Thorax To Rectum

PHYSICAL EXAMINATION OF THE HEART INSPECTION: > cyanosis - central or peripheral - cardiac or pulmonary? > bulge or deformity over chest

PHYSICAL EXAMINATION OF THE HEART PALPATION: - peripheral pulses brachial a.- neonates & infants temporal a. femoral a. dorsalis pedis a. posterior tibial a.

- pulses: sharp rise, firm, well localized

PHYSICAL EXAMINATION OF THE HEART PALPATION: PMI (point of maximal impulse) neonate – 4th left ICS MCL > 2y.o. - 5th left ICS MCL precordial bulge – cardiac enlargement substernal thrust – R ventricular enlargement apical heave – L ventricular hypertrophy hyperdynamic precordium – large shunts - maybe normal in thin patients

PHYSICAL EXAMINATION OF THE HEART PALPATION: - palms or base of fingers and not fingertips THRILL – palpable turbulence within the heart or great vessel APICAL THRILL – patient on left lateral decubitus BASAL THRILL – patient sitting up

PHYSICAL EXAMINATION OF THE HEART

AUSCULTATION: Rate newborn: 120-160/min

Rhythm normal sinus dysrhythmia skipped beats (PACs, PVCs)

PHYSICAL EXAMINATION OF THE HEART AUSCULTATION: Heart Sounds S1 – AV valve closure S2 – aortic v., pulmonic v. S3 – early filling and distension of ventricles S4 – atrial contractions - beginning phase of active ventricular filling

PHYSICAL EXAMINATION OF THE HEART AUSCULTATION: MURMURS timing – systolic, diastolic, transient, continuous nature – soft, blowing, crescendo-decrescendo grade* duration point of maximal intensity degree and localization of transmission (ex. Grade 3 blowing holosystolic murmur heard best at the mitral area with radiation to the axilla)

PHYSICAL EXAMINATION OF THE HEART AUSCULTATION: Grading of murmurs 1/6 – soft, transient 2/6 – soft, persistent 3/6 – moderate intensity 4/6 – loud, (+) thrill 5/6 – extremely loud, still require stet 6/6 – very loud, even with stet off the chest

Heart sounds are louder due to thinner chest wall and with higher pitch

1. innocent murmur = systolic, short duration grade 3 or less in intensity low-pitched vibratory, musical groaning quality = loudest along the left sternal = heard best in supine position = heard in the absence of any other demonstrable evidence of cardiovascular disease

2. non-innocent or organic murmur = caused by congenital or acquired heart ds. = before 3 years of age – congenital = after 3 years old – rheumatic valvulitis = caused by abnormal communications between the arterial and venous circuits of the heart and great vessels or by valvular deformities = usually coarse in character, systolic in timing and heard best at the base of the heart

3. hemic murmur = caused by increase blood flow through the heart = occurs when the body’s tissues require more oxygen than usual (exercise) or when hemoglobin-depleted red blood cells are not delivering oxygen to tissues (anemia)

PHYSICAL EXAMINATION OF THE HEART PERCUSSION: - cardiac area of dullness - not useful in pediatric patients except in cases of dextrocardia

Physical indications of severe heart disease: • tachypnea • tachycardia • hyperdynamic precordium • cyanosis • clubbing • delayed development

Heart failure: • venous engorgement • pulsus alterans = pulse alternates in amplitude from beat to beat though the rhythm is basically regular = indicates left ventricular failure • gallop rhythm • hepatic enlargement

PHYSICAL EXAMINATION OF THE ABDOMEN INSPECTION: • protuberant – due to poorly developed abdominal musculature • concave – diaphragmatic hernia - displacement of some of the abdominal organs into the thoracic cavity

PHYSICAL EXAMINATION OF THE ABDOMEN Umbilical cord -number of vessels present - two thick-walled umbilical arteries and one thin-walled umbilical vein - amniotic portion dries up within 1 week and falls off within 2 weeks

• Diatasis recti = congenital weakness of the abdominal musculature or result from a chronically distended abdomen. = most are normal variants and disappear in early childhood

Omphalocele = herniation of abdominal contents into the base of the umbilical cord

Gastrochisis = centrally located, full thickness abdominal wall defect

Auscultation: • Metallic tinkling every 10-30 seconds

Percussion: • Test for fluid wave

Palpation: • • • •

Hold legs, flex knees and hips Start palpating low in the abdomen liver edge and spleen tip palpable both kidneys can be felt

Early and Late Childhood: • ticklish = place child’s hand under examiner’s hand to reduce apprehension and increase relaxation of the abdominal musculature • Palpate lightly and then deeply in all quadrants • Examine last the area that the history suggests as the site of pathology

PHYSICAL EXAMINATION OF THE ABDOMEN • liver and spleen easily palpated • liver edge 1-2 cm below the right costal margin • Size of liver is better determined by percussion than by palpation

• Rovsing’s sign = press deeply and evenly the left lower quadrant – pain in the right lower quadrant • Referred rebound tenderness = right lower quadrant pain on quick withdrawal of left pressure

• Psoas sign = place hand just above the patients right knee and ask the patient to raise the thigh against the examiner’s hand = ask the patient to turn to the left side and extend patient’s right leg at the hip = positive sign is pain on the abdomen

Obturator sign = flex the patient’s right thigh at the hip with

the knee bent and rotate the leg internally at the hip

• • • • • • • • • • • • • • •

Expected liver span of infants, children and adolescents by percussion: Age Males Females 6 months 2.4 2.8 1 2.8 3.1 2 3.5 3.6 3 4 4 4 4.4 4.3 5 4.8 4.5 6 5.1 4.8 8 5.6 5.1 10 6.1 5.4 12 6.5 5.6 14 6.8 5.8 16 7.1 6.0 18 7.4 6.1 20 7.7 6.3

GENITALIA AND RECTUM Infancy: Boys: • Phimosis = tight prepuce that cannot be retracted over the glans

Hypospadia = urethral orifice appears at some

point along the ventral surface of the glans or shaft of the penis

Epispadia = urethral orifice appears at the dorsal surface

Circumcision difference between hydrocele and hernia : hydrocele does not transilluminate and not reducible

HYDROCELE

Inguinal hernia

Umbilical Hernia

Girls: • Inspect the perineal structures, the urethral orifice, the hymen, and the vaginal mucosa by separating the labia with the thumb and forefinger of one hand while pressing forward and downward from within the rectum with the index finger of the other hand. Early and late childhood: • size of the penis in early childhood and prepubescence is of little significance unless it is very large ( obese boys, fat pad over the symphisis pubis may envelope the penis)

Cryptorchidism = undescended testicle,

unilaterally or bilaterally, with the testicle remaining in the abdomen or within the inguinal canal

• Fusion of the labia minora = may be partial, with only the posterior portion of the labia is fused = complete – both anterior and posterior portion is fused