diff --git a/public/data/pe-guide.json b/public/data/pe-guide.json
new file mode 100644
index 0000000..4f916a1
--- /dev/null
+++ b/public/data/pe-guide.json
@@ -0,0 +1,4177 @@
+{
+ "scales": {
+ "mrc": {
+ "title": "MRC strength grade (0–5)",
+ "icon": "fa-hand-fist",
+ "rows": [
+ [
+ "5",
+ "Normal power — holds against full resistance"
+ ],
+ [
+ "4",
+ "Reduced — moves against gravity + some resistance"
+ ],
+ [
+ "3",
+ "Moves against gravity only (no added resistance)"
+ ],
+ [
+ "2",
+ "Full range with gravity eliminated (horizontal plane)"
+ ],
+ [
+ "1",
+ "Flicker / trace contraction, no joint movement"
+ ],
+ [
+ "0",
+ "No contraction"
+ ]
+ ]
+ },
+ "dtr": {
+ "title": "Deep-tendon reflex grade (0–4+)",
+ "icon": "fa-circle-dot",
+ "rows": [
+ [
+ "0",
+ "Absent"
+ ],
+ [
+ "1+",
+ "Hypoactive — trace, only with reinforcement"
+ ],
+ [
+ "2+",
+ "Normal"
+ ],
+ [
+ "3+",
+ "Brisk — may still be normal in anxious patients"
+ ],
+ [
+ "4+",
+ "Hyperactive with sustained clonus — always abnormal"
+ ]
+ ]
+ },
+ "plantar": {
+ "title": "Plantar response (Babinski)",
+ "icon": "fa-shoe-prints",
+ "rows": [
+ [
+ "Down-going",
+ "Normal in anyone ≥ 2 years"
+ ],
+ [
+ "Up-going",
+ "Normal < 2 years; abnormal after — UMN lesion"
+ ],
+ [
+ "Asymmetric",
+ "Always abnormal at any age"
+ ]
+ ]
+ },
+ "beighton": {
+ "title": "Beighton hypermobility score (0–9)",
+ "icon": "fa-hands",
+ "rows": [
+ [
+ "≤ 3",
+ "Normal flexibility"
+ ],
+ [
+ "4",
+ "Borderline — consider in context"
+ ],
+ [
+ "≥ 5",
+ "Hypermobility spectrum; screen for hEDS if other features present"
+ ]
+ ]
+ },
+ "atr": {
+ "title": "Scoliometer — angle of trunk rotation",
+ "icon": "fa-ruler",
+ "rows": [
+ [
+ "< 5°",
+ "Normal, no follow-up"
+ ],
+ [
+ "5–6°",
+ "Borderline — re-check at each visit"
+ ],
+ [
+ "≥ 7°",
+ "Refer for PA/lateral spine x-ray + orthopedic evaluation"
+ ]
+ ]
+ },
+ "rr": {
+ "title": "Respiratory rate — upper limit by age (awake)",
+ "icon": "fa-lungs",
+ "rows": [
+ [
+ "Newborn",
+ "≤ 60 /min"
+ ],
+ [
+ "< 2 months",
+ "≤ 60 /min (WHO tachypnea cutoff)"
+ ],
+ [
+ "2–12 months",
+ "≤ 50 /min (WHO tachypnea cutoff)"
+ ],
+ [
+ "1–5 years",
+ "≤ 40 /min (WHO tachypnea cutoff)"
+ ],
+ [
+ "6–11 years",
+ "≤ 30 /min"
+ ],
+ [
+ "≥ 12 years",
+ "≤ 20 /min (adult pattern)"
+ ]
+ ]
+ },
+ "spo2": {
+ "title": "Pulse oximetry (SpO₂) — at room air",
+ "icon": "fa-heart-pulse",
+ "rows": [
+ [
+ "≥ 95%",
+ "Normal"
+ ],
+ [
+ "92–94%",
+ "Mild hypoxemia — investigate cause"
+ ],
+ [
+ "< 92%",
+ "Moderate hypoxemia — supplemental O₂"
+ ],
+ [
+ "< 88%",
+ "Severe — urgent intervention; target ≥ 90% acutely"
+ ]
+ ]
+ },
+ "silverman": {
+ "title": "Silverman–Andersen retraction score (neonatal, 0–10)",
+ "icon": "fa-baby",
+ "rows": [
+ [
+ "0",
+ "No respiratory distress"
+ ],
+ [
+ "1–3",
+ "Mild — close observation"
+ ],
+ [
+ "4–6",
+ "Moderate distress — consider CPAP / support"
+ ],
+ [
+ "7–10",
+ "Severe — imminent respiratory failure, intubate"
+ ]
+ ]
+ },
+ "westley": {
+ "title": "Westley croup severity score",
+ "icon": "fa-stethoscope",
+ "rows": [
+ [
+ "≤ 2",
+ "Mild — home management, cool mist, oