Pediatric Assessments PDF

OT1028 MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS SHIFT 1 Pediatric Assessments...

OT1028 MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS SHIFT 1 Pediatric Assessments LESSON Dr. Richelle Ann S. Santiano| August 30, 2024 02 TABLE OF CONTENTS 1. History 1.1. Brief History 1.2. History of Presenting Problem 1.3. Family History 1.4. Social and Educational History 2. Physical Examination 2.1. Observation 2.2. Examination by Age 2.3. Growth 2.4. Inspection 2.5. Palpation 2.6. Neuromuscular System 3. Assessment 3.1. Musculoskeletal Assessment 3.2. Neurologic Assessment 3.3. Functional Assessment LEGEND Fetal alcohol syndrome ★ Important / Take Note ✤ Textbook Information ○ Short intercanthal space ➤ Lecturer’s Verbatim ❐ Other Transes/Resources ○ Fascies SETTING THE TONE SUBSTANCES AND ABNORMALITIES Child-friendly Small table and chair Categories Description Toys for different ages, pictures of cartoon characters or animals on the wall A Adequate studies on pregnant women indicated Examiner’s attire (bright colors) no foetal risk Valuable skills: observant, flexible and spontaneous, B Animal studies have showed no evidence of creative with play and other activities that foster intrinsic harm to the foetus, but lack of studies in motivation in children pregnant women HISTORY C Animal studies have shown adverse effect or no animal studies are conducted and no adequate Based on age and developmental level studies in pregnant women Reason for referral, evaluation process, and management D Studies showed risk to foetus, but benefit may BIRTH HISTORY outweigh the risk Maternal complications during pregnancy: seizures, X Studies showed evident risk to the foetus and febrile illnesses, hypertension, or hyperglycemia use of the drug is contraindicated in pregnant Medications, supplements, alcohol, tobacco or other women substances Duration of gestation, presence of multiple fetuses, fetal NEURAL TUBE DEFECTS presentation Folate intake Decrease in fetal movement Complications with previous pregnancies–stillbirth, miscarriages, or fetal anomalies Child’s birth weight, length, and Apgar scores Postnatal complications: Hyperbilirubinemia, retinopathy of prematurity, respiratory difficulties, feeding difficulties, and duration of respiratory support UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 1 OT1026 SHIFT #1 | LESSON #1 | Pediatric Assessments Defect Description Craniorachischisis Completely open brain and spinal cord Anencephaly Open brain and lack of skull vault Encephalocele Herniation of the meninges (and the brain) Iniencephaly Occipital skull and spine defects with extreme retroflexion of the head Spina Bifida Closed asymptomatic NTD in which some of the Occulta vertebrae are not completely closed Closed Spinal Deficiency of at least two vertebral arches, here Dysraphism covered with a lipoma Meningocele Protrusion of the meninges (filled with CSF) through a defect in the skull or spine Myelomeningocele Open spinal cord (with a meningeal cyst) HISTORY OF PRESENTING PROBLEM Onset Associated factors Progression of symptoms ○ Static? Worsening? Improving? Diagnostic tests and treatment ○ Therapeutic modalities? Temperament and personality ○ Have an idea of child’s readiness to participate in therapy ○ Whether it’s not not normal if child is restless, no crying, excessive crying, hyperactive DEVELOPMENTAL HISTORY Significant illnesses, hospitalizations, surgeries, previous trauma, injuries, burns, fractures, allergies, feeding intolerance, respiratory complications Medications Immunization ○ Risk for disorders like polio and tetanus APGAR SCORES SIGN 0 1 2 Appearance Pale Body Pink, Extr. All Pink Blue Pulse Absent Less than 100 Over 100 Reflex No Response Grimace Cry Irritability Muscle Tone Limp Some Flexion Active Motion Delay motoric in nature → neuromuscular disorder Respiratory Absent Slow, Irregular Good Cry ○ First report → Lack of spontaneous movement Rate when a child is put on the crib (hypotonic or Recorded at 2 minutes, 5 minutes, and 10 minutes spastic) Score of 7-10 is considered normal Delay in speech ○ Hearing loss (infants start to fall behind after 6-8 months) ○ True language dysfunction Affects reception and expression ○ Oral motor dysfunction History of recurrent ear infections and antibiotic use ○ Aminoglycocites and cochlear toxicity Visual impairment UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 2 OT1026 SHIFT #1 | LESSON #1 | Pediatric Assessments FAMILY HISTORY SCHOOL-AGED AND ADOLESCENTS Early stroke, early myocardial infarction, peripheral Children with cognitive deficits need to be approached