Newborn Physical Examination

Newborn: complete physical exam within 24 hours of birth

Listen to heart and lung first when the infant is quiet

Warming the statescope before using

VITAL SIGN

Temperature

Respirations: normal rate is 40-60 breaths/min

Blood Pressure

Pulse rate: normal rate is 100-180 beats/min

HEAD CIRCUMFERENCE, LENGTH, WEIGHT, AND GESTATIONAL AGE

Head circumference and percentile: place the measuring tape around the front of the head (above the brow) and the occipital area, the tape should be above the ears, normally 32-37 cm at term.

Length and percentile

Weight and percentile

Assessment of gestational age

GENERAL APPEARANCE

Activity

Skin color

Obvious congenital abnormality

SKIN

COLOR

Plethora (deep, rosy red color): common in polycytemia, can be seen in overoxygenation and overheated infant.

Erythema neonatorum: normal, phenomenon in transition period and can occur when the infant has been stimulated

Jaundice

Pallor (washed-out, whitish appearance)

Cyanosis

Central cyanosis: bluish skin, including the tongue and lips

Peripheral cyanosis: bluish skin with pink lips and tongue

Acrocyanosis: bluish hands and feet only

Extensive bruising (ecchymoses): prolonged and difficult delivery

‘Blue on pink’ or ‘pink on blue’: poor perfusion, inadequate oxygenation, inadequate ventilation, or polycytemia.

Harlequin coloration (clear line of demarcation between an area of redness and an area of normal coloration)

Mottling (lacy red pattern): maybe seen in healthy infants and in those with cold stress, hypovolemia, or sepsis. Persistent mottling (cutis marmorata) found in infants with Down syndrome, trisomy 13 or trisomy 18.

Vernix caseosa: substance that covers the skin until 38th week of gestation

Collodion infant: skin resembles parchment, restriction in growth of the nose and ears.

Dry skin: postdate or postmature infant, congenital syphillis, and candidiasis

RASHES

Milia: withish, pinhead-sized on chin, nose, forehead, and cheeks.

Erythema toxicum: small areas of red skin with a yellow-white papule in the center.

Candida albicans rash: erythematous plaques with sharply demarcated edges.

Transient neonatal pustular melanosis: pustules, ruptured vesicupustules, and hiperpigmented macules.

Acne neonatorum: comedones and papules over the cheeks, chin, and forehead.

Herpes simplex: pustular vesicular rash, vesicles, bullae, or denuded skin.

Nevi

Macular hemangioma (‘stork bites’): dissappear spontaneously within 1st year of life.

Port-wine stain (nevus flammeus): does not blanch with pressure and not disappear with time.

Mongolian spot: dark blue or purple bruise-like makular spots, most common birthmark

Cavernous hemangioma: large, red, cyst-like, firm, ill-defined mass. If associated with thrombocytopenia (Kasabach-Merrit syndrome)

Strawberry hemangioma (macular hemangioma): flat, bright red, sharply demarcated lesions.

HEAD

Anterior and posterior fontanelles :anterior fontanelle usually closes at 9-12 mo and the posterior at 2-4 mo

Molding: temporary asymmetry of the skull resulting from the birth process.

Caput succedaneum

Cephalhematoma

Subgaleal hematoma

Increased intracranial pressure: bulging anterior fontanelle, separated sutures, paralysis of upward gaze (setting-sunsign, prominent veins of the scalp, increasing macrocephaly

Craniosynostosis: premature closure of one or more sutures

Craniotabes: softening of the skull

Plagiocephaly: oblique shape of a head, asymmetric and flattened.

