FCM Block 1 Exam Notes - Shail

9/6/2014 9:26 PM

Pediatric Interview/Evaluation
Head-to-Toe Assessment: Infant

How to approach the infant patient

o Try to examine infants one to two hours after feeding, when they are most
responsive. At this stage they are neither satiated, which makes them less
responsive nor too hungry which makes them more responsive.
o Examine the infant in the presence of the parents. Parents can help a
restless or screaming baby.
o Observe parents interaction with the baby bonding or behavior during
feeding this helps to assess parenting strengths and to advise or instruct
o Start with the infant swaddled and comfortable. Then undress the infant in
stages
o Encourage the babys eyes to open by dimming the lights and rocking or
placing the baby on a parents shoulder
o Try re-swaddling to silence the infant

Sequence of examination
o Begin the examination with a general survey, then assessment of somatic
growth, then vital signs, skin, head and neck, eyes, ears and nose, mouth and
pharynx, thorax and lungs, cardiovascular system, breasts, abdomen,
genitalia and rectum, musculoskeletal system, nervous system, otoscopic
examination of the ears

General Survey and Somatic Growth

o observe seeing, hearing, and smiling, skin markings etc.
o Growth is one of the most important indicators of a childs health. Deviations
from normal maybe an early sign of an underlying problem
o For infants to determine height place the baby supine on a measuring
board with hips and knees fully extended
o Head circumference indicates babys cranial growth place the measuring
tape over the occipital, frontal and parietal prominence

Vital Signs
o For infants you measure pulse, respiratory rate, blood pressure, and
temperature
o Pulse palpate the femoral artery or brachial artery or oscillate the heart
o Normal respiratory rate in infants between 30-60 bpm
o Temperature is determine in infant by rectal examination

The average rectal temperature is higher in infancy than in adulthood,

usually not falling below 99 degrees F until after 3 years, and may
fluctuate as much as 3 degrees F during a single day

The Skin
o Notice the texture (normally soft and smooth in infants)
o Common skin conditions and rashes include
Vernix caseosa, Edema, Milia, Miliaria rubra
o In well hydrated infants the skin returns to its original form instantly (no
jaundice)

Head and Neck

o Palpate the sutures it will feel like ridges
o Assess the symmetry of the skull and face
o Palpate the neck while the baby is supine to check for Thyroglossal duct cyst,
2nd branchial cleft cyst, or cystic hygroma
o Check for neck mobility
o In newborns and infants, nuchal rigidity is a more reliable indicator of
meningeal irritation then is Brudzinskis sign or Kernigs sign

Eyes
o Use less lighting so they dont blink
o During the first month, some babies have cross eyes
o By one month of age, an infant should be able to fix on objects such as your
face and follow a bright light, provided you catch the baby during an alert
period

Ears and Nose

o Make a sharp noise to test the hearing
o The otoscopic examination should be left until the end of the examination
because it may be uncomfortable for the infant. During the first few weeks of
life the otoscopic examination may detect only patency of the ear canal
o Do not occlude both nostrils at once, which would cause stress

Thorax and Lungs

o Note the respiratory rate, color, and nasal component of breathing
o Percussion is not helpful in the examination of the chest of infants, as the
infants chest is hyper resonant throughout
o Breath sounds are louder and harsher in infants than in adults because the
stethoscope is closer to the origin of the sounds

o The characteristics of the breath sounds such as crackles, wheezes, and

rhonchi are the same as those for adults

Cardiovascular System
o Notice the skin for cyanosis
o Palpate the peripheral pulses or femoral pulse
o The point of maximal impulses is often not palatable in infants
o Listen to the S1, S2, S3, and sometimes S4
o Listen for systolic or diastolic murmurs

Breasts and abdomen

o For normal infants, breaths of both male and female are large
o The breasts may be engorged with a white liquid, sometimes colloquially
called witchs milk. This finding may last for the first week or two of life
o Notice the shape and symmetry of the abdomen

Genitalia and Rectum

o Notice the penis, scrotum, testes swelling and such
o Familiarizing yourself with the appearance of the genitalia at different ages
will help you recognize normal variations from subtle abnormalities
o For infants the rectal examination consists of visual inception of the anus.
Digital examination is not routinely performed unless pathology is suspected

Musculoskeletal System
o Much of it is to notice for congenital abnormalities
o With a little practice, you will be able to combine the musculoskeletal
examination with the developmental and nervous system examination
o Some normal infants exhibit twisting (torsion of the tibia) inwardly or
outwardly on the tibias longitudinal axis

Nervous System
o The examination of the nervous system in infants includes techniques
specific to their particular age and depending on:
Internal factors: alertness and timing with respect to feeding and
sleeping
External factors: presence of parents, or the presence of fearful
stimuli
o Primitive reflexes, present only at certain age and then disappear
o Neurologic changes, often present as developmental abnormalities
o Do not use a pin to test for pain!

