CLINICAL EXAMINATION IN NEONATES

1. CLINICAL EXAMINATION IN NEONATES Prof. Dr. Sjarif Hidayat Effendi, dr., Sp.A(K) Division of Perinatology Department of Child Health Padjadjaran University

2. CLINICAL EXAMINATIONIN THE NEONATES I. HISTORY II. PHYSICAL EXAMINATION

3. I. History ( The importance of HT must be explained precisely to the family) * Chief complaint * Maternal Pregnancy: Prenatal care Duration of pregnancy General health * Birth history : Onset & events of labor Amniotic fluid * Neonatal history : Timing of umbilical cord clamping

4. Family history: congenital disease : metabolic, haemophilia, etc) • History of mother : marital status, age of marital, blood type, chronic disease, DM, etc • History of previously pregnancy (if not 1st pregnancy): abortus, fetal death, premature, etc • History of drug use and habit : drug, alcohol, smoking, etc • History of recent pregnancy : pre-ecklampsi, polyhidramnion, etc

5. II. Physical examination (infant examination must be calm and gently) * Normal Baby done at least 3 times: - After delivery - at 12 hours of age - at discharge * Examination at the Delivery Room * Examination at the Neonatal Ward

6. Physical examination at the Delivery Room General examination * General condition * To rule out major anomalies • For high risk baby * Cardiorespiratory system - metabolic * Detail examination : in 24 h after stabilization

7. Physical examination at the Delivery Room • APGAR score • Placenta • Umbilical • Birth trauma • Congenital anomalies • Nasal and gastric catheterization • Color : cyanotic, pale, reddish pink

8. Physical examinaton at the Delivery Room APGAR Scores Sign Score = 0 Score = 1 Score = 2 ---------------------------------------------------------------------------------------------------- APPEARANCE Blue all over, Acrocyanosis Pink all over (color) or pale PULSE Absent Below 100 Above 100 (heart rate) GRIMACE No response Grimace or Good cry (reflex irritability) weak cry ACTIVITY Flaccid Some flexion of Well flexed, or active (muscle tone) extremities movements of extremities RESPIRATIONS Absent Weak, irregular, Good crying or gasping ============================================ The APGAR score should be assigned at one minute and five minutes, finding the total score (0-10) at each time by adding up points from the table above. Continue to assign scores every five minutes thereafter as long as the APGAR score is less than 7.

9. Physical Examination at the Neonatal Ward • The first 12 hours after birth • The mother, and, if possible, the father should be present • The infant is unclothed under a radiant warmer • Auscultation of heart & lung • Palpation of abdomen • Vital sign : Respiration and heart rate, temperature, blood pressure

10. Physical Examination at the Neonatal Ward • General Appearance • Head • Neck • Thorax • Facial Appearance • Respiratory- Cardiovascular • Neurological examination

11. Physical Examination at the Neonatal Ward General appearance • Symmetry • Face • Gestational age • Skin: color and texture, scratch marks, rash • Neuromuscular : motion, reflex, tone.

12. Breech presentation Hydrocephalus

13. Feto-fetal tranfusion syndrome Bronze baby syndrome

14. Growth retardation Harlequin Discordant twins

15. Cytomegalovirus Multiple purpura Hepatosplenomegaly Cranial CT scan • Hydrocephalus • Periventricular calcification

16. Physical Examination at the Neonatal WardSkin • Vernix caseosa • Lanugo • Milia • Mongolian spots • Erythema toxicum • Hemangioma • Birth trauma • Color : pale, icterus, cyanosis, plethora, cutis marmorata

17. Miliaria Cutis marmorata

18. Physical Examination at the Neonatal WardHead • Shape • Circumference • Scalp • Caput succedaneum • Cephalhematoma • Suture lines • Fontanelles

19. Birth Trauma Laceration post VE Laceration post SC

20. Cephalohematoma Caput succedaneum

21. Facial Appearance Pre term baby Post term baby

22. Facial Appearance SGA Infant of diabetic mother : macrosomia

23. Physical Examination at the Neonatal Ward Eyes - Scleral hemorrhage - Icterus - Exudate - Pupillarry size - Cataract

24. Physical Examination at the Neonatal WardEars Position Shape Auditory canals

25. 28 weeks” gestation : little cartilago, pliable 36 weeks to term gestation : firm ear, well-formed margin

26. Hypoplastic auricle Low-set ear Microtia

27. Physical Examination at the Neonatal WardMouth • Symmetry • Size • Cleft (Labio-palatoschizis) • Teeth • Ranula • Cyst (Epstein,s pearls) • Oral thrush

28. Oral thrush Labio-palatoschizis

29. Macroglossia True teeth with roots

30. Goiter : iodine deficiency Ectopic thyroid

31. Chest & Lung • Symmetry • Pectus excavatum • Nipples • Auscultation

32. Nipple 28 weeks’ gestation : No breast tissue, areola barely visible 32 weeks’ gestation : visible areola, little breast tissue 36 weeks gestation : well-defined areola, breast nodule

33. Physical Examination at the Neonatal WardRespiratory - Cardiovascular RESPIRATION HEART - Rate - Rhythm • Apnea - Retraction • Grunting • Position • Rate • Rhythm • Murmurs

34. Physical Examination at the Neonatal WardAbdomen • Inspecting : - Movement patterns - omphalocele, gastroschisis - Shape (scaphoid, distended) - Umbilical cord • Auscultation : bowel sounds • Palpation : - Liver edge is felt 1-2 cm below the right costal margin - Normally; spleen not felt

35. Umbilical cord

36. Umbilical hernia Omphalocele

37. Physical Examination At The Neonatology RoomGenital System FEMALE MALE - Labia majora - Mucosal tag • Vaginal discharge - Scrotum - Hydroceles - Testes - Length of penis - Phymosis • Hypospadia / Epispadia

38. Genitalia - Male 36 weeks to term gestation : testis well descended, increased scrotal pigmentation 28 weeks’ gestation : testis high in scrotum

39. Micropenis Undescensus testis

40. Ambiguous genitalia Male (XY) Testes in labioscrotal fold Female (XX) Clitoral enlargement

41. Physical Examination at the Neonatal WardAnus • Patency • Size • Position • Fistulae

42. Physical Examination at the Neonatal WardMusculo Sceletal System Extremities • Anomalies of digit • Club foot • Hip dislocation  Ortholani Manuver • Plantar creases

43. Anal atresia

44. Rectovaginal fistula Dermatitis

45. Thumb hypoplasia Polydactily Sindactily

46. Foot sole creases 32 weeks’ gestation : creases in anterior one third 36 weeks’ to term gestation : creases over the majority of the sole

47. Post-Term Long nails, peeling skin Simian crease

48. Clubbing of fingers SepsisSCLEREMA Talipes equinovarus

49. Physical Examination at the Neonatal Ward Neurologic examination • Symmetry of movement • Muscle tone : hypotonic /hypertonic • Reflex : Grasp, Moro, Rooting • Cranial nerve • Peripheral nerve : - Erb-Duchenne paralysis - Klumpke’s paralysis • GESTATIONAL AGE

50. Reflex Grasp Reflex Plantar grasp Reflex Rooting Reflex