Author: Kristopher Maday PA-C

PAINE #PANCE Pearl – Psychiatry

Posted by

0

Question

You are asked to evaluate a 23yo male prisoner for underlying psychiatric illness prior to standing trial for his third aggravated assault arrest in 12 months. During your discussion, he discloses that he doesn’t hold jobs down very well because “his bosses are idiots”, does not speak with his family, and prefers to not have friends because “everybody is stupid”. He was expelled from 3 different high schools and finally dropped out at 16. In reviewing his criminal record with his attorney, it is revealed he has been arrested 9 times starting at age 14 for theft, burglary, assault, and intoxication infractions.

  1. What condition is high on your differential?
  2. What are the DSM-V criteria for this condition?

Answer

  1. This patient is exhibiting the signs and symptoms of Antisocial Personality Disorder
  2. To make this diagnosis, the patient must have shown examples of conduct disorder before the age of 15, be olde than 18 years, and have a pervasive pattern of disregard for and violation of the rights of others as evidenced by at least three (3) of the following DSM-V criteria:
    1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
    2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
    3. Impulsivity or failure to plan ahead
    4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
    5. Reckless disregard for safety of self or others.
    6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
    7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

Ep-PAINE-nym

Posted by

0

Korsakoff Syndrome

Other Known Aliases – none

Definition – chronic, irreversible amnestic disorder caused by thiamine deficiency classically associated with longstanding alcohol use

Clinical Significance – there are seven major symptoms of Korsakoff syndrome that can be seen clinically:

  1. Anterograde amnesia
  2. Retrograde amnesia
  3. Amnesia of fixation
  4. Confabulation
  5. Minimal content in conversation
  6. Lack of insight
  7. Apathy

This is classically taught as a continuation of Wernicke’s encephalopathy, though patients may not present in early stages.

History – Named after Sergei Sergeievich Korsakoff (1854-1900), who was a Russian neuropsychiatrist and received his medical doctorate from Moscow State University in 1875. He would go on to gain fame in fields of neurology and psychiatry culminating in his appointment as professor extraordinarius at a dedicated psychiatric hospital in Moscow and helping to found the Moscow Society of Neuropathologists and Psychiatrists. His eponymous condition was first described in 1887 in his graduate thesis entitled “Alcoholic Paralysis”

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Kessels RP – Korsakoff Syndrome. The Corsini Encyclopedia of Psychology. [link]

PAINE #PANCE Pearl – Psychiatry

Posted by

0

Question

You are asked to evaluate a 23yo male prisoner for underlying psychiatric illness prior to standing trial for his third aggravated assault arrest in 12 months. During your discussion, he discloses that he doesn’t hold jobs down very well because “his bosses are idiots”, does not speak with his family, and prefers to not have friends because “everybody is stupid”. He was expelled from 3 different high schools and finally dropped out at 16. In reviewing his criminal record with his attorney, it is revealed he has been arrested 9 times starting at age 14 for theft, burglary, assault, and intoxication infractions.

  1. What condition is high on your differential?
  2. What are the DSM-V criteria for this condition?

Ep-PAINE-nym

Posted by

0

Tourette Syndrome

Other Known Aliases – Brissaud’s Disease

Definition – neurodevelopmental disorder characterized by motor and vocal tic with onset during childhood

Clinical Significance – the exact cause is still largely unknown, but likely results from a disturbance in the cortico-striatal-thalamic-cortical (mesolimbic) circuit, which leads to disinhibition of the motor and limbic system. There are no specific tests to confirm and is a clinical diagnosis. The severity of the tics largely decreases, and in some instances disappears, in adolescence and adulthood.

History – Named after Georges Gilles de la Tourette (1857-1904), a French neurologist who recieved his medical doctorate from University of Poitiers at the age of 16. He subsequently moved to Paris to train at the famous Laennec Hospital and Salpêtrière Hospital under Jean Martin Charcot. Under the tutelage of Charcot, he made tremendous strides in the area of psychotherapy, hysteria, psychology, and neurology and described his eponymous condition in a nine patient case series in 1884. In a rather cruel twist of fate, he was shot in the neck by a patient he had treated with hypnotism in 1893, fell into a deep depression, committed to a psychiatric hospital due to tertiary neurosyphilis, and died there in 1904.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com

Ep-PAINE-nym

Posted by

0

Klumpke’s Palsy

Other Known Aliases – none

Definition – paralysis of the upper extremity from a lower trunk injury classically effecting C8-T1.

Clinical Significance – this brachial plexopathy can be infants as a result of birth trauma from pulling on an extending arm or in older children/adults from hanging from an outstretched arm. The classic manifestations are paralysis of the intrinsic hand muscles, fixed and flexed wrist and finger flexors, and sensory numbness of the C8/T1 dermatome leading to the textbook “claw hand” deformity.

History – Named after Augusta Déjerine-Klumpke (1859-1927), an American-born French physician who received her medical doctorate from the University of Paris in 1889 after becoming the first woman to be appointed interne des hôpitaux. She would immediately make a reputation for herself by being able to speak three languages and took an interest in neuroanatomy and physiology. She would meet fellow physician and future husband, Jules Dejerine, during her studies in medical school and the two would study and publish extensively together in the realm of neurology including the classic two-volume textbook on the anatomy of the nerve centers entitled “Anatomie des Centres Nerveux”. She would describe her eponymous condition in her 1885 case review of 18 patients taken from the available medical literature and would win her the Godard prize in 1886.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Yildirim FB, Sarikcioglu L. Augusta Dejerine-Klumpke (1859-1927) and her eponym. J Neurol Neurosurg Psychiatry. 2008; 79(1):102. [pubmed]
  7. Shoja MM, Tubbs RS. Augusta Déjerine-Klumpke: the first female neuroanatomist. Clin Anat. 2007; 20(6):585-7. [pubmed]
  8. Déjerine, JJ, Déjerine-Klumpke, A. Anatomie des Centres Nerveux. 1895. [link]
  9. Déjerine-Klumpke, A. Contribution à l’étude des paralysies radiculaires du plexus brachial. Paralysies radiculaires totales. Paralysies radiculaires inférieures. De la participation des filets sympathiques oculo-pupillaires dans ces paralysies. Revue de médecine 1885, 5: 591-616, 739-90.

#71 – Guillain-Barré Syndrome

Posted by

0

***LISTEN TO THE PODCAST HERE***

DEFINITION

  • Acute monophasic paralyzing illness usually provoked by a preceding event
    • Most commonly this is an infection (2/3rds of patients)
    • Other causes
      • Immunizations
        • Influenza, meningococcal (MCV4)
      • Surgery
      • Trauma
      • Medications
  • Was considered to be a SINGLE condition, but now is recognized to be an umbrella term for a mix of many different variants
    • Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)
      • Most common in the US (85-90%)
    • Miller Fisher syndrome (MFS)
    • Acute motor axonal neuropathy (AMAN)
    • Acute sensorimotor axonal neuropathy (AMSAN)

EPIDEMIOLOGY

  • 1-2 cases per 100,000 per year
  • Incidence increases 20% with every 10-year increase in age after the first decade of life
  • Slightly higher incidence in men than women

PATHOGENSIS

  • Molecular Mimicry
    • Antecedent event provokes an immune response, which produces antibodies that cross-reacts with nerve components due to the sharing of epitopes
      • If directed at Schwann cell surface membranes à AIDP
        • Infiltration of lymphocytes in the epineural and endoneural veins causing myelin degeneration at the dorsal and ventral roots
      • If directed at axonal membrane à AMAN and AMSAN
        • Attack is directed at the nodes of Ranvier of the ventral roots of the peripheral nerves
    • End result is blocking the neuro-electrical transmission of impulses
  • Common infections
    • C. jejuni (most common)
    • HIV
    • H. influenza
    • M. pneumoniae
    • CMV

CLINICAL FEATURES

  • Ascending (distal to proximal) symmetric muscle weakness with absent deep tendon reflexes progressing over days to weeks
    • Weakness can vary from mild difficulty with walking to complete paralysis
    • Symptom peak at around 4 weeks
  • Respiratory dysfunction – 10-30%
  • Facial nerve palsies or oropharyngeal weakness – 50%
  • Oculomotor – 15%
  • Paresthesias – 80%
  • Dysautonomia – 70%
    • Diarrhea, constipation, hyponatremia, bradycardia, urinary retention
  • Variant Discrepancies
    • AMAN – preservation of deep tendon reflexes
    • AMSAN – more sensory disturbances
    • Miller Fisher – ophthalmoplegia with ataxia and areflexia

DIAGNOSIS

  • CSF Analysis
    • Albuminocytologic dissociation
      • Elevated protein with normal WBC
      • Present within first week and peaks at 3 weeks
      • Thought to be due to the increased permeability of the blood-nerve-barrier of the proximal roots
  • Electrodiagnostic Studies (EMG and NCS)
    • Demyelinating forms
      • Decreased motor nerve conduction velocity
      • Prolonged distal motor latency
      • Complete conduction blocks
    • Axonal forms
      • Decreased distal motor and/or sensory amplitudes
    • Serial studies can be helpful since the condition can progress over time
  • Antibodies
    • Specific autoantibodies can help differentiate variant subtypes
  • MRI
    • Thickening and enhancement of the intrathecal spinal nerve roots and cauda equina

DIAGNOSTIC CRITERIA

  • Developed in 1978 and modified over the decades based on evolving research

TREATMENT

  • Supportive care
    • Respiratory support
      • Up to 30% will require ventilatory support
      • Impending respiratory arrest
        • FVC < 20 mL/kg
        • Maximum inspiratory pressure < 30 cmH2O
        • Maximum expiratory pressure < 40 cmH2O
      • Predictors of respiratory failure
        • Time of onset to admission < 7 days
        • Inability to cough, stand, lift elbows, or lift head
        • Elevated LFTs
        • Vital capacity < 60% predicted
    • Autonomic Dysfunction
      • Cardiovascular monitoring and support
        • Hypertension and hypotension
        • Bradycardia and tachydysrhythmias
      • Bowel and Bladder care
        • Urinary retention
        • Ileus management
  • Disease-Modifying Treatment
    • Started within 4 weeks of symptom onset
    • Plasma exchange
      • Remove circulating autoantibodies
      • 4-6 treatments over 8-10 days
      • Complications
        • Hypotension, sepsis
    • IVIG
      • Interferes with production and function of cytokines, B-cells, and T-cells
      • 0.4 grams/kg/day for 5 days
      • Complications
        • Meningitis, rash, renal failure

PROGNOSIS

  • 60% will fully recover by 1 year
  • 15% will have persistent severe motor problems
  • 3-7% will succumb to the illness
    • 20% of patients requiring mechanical ventilation

COTTAGE PHYSICIAN (1893)

REFERENCES

  1. Gibbons CH, Engstrom JW. Disorders of the Autonomic Nervous System. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill; Accessed May 09, 2021.
  2. Diseases of the Peripheral Nerves. In: Ropper AH, Samuels MA, Klein JP, Prasad S. eds. Adams and Victor’s Principles of Neurology, 11e. McGraw-Hill; Accessed May 09, 2021.
  3. Yuki N, Hartung HP. Guillain-Barré syndrome. N Engl J Med. 2012; 366(24):2294-304. [pubmed]
  4. Willison HJ, Jacobs BC, van Doorn PA. Guillain-Barré syndrome. Lancet. 2016; 388(10045):717-27. [pubmed]
  5. Sejvar JJ, Baughman AL, Wise M, Morgan OW. Population incidence of Guillain-Barré syndrome: a systematic review and meta-analysis. Neuroepidemiology. 2011; 36(2):123-33. [PDF]
  6. Alshekhlee A, Hussain Z, Sultan B, Katirji B. Guillain-Barré syndrome: incidence and mortality rates in US hospitals. Neurology. 2008; 70(18):1608-13. [pubmed]
  7. Fokke C, van den Berg B, Drenthen J, Walgaard C, van Doorn PA, Jacobs BC. Diagnosis of Guillain-Barré syndrome and validation of Brighton criteria. Brain. 2014; 137(Pt 1):33-43. [pubmed]
  8. Hadden RD, Cornblath DR, Hughes RA, et al. Electrophysiological classification of Guillain-Barré syndrome: clinical associations and outcome. Plasma Exchange/Sandoglobulin Guillain-Barré Syndrome Trial Group. Ann Neurol. 1998; 44(5):780-8. [pubmed]
  9. Lawn ND, Fletcher DD, Henderson RD, Wolter TD, Wijdicks EF. Anticipating mechanical ventilation in Guillain-Barré syndrome. Arch Neurol. 2001; 58(6):893-8. [pubmed]
  10. Raphaël JC, Chevret S, Hughes RA, Annane D. Plasma exchange for Guillain-Barré syndrome. Cochrane Database Syst Rev. 2012; [pubmed]
  11. Hughes RA, Swan AV, van Doorn PA. Intravenous immunoglobulin for Guillain-Barré syndrome. Cochrane Database Syst Rev. 2014; [PDF]

