Advanced Physical Assessment
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| Feeding / nutritional assessment | Breast vs. formula – if formula what type ? 24 hr recall -Frequency, Duration AND Tolerance
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| Head circumference done until | 24 months b/c fontanelles close- anterior 24 mo and posterior is at 12 mo
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| Growth chart outliers | >95th % or <5th%- what could be a reason for this?
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| Denver | Standardized screening tool- Designed to be used on well children between 1month & 6 years of age- done by professional- assesses performance
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| 4 categories of Denver II | Personal-Social: getting along w/peopleFine Motor-Adaptive: eye-hand coordination, manipulation & problem-solving, Language: hearing, understanding, & language, Gross Motor: sitting, walking, jumping
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| Term | 38-41 weeks
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| Brain growth continues until | 12 to 15 years of age
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| The patellar tendon reflexes are | present at birth, and the Achilles and brachioradial tendon reflexes appear at 6 months of age
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| Suck reflex begins at | 32nd week of prego so premature can be a problem
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| Moro reflex | startle reflex because it usually occurs when a baby is startled by a loud sound or movement- gone by 4-6 months
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| Tonic neck reflex | head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow- "fencing" position till 4-6 months- cannot roll over if it doesn’t go away.
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| Palmer Grasp reflex | Stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp. Disappears by 4 months
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| Babinski reflex | When the sole of the foot is firmly stroked, toes fan out- up to 2 years of age.
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| Step reflex - | This reflex is also called the walking or dance reflex because a baby appears to take steps with feet touching a solid surface- diminished by 4 months
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| Meningitis | high pitch cry b/c neck rigidity is hard to assess—maybe fever, not eating
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| 2 months | Gross motor – lifts head , Fine motor/adaptive – follow past midline, Language – vocalize / laugh, Social-emotional – smile
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| 6 months | Gross motor – roll over, Fine motor – reach, Language – turn to sound of rattle, Social – work of toy out of reach, feed self
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| 9 months | Gross motor – pull to stand – stand holding on , Fine motor – transfer objects between hands, Language – single syllables – mama / dada, Social-emotional – wave bye bye
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| 18 months | Gross motor – walk backwards, run, Fine motor – scribble, Language – uses at least 3 words, Social – helps in house
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| 2 years | Gross motor – walk up & down stairs (gate), Fine motor/adaptive – tower of 4 cubes , Cognitive, language – combined words, point to 2 pictures, Social – remove clothes
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| 3 years old | Gross motor – rides a tricycle, Fine motor – tower of 8 blocks, Cognitive / language –name 6 body parts, Social – name a friend
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| Cerebral palsy | anoxia? Prolonged labor, stay in the NICU- Permanent d/o of movement and posture development
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| Cephalohematoma | collection of blood in the head so check Hb
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| Lymph Nodes of concern | Supra-clavicular nodes are a concern at any age-
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| Normal lymph node finding | small, firm, discrete, movable nodes with no warmth, tenderness, non-matted, non-erythematous located in (cervical/inguinal areas in child)…
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| Vision development depends on | nervous system maturation and occurs over time.
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| Term infants vision | hyperopic [20/400]
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| Peripheral vision fully developed | at birth
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| Central vision develops | later
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| By 6 months of age, binocular vision development | is complete and the infant can differentiate colors.
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| Red light reflex | retinoblastoma for lack of reflex/blindness
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| Full vision at what age | 4
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| Strabismus / pseudo strabismus | inward deviation of eye vs flat bridge and optical illusion but light reflex will be equal so it’s pseudo- do Hirschberg test – corneal light reflex
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| Lacrimal duct | clogs up- clean b/c it starts to drain
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| Absence of fix and follow by 3-4 months of age | eyes red flag- refer
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| Unresolved strabismus by 3 months of age | red flag- refer
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| More than 20/40 in a 5 year old | red flag- refer
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| Retinoblastoma | Malignant tumor arising from retina
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| Retinopathy of prematurity | Disruption of normal progression of retinal vascular development in preterm infant
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| Retinal hemorrhages in infancy | Occurs in infant victims of shaken-baby syndrome
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| Ears, Eustachian tubes are | shorter, more horizontal than adults- Position – superior portion of the auricle should line up with the outer canthus of eye
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| What can cause hearing issues | hyperbilirubinemia in the hx
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| Test hearing by age? | 4 but 1st hearing test is in the hospital and by 3 months make sure infant can hear
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| T.M- tympanic membrane | INTACT ? COLOR, MOBILITY, FLUID, BLOOD
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| Tag in front of the ear | renal issue- how many diapers a day?