Tanner Development Stages

Aka Tanner scale scale of physical development in children and adults

Males
o Tanner 1 prepubertal, small penis of 3cm or less (typically age < 9)
o Tanner 2 skin on scrotum thins, reddens and enlarges; penis length
unchanged
o Tanner 3 scrotum enlarges further; penis begins to lengthen to about 6cm
o Tanner 4 scrotum enlarges further and darkens; penis increases in length to
10cm
o Tanner 5 adult scrotum and penis of 15 cm in length ( typically age 14+)

Females

o Tanner 1 no glandular tissue; areola follows the skin (prepubertal, typically

age 10 or younger)
o Tanner 2 breast bud forms with small area of surrounding glandular tissue;
areola begins to widen
o Tanner 3 - breast begins to become more elevated, and extends beyond the
borders of the areola
o Tanner 4 - increased breast size and elevation; areola and papilla form a
secondary mound projecting from the contour of the surrounding breast
o Tanner 5 - breast reaches final adult size; areola returns to contour of the
surrounding breast, with a projecting central papilla ( typically 15+)

How to Live To 100 years

Longevity Myth 1 If I try really hard, I can live to be 100

o This is false because only 1/5000 people in America are live to be 100
o We are not programed to live for 100 years
o To live for 100 years, you not only need a healthy lifestyle but win the genetic
lottery

Longevity Myth 2 Treatments exist that can slow aging

o Our cells regenerate every 8 years, but in the process there could be damage
that can rise exponentially
o The average capacity of the human body is 90 years, but life expectancy is
only 78 in America
o How to treat older people (interactions) can affect your life expectancy by 4-
6 years
o Plant based diet helps increase life expectancy stop eating after your
stomach is 80% full

Note
o Your ekiguy reason why you wake up in the morning affects how long you
live ex. A 102 year old fisherman wakes up every morning to provide fish 3
times a day for his family.
o Adventist are known to live longer in certain parts of the world

Tips for living longer

o Move naturally not exercise, but live as you get active movement
o Right outlook ex. Positive thinking, praying
o Eat Wisely wine @5, plant slant, 80% rule
o Connect loved ones first, belong, right tribe

o
Urology

Problems related to the urinary tract: Symptoms

o Suprapubic pain
also known as pain over bladder, most common causes are UTI,
cystitis, and kidney stone
o Dysuria
painful , discomfort, burning during urination
o Urgency
importance requiring swift action, urination
o Frequency
how often you require to urinate
o Polyuria
defined as excessive or abnormally large production of passage of
urine
o Nocturia
need to wake up at night to urinate
o Incontinence
involuntary urination, is any leaky of urine or fecal matter
o Hematuria
blood in urine
o Flank Pain/Ureteral colic
pain or discomfort in your upper abdomen or back

o Groin Pain
Muscle, tendon or ligament strain

Signs and Symptoms associated with

o Uncomplicated lower urinary tract infection
o Pyelonephritis
Is an inflammation of the renal parenchyma, calyces and pelvis
o Benign prostatic hypertrophy (BPH)
Enlargement of the prostate, cancerous
o Prostatitis
Inflammation of the prostate
o Testicular torsion

Risks factors for

o UTI
being sexually active, using certain types of birth control, completing
menopause, blocked urinary tract, tract abnormalities
o Urinary retention
Abnormal bladder, urethra, injury. Bladder surgery, elderly, prostate
enlargement
o Bladder Cancer
Smoking, increasing age, exposure of certain chemicals, previous
cancer treatment, taking certain diabetes medication
o Pyelonephritis
Same as UTI
o Kidney Stone
Dehydration, certain diets, being obese, family or personal history

Metabolic Syndrome

Diagnosis of metabolic syndrome include at least 3/5 of the following

o Hypertension BP >130/85
o Abdominal obesity: waist circumference 40in (M) 35 (W)
o Hyperglycemia: impaired fasting glucose >100mg/dl
o Hypertriglyceridemia: Raised triglycerides >150mg/dl
o Reduced HDL <40 (M) 50 (W)

Epidemiology and Etiology

o 2/3 USA population is obese/overweight
o 30% prevalence of metabolic syndrome

o Mexican/African/Asian Americans
o Risk factors include genetic factor South Asians, poor diet and inadequate
exercise
o Adipose tissue dysfunction
o Insulin resistance is the primary mediator of metabolic syndrome

Clinical Consequences
o Cardiovascular disease
o Stroke
o Diabetes
o Fatty liver
o Cancers

Diabetes Mellitus
o Type 1 autoimmune destruction of beta islet cells
o Type 2 Obesity related insulin resistance (defect insulin receptor)
o Type 3 Alzheimers disease

Management
o Aggressive therapeutic life style changes
o Diet rich in fruits, veggies, whole grains, avoid sat/trans fat
o Exercise at least 30mts five times a week
o Reduce LDL with statins <100
o Increase HDL: aerobic exercise, niacin
o Increase insulin sensitivity: methformin

Polyunsaturated Fats
o Omega 6 linoleic acid in vegetable oils
o Omega 3
Plant source alpha-linoleic acid (ALA) walnuts, flaxseeds, canola oil
Marine Source DHA & EPA, wild fish (salmon), tuna mackerel

Chronic Inflammation
o Current Omega-6 to Omega-3 ratio is 15:1
o Rich sources of omega 3 (flaxseeds, fish) are both anti-inflammatory and
prevent oxidative stress closes linked to vascular dysfunction

Pro-Inflammatory Diet Include

o Standard American Diet (SAD)
High in
Refined sugars, omega-6, processed foods
Low in

Omega-3, fiber, fruits and vegetables

Anti-Inflammatory Diet Include

o High in
Omega-3, monounsaturated fats, fiber, highly pant based with some
fish
o Low in
Omega-6, no refined sugar without fiber
Mediterranean diet rich in olive oil, veggies, fruits, fish, nuts and
seeds