PAINE #PANCE Pearl – Neurology

Posted by

0

Question

49yo man presents to his primary provider’s office with a 2-week history of bilateral leg weakness. He denies any pain associated with it and has never had any symptoms like this before. He denies any previous back problems and reports never remembers injuring his back. He thinks it first started in his feet when he noticed he was dragging is toes when walking, but now finds some difficulty lifting his legs when going up stairs. PMH is significant for hypertension (controlled on lisinopril) and osteoarthritis (controlled with exercise and celecoxib). He also reports having a pretty severe case of “food poisoning” a month ago when vacationing in the gulf, but is otherwise healthy.

Physical examination reveals 3/5 strength bilaterally with plantarflexion and dorsiflexion of the ankles and 4/5 strength bilaterally with hip and knee flexion. His ankle deep tendon reflex is absent and knee is diminished at 1+. Sensation and two-point discrimination of the feet are intact

  1. What would be the next step in the diagnostic evaluation of this patient?
  2. What is the most likely diagnosis and cause of this disease?

Answer

  1. Due to the acute nature of the symptoms and the absence of DTRs, Guillain-Barré Syndrome should be high on the differential. The next step should be performing an LP and performing a CSF analysis. Albuminocytologic dissociation (elevated protein with normal cell counts) is the hallmark of GBS.

Ep-PAINE-nym

Posted by

0

Erb’s Palsy

Other Known Aliases – none

Definition – paralysis of the upper extremity from an upper trunk injury classically effecting C5-C6.

Clinical Significance – this brachial plexopathy is most commonly associated with birth trauma from a shoulder dystocia and depending on the severity of the injury, can resolve on its own or be permanent. The arm is classically internally rotated, with an extended and pronated forearm referred to as the “waiter’s tip” or “porter’s tip” sign.

History – Named after Wilhelm Heinrich Erb (1840-1921), a German neurologist who received his medical doctorate from the the University of Heidelberg in 1864. He would spend his early career assisting Nikolaus Friedreich and Ludwig von Buhl in Munich, before becoming chair of the pathology department at the University of Leipzig in 1880, and ultimately succeeding Friedreich in 1883. He is credited with popularizing the reflex hammer use in neurologic examinations and would be instrumental in identifying and describing myasthenia gravis, tabes dorsalis, and his eponymous point in the brachial plexus where this injury arises. Of note, he is also credited with the cardiac auscultation point where the S2 is best heard.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Sarikcioglu L, Arican RY. Wilhelm Heinrich Erb (1840-1921) and his contributions to neuroscience. J Neurol Neurosurg Psychiatry. 2007; 78(7):732. [PDF]

PAINE #PANCE Pearl – Neurology

Posted by

1

Question

49yo man presents to his primary provider’s office with a 2-week history of bilateral leg weakness. He denies any pain associated with it and has never had any symptoms like this before. He denies any previous back problems and reports never remembers injuring his back. He thinks it first started in his feet when he noticed he was dragging is toes when walking, but now finds some difficulty lifting his legs when going up stairs. PMH is significant for hypertension (controlled on lisinopril) and osteoarthritis (controlled with exercise and celecoxib). He also reports having a pretty severe case of “food poisoning” a month ago when vacationing in the gulf, but is otherwise healthy.

Physical examination reveals 3/5 strength bilaterally with plantarflexion and dorsiflexion of the ankles and 4/5 strength bilaterally with hip and knee flexion. His ankle deep tendon reflex is absent and knee is diminished at 1+. Sensation and two-point discrimination of the feet are intact

  1. What would be the next step in the diagnostic evaluation of this patient?
  2. What is the most likely diagnosis and cause of this disease?

