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in this lecture I'm going to discuss the
newborn physical exam so before I even
start I want to say two things about the
newborn exam one is it can be tricky
from the standpoint of making sure that
the child is adequately warm so
sometimes you have to be a little bit
quick because if you light leave the
child unexposed for a period of time
they can start getting cold you'll
notice that the skin starts to model or
look like marble a little bit and let's
assign that infinite getting cold if you
can you can do a very careful exam under
a warmer the other thing about the new
more exam is it can be frustrated it's
frustrating especially with auscultation
and the reason is newborn infants might
cry and make it hard to hear what's
going on it's okay
if you leave an infant and then come
back to them later when they're sleeping
to get the rest of your exam but let's
go through the normal new born exam
really carefully here so we can
understand not only for an exam that
might happen but also for your general
practice on the pediatric wards so first
let's review vital signs and growth
parameters it's important that you have
the height the weight and the head
circumference on every infant new exam
and it's important we review the vital
signs the heart rate should be usually
between 90 and 160 and a healthy newborn
child the respiratory rate is usually
high between 30 or 60 that's fine
from the standpoint of blood pressure we
often don't have one this is because
it's a bit challenging to make we will
use it in infants who are ill but if an
infant as well the blood pressure is not
a critical measurement and remember
pulse ox is abnormal in the first day of
life and very abnormal in the first 10
minutes so during the first 10 minutes
it's normal for infant to go from 60% at
birth to 90 percent then it can take the
rest of the day to go up to a hundred
percent but
expect abnormalities in the pulse ox
early in the second day of life that
pulse ox should pretty much be normal in
fact many centers use that pulse ox as a
screen for congenital heart disease okay
now you've got the vitals you've got the
height the weight and the head
circumference and you've plotted them so
you have percentiles now we're going to
do an exam and we're gonna start at the
head and work our way down the first
thing you're going to do on the head is
feel the sutures early in birth
sometimes they are slightly overriding
and elevated but that should stabilize
out relatively quickly also you should
feel a fontanel in the anterior portion
of the skull as is pictured here and a
very small sort of finger large
posterior fontanelle
you should feel both of those and you
should feel all those sutures and if you
feel any asymmetries or abnormalities
those should be noted this could be a
partial craniosynostosis for example
next we're going to check the eyes and
we absolutely are going to a do a red
reflex the red reflex is useful is
because when you're looking and you're
seeing not only the red reflex but also
the possibility of slipped lenses which
can happen with a variety of infant
diseases also the red reflex may be
absent in a patient with retinal
blastoma
so it's crucial to check those eyes also
look at the irises if a coloboma is
press present this might be charged
syndrome now take a look at the ears as
you draw a line backward from the eye it
should intersect the top third of that
ear also you should note any
abnormalities of the year is it
posterior placed but is it rotated are
there pits are there tags
abnormalities of the year may be
associated with syndromes or maybe even
just associated with renal abnormalities
for reasons I don't understand ears and
kidneys can sometimes go together in so
many different ways next we're going to
check the mouth we're going to look for
abnormalities of the lips but we're also
going to put our finger into the mouth
and palpate the
top of the mouth if there's
abnormalities in a cleft palate you may
note them obviously on exam but a palate
on the inside may be high arched or may
be abnormal as well with a lack of
patency on the inside and that should
all be noted while we've got our finger
in there check the babies suck it should
be vigorous that's technically part of
the neuro exam but I would absolutely do
it also we're gonna check the nose in
pretty much any infant at some point we
may suck out both nares that usually is
done in the resuscitating room but we're
gonna check patency of the nose if a
tube goes in but can't get through that
patient may have Co anal atresia which
can cause respiratory distress in an
infant next we're gonna look at the neck
the neck is important in infants because
it can have abnormalities that are hard
to see unless you really extend the neck
and look at it
examples are a firebug lhasa duct system
it line or a bronchial cleft cyst which
is lateral so we'll look for
abnormalities next palpate the clavicles
it's common for clavicular fractures to
happen in large babies or with bad
shoulder dystocia next listen to the
heart and lungs remember that half of
normal newborns will have a murmur in
the first day of life okay
we're moving down to the liver it's
normal to feel a liver and a baby in
fact if you examine a baby well and you
don't feel a liver
you probably didn't examine them well
enough you should be able to palpate
livers in most babies it's even normal
to be able to palpate kidneys in babies
so you're gonna feel that liver and it
should be generally no larger than 3
centimeters below the costal margin 3
centimeters is a pretty big distance
babies can have big livers the spleen
and the kidneys may be palpable and that
may be normal
next checked for the paitent rectum
don't forget to check during that first
newborn exam because a in peyton rectum
can be a real critical
surgical emergency in an infant so take
a look and make sure that rectum is
present while you're down there inspect
the genitalia here's an example of a
sample of an abnormal genitalia this
child has ambiguous genitalia which are
probably associated with congenital
adrenal hyperplasia this child is a girl
with a very large clitoris and a fused
labrum majorem okay we're done with the
genitalia are gonna move on to the
extremities check the stability of the
hips do a little bit of an Ortolan iam
Barlow to make sure that's okay next
inspect the spine and look for sacral
dimples or Tufts acrocyanosis or blue
hands and feet is normal and common but
syndactyly such as this patient has or
polydactyly which is even more common
with an accessory digit is very common
we need to look and count fingers and
toes in every patient and make sure they
look normal even subtle findings like a
polymer crease may be your sign that the
patient has for example Down syndrome
lastly we're gonna do our neurologic
exam we've already done the suck reflex
but we're gonna comment on it during the
neurologic exam check for their overall
tone babies should prefer to be all
balled up they don't want to have their
extremities relaxed if a child is
relaxed and open something is wrong
neurologically check the sutt the suck
check for a rooting reflex where you
stroke their chin and they move towards
it to suck check their grasp these
infants should want to hold your finger
holding your finger is a normal reflex
in infants it's nice to not tell the
mother that this is a reflex let her
think her child wants to hold her finger
also check the Moro reflex the Muro
which should be done carefully is when
you suddenly lower the head and the
infants arms will come out and spread
they may shake a little bit and then
come back in again if infants do that
that is normal what we're looking for is
a symmetry of the Muro reflex
if only one arm comes out that could be
a sign of nerve damage perhaps from a
brachial plexus nerve injury as a result
of birth lastly it is good to check the
DTRS the deep tendon reflexes are easy
to appreciate in the knees for example
of infants and we can also check the
heels for clonise a little bit of clonus
might be okay early in infancy so that's
my summary of the neurologic exam from
head to toe in infants thanks for your
time
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