neuropathy, joint or tissue abnormalities, myopathies, or according to their mental rather than chronologic age bony abnormalities, gait abnormalities, or developmental Older children and adolescents can easily be evaluated delays on the examination table ○ Pattern of inheritance of diseases Adolescents’ concerns may be different from those of the Genetic testing if warranted family and should be addressed with respect and privacy Take note of the increasing functional needs in IADLs and other areas of competence – educational achievements, SOCIAL AND EDUCATIONAL HISTORY writing, reading, arithmetic (3Rs) Child’s environment ○ Who lives with the child at home? Siblings? Own room? GROWTH Accessibility Peer group HEIGHT ○ Influence on the child Measuring Height: Extracurricular activities ○ Average full-term newborn — 50 cm in length ○ Hobbies, interests, sports ○ Increases 50% by age 1 Educational history ○ Doubles by 4 years of age ○ Delays in schooling? Regular school or SPED? ○ Adult height can be estimated by doubling its height at age 2 years PHYSICAL EXAMINATION Turner and Down syndrome – short stature ○ Turner – XO chromosome instead of XX OBSERVATION ○ Down’s – Trisomy 21 Reaction to separation from the parents (in young Precocious puberty – growth Arrest children) ○ Onset of puberty in girls younger than 8 years Apparent visual and auditory awareness and boys younger than 9 years of age (early) Temperament (calm or hyperactive, compliant or difficult) Spina bifida and other disabilities that require full time Spontaneous exploration and interest in toys, games, or wheelchair use, arm span measurement is recommended books in the room instead of height. Style, concentration, attention span or distractibility during Extremity length and girth are recorded in children with play neurogenic weakness, epiphyseal fracture, or arthritis. Level and manner of motor activities Attempts to engage the parents and examiner in WEIGHT conversation, vocabulary, complexity of language, and Normal for the infant to initially lose weight quality of speech By 5 months of age, the weight should have doubled Interaction with parents or examiner (appropriate, shy, or By a year, the child should have tripled its birth weight demanding) Decreases in height velocity or weight loss Poor nutrition or malabsorption Significant increase in weight EXAMINATION BY AGE ○ Pituitary tumor, metabolic disorder, or poor diet HEAD CIRCUMFERENCE INFANTS AND YOUNG CHILDREN Average head circumference at birth is 35 cm Develop rapport ○ Increases to 47 cm by 1 year of ageA ○ Popular cartoon character to gain interest while Macrocephaly testing ○ HC greater than 2 SDs above the mean Easy tools to engage a child and test visual fixation, ○ Quick inspection of the parents’ head sizes may reach, grasp, and release help to differentiate between a familial trait and Hearing, vision, cranial nerves and postural abnormalities hydrocephalus or some type of mass also can be observed Microcephaly ○ Vision: Follows pen light ○ HC greater than 2 SDs below the mean ○ Hearing: Name calling ○ Brain has not fully formed or growth has been A very young child is typically most comfortable on the arrested parent’s lap during the examination The actual hands-on examination is the last stage; anxiety-provoking or painful tests are preferred to the end Giving choices involves preschool child in examination UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 3 OT1026 SHIFT #1 | LESSON #1 | Pediatric Assessments INSPECTION PALPATION Facial anomalies, epicanthal folds, increased intercanthal In infants and young children, the fontanelles and cranial distance, external ear anomalies, palmar simian crease, sutures should be palpated for patency, tension, and size malformations of toes and fingers The skin should be felt for texture, temperature, and Skin examination: port wine stains (Sturge-Weber absent or excessive perspiration syndrome), café-au-lait spots, axillary freckling, scalded Subcutaneous abnormalities may be palpable skin appearance, purpura, ash-leaf spots, telangiectasia, When arthritis is suspected, each joint should be felt for malar rash cardinal signs of inflammation ○ Warmth, discomfort, swelling Palpation of muscle tone and bulk NEUROMUSCULAR SYSTEM Testing reflexes, tone, active motion, strength, and coordination After 4-5 years of age the standard examination is generally applicable Infancy reflex testing In the first few months of life, flexor tone predominates Hypo or hypertonia signals neurologic abnormalities Child should be examined in supine, prone, and vertical positions to elicit typical postures ○ Increased