#70 – Newborn Examination

Posted by

0

***LISTEN TO THE PODCAST HERE***

PURPOSE

  • The first full examination of the child’s life
    • Occurs within 24 hours after birth
    • Comprehensive review of history (maternal, family, prenatal) and complete physical examination
  • Identify medical conditions while still in the hospital to address any significant pathologies
    • Congenital anomalies, birth injuries, cardiopulmonary disease, neurologic abnormalities

HISTORY

  • Maternal and Family History
    • Chronic medical conditions, medications taken during pregnancy, dietary habits during pregnancy, tobacco/alcohol/substance use during pregnancy
      • UTIs, PIH, eclampsia, gestational diabetes, vaginal bleeding
    • Family history of congenital anomalies
  • Obstetric History
    • Maternal age (<19 or >35), gravidity and parity, pregnancy outcomes, blood type
    • Procedures and tests performed during pregnancy (US, amniocentesis)
    • Results any antepartum well-being tests
  • Peripartum History
    • Maternal fever
    • Duration of labor
    • Fetal distress
    • Duration of ruptured membranes
    • Type of delivery, anesthesia used, complications
    • Any resuscitative measures performed

APGAR Scores

  • Recorded at 1- and 5-minutes after birth
  • Score out of 10, 2 points for each criteria
    • < 7 warrants resuscitation and intervention
  • Appearance, Pulse, Grimace, Activity, Respiration (APGAR)
  • How (heart rate) Ready (respiration) Is (irritability) This (tone) Child (color)

ASSESSMENT OF GESTATIONAL AGE AND PHYSICAL MATURITY

  • Important to calculate to determine what is physiologically “normal” for the infant

MEASUREMENTS

  • Compared in relation to gestational age
  • Birth weight
    • Appropriate for Gestational Age (AGA)
    • Small for Gestational Age (SGA) or Intrauterine Growth Restriction (IUG)
      • < 10th percentile
      • Low-Birth Weight < 2500g
      • Very-Low Birth Weight < 1500g
    • Large for Gestational Age (LGA)
      • >90th percentile
  • Length and Head Circumference
    • Length = top of head to bottom of feet with legs fully extended
    • HC = above eyebrows around most prominent posterior aspect of head
    • Use Olson Growth Curves to determine percentiles by gender
  • If SGA/IUG, then determine if symmetrical or asymmetrical
    • Symmetrical = weight, length, AND head circumference all < 10th percentile
      • Implies early pregnancy event
    • Asymmetrical = only weight < 10th percentile
      • Implies late pregnancy event

VITAL SIGNS

  • Should be documented every 30-60 minutes for first 6 hours of life, then every 8-12 hours
  • Axillary temperature (36.5-37.5oC) (97.7-99.5oF)
    • Any deviation from normal, proceed with rectal measurement
  • Respiratory Rate (35-60 bpm)
    • Counted over a FULL minute
  • Heart Rate (100-160 bpm)
  • Blood Pressure (60-80/30-50 mmHg)
    • General rule = MAP > GA

SKIN

HEAD

  • Assess the shape and size of the head
  • Presence of any abnormal hair/scalp defects, unusual protuberances
    • Cephalohematoma
      • Subperiosteal collection of blood
      • Does NOT cross suture lines, resolves over several weeks
    • Caput succedaneum
      • Edema over presenting part of the head
      • Crosses suture lines, resolves in a few days
    • Subgaleal hematoma
      • Collection of blood between aponeurosis and periosteum of scalp
      • Crosses suture lines, may be significant enough to cause hemodynamic problems
  • Fontanelles and Sutures
    • Anterior
    • Posterior
    • Should be open, soft, and flat
      • Closed = craniosynostosis
      • Tense, bulging = raised ICP, infections

FACE

  • Examine for symmetry during crying
  • Facial Palsies
    • Usually associated with forceps delivery with injury to the mandibular branch of the facial nerve
      • Loss of nasolabial fold, partial closing of the eye, inability to contract lower facial muscles
      • Generally, resolve over days to weeks
      • Persistent palsy may indicate complete nerve laceration
  • Asymmetric Crying Facies (ACF)
    • Syndromic condition due to congenital absence of depressor anguli oris muscle
    • Eye and forehead muscles normal, only affects the mouth

