Download Respiratory rate (30

History and Physical
Examination in the Newborn
History
1) identify disabling diseases that are
amenable to prompt preventive
actions or tx (e.g.respiratory
distress syndrome)
2) Anticipate conditions that may be of
later importance (gonococcal
conjunctivitis)
3) Uncover possible causative factors
that may explain pathologic
conditions (screening for inborn
errors of metabolism)
Perinatal history
• Includes demographic and social
data
• Past medical illnesses in the family
• Previous maternal reproductive
problems
• labor and delivery
• Maternal drug intake/ exposure to
roentgen
• Maternal smoking / alcoholic
beverage intake
PHYSICAL EXAMINATION
• Initial examination
- to detect abnormalities
- to establish a baseline for
subsequent examination
• At 24 hours of life
• Upon discharge
Physical Examination
• Pulse rate ( N: 120-160 bpm when
awake, 70-80 when asleep)
• Respiratory rate (30-60 breaths/min)
• Temperature
• Weight (2.5 -4.5 kg), length (45-55
cm), head circumference (32-37 cm),
CC (32-34 cm), AC
• Dimensions of any visible or
palpable structural abnormality
• General appearance
- Physical activity, skin color,
obvious congenital abnormalities
- Unusual posture, muscle tone
- Edema (skin of the fingers & toes
lacks the normal fine wrinkles
when filled w/ fluid)
Physical Examination
• Pulse rate ( N: 120-160 bpm when
awake, 70-80 when asleep)
• Respiratory rate (30-60 breaths/min)
• Temperature
• Weight, length, head circumference
(32-37 cm)
• Dimensions of any visible or
palpable structural abnormality
• General appearance
- Physical activity, skin color,
obvious congenital abnormalities
- Unusual posture
- Edema (skin of the fingers & toes
lacks the normal fine wrinkles
when filled w/ fluid)
• Skin
- Vasomotor instability & peripheral
circulatory sluggishness- deep redness or
purple lividity in a crying infant;
- Mottling – lacy red pattern; in healthy
infants, cold stress, hypovolemia or
sepsis. Cutis marmorata- persistent
mottling (Down syn, tri 13 or 18)
- Cyanosis, icterus, pallor, plethora (ruddy
red appearance seen in polycythemia)
• Harlequin color change – division of
the body fr the forehead to the pubis
into red and pale halves; transient &
harmless
- Mongolian spots – slate blue, well
demarcated areas of pigmentation
over the buttocks, back & other
parts;most common birthmark; tend
to disappear w/in the first year
- Lanugo – fine, soft, immature hair in
premature infants
- Post-term infants – peeling,
parchment-like skin
- Erythema toxicum – small, white,
occasionally vesiculopustular
papules on an erythematous base
that develop 1-3 days after birth;
benign rash
- Pustular melanosis – benign lesion
predominantly seen in black neonates;
vesiculopustular eruption
- Vernix caseosa – greasy white substance
that covers the skin until the 38th wk of
gestation; provides a moisture barrier
Head
- General shape of the head
- Micro or macrocephaly
- Large fontanelles- hypothyroidism,
trisomy 13,18,21 syndromes
- Small fontanelles – hyperthyroidism,
microcephaly, or craniosynostosis
Common Forms of head trauma in the NB:
1.
Caput succadanuem – after prolonged
labor secondary to accumulation of blood or
serum above the periosteum; poorly
demarcated soft tissue swelling that crosses
the sutures lines, w/ accompanying pitting
edema & overlying petechiae, ecchymoses
& purpura; resolves w/in days
2.
Cephalhematoma – secondary to rupture of
bld vessels; well demarcated, fluctuant
swelling that does not cross suture lines, no
overlying skin discoloration; resolves w/in 2
wks-3mos
3.
