PEP Final

Measurements performed at 18 months old

Head circumference and recumbent height (both done until 24 months or 2 years old)

How to measure head circumference

At occipital protuberance and super orbital brow using a flexible ruler

Growth charts

1. Birth → Two

2. Two→ Twenty

Guidelines for growth

• Doubled weight by: 5 months

• Triple weight by: 1 year old

• Quadruple weight by: 2 year old

Female Tanner Stages

I. Preadolescent breasts with no pubic hair

II. Breast bud with sparse, long and straight pubic hair

III. Areolar diameter enlarges and pubic hair gets darker, curls, and increases in amount

IV. Secondary mound of breast tissue with separation of countours and coarse curly and adult type of pubic hair

V. Mature female, pubic hair is adult and extends to legs

Male Tanner Stages

I. Childhood genitalia

II. Enlargement of scrotum/testes

III. Penis grows in length and testes enlarge

IV. Penis grows in length/breadth, scrotum darkens and testes enlarge

V. Adult shape/size

First teeth- “Baby Teeth” erupt

between 4-6 months old

Permanent teeth erupt

between 5-6 years old

Guidelines to assess developmental milestones

Bright Futures (guides entire well visits)

Apgar Scores

Measure- Activity (muscle tone), Pulse, Grimace, Appearance (color) , Respirations

• Measure at 1 and 5 minutes

• can re-do every 5 minutes up to 20 minutes (at minute 10, 15, 20)

How many days after discharge should a healthy, full-term newborn baby see their pediatrician?

2-3 days

Normal PE findings in infants that may be alarming to parents

Mottling, erythema toxicum, physiologic jaundice, metatarsus adductus, Epstein pearls, swollen genitalia

Normal size of anterior fontanelle

1-4 cm

What could a depressed fontanelle mean?

dehydration

What could a bulging fontanelle mean?

increased ICP, hydrocephalus, baby crying 

Good infant sleep practices

Back to sleep (supine), no blankets/pads/stuffed animals, sleep in bassinet/crib, no co-sleeping

Moro (primitive reflex)

drop and baby puts arms out

Rooting (primitive reflex)

turn to a finger brushing the cheek 

Suckling (primitive reflex)

suck on what is put in their mouth 

Babinski (primitive reflex)

may be present and normal  

Galant (primitive reflex)

Stroke lateral chest and they will curve toward the stimulus

Grasping (primitive reflex)

fingers or toes curl around a stimulus  

Tonic neck/fencing reflex (primitive reflex)

infant’s head is turned to one side, the arm and leg on that same side extend outward, while the opposite limbs bend

Steppage (primitive reflex)

they will appear to be “walking” when you put their foot down 

Preterm infants will have

• translucent/thin skin

• no brown fat (frail) looking

• underdeveloped lungs

• a lot more lanugo

• less creases on feet d/t low fat (flat footprint)

• not a great suck reflex

Birth trauma

Breech, shoulder dystocia, cephalohematoma, caput succedaneum, torticollis, clavicle fracture

When would you see an erythematous TM?

• Otitis Media (missing cone of light)

• When a baby is cringe (cone of light will be visible and intact)

The infant Eustachian tube

curves upwards and more flat (pull down and back for exam)

Sacral dimple concern

• If it is further from the buttocks crease or further to one side versus another

• How deep it is (concerning if you cannot see the termination point)

• Tufts of hair around or near the dimple

Normal skin findings at birth

Vernix (waxy coating on baby), cafe au lait, nevi simplex, erythema toxicum, mottling, transient cyanosis of the hands and feet, port wine spots

Benign skin findings

Hemangiomama, port wine stain, Mongolian spots, infant acne, seborrheic dermatitis (cradle cap), milliaria, erythema toxicum, harlequin skin changes

Measles (Rubeola)

• Starts on face and spreads downwards

• 4 C’s: Cough, coryza, conjunctivitis, “C”Koplik spots

Rubella (German Measles)

• Cephalocaudal spread

• arthralgias, mild, serious congenital affects in pregnancy, postauricular and occipital lymphadenopathy

Roseola

(HHV-6)

• Rash appears after the fever resolves

• high fever first, rash starts on trunk

Erythema Infectiosum

(Parvovirus B19)