EYES

  • Spacing
    • Wide interpupillary distances suggest syndromic abnormality
  • Symmetry
    • Prominent epicanthal folds, size of globes, ptosis
  • Palpebral Fissures
    • Wide or narrow palpebral fissures can be normal or syndromic
  • Examine sclera, conjunctiva, cornea, pupils for abnormalities
  • Red Light Reflex

EARS

  • Examine for position, size, and appearance
    • Normal position = helix intersected by horizontal line drawn from outer canthus of eye perpendicular to the vertical axis of the head
  • Preauricular skin tags, branchial cleft cysts, and pits could indicate syndromic conditions

NOSE

  • Assess for patency, shape, and position
    • Hold mirror or cold metal under nose and look for bilateral fogging
    • Any concern for patency should be assessed with small NG tube passage

MOUTH

  • External
    • Assess for size and shape, cleft lip, micrognathism
  • Internal
    • Epstein pearls = benign, small, white inclusion cysts on palate
    • Lingual frenulum
    • Cleft of palate
    • Macroglossia associated with syndromic conditions

NECK

  • Masses
    • Cystic hygromas – transilluminated, soft mass above clavicles, posterior to SCM
    • Branchial cleft cysts – anterior margin of SCM
    • Thyroglossal cysts – midline neck mass
  • Mobility
    • Torticollis – caused by birth injury or neurologic syndrome
  • Excessive Skin
    • Webbing – feature of syndromic or genetic conditions

CLAVICLES

  • Palpate for BOTH clavicles
    • Absence associated with congenital syndrome
  • Fractures or birth injuries

CHEST

  • Assess for size, symmetry, and structure during respirations
    • Pectus excavatum, pectus carinatum

BREAST

  • Nipple spacing
    • Wide spaced may be associated with genetic conditions
  • Supernumerary nipple presence along milk line

LUNGS

  • Assess for retraction, grunting, nasal flaring
  • Abnormal breath sounds are unusual in the absence of other respiratory distress findings

CARDIAC

  • PMI in newborn is near left lower sternal border
    • RV is dominant in the newborn
  • Auscultation for murmurs
    • Most newborns have benign, transient flow murmur as physiology shifts from in-utero to ex-utero
  • Pulses

ABDOMEN

  • Assess for size and protuberance
    • Distension – congenital intestinal atresia, organomegaly, ascites
    • Scaphoid – diaphragmatic hernia
  • Assess for abdominal wall defects or masses
  • Palpate for tenderness or organomegaly
  • Umbilical Cord Stump
    • Assess for erythema or streaking of omphalitis

GENITALIA

  • Identify infant’s gender at birth
  • Phenotypic Female
    • Assess size and location of labia, clitoris, meatus, vaginal opening
  • Phenotypic Male
    • Presence of both testes, size of penis, appearance of scrotum, position of urethral opening
  • Ambiguous Genitalia
    • Female – enlarged clitoris, fused labial folds
    • Males – bifid scrotum, severe hypospadias, micropenis, cryptorchidism
    • Consultation with endocrinology, urology, and genetics is warranted

ANUS

  • Assess location, patency, sphincter tone

TRUNK AND SPINE

  • Assess down vertebral column for masses, hair tufts, dimples

EXTREMITIES

  • Hands and Feet
    • Inspect for syndactyly or polydactyly
    • Single palmar crease
  • Hips
    • Assess for developmental hip dysplasia
      • Ortolani – adduction and posterior pressure to feel dislocation
      • Barlowe – abduction and elevation to feel for reduction
  • Movement
    • Assess for spontaneous and symmetric movement
      • If upper asymmetric movement present:
        • Assess for brachial plexus injury
          • C5-6 – Erb’s Palsy
            • Upper arm is adducted, internally rotated, forearm extended (Waiter’s tip)
          • C7-T1 – Klumpke Palsy
            • forearm extension and pronation and flexion of wrist and fingers (“claw hand”)

