PHYSICAL EXAMINATION
Includes: general examination, anthropometric data, segments exam, examination of the
body cavities.
Conditions of examination:
- Room temperature of 22-24 ° C
- Special table for infants and young children examination,
- Hands Examiner - disinfected and heated
- The child, completely naked, will be placed supine on a table, head to the left of the
examiner;
- The child will be covered with a blanket, in part, on each half of the body during the
whole examination.
Physical examination is preceded by measuring weight, height and temperature.
A. GENERAL SURVEY
General Condition:
- child`s face and behavior are assessed:
- Good general condition - child alert, watch what is happening around, grab objects and
play with them.
- General status changed - evaluation of vital signs (heart rate, respiratory rate, blood
pressure) to establish an emergency treatment plan.
Examination skin and visible mucous membranes:
- Appearance:
color (white, pink, pale gray, cyanotic, jaundice)
smooth or rough;
their humidity;
abnormal pigmentation;
deposits;
- skin lesions and trophic disorders (rash, erythema, eschar or allergic pyoderma
elements, nevi, hemangiomas, etc..), Describing their morphological character and
location;
- hemorrhagic manifestations: bruising, petechiae, hematomas, etc. (their location and
spreading);
- superficial collateral venous circulation;
- presence of generalized or localized edema mainly in some regions, describing their
nature and location;
- postoperative or accidental scars, their character: normal, keloid, retractable.
- skin elasticity, which is assessed by pinching the abdomen, at the umbilical level: in the
normal states the skin fold return to it`s form immediately; in dehydration it returns
slowly or it is persistent.
Mucosal examination:
- Inspection of the lower eyelid conjunctiva:
- Changes in color: pale, red, jaundice
- Pathological secretions: serous, purulent.
Clinical examination of the nutritional status (subcutaneous tissue status)
Inspection:
- Assessing the thickness of the limbs,
- Folds and fissures in the joints,
- Presence of folds in front of thigh adductors.
Palpation:
- Thickness of the chest fold (parasternal, above the breast - 1 cm)
- Thickness of the abdominal fold (paraumbilical: 1.5 - 2 cm)
- Turgor (feeling a firm consistency when we pinch the outer thigh).
Lymph node examination:
- Location, size, consistency, mobility of the lymph nodes
- superjacent skin sensitivity and change.
- Normally, lymph nodes are the size of rice grains
- in Eutrophic infants we often can not feel them because of the development of
subcutaneous tissue.
Examination of muscles:
muscle`s trophicity - inspection: symmetry in muscle growth, the
thickness of the limb.
Muscle tone - resistance to passive movement of the
limbs
- increased muscle tone is physiolog during the first month of life
- normal muscle tone after the age of 2 months
Examination of sckeleton:
- Inspection of the active movements of the infant,
- Palpation of the long bones
- Passive movements.
It will note the appearance, sensitivity, mobility, active and passive movements
superjacent joints and skin appearance.
NB: examining the hip in newborns for the diagnosis of dysplasias.
B. ANTHROPOMETRIC DATA
1. WEIGHT (W)
Birth weight: Wb = 2500 - 4000g, with an average of 3000g
Must be determined at the same time of the day, 2 hours after the last meal.
Weight gain during infancy and childhood:
0-4 months: 750g/month
5-8 months: 500g/ month
9-12 months: 250g/ month
At 4 months must doubled their Wb.
In one year tripled Wb
W at 1 year = 9kg
1-2 years: 250g/ month
After the age of 2years, until 12 years:
W = 2 x Age + 9 kg
age in years
2. HEIGHT (H)
The distance between the vertex and soles.
Height at birth: Hb = 48 - 55cm, with an average of 50cm.
The increase in height during infancy and childhood:
0-3 months: 3cm/ month
4-6 months: 2cm/ month
7-12 months: 1cm/ month
Or
I month: 4cm
II month: 3cm
III of the month: 3cm
Fourth month: 2cm
V - XII of the month: 1cm/ month
H at 1 year = 70-72cm
1-2 years: 1cm/ month
H at 2 years = 80 - 82cm
After the age of 2 years , until 12 years:
H = 5 xAge + 80cm
age in years
3. HEAD CIRCUMFERENCE (HC)
We put the metric tape over the occipital, parietal and frontal areas.
At birth, HCb = 34.5 - 35cm
At 1 year: HC = 45cm
HC = H / 2 + 10 (± 2cm)
4. CHEST CIRCUMFERENCE (CC): superior, middle, lower
In practice, we only measure the middle CC using the metric tape, passing through the
nipple.
At birth (CCb) is ~ 1cm less than HC. CC equals HC at the age of 1 year.
5. ABDOMINAL CIRCUMFERENCE
We use the metric tape: the child in the supine position, it passes through the navel.
Its value varies with nutritional status.
6. WEIGHT INDEX (WI):
We calculate it in the period 0-2 years to assess the nutritional status of the children.
After two years of age can be calculated body mass index (BMI).
WI = Real weight / Ideal Weight of an infant of the same age
Values:
0.90 to 1.10 eutrophic
> 1.10 Paratrophic
<0.90 Dystrophy
0.89 to 0.76 Dystrophy Grade I
0.75 to 0.61 Dystrophy Grade II
<0.60 Dystrophy Grade III
Example: 8-month-old infant with W= 6000g
ideal W of an infant of 8 months = Wb (3000g) + 4 x 750 + 4 x 500 = 8000g
IP = 6000/8000 = 0.75 Dystrophy Grade II
C. EXAMINATION OF THE BODY SEGMENTS
1. THE HEAD
Skull- we examine: the shape, fontanels, sutures, bones` consistency,
the hair and ears.
• Anterior or bregmatic fontanel:
- Bounded by the frontal and parietal bones (as diamonds);
- At birth 3 / 4 inches.
- Closes to one year and six months.
• Posterior fontanel or lambda:
bounded by the parietal and occipital (triangular)
usually closed at birth;
sometimes it is open (0.7 to 0.8 cm) and closes to two months.
• skull deformaties arising from new bone tissue proliferation in rickets (bose). The flat
skull (plagiocefalia) may be symmetrical, in the occipital region, or asymmetric, in the
parieto-occipital region.
Craniotabes – ping pong sign - occur in rickets due to insufficient mineralization, is
emphasized by palpation in the parietal and occipital areas.
Face - we examine the shape and appearance of the eyes, nose, mouth and
ears.
2. THE NECK is short, cylindrical and mobile in infants
3. THE CHEST
- Cylindrical at birth: horizontal ribs, the anterior - posterior diameter =
the transverse diameter
- Trapezoid shape after six months: the ribs are oblique; increases the transverse
diameter.
Chest deformities in rickets: pigeon chest (sternum prominent), flared at the base chest,
breastbone blocked (the funnel), rachitic rosary (beads like thickening of the joints
between ribs and cartilage), Harrisson's ditch (trench oblique top down and out,
submamelonar) during respiration due to traction exerted by the diaphragm wall inserts
poorly mineralized rib.
4. THE SPINE
at birth - linear;
after three months - cervical lordosis (infant keeps his head);
after six months - dorsal kyphosis (infant sits)
after one year - lumbar lordosis (infant walks).
5. THE ABDOMEN
- infant placed supine - abdomen should be flush with the chest, both before and rear.
- Inspection of the umbilical region: will see the position, the umbilicus, umbilical wound
appearance, the presence of umbilical hernia.
6. THE LIMBS
- are examined in extension
- observ any limb malformations: Amiely, focomielie, sindactilie, polydactyly, leg, etc.
ecquin var.
- discrete curves of the calfs are physiological - slower development of the internal
condyle compared to the external condyle.
In rickets:
- Pronounced curvature of the calfs ± femur as genu varum (form ()) or genu valgum
(form X).
- Bracelets rickety