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| Otoscope with insufflator | – provides puff of air to assess if TM is mobile- means it flutters and not sticky against fluid and puss (effusion, or resolving)- no need for anbx
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| Drooling is normal at what age | 6 months- when teeth come in- not appropriate at 2 months when they cannot swallow
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| Epstein’s Pearls in the back of the mouth are | normal- go away in a few days
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| Well child care | height weight, eating habits, 24h recall
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| Cleft lip make sure you take extra care with assessment of | lungs for aspiration
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| Recommend weaning from bottle by | 12 months to avoid dental decay
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| 1st dental appointment by | 6 months- 1st tooth
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| Chest/respiratory | percussion less reliable, chest circumference 2 to 3 cm smaller than head, RR 40- 60 per minute, Coughing and hiccups are rare; sneezing is frequent
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| Periodic breathing | a sequence of relatively vigorous respiratory efforts followed by apnea of as long as 10 to 15 seconds, is common.
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| Oxygen during an anoxic event is a potent | vasoconstrictor- closes ducts
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| Child’s chest is thinner and ordinarily more | resonant than the adult’s chest- Listen out laterally – under the axilla in an effort to isolate the right and left lungs and RML
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| Breath sounds | More resonant, Hyperresonance common, Easy to miss dullness, Bronchovesicular sounds may predominate.
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| Infant & Toddler = apex of the heart is at the | 4th left ICS MCl
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| Changes at birth with the heart | Ductus arteriosus and interatrial foramen ovale close. Right ventricle assumes pulmonary circulation. Left ventricle assumes systemic circulation.
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| Adult heart size at age | 7
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| Systolic ejection murmurs | heard best at the LLSB, vibratory or musical quality. grade 2 or 3, short in duration, well located, Usually begin age 3-4, disappear approx 7 years of age
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| Venous hum | common and has no pathologic significance- Caused by the turbulence of blood flow in the internal jugular veins
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| HTN most often caused by | kidney disease, renal disease, coarctation or pheochromocytoma.
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| Atrial septal defect | Congenital defect in the septum dividing the left and right atria
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| Acute rheumatic fever | Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection
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| Kawasaki disease | Condition causing inflammation in walls of small and medium-sized arteries throughout the body, including coronary arteries
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| Hepatomegaly is a red flag because | - right sided heart failure- fluids
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| Diastasis recti is caused by a | relative weakness of the fascia between the two rectus abdominus muscles. It is not a herniation and is not pathologic. Resolves over time
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| Umbilical cord usually detaches by | 10th day but can take up to 3 weeks…once detached stump should remain dry & heal within a few days
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| Umbilical cord Drainage | (serous with umbilical granulomas—prolonged drainage may need cauterization or may be cyst)-Infection (purulent, erythemic, swollen, malodorous…REFER IMMEDIATELY for aggressive treatment!
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| Omphalitis | –serious infection- infection around umbilical cord
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| Palpation of the abdomen | THE MOST IMPORTANT TECHNIQUE, assess last, Infant pain scale & FACES, Lesions, Masses, Organomegaly, infant/toddler=detectable liver tip common <3 cm; Spleen tip may be felt in 5-10%, DO NOT do deep
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| Necrotizing enterocolitis | Inflammatory disease of GI mucosa associated with prematurity and immaturity of GI tract
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| Meconium ileus | Distal intestinal obstruction caused by thick impacted meconium in the lower intestine
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| Adduct to dislocate | Barlow (in)
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| Abduct | to reduce = ortalani (out)
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| Barlow-Ortolani maneuver to detect | hip dislocation or subluxation- performed each time you examine the infant during the first year of life.
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| Bowlegs | (genu varum) –normal in toddlers but pat a certain measurement you want to refer to ortho
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| Knock-knees | (genu valgum)
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| Seborrheic dermatitis | within the first 3 months of life.
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| Miliaria (prickly heat) | Caused by sweat retention from occlusion of sweat ducts during periods of heat and high humidity. Clear fluid filled pimples
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| Impetigo | Common, contagious superficial bacterial skin infection- Honey crusted lesions
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| Red flags for infants in need for f/u | Fever of 100.4, Seizure, Skin rash or ecchymotic spots, Change in activity or behavior that raises a parent’s concern, Excessive irritability or lethargy, Failure to eat, Falling “off” growth curve, Vomiting, Diarrhea, Dehydration, jaundice, Cough
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| Infant Developmental Warning Signs – must know! | No rx to noise/voice, Apparent visual delay, Does not raise head when prone by 3 months, Hyper OR Hypotonic; scissoring of legs, Does not pick up toy by 6 months, Does not laugh, no interpersonal contact, Does not sit up
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