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*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
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)
POSTERIOR FONTANELLE * normally closed at birth/up to 2 months in PT 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 ms 6 ms 1 yr 35 40 43 45 cm cm cm cm 2. SIGNS OF MENINGEAL IRRITATION (pg228) *never appear before the age of 18 months/ 2 yrs i) neck rigidity *sitting, active flexion of head (ask him to look at his button), 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 *look at his face! = inability to extend the knee when the hip is flexed iii) Bruziniskis sign *supine! leg to leg * look at another leg! withdrawal (+ve) = full flexion of one leg flexion of another leg neck to leg *support anterior chest wall! press * look at leg! = head flexion leg flexion
causes of : large head (macrocephaly) - hydrocephalus - subdural hematoma/effusion - achondroplasia - familial microcephaly = 3 S.D below the mean - craniosynotosis - familial
DDx of neck rigidity : - meningitis - meningismus (neck rigidity not due to meningitis) nerve: cerebral palsy, tetanus muscle: muscle spasm bone: fracture neck pharynx: retropharyngeal abscess, peritonsillar abscess post subdural hemorrhage apical pneumonia
Signs of meningeal irritation: *not elicited in <2 y/o! - fever - photophobia - irritability headache - back signs = opisthotonus, back pain, inability to sit normally, tripod sign (sits supported on LL, buttocks & UL) * mechanism of back sign = irritation of spinal nerve reflex paravertebral muscle spasm Signs in small infant : - bulging AF - irritability - continuous crying
Anything about meningitis (pg 228 & 256) causative C/P organism - age-related ! 1. Fever NB : E.Coli, group B streptococcus, Staph. Aureus, Listeria Infant : H. Influenzae type B, Pneumococcus, Meningococcus Older children : meningococcus 2. Signs of meningeal irritation -as above3. Signs & symptoms of ICP - small infant: bulging AF - older children : headache, projectile vomiting, photophobia
Complication 1. Hydrocephalus (dt to csf flow obstruction) 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
Investigation: LUMBAR PUNCTURE at L4, L5 + sitting/lateral position Normal CSF Septic/Bacterial Meningitis aspect crystal clear turbid glucose 40-60mg/dl proteins 20-40 mg/dl WBC <5, all mononuclear , >100, mostly PNL
Aseptic/Viral Meningitis usually clear normal slightly increased >20, early PNL, later mononuclear
3. EXAMINATION OF LIVER * in supine *exposure to xiphisternum i) superficial palpation *look at his face! sit its tender ii) deep palpation (right lobe) + comments site = lower __ cm below right costal margin in MCL border of *liver edge i) right lobe NB 4 ms older 3-4 cm 2 cm 1 cm below the right costal margin ii) left lobe __cm below xiphisternum in midline surface smooth/nodular consistency soft/firm lower border rounded/sharp tenderness tender/not pulsatile pulsatile/not iii) tidal percussion @ MCL upper border = 5th 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 iv) left lobe deep palpation & comments 4. EXAMINATION OF SPLEEN * in supine *exposure to xiphisternum i) superficial palpation *look at his face! sit its tender ii) deep palpation size surface ant border notch consistency tenderness
hepatomegaly - infective : hepatitis - congestion: heart failure, Bud Chiari syndrome - infiltration: Beta-thalassemia, glycogen storage disease - malignancy
Causes of ptosed liver: - hyperinflation of lung - pleural effusion - weak ligament/abdomen (hypotonia)
splenomegaly - haematological : Beta thalassemia - infective : thyphoid, malaria, TB - neoplasm : leukemia - collagenic : SLE, RA
In beta thalassemia; i) indications of splenectomy - hypersplenism (pancytopenia with hyperactive BM) - huge with dragging pain ii) hepatomegaly with NO tenderness in: - extramedullary hematopoiesis - hemosiderosis ii) hepatomegaly with tenderness in : - hepatitis - heart failure Differentiate between renal and splenic swelling: splenic swelling renal swelling direction of downwards, downwards enlargement medially movement with free mivsble limited movement respiration Ballotment -ve +ve splenic notch +ve -ve Traubes area dull resonant renal angle resonant dull
iii) tidal percussion @ MAL upper pole = left 9th IC space in midaxillary line
5. AUSCULTATION OF 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 not heard 2 easily audible 3 loud but no thrill 4 loud + thrill 5 very loud + thrill 6 heard w/out stethoscope
S1 Accentuated: - PHTN Abnormal splitting: i) Wide fixed : ASD ii) Absent : - severe PS/AS - Fallots tetralogy - TGA MR muffled heard/not pansystolic harsh mitral/apex Signs of PHTN: 1. pulsation in pulmonary area 2. diastolic shock (palpation) 3. dullness (percussion) at pulmonary area 4. accentuated S2 ( auscultation)
S1 S2 Sdditional HS Precardial rub Murmur Timing Character Site of maximum intensity Propagation Grading
pansystolic harsh left parasternal axilla whole precordium 2/3 : heard with no thrills Type of breathing Vesicular breathing with prolonged exp: - bronchial asthma - bronchitis - FB Bronchial breathing (trachea) - consolidation (pneumonia)
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: Air entry in: - obstruction of airways - lung collapse - pleural effusion - pneumothorax - lung fibrosis
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 - LOWER LIMB EDEMA *30 sec pressure on dorsum of foot + shin of tibia (both leg 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 moderate *turn to ascites opposite side modified mild shifting dullness ascites transmitted tense thrill ascites *one hand in the midline
causes of generalized edema - nutritional : kwashiorkor - renal : nephrotic, nephritic synd - cardiac : congestive HF - fulminant hepatic failure - urticaria - protein losing enteropathy - cirrhosis
causes of unilateral edema - DVT - lymphatic obstruction *localized - allergy (angioneurotic edema) - local inflammation
site for edema - dorsum of foot - lateral malleolus - shin of tibia - genitalia (scrotum & vulva) - sacrum - ascites (abdomen) - pleural effusion - pericardial effusion - palm - eye
*read nephritis & nephritic! * DDx of dark urine! (jaundice hepatitis, AHA, acute nephritis)
8. REFLEXES *both sides! expose the tested muscle! * support the joint! + st identify the tendon 1 ! i) Knee reflex *lift knee with heal touching the bed tap patellar tendon ii) Ankle reflex *rotate hip externally + gentle dorsiflexion of foot * support weight of foot at the ankle tap Achilles tendon ii) Plantar reflex * supine & relax *lateral aspect of sole, from heel across ball of foot medially *in hyperreflexia test for CLONUS!
tap/ strike
Superficial reflex Abdominal Plantar reflex reflex sole, along skin towards outer edge umbilicus from heel *assess in all 4 quadrants of abdominal wall L4, L5, S1, S2 upper : T8,T9,T10 lower: T10, T11,T12 umbilicus move towards stimulus may be absent in 1st 6 months of life
centr e
Deep tendon reflex Brachioradialis Triceps jerk jerk triceps radius 2.5cm tendon above the above the wrist, in elbow, with relaxed arm arm bent and forearm and forearm position with supported palm down. C6, C7, C8 C5, C6
Ankle jerk Achilles tendon, with knee flexed and foot lightly supported S1, S2
L2, L3, L4
respo nse
normal: - plantar flexion in > 1 y/o - plantar extension in < 1 y/o, with no other neuro manifestation abnormal (+ve Babinski sign) : dorsiflexion of foot + fanning of toes (plantar extension)
extension of forearm
knee extension
plantar flexion
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