Examination + Normal value 1. ANTERIOR FONTANELLE *semi-sitting position, calm pt!

*comment on: i) open/not = normally closed at 18 months (9-18ms) ii) shape = rhomboidal iii) size = at birth 2.5x2.5 cm iv) character = soft, flat, pulsatile - normal - bulge/tense - depressed - pulsatile/not POSTERIOR FONTANELLE * normally closed at birth/up to 2 months in PT

Qs related causes of: early closure - microcephaly - craniosynotosis (premature closure of suture line) delayed closure - rickets - hypothyroidism - Down syndrome - hydrocephalus - osteogenesis imperfecta bulging AF - crying/straining/supine - ICP (in intracranial infection, hydrocephalus, neoplasm, subdural effusion or hematoma) - pseudotumor cerebri (rickets, roseola infantum, lead poisoning, Addisons disease, hypoparathyroidism) depressed AF - dehydration (eg:diarrhea) - malnutrition (eg:marasmus) very wide AF

causes of persistently open PF: causes of wide PF: early manifestation of congenital hypothyroidism causes of : large head (macrocephaly) microcephaly = 3 S.D below the mean - hydrocephalus - craniosynotosis - subdural hematoma/effusion - familial - achondroplasia - familial DDx of neck rigidity : - meningitis - peritonsillar abscess - muscle spasm

HEAD CIRCUMFERENCE * tape just above the eyebrow to the most prominent part of the skull ( occipital protuberance etc) * interpret with the table (age related) birth 3 months 6 months 1 yr 35cm 40cm 43cm 45cm 2. SIGNS OF MENINGEAL IRRITATION (pg228) *never appear before the age of 18 months i) neck rigidity *sitting, active flexion of head, chin touching the chest * infant lying on bed, passive neck flexion = grade: guarding rigidity hyperextension ii) Kernigs sign * in supine position! hip & knee flexed at right angle! * extend knee > 90 limited movement (spasm) * feel hamstring tendon contraction of tendon * painful facial feature = inability to extend the knee when the hip is flexed iii) Bruziniskis sign * leg to leg = flexion of one leg flexion of another leg * neck to leg = head flexion leg flexion

- cerebral palsy - retropharyngeal abscess - fracture neck

- tetanus - post subdural hemorrhage - apical pneumonia

Signs of meningeal irritation: *minimal in small infants - fever - photophobia - irritability - headache - back signs = opisthotonus, back pain, inability to sit normally, tripod sign (sits supported on LL, buttocks & UL) Anything about meningitis (pg 228 & 256) causative organism C/P (NB) 1. Fever E.Coli, group B 2. Signs of meningeal irritation streptococcus, -as aboveStaph. Aureus, Listeria 3. Signs & symptoms of ICP (Infant) - small infant: bulging AF H. Influenzae type B, - older children : headache, Pneumococcus, projectile vomiting, photophobia Meningococcus

Complication 1. Hydrocephalus 2. Subdural effusion 3. Suprarenal failure Dx : Hx of preceding infection + lumbar puncture L4,L5

Rx 1. Supportive : rest, hydration, good nutrition, Rx of convulsion 2. Antibiotics 3. Dexamethasone (CS) - inflmtn & neuro complication 4. Rx complication

3. EXAMINATION OF LIVER * in supine *exposure to xiphisternum i) superficial palpation ii) deep palpation (lt & rt lobe) + comments
site = lower border of i) right lobe __ cm below right costal margin in MCL *liver edge NB 4 months older 3-4 cm 2 cm 1 cm below the right costal margin __cm below xiphisternum in midline smooth/nodular soft/firm rounded/sharp tender/not pulsatile/not

hepatomegaly - infective ( hepatitis) - congestion (heart failure, Bud Chiari syndrome) - infiltration (eg: thalassemia, glycogen storage disease) - malignancy Causes of ptosed liver: - hyperinflation of lung - pleural effusion - weak ligament/abdomen (hypotonia)

tender hepatomegaly - liver congestion in pericardial effusion - infection: hepatitis

pulsatile hepatomegaly - tricuspid regurge

ii) left lobe surface consistency lower border tenderness pulsatile

iii) tidal percussion @ MCL upper border th = 5 intercostals space in MCL iv) liver span (distance between upper and lower border) years 1 2 3 4 5 12 cm 6 6.5 7 7.5 8 9 - ptosed liver = upper border below 5th IC space + liver span <7cm - hepatomegaly = liver span > 7cm 4. EXAMINATION OF SPLEEN * in supine *exposure to xiphisternum i) superficial palpation ii) deep palpation size 1-2cm below costal margin surface smooth/nodular ant border rounded notch palpable/not consistency firm/soft/hard tenderness tender/not iii) tidal percussion @ MAL upper pole = left 9th IC space in midaxillary line

hepato-splenomegaly - congenital infection (ToRCH) - thalassemia

splenomegaly - haematological : AHA, thalassemia - infective : thyphoid, malaria, TB, - neoplasm : leukemia - collagenic : SLE, RA

tender splenomegaly - infection: SABE, thyphoid - infarction - infiltration by malignancy

Differentiate between renal and splenic swelling: direction of enlargement movement with respiration Ballotment splenic notch Traubes area renal angle splenic swelling downwards, medially free mivsble -ve +ve dull resonant renal swelling downwards limited movement +ve -ve resonant dull

