PAEDIATRIC EXAMINATION
Q&A COUNT: 39*
External Markers of Tuberculosis
External Markers of Liver cell failure
1. Alopecia
2. Hepatic facies - sunken cheeks/ eyes with malar prominence, enlarged parotids
3. Bitot spots
4. KF ring
5. Conjuctival hemorrhage
6. Xanthalesma
7. Icterus
8. Loss of buccal pad of fat
9. Parotid enlargement
10. Foetor hepaticus
11. Spider nevi
12. Gynecomastia
13. Palmar erythema
14. Dupuytren's contracture
15. Asterixis
16. Leuconychia
17. Caput medusae
18. Testicular atrophy
19. Scratch marks/ Pruritus) Bruising
20. Loss of axillary hair
Criteria for Short Neck?
Measure distance between occipital prominence and C7 vertebra
If this distance/total body height =13: it is normal
If this distance/total body height >14: it is a case of SHORT NECK
Criteria for Micropenis?
Less than -2.5 SD for any age
(or)
Less than 2.5 cm at birth
Normal Penis Size
Birth - 4 cm
4 years - 5 cm
11 years - 6 cm
Adolescent - 12 cm
How to assess Brachycephaly?
Using CRANIAL INDEX
Cranial Index = (Biparietal diameter/Occipitofrontal diameter) x 100
Normal Cranial index = 76-80
Cranial Index in Brachycephaly = 81-85
Criteria for Hypertelorism?
Using Canthal Index
Canthal Index = (Distance between inner canthus/ Distance between outer canthus) x 100
Normal Canthal index = 33-38
In Hypertelorism, canthal index will be >38
Also seen in Thalassemia*
Criteria for Low set ears
Normally, 1/3rd of ear lies above outer canthus and 2/3rd of ear lies below outer canthus of eye.
If <1/3rd of ear lies above outer canthus of eye, we can call it as "Low set ears"
What is Clinodactyly?
Congenital radial or ulnar deviation of little finger
What is Syndactyly?
Fusion or webbing of two or more digits
What is Polydactyly?
More than 5 fingers
What is Brachydactyly?
Short and stubby fingers
(8) Fontanelles, Bossing, Craniotabes
Method of measuring Anterior Fontanelle
Causes for Delayed closure of Anterior Fontanel (related to our cases)
1. Down syndrome
2. Preterm infants
3. Malnutrition
4. Congenital hypothyroidism
5. Rickets
6. Thalassemia
Sunken Fontanelle seen in?
Dehydration
Clinical sign for Increased Intracranial pressure which occurs only in children less than 2 years
Bulging of Anterior Fontanelle
(This is considered to be a contra-indication for Lumbar puncture)
Note: Another cause for Bulging Fontanelle - Vitamin D dependent Rickets
CRANIAL BOSSING?
Characterized by rounded prominence at centre of skull bones
Causes of bossing at different skull bones
Frontal & parietal bossing - Rickets
Occipital bossing - Thalassemia
What is Craniotabes?
Thin, parchment like soft areas that can be intended like ping pong ball, along suture lines. Seen preferably in Parietal bones.
Causes:
1. Physiological - upto 3 months
2. Rickets
3. Hydrocephalus, Hypervitaminosis A, Osteogenesis imperfecta, Congenital syphilis
Q&A COUNT: 39*
(1) External Markers:
Name the external markers of Congenital Heart disease
 |
| This picture is taken from Aruchamy textbook of Paediatrics |
External markers of cardiac failure
 |
| This picture is taken from OP Ghai textbook of Paediatrics |
Neuro cutaneous markers
 |
| This picture is taken from Aruchamy textbook of Paediatrics |
External Markers of Tuberculosis
TUBERCULOSIS:
a) Scrufuloderma (side of neck)
b) Phlyctens (eyes)
c) Lupus vulgaris (face/neck)
d) Tinea versicolor
e) Erythema nodosum (shin)
f) Coroid tubercle (fundus)
g) Nimbus (spine)
h) Epididymo orchitis
a) Scrufuloderma (side of neck)
b) Phlyctens (eyes)
c) Lupus vulgaris (face/neck)
d) Tinea versicolor
e) Erythema nodosum (shin)
f) Coroid tubercle (fundus)
g) Nimbus (spine)
h) Epididymo orchitis
2. Hepatic facies - sunken cheeks/ eyes with malar prominence, enlarged parotids
3. Bitot spots
4. KF ring
5. Conjuctival hemorrhage
6. Xanthalesma
7. Icterus
8. Loss of buccal pad of fat
9. Parotid enlargement
10. Foetor hepaticus
11. Spider nevi
12. Gynecomastia
13. Palmar erythema
14. Dupuytren's contracture
15. Asterixis
16. Leuconychia
17. Caput medusae
18. Testicular atrophy
19. Scratch marks/ Pruritus) Bruising
20. Loss of axillary hair
(2) Typical Facies
Mention some Typical Facies
- Hypothyroid facies - related to Neonatal Jaundice case
- Hemolytic facies - related to Hemolytic anemia case
- Mongoloid facies - related to Down's syndrome case
- Oldman facies - seen in Marasmus
Hypothyroid or Cretinoid facies - describe
Thick, heavy face with a dull look
Thick eyebrows
Thick protruding tongue
Describe Hemolytic or Chipmunk facies
1. Maxillary hyperplasia
2. Prominent parietal eminence
3. Occipital bossing
4. Prominent malar bones
5. Widely spaced eyes
6. Depressed nasal bridge
What is Mongoloid facies?