NECK

Eliciting the rooting reflex

Palpate the sternocleidomastoid

Short neck: Turner’s, Noonan’s, and Klippel-Feil syndromes

FACE

Note the general shape of the nose, mouth, and chin

Note the presence of hypertelorism (eyes widely separated)

Note the presence of low-set ears

Facial nerve injury: unilateral branches of the facial nerve

EARS

Look for unusual shape or position

Low-set ears: congenital anomalies

Preauricular skin tags (papillomas): benign

Hairy ears: infants of a diabetic mothers

Gross hearing: when infant blinks in response to loud noises

EYES

Check the red reflex with an ophthalmoscope

Opacification of the lens: cataract

Sclera bluish tint: premature

Sclera deep blue: osteogenesis imperfecta

Brushfield’s spots (salt-and-pepper specling of the iris): Down syndrome

Subconjunctival hemorrhage: 5% newborn infant.

Conjunctivitis

NOSE

Nasal flaring: respiratory distress

Sniffing and discharge: congenital syphilis

Sneezing: response to bright or drug withdrawal.

MOUTH

Ranula: cystic swelling in the floor of the mouth.

Epstein’s pearls: keratin-containing cysts

Mucocele: small lesion on the oral mucosa

Natal teeth:

Predeciduous teeth: supernumerary teeth

True deciduous teeth: true teeth that erupt early.

Macroglossia: enlargement of the tongue, can be seen in Beckwith’s syndr and Pompe’s disease

Frothy or copious saliva: esophageal atresia with tracheoesophageal fistula.

Thrush: sign of infection C. albicans.

CHEST

Observation

Breath sound

Pectus excavatum

Breast in a newborn: usually 1cm in diameter in term

abnormally 3-4 cm: effects of maternal estrogens

witch’s milk: white discharge

HEART

Murmur: VSD, PDA, Coarctatio aorta, PS, PA, TA, TGA, etc

Palpate the pulses (femoral, pedal, radial, and brachial)

Check for signs of CHF: gallop, tachypnea, hepatomegaly, wheezes and rales, tachycardia, and abnormal pulses.

ABDOMEN

Observation: omphalochele, gastroschisis, scaphoid abdomen.

Auscultation

Palpation: check for distention, tenderness, or masses.

UMBILICUS

Two arteries and one vein

Normal cord: translucent

Greenish-yellow color: meconium staining

GENITALIA

Male

check dorsal hood, hypospadias, epispadias, and chordee.

normal penile leghth at birth is > 2 cm

Determine site of meatus, verife the testicles and the color of scrotum

Female

examine the labia and clitoris

LYMPH NODES

Palpable lymph nodes usually in the inguinal and cervical 33% of normal neonates.

ANUS AND RECTUM

Check for patency of the anus

Check the position of the anus

Meconium should pass within 48 h

EXTREMITIES

Syndactyly : abnormal fusion of the digits

Polydactyly: supernumerary digits

Simian crease: a single transverse palmar crease (Down syndrome)

Talipes equinovarus (clubfoot): foot is turn downward and inward and the sole is directed medially

Metatarsus varus: adduction of the forefoot

TRUNK AND SPINE

Check for:

any gross defect of the spine

abnormal pigmentation

hairy patches over the lower back

sacral or pilonidal dimple: small

meningocele

Fetal Phenytoin syndrome: Hirsutism

HIPS

Congenital hip dislocation

Ortolani and Barlow maneuvers: place in the frog position, abduct the hips by using middle finger to apply gentle inward and upward pressure over the greater trochanter (Ortolani’s sign), adduct the hips by using the thumb to apply outward and backward pressure over the inner thigh (Barlow’s sign), a click of reduction and a click of dislocation: hip dislocation.

NERVOUS SYSTEM

Observe for abnormal movement or excessive irritability

Muscle tone: hypotonia, hypertonia

Reflexes: rooting, glabellar, grasp, neck-righting, and moro

Cranial nerves

Movement

Periveral nerves: Erb-Duchenne paralysis, Klumpke’s paralysis

General sign of neurologic disorder: Symptom of increased ICP, Hypotonia or hypertonia, Irritability or hyperexcitability, Poor sucking and swallowing reflexes, Shallow, irregular respirations, Apnea, Apathy, Staring, Seizure activity, Asymmteric reflexes

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