Molding – temporary asymmetry of the skull
resulting fr the birth process; normal head
shape regained w/in 1 wk
• Neck
- Palpate SCM for hematoma &
thyroid for enlargement
- Neck masses
FACE
• General shape & appearance: dysmorphic
features may imply congenital syndromes
(wide set eyes/hypertelorism, low set ears,
epicanthal folds, microphthalmos, long
philtrum, asymmetry)
• Facial nerve injury – apparent on 1st or 2nd
day of life
• Asymmetry: 7th nerve palsy, hypoplasia of
depressor ms, abN fetal posture
• Symmetric palsy: hypoplasia of the 7th
nerve nucleus or Mobius syndrome
EARS
• Shape, size, position, canal, extraneous
tags or pits
• Tympanic membrane: dull gray
• Imaginary horizontal line from the inner
and outer canthus of the eye peprendicular
to vertical axis of the head
• Low set: helix is below the line
• Preauricular tags or papillomas – benign,
common; if pedunculated, may be ligated
at the base (leading to dry gangrene &
sloughing)
• Deformities of the pinnae
• Hairy ears – diabetic mothers
EYES
• STRUCTURE, ROR
• Doll’s eye maneuver (labyrinthine and
neck reflexes)
• Conjunctival and retinal hemorrhages (2-4
wks)
• Pupillary reflex – 28-30 wks AOG
• Cat’s eye reflex (white pupil) – lens,
vitreous or fundus abN
• White pupil reflex/ leucokoria – Cataract,
tumor, chorioretinitis, retinopathy of
prematurity, persistent hyperplastic
primary vitreous
• Iris – colobomas & heterochromia
• Cornea > 1cm, photophobia, tearing –
congenital glaucoma
NOSE
• Shape, size, patency (catheter),
swelling over the nasolacrimal duct,
size of philtrum, definition of
nasolabial folds
• Assymetry: facial compression and
molding
MOUTH
• Rest & crying
• Mandible, maxilla fit
• Tongue, buccal surface, palate, back
of mouth
• Gums & hard palate – palpate for
masses or submucous defects
• Ranula, Epstein pearls, mucocele,
natal teeth, macroglossia
(Beckwith’s syndrome)
CHEST
• RATE – full minute in resting; N term – 3040/min
• OBSERVE – if assymetric: tension
pneumothorax
- tachypnea, retractions, grunting on
expiration: respiratory distress
- minimal retractions N (compliant chest
walls), abdominal breathing
• BREATH SOUNDS – ® axilla
- more tubular than vesicular
- auscultate extrathoracic airways,
transmitted well through the chest
(possible obstruction)
- Pneumothorax/atelectasis: unequal or
absent
- Diaphragmatic hernia: absent BS w/
bowel sounds
CHEST
• PECTUS EXCAVATUM – not significant
• CLAVICLES – hypoplastic, absent or
fractured
- clavicular fractures: most common,
decreased or absent movement, pain or
tenderness on movement, deformity,
discoloration, crepitus
- tx: minimize pain/discomfort
• BREASTS – usually 1 cm in diameter (M/F)
at term
- enlarged (3-4 cm) due to maternal
estrogen
- supernumarary nipples
- witch’s milk
HEART
• Heart rate, rhythm, quality of heart
sounds, active precordial activity,
murmurs
• Goal: rule out cardiac disease or
determine if sxs are cardiac in origin
• N HR: 120 to 160
- stimulate, if no increased activity,
do ECG and serum electrolyte
studies
• Murmurs – if + after 12 hrs,
significant
ABDOMEN
• OBSERVE – omphalocoele,
gastroschisis, scaphoid (diaphragmatic
hernia)
• AUSCULTATE – Nly hypoactive
• PALPATE – distention, tenderness,
masses
- liver: 1-2 cm below costal margins
- spleen tip: below the costal margin
Hepatomegaly – CHF, hepatitis, sepsis
Splenomegaly – CMV, rubella, sepsis
Kidney – Nly palpable, esp R
- kidney size increased in RVT,
polycystic kidney dse, hydronephrosis
UMBILICUS
• Bleeding, infection, granuloma, abN
communication with intra-abdominal
organs
• Redness, discharge, edema at base:
patent urachus or omphalitis
• N: 2 arteries, 1 vein; if only 2
vessels: renal or genetic problems
• Cord: translucent; if greenish
yellow: meconium staining (fetal
distress)
GENITALIA
• MALE – dorsal hood, epispadias,
hypospadias, chordee
- penis (> 2cm) w/ phimosis, meatus,
testes in the scrotum, hernias
- small penis: decreased androgen
effect / growth hormone action in the
2nd & 3rd tri.
- hydrocele: common, usually
resolve: 1 yr
GENITALIA
• FEMALE – size and location of labia,
clitoris, meatus, vaginal opening, relation
of posterior fourchette to the anus
- redundant hymenal tissue, imperforate
hymen
- discharge: common, blood-tinged due to
maternal estrogen withdrawal
- clitoris prominent
• Ambiguous genitalia – medical emergency
- determine pituitary and adrenal integrity
ANUS
• Meconium passage – usually 1st
12 hrs after birth
- within 48 hours after birth
• Imperforate anus – gentle
insertion of finger or rectal tube,
x-ray
• Rectovaginal fistula,
neurocutaneous sinus
EXTREMITIES
• PULSES – both UE and LE
(coarctation of the aorta)
• EFFECTS OF FETAL POSTURE –
to explain cause and usual transitory
nature (ie. Breech)
• ACTIVITY – spontaneous or
stimulated; to rule out fracture or
nerve injury
• HANDS & FEET – polydactyly,
syndactyly, ab(N) dermatoglyphic
patterns (Simian crease)
• HIPS – rule out congenital dislocation
(Barlow, Ortolani)
TRUNK AND SPINE
• GROSS DEFECTS
• abN pigmentation, hairy patches –
underlying vertebral anomaly
• Sacral or pilonidal dimple –
meningocele, etc.
NEUROLOGIC EXAMINATION
• IN UTERO MUSCULOSKELETAL
DISEASES: limited fetal motion, ssx
independent of specific disease
• Arthrogryposis
• Other manifestations: breech,
polyhydramnios, failure to breath at birth,
pulmonary hypoplasia, dislocated hips,
undescended testes, thin ribs, clubfoot
• State, spontaneous ms activity, tone,
cranial nerves
APGAR
0
1
2
Appearance
(color)
Blue, pale
Pink body,
blue
extremities
Pink
Pulse rate
-
<100
>100
Grimace
None
Grimace
Cough or
sneeze
Activity
Limp
Some
flexion
Active
motion
Respiratory
rate
-
Slow,
irregular
Good,
crying
Thank you!