetus.

 

Scoring system designed by Virginia Apgar ca. 1953 for heart rate, respiratory effort, tone, reactivity, color. By convention, scores are assigned at 1 and 5 minutes, with additional scores given at 5-minute intervals if the most recent score is less than 7.

 

HISTORY

 

Inquire about high risk factors which may be associated with respiratory depression, such as: antepartum fetal bradycardia or tachycardia, meconium-stained amniotic fluid, maternal fever, placental abnormalities, premature or prolonged rupture of membranes (PROM), administration of narcotics, preeclampsia or eclampsia, diabetes, multiparity, use of recreational drugs, abnormal presentation of the fetus.

 

APGARS

Scoring system designed by Virginia Apgar ca. 1953 for heart rate, respiratory effort, tone, reactivity, and color. By convention, scores are assigned at 1 and 5 minutes, with additional scores given at 5-minute intervals if the most recent score is less than 7.

 

Apgar Score

 

Sign	Score=0	Score=1	Score=2
Heart Rate	Absent	Below 100	Above 100
Respiratory Effort	Absent	Weak, irregular, or gasping	Good, crying
Muscle Tone	Flaccid	Some flexion of extremities	Well flexed, or active movements of extremities
Reflex Irritability	No response	Grimace or weak cry	Good cry
Color	Blue all over, or pale	Acrocyanosis	Pink all over

 

Physical Examination

General

Petichiae, rash, evidence of birth trauma, lacerations, jaundice?

Weight <1800 gm?

Fontanelle

Bulging, depressed, anterior fontanelle abnormally large (>2x2 cm), posterior fontanelle open?

HEENT

Caput succadaneum? (Soft, ill defined in outline, represents edema of the scalp e.g. often seen after suction extraction)

Cephalhematoma? (Doesn't cross suture lines, usually appears on 2nd day of life.)

Eyes? Ears normally positioned? Nares patent? Cleft lip or palate? Neck masses? NG tube passes OK?

Chest

Breath sounds equal? Good air entry? Presence of stridor, wheezing, flaring, retracting, grunting, cyanosis in room air?

Cardiovascular

Rate >120 and regular? Murmers? Normal PMI?

Femoral pulses easily palpated?

Abdomen

Masses? Size of liver and spleen below mid-costal margin? Distension? Scaphoid?

3-vessel cord?

Genitourinary

If male, testes descended bilaterally? Inguinal masses? Hypospadias?

If female, bulging hymen (imperforate)?

Back

Midline defects? Anus patent?

Neurologic

Alertness? Tone? Symmetric movement?

Erbs Palsy: lack of movement in one arm. Facial palsy?

Moro, grasp, suck, cry, Babinski? Evidence of neural tube abnormalities?

 

Newborn Exam - Nursery

Measure and record height, weight, and head circumference.

If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid).

The exam is divided into two parts: an external characteristics score, which is best done at birth, and a neuromuscular score, which should be done within 24 hours after birth.

If the infant appears small evaluate for causes of SGA.

If the infant appears large evaluate for causes of LGA.

SGA - Small for gestational age

Symmetric (HC = Wt = Len, all <10 %ile)

Makes up approximately 33% of SGA infants

• Genetic
• Small maternal size
• Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome)
• Congenital abnormalities
• Intrauterine infections
• Viruses (rubella, CMV, ?varicella, ?HIV)
• Bacteria (tuberculosis)
• Spirochete (syphilis)
• Protozoan (toxoplasmosis, malaria)
• Inborn errors of metabolism
• Hypophosphatasia
• Leprechaunism
• Some amino acidurias
• Environmental
• Drugs (heroin, methadone, ethanol, diphenylhydantoin)
• X-rays (therapeutic)
• Smoking

Asymmetric (HC = Len > Wt, Wt <10 %ile)

Makes up approximately 55% of SGA infants

• Chronic hypertension
• Preeclampsia
• Renal disease
• Cyanotic heart disease
• Hemoglobinopathies
• Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation.
• Altitude

Combined (symmetric or assymetric)

Makes up approximately 12% of SGA infants.

• Environmental
• Drugs (including ethanol)
• Smoking
• Placental unit insufficiency
• Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation.

LGA - Large for gestational age

 

Physical Maturity Sign	SCORE								Record Score Here
	-1	0	1	2		3	4	5
SKIN	Sticky friable transparent	gelatinous red  translucent	smooth pink visible veins	superficial peeling &/or rash, few veins		cracking pale areas rare veins	parchment deep cracking no vessels	leathery cracked  wrinkled
Lanugo	none	sparse	abundant	thinning		bald areas	mostly bald
Plantar Creases	heel-toe 40-50mm:-1 <40 mm: -2	>50 mm	no crease	faint red marks		anterior transverse crease only	creases over entire sole
Breast	imperceptible	barely perceptible	flat areola no bud	stippled areola 1-2 mm bud		raised areola 3-4 mm bud	full areola 5-10 mm bud
EYE/ EAR	Lids fused loosely: -1 tightly: -2	lids open pinna flat stays folded	sl curved pinna; soft slow recoil	well-curved pinna; soft but ready recoil		formed and firm instant recoil	thick cartilage ear stuff
Genitals Male	scrotum flat, smooth	scrotum empty faint rugae	testes in upper canal rare rugae	testes descending few rugae		testes down good rugae	testes pendulous deep rugae
Genitals Female	clitoris prominent & labia flat	prominent clitoris & small labia minora	prominent clitoris & enlarging minora	majora & minora equally prominent		majora large minora small	majora cover clitoris and minora
					Total Physical Maturity Score

 

Gestational Age
Score	-10	-5	0	5	10	15	20	25	30	35	40	45	50
Weeks	20	22	24	26	28	30	32	34	36	38	40	42	44