Comprises the following:
1. Flat facial profile
2. Flat nasal bridge
3. Mongoloid slant - outer canthus at a higher level than inner canthus* (most important)
4. Hypertelorism
5. Small mouth
6. Protruding tongue
Seen in Down's syndrome
Describe Oldman facies
1. Pinched facies (loss of subcutaneous fat)
2. Sunken eyes
3. Hollow cheeks and temples
4. Alert child who is interested in surroundings
Seen in Marasmus
Describe Oldman facies
1. Pinched facies (loss of subcutaneous fat)
2. Sunken eyes
3. Hollow cheeks and temples
4. Alert child who is interested in surroundings
Seen in Marasmus
(3) SAM case
Head to Toe examination - What to look for in a Malnutrition case?
 |
| The pictures above are taken from Aruchamy textbook of Paediatrics |
Why flag sign is occuring in Kwashiorkar? (Denotes Alternative periods of malnutrition and normal nutrition)
(4) ADD Case
Signs of dehydration
Signs of dehydration
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| This picture is taken from OP Ghai textbook of Paediatrics |
(5) Down's syndrome
Hall's Criteria for Down's syndrome
Hall's criteria composed of 10 neonatal signs, out of which presence of more than 6/10 is more probable for Down's syndrome
1. Poor Moro Reflex
2. Hypotonia
3. Flat Facial profile
4. Upward slanting palpebral fissures
5. Morphologically, simple small round ears
6. Redundant loose neck skin
7. Single Palmar crease
8. Hyperextensible large joints
9. Pelvis radiograph morphologically abnormal
10. Hypoplasia of 5th finger middle phalanx
Hall's Criteria for Down's syndrome
Hall's criteria composed of 10 neonatal signs, out of which presence of more than 6/10 is more probable for Down's syndrome
1. Poor Moro Reflex
2. Hypotonia
3. Flat Facial profile
4. Upward slanting palpebral fissures
5. Morphologically, simple small round ears
6. Redundant loose neck skin
7. Single Palmar crease
8. Hyperextensible large joints
9. Pelvis radiograph morphologically abnormal
10. Hypoplasia of 5th finger middle phalanx
Head to Toe findings of Down's syndrome in examination
Head to Toe examination: (very important and must asked)
- Short stature
- Head - Brachycephaly*
- Face - Dysmorphic "Mongoloid" facies/ slant*, Small dysplastic ears
- Eyes - Brush field spots in iris, Cataract, Epicanthic folds of skin extending from upper lid to cover medial canthus of eye
- Oral cavity - High arched palate, fissured tongue
- Neck - Skin folds in neck, Short neck*
- Hand - Clinodactyly, Brachydactyly, Syndactyly, Low set thumb, Simian crease, Distal t triradius, Ulnar loops, Increased atd angle
- Chest - Short sternum
- External Genitalia - Small, Micropenis*
- Feet - Kennedy crease**, Sandal gap**
Criteria for Short Neck?
Measure distance between occipital prominence and C7 vertebra
If this distance/total body height =13: it is normal
If this distance/total body height >14: it is a case of SHORT NECK
Criteria for Micropenis?
Less than -2.5 SD for any age
(or)
Less than 2.5 cm at birth
Normal Penis Size
Birth - 4 cm
4 years - 5 cm
11 years - 6 cm
Adolescent - 12 cm
How to assess Brachycephaly?