scissoring, extension, and plantarflexion when child is suddenly lifted into vertical suspension (cerebral palsy) A 4-month old infant elevates the head and trunk on extended arms in the prone position Sacral dimple, skin lesions over the spine, and/or a hairy ○ Scapular winging → weak serratus anterior mm tuft Lifting up under the axilla elicits spontaneous active Cranial deformities, facial dysmorphisms, and shoulder depression asymmetries ○ Shoulders slide upward, virtually touching the Joint abnormalities or asymmetry of stature or sides ears → suggest myopathy with proximal ○ Varus or valgus deformity or claw toes weakness ○ Calluses, bruises and abrasions Walking on tiptoes, squatting and rising without using the ○ Anterior axillary and upper chest muscle atrophy arms for assistance, and straight sitting up from supine ○ Congenital clubfeet or multiple joint deformities position or to the side – 3 years ○ Hypertrophy of the calf (Duchenne muscular Testing for Trendelenburg sign and grading the triceps dystrophy) surae – 4 years ○ Scoliosis The standard technique of manual muscle testing – after school age, except in children who have serious behavioral problems or mental retardation Detection of coordination deficit is based mostly on observation of gross and fine motor function – less than 2-3 years Around 3 years of age, the child can walk along a straight line, unsteadily placing one foot in front of the other Clumsiness of handwriting and drawing, difficulties in physical education or sports, and other subtle signs may be suggestive of apraxia, visuomotor perceptual deficit, or learning deficit UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 4 OT1026 SHIFT #1 | LESSON #1 | Pediatric Assessments ASSESSMENTS MUSCULOSKELETAL ASSESSMENT Inspection and palpation of the bones, joints, and muscles Lymphedema, congenital amputations, calf hypertrophy Brachydactyly (lack finger/s), polydactyly (extra finger/s), syndactyly (webbed finger/s) Tenderness, swelling, warmth, and synovial thickening Passive and active range of motion of all joints ○ A full-term infant may lack as much as 25° of elbow extension and 30° of hip extension ○ A preterm infant has increased range of motion Gait Abnormalities Description as a result of lower muscle tone (scarf sign) ○ Differences between bilateral hip abduction, Talipes Congenital deformity in which the foot is twisted from its normal position apparent shortening of one leg and asymmetric gluteal and upper thigh skin folds are highly Tail Ankle suggestive of congenital or acquired hip dysplasia Pes Foot ○ An early varus configuration of the tibia Talipes Cavus High arched foot contribute to the physiologic bowleg appearance in infancy and corrects itself by 2-3 years of age Talipes equinus Plantar Flexion Talipes calcaneus Dorsiflexion Talipes Valgus Abduction and eversion Talipes Varus Adduction and inversion Passive and active range of motion of all joints ○ Loss of range of motion - joint contracture from arthrogryposis, orthopedic conditions such as Klippel-Feil syndrome, spasticity, pain, inflammatory disorders such as juvenile inflammatory arthritis, or trauma. ○ Hypermobility of joints and skin elasticity – Marfan syndrome Gait abnormalities evident on clinical observation UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 5 OT1026 SHIFT #1 | LESSON #1 | Pediatric Assessments Tibial Torsion — In-toeing in toddler GAIT ABNORMALITIES Femoral Anteversion — In-toeing in older child Hip or leg length discrepancy – hip may be subluxed or Gait Characteristic(s) Clinical Association dislocated Spastic Adducted hips Cerebral palsy Child’s knee should be evaluated for stability, mobility, Internal rotation of hips and positioning Toe walking Child’s foot can be normal at (pes planus) until 3-5 years Crouched Weak quadriceps Neuromuscular Charcot-Marie-Tooth disease Weak hip extensors disease ○ Pes cavus with sensory loss, weakness in ankle Excessive dorsiflexion Cerebral palsy dorsiflexors and clawing of toes Hip or knee contractures Hemiparetic Posturing of upper limb Cerebral palsy Circumduction of hip Cerebral vascular Inversion of foot accident (CVA) Waddling / Weakness of hip girdle Neuromuscular Trendelenburg Wide-based gait disease Ataxic Coordination problems Cerebellar ataxia Poor tandem walking Friedreich ataxia NEUROLOGIC ASSESSMENT Cranial nerve function, sensory function, strength, movement, reflexes, coordination, balance, gait, and cognitive function Sensory function - light touch, proprioception, vibratory, pain, and temperature sensation Back and Spine Examination ○ Objective evaluation is generally feasible