• slapped cheek and lacy body rash

• high fever first

Varicella

• vesicles in different stages of healing

• dew drops on a rose petal, crops of lesions

Exam exam techniques

• All: fundoycopic exam, reaction to light, strabismus

• Newborn: red reflex, check for congenital cataracts

• 6-12 mo: tracking

• 2-4 yo: tumbling E chart

• 5 yo: start using the Rosenbaum chart (or when they start to know letters and numbers)

Abnormal red reflex can indicate

Retinoblastoma or congenital cataracts

Visual acuity in stages

• Newborn: 20/400

• 6 mo: 20/200

• 12 mo: 20/100

• 5 yo: 20/20 (should be)

Osgood Schlatter Disease

• 11-13 yo girls, 12-14 yo boys

• Complain of knee pain that is worse with activity

• Painful limp

• tidal tuberosity tenderness/swelling

Legg-Calve-Perthes Disease

• Younger boys, painless limp

• Predominantly hip pain but can radiate to the knee

• Worsens with activity

• Limited ROM- internal rotation and abduction are limited

SCFE

• Common in obese adolescence or fast growth spurt

• Unilateral painful limp with referred knee pain

• PE- limited internal rotation

Barlow and Ortalani are

Special test to identify DDH in a patient less than 1 yo

Barlow test

Dislocation of the head; flex and abduct then move into adduction to test if the hip dislocates

Ortalani test

Reducing the hip back into place; anterior pressure from the back to see if the hip relocates

Risk factors for DDH

Breech, female, first born, oligohydramnios, if a previous child had it, frequent swaddling

Normal alignment development

• Toddlers pronated until 2-3 yo

• Genu varum until 24 yo→ genu valgum until 5 yo

Pyloric stenosis

• projectile non-billious vomiting after eating

• S/S: olive shaped mass RUQ, weight loss, dehydration (depressed fontanelles)

Esophageal Atresia

Vomiting (bilious or non bilious), choking, aspiration, drooling (cannot tolerate own secretions), weight loss 

Intussusception

• S/S: currant jelly stool, sausage shaped mass in RUQ, bilious vomiting, sudden onset crying

• Relieve with- knees to chest

Respirations of a newborn

• 40-60 respirations per minute (calm)

• measure a full minute, no x2

AP diameter of an infant

1:1, barrel chest

Signs of respiratory distress in a newborn

Grunting, cyanosis, retraction, gasping, nasal flaring, head bobbing

Adventitious breath sounds

• Pneumonia- rales

• Crackles

• Asthma- wheezing

• Croup/FB- stridor

PDA is abnormal after _ days

2

PDA

Failure of closure of ductus arteriosus after birth d/t high PGs

• Continuous machinery murmur

• Bounding pulse pressure and volume

• Acyanotic L→R shunt

Teratology of Fallot

4 defects- VSD, RVH, right ventricular outflow obstruction, overriding aorta

• Harsh loud systolic ejection murmur at left sternal border

• “TET” spells: squat or knee to chest relieves this

• Cyanotic R→L shunt

VSD

MC congenital anomaly of the heart

• Acyanotic, L→R shunt

• pan/holosystolic murmur @LLSB ± thrill

Coarctation of the aorta

• Weak and delayed femoral pulse compared to radial pulse

• weakness/cramps in the legs d/t low circulation

Main purpose of pre-op H&P

• Risk assessment of patient

• Optimize comorbid conditions to minimize risk

• consent and education for the patient

• tools to be ready for the day of surgery (minimize concern, delays, cancellations day of) 

Unique components of Pre-Op H&P

• Anesthesia and complications or reactions with anesthesia 

• Prior surgery, outcome, complications 

Difficult intubation

• Short neck 

• Rigid neck  

• Small mandible  

• Large overbite 

Mallampati Classification

Visual scoring system used to predict how difficult it will be to manage a patient’s airway or place a breathing tube

• soft palate and how much you can see when you open your mouth, best case scenario you can see a lot when they open their mouth

• Low risk (Class I→ high risk class IV)

5 P’s of compartment syndrome

• P- Pain

• P- Pallor

• P- Pulselessness (pulse deficit)

• P- Paresthesias

• P- Paralysis