Using CRANIAL INDEX
Cranial Index = (Biparietal diameter/Occipitofrontal diameter) x 100
Normal Cranial index = 76-80
Cranial Index in Brachycephaly = 81-85
Criteria for Hypertelorism?
Using Canthal Index
Canthal Index = (Distance between inner canthus/ Distance between outer canthus) x 100
Normal Canthal index = 33-38
In Hypertelorism, canthal index will be >38
Also seen in Thalassemia*
Criteria for Low set ears
Normally, 1/3rd of ear lies above outer canthus and 2/3rd of ear lies below outer canthus of eye.
If <1/3rd of ear lies above outer canthus of eye, we can call it as "Low set ears"
What is Clinodactyly?
Congenital radial or ulnar deviation of little finger
What is Syndactyly?
Fusion or webbing of two or more digits
What is Polydactyly?
More than 5 fingers
What is Brachydactyly?
Short and stubby fingers
DERMATOGLYPHICS
Dermatoglyphics in Down's syndrome
1. Simian crease
2. Kennedy crease
3. Sydney line
4. Increased atd angle
5. Ulnar loops on most fingers. Radial loops on fingers 4,5
 |
| Angle between two creases forming atd angle will be obtuse. Look at your hand - you can see it to be acute* (This picture is taken from Aruchamy textbook of Paediatrics) |
 |
| In Down's syndrome, fingerprint will be of Loop type towards ulnar side of hand. (This picture is taken from Aruchamy textbook of Paediatrics) |
What is Kennedy crease?
Deep sole crease between first and second toes
Seen in Down's syndrome
What is Simian crease?
Single palmar crease running across the palm fully - due to fusion of two distal creases
Associated with Down's syndrome
If there are two transverse creases and proximal one runs fully across palm, then it is called Sydney line* (seen in Down's syndrome and Congenital Rubella)
What is Sandal Gap?
Wide gap between the 1st and 2nd toes
Seen in Down's syndrome
(6) Preterm and Term Newborn Baby - Differences
(6) Preterm and Term Newborn Baby - Differences
1) Moro reflex, Sucking and swallowing reflex are incomplete in a preterm baby
2) Posture - Extended in preterm (due to poor tone) (A term baby keeps its hands and legs flexed)
3) Preterm baby has large head, widely seperated sutures with large fontanelles, small chin, protruding eyes
4) Preterm's hair appears wooly and fuzzy, individual hair fibres can be appreciated seperately
5) Preterm's hair is shiny, thin, gelatinous, bright pink with very little vernix caseosa
6) Breast Bud is absent in preterm
7) Lack of subcutaneous fat in preterm. Small vessels clearly visible underneath epidermis
8) Preterm males - Undescended testis, scrotum poorly developed and less pigmented; Preterm females - labia majora widely seperated exposing labia minora
9) Soles and palms have minimal creases in preterm
10) Soft and pliable ear cartilage
11) Scarf sign - Elbow can be easily brought across the chest with little or no resistance
(7) Neonatal Jaundice case
Quebec's criteria for Congenital Hypothyroidism (in a case of Neonatal Jaundice) |
| This picture is taken from Google search |
(8) Fontanelles, Bossing, Craniotabes
Fontanelles - age of closure?
AF by 7-19 months
PF by 2 months
Method of measuring Anterior Fontanelle
Normally it would be around 2 x 2 cm approximately
Causes for Delayed closure of Anterior Fontanel (related to our cases)
1. Down syndrome
2. Preterm infants
3. Malnutrition
4. Congenital hypothyroidism
5. Rickets
6. Thalassemia
Sunken Fontanelle seen in?
Dehydration
Clinical sign for Increased Intracranial pressure which occurs only in children less than 2 years
Bulging of Anterior Fontanelle
(This is considered to be a contra-indication for Lumbar puncture)
Note: Another cause for Bulging Fontanelle - Vitamin D dependent Rickets
CRANIAL BOSSING?
Characterized by rounded prominence at centre of skull bones
Causes of bossing at different skull bones
Frontal & parietal bossing - Rickets
Occipital bossing - Thalassemia
What is Craniotabes?
Thin, parchment like soft areas that can be intended like ping pong ball, along suture lines. Seen preferably in Parietal bones.
Causes:
1. Physiological - upto 3 months
2. Rickets
3. Hydrocephalus, Hypervitaminosis A, Osteogenesis imperfecta, Congenital syphilis