after ○ Examined in both sitting and standing positions 5-6 years Any leg length discrepancy may affect ○ Nonverbal cues – looking at a light touch the spine and pelvis examination stimulus or pulling the limb away when touched Shoulder height, the position of the scapulae, the space Visual stimulus – bright light or interesting object between the trunk and the upper limbs, and the height of ○ Track an object to midline at 1 month the pelvis should be evaluated ○ Track an object from side to side at 3 months Idiopathic scoliosis in adolescent girls is the most ○ Perception of color at 8 weeks common type of scoliosis ○ Depth perception at 3-5 months ○ The spine curve should be evaluated by serial Visual evaluation radiographs to determine the severity, flexibility, ○ Stycar test and the illiterate E chart are used for and progression of the curve over time screening preschool children at risk for visual ○ The rib hump can be further accentuated by deficit. having the child bend forward Auditory evaluation ○ In the infant, hearing can be evaluated by clapping or making a loud noise and watching for a startle (Moro) or blink response ○ Older children should respond to rubbing one’s fingers close to their ears or using toys that make sounds Primitive and postural responses ○ Primitive reflexes are suppressed between 3-6 months UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 6 OT1026 SHIFT #1 | LESSON #1 | Pediatric Assessments Manual muscle examination FUNCTIONAL ASSESSMENT ○ Not very accurate before the age of 5 years, but Functional independence wee the child should show at least antigravity ○ Functional Independence Measure (weeFIM) strength Developmental skills Tone ○ Denver Developmental Screening Test (DDST-II) ○ Hypotonia – neuromuscular abnormality - birth to 6 years of age ○ Hypertonia – spasticity (catch), dystonia ○ Bayley Scales of Infant Development - from birth (co-contraction), and rigidity (all throughout) to 30 months of age Gait ○ Gesell Developmental Schedule - from 4 weeks ○ Pattern changes and progresses from 1-7 years to 6 years Intellectual evaluation PRIMITIVE REFLEXES ○ Stanford-Binet Intelligence Scale ○ Wechsler Preschool and Primary Scale of Resolves by Reflex Stimulus Response Intelligence-Revised (WPPSI-R) (Months) ○ Wechsler Intelligence Scale for Moro Sudden neck Shoulder abduction, 3-4 Children-Revised (WISC-R) extension elbow and finger extension followed by ○ Kaufman Assessment Battery for Children shoulder adduction Academic achievements and elbow flexion, ○ Wide Range Achievement Test—Revised infant may cry (WRAT) Rooting Stroking area Head and mouth 4 ○ Woodcock-Johnson Psychoeducational Battery: around the mouth move toward Test of Achievement stimulus ○ Peabody Individual Achievement Test Galant Stroke skin along Trunk flexes to the 2-6 Visual motor abilities the side of the side that is stroked ○ Beery-Buktenica Developmental Test of Visual spine with the child in prone Motor Integration and the Bender Visual Motor Gestalt Test Palmar Touch palm Flexion of all fingers 5-6 ○ Rey-Osterrieth Complex Figure Test Grasp Social and adaptive skills and perceived quality of life ATNR Head turned to Arm and leg on face 6-7 ○ Vineland Adaptive Behavioral Scale side side and flex on ○ Pediatric Quality of Life Inventory (PedsQL) occipital side Disability-specific assessment STNR Neck flexion and Arm flex, legs 9 - 11 ○ Gross Motor Function Measure (GMFM-66) neck extension extends, arm extend, ○ 32 the Manual Abilities Classification Scale legs flex (MACS) ○ Quality of Upper Extremity Skills Test (QUEST) POSTURAL REACTIONS SUMMARY Reflex Stimulus Response Age of Emergence Pediatric history and examination should be Head Vestibular or Head and face Prone: 2 months individualized. righting visual aligned vertical and Rehabilitation approaches and goals should be tailored to mouth aligned Supine: 3-4 months horizontal the child’s developmental level. Assessment tools will assist in determining the child’s Protective COG Abduction of upper Sititng anterior: 5-7 strengths and weaknesses in all domains. extension displaced limb toward months outside base displacement to Inform the family about the findings of the examination of support in prevent falling Lateral: 6-8 months and the rehabilitation plan. sitting The client should be treated holistically. Posterior: 7-8 Future needs in care and functional rehabilitation should months be provided. Parachute COG Extension of upper Standing: 12-14 reaction displaced limbs outside base months toward of support in displacement to standing prevent falling UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 7