5. AUSCULTATION OF THE HEART *locate first! * auscultate - S1 at mitral area - S2 at pulmonary area - murmur at mitral area * comment murmur on; - site of max intensity - timing - character - grading - propagation Grading 1 2 3 4 5 6

S1 Accentuated: - mitral stenosis

S2 Accentuated: - PHTN

MR S1 S2 Sdditional HS Precardial rub muffled heard/not -

VSD normal heard/not -

PHTN heard/not accentuated

Coarctation of aorta normal -

Muffled: - mitral regurge (in RHD)

Abnormal splitting: i) Wide fixed : - ASD ii) Absent : - severe PS/AS - Fallots tetralogy - TGA

Murmur Timing Character Site of maximum intensity Propagation

pansystolic harsh mitral

pansystolic harsh left parasternal

not heard easily audible loud but no thrill loud + thrill very loud + thrill heard w/out stethoscope

ejectionsystolic soft ejection pulmonary area ??

ejection systolic harsh interscapular area

axilla

Grading Signs of PHTN: 1. pulsation in pulmonary area 2. diastolic shock (palpation) 3. dullness (percussion) at pulmonary area 4. accentuated S2 ( auscultation) Air entry in: - obstruction of airways - lung collapse - pleural effusion - pneumothorax - lung fibrosis Type of breathing Vesicular breathing with prolonged exp: - bronchial asthma - bronchitis - FB Bronchial breathing (trachea) - consolidation (pneumonia)

whole precordium 2/3 : heard with no thrills

6. CHEST AUSCULTATION *on all line (MCL, MAL, scapular, paravertebral line) * compare right & left side *comment - air entry - type of breathing - vocal resonance - adventitious sound

DDx of:
Vocal Resonance (solid media) - consolidation (pneumonia) (fluidy media) - hydrothorax - pleural effusion Adventitious sound Ronchi = i) sonorous (large airway) - bronchitis ii) sibient = wheezes (small airway) - bronchiolitis - asthma - bronchiectasis Crepitation = i) fine (inspiratory) - pumn. Edema - CHF -LV failure ii) median sized - consonating : bronchopneumonia - non consonating : bronchitis, b.asthma iii) coarse (expiratory, large bronchi) -bronchiectasis - bronchitis -pulm. edema

7. TEST FOR EDEMA *30 sec pressure on dorsum of foot + shin of tibia (both at the same time) *comment on - edema/not - level of edema - soft pitting/non pitting - uni/bilateral *baby (recumbent) same method for sacral edema ASCITES *percuss below umbilicus * shifting dullness * opposite side modified shifting dullness transmitted thrill *one hand in the midline

causes of generalized edema - nutritional : kwashiorkor - renal : nephritic syndrome - cardiac : congestive HF - fulminant hepatic failure - cirrhosis

causes of unilateral edema - DVT - lymphatic obstruction *localized - allergy (angioneurotic edema) - local inflammation

non pitting edema - myxedema - scleroderma

site for edema - dorsum of foot - shin of tibia - sacrum - eye - abdominal wall - palm - lateral malleolus - genitalia - pleural effusion - pericardial effusion - ascites (abdomen)

moderate ascites mild ascites tense ascites

8. REFLEXES *both sides! expose the tested muscle! * support the joint! + identify the tendon 1st! i) Knee reflex *lift knee with heal touching the bed tap patellar tendon ii) Ankle reflex *rotate hip externally + gentle dorsiflexion of foot
centre tap/ strike

Superficial reflex Plantar reflex sole, along outer edge from heel Abdominal reflex skin towards umbilicus *assess in all 4 quadrants of abdominal wall Biceps jerk strike our thumb on the antecubital fossa, in partially flexed forearm C5, C6

L4, L5, S1, S2

ii) Plantar reflex * supine & relax * support weight of foot at the ankle tap Achilles tendon *lateral aspect of sole, from heel across ball of foot medially *in hyperreflexia test for CLONUS!

response

normal: - plantar flexion (after 1 years old) - plantar extension ( before 1 years old, with no other neuro manifestation) abnormal (+ve

upper : T8,T9,T10 lower: T10, T11, T12 umbilicus move towards stimulus may be absent in 1st 6 months of life

Deep tendon reflex Brachioradialis Triceps jerk jerk triceps radius 2.5cm tendon above above the the elbow, wrist, in relaxed with arm bent arm and and forearm forearm supported position with palm down. C6, C7, C8 C5, C6

Knee jerk patellar tendon, just below the patella

Ankle jerk Achilles tendon, with knee flexed and foot lightly supported S1, S2

L2, L3, L4

extension of forearm

forearm flexion and palm turns upwards

knee extension

plantar flexion

Babinski sign) : dorsiflexion of foot + fanning of toes (plantar extension)

reflex tone 9. MUSLCE TONE * lie flat *start with normal side * make sure patient is not contracting his muscle or making resistance * passively flex & extend both UL few times & compare * passively flex & extend both LL few times & compare

UMNL hyperreflexia hypertonia

LMNL hyporeflexia hypotonia

Test Response in hypotonia

Pull to sit test head lag

Ventral suspension body in inverted U shape

Hypertonia UMNL Hypotonia LMNL