NEUROLOGIC

  • Assess resting motor tone
    • Hypertonia
      • Spasticity, tractional positioning
    • Hypotonia – infant lying supine with hips fully abducted (frog-leg position) and limbs fully extended
      • Vertical Suspension Test
        • Decreased shoulder girdle tone allows infant to slip through examiner’s hands
      • Ventral Suspension Test
        • Infant appears limp with extended limbs and head drooping
      • Head Control Test
        • Head lags behind as infant is pulled up from supine to sitting position
  • Assess primitive reflexes
    • Why important
      • Brainstem mediated
      • Complex automatic movement patterns (not really reflexes)
      • Pathology may be present if absent when it should be present or present when it should be absent
  • Rooting and Sucking Reflex
    • Rooting – infant turns head toward examiner stroking cheek or mouth
    • Sucking – infant strongly latches onto finger
    • Present – at birth
    • Disappears – by 4 months
  • Moro or Startle Reflex
    • Lifting infants head and shoulders and allow head to drop relative to the body
    • Normal – infant extends and abducts arms, then flexes and adducts
    • Present – at birth
    • Disappears – by 6 months
  • Palmar Grasp Reflex
    • Examiner places finger in the palm and applies gentle pressure
    • Normal – fingers curl to grasp finger and hold
    • Present – at birth
    • Disappears – by 6 months
  • Stepping Reflex
    • Hold infant upright and slightly leaning forward and allow feet to touch a surface
    • Normal – infant raises leg as if stepping
    • Present – at birth
    • Disappears – by 2 months
  • Babinski Reflex
    • Apply lateral pressure on plantar surface moving from heel curving towards 1st metatarsal
    • Normal – fanning (extension) or toes
      • This is a POSITIVE Babinski and NORMAL in infants
    • Present – at birth
    • Changes from POSITIVE to NEGATIVE by 2 year’s of age
  • Asymmetric Tonic Neck Reflex
    • Infant is supine and examiner turns head for 15 seconds
    • Normal – Ipsilateral extremities extend and contralateral extremities flex
    • Present – at birth
    • Disappears – by 6 months

COTTAGE PHYSICIAN (1893)

REFERENCES

  1. Smith D. The Newborn Infant. In: Hay Jr. WW, Levin MJ, Abzug MJ, Bunik M. eds. Current Diagnosis & Treatment: Pediatrics, 25e. McGraw-Hill; Accessed April 24, 2021. https://accessmedicine-mhmedical-com.ezproxy.uthsc.edu/content.aspx?bookid=2815&sectionid=244254981
  2. Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score, expanded to include extremely premature infants. J Pediatr. 1991; 119(3):417-23. [pubmed]
  3. Olsen IE, Groveman SA, Lawson ML, Clark RH, Zemel BS. New intrauterine growth curves based on United States data. Pediatrics. 2010; 125(2):e214-24. [pubmed]
  4. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Care of the Newborn. In: Guidelines for Perinatal Care, 7th ed, Riley LE, Stark AR (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2012.
  5. Tveiten L, Diep LM, Halvorsen T, Markestad T. Respiratory Rate During the First 24 Hours of Life in Healthy Term Infants. Pediatrics. 2016; 137(4):. [pubmed]
  6. Red reflex examination in neonates, infants, and children. Pediatrics. 2008; 122(6):1401-4. [pubmed]
  7. Lewis ML. A comprehensive newborn exam: part I. General, head and neck, cardiopulmonary. Am Fam Physician. 2014; 90(5):289-96. [pubmed]
  8. Lewis ML. A comprehensive newborn exam: part II. Skin, trunk, extremities, neurologic. Am Fam Physician. 2014; 90(5):297-302. [pubmed]
  9. Salandy S, Rai R, Gutierrez S, Ishak B, Tubbs RS. Neurological examination of the infant: A Comprehensive Review. Clin Anat. 2019; 32(6):770-777. [pubmed]
  10. Hamer EG, Hadders-Algra M. Prognostic significance of neurological signs in high-risk infants – a systematic review. Dev Med Child Neurol. 2016; 58 Suppl 4:53-60. [pubmed]
  11. Futagi Y, Toribe Y, Suzuki Y. The grasp reflex and moro reflex in infants: hierarchy of primitive reflex responses. Int J Pediatr. 2012; 2012:191562. [PDF]
  12. Allen MC, Capute AJ. The evolution of primitive reflexes in extremely premature infants. Pediatr Res. 1986; 20(12):1284-9. [pubmed]
  13. Pediatric EM Morsels.  Primitive Reflexes in Children.  04/23/2021. https://pedemmorsels.com/primitive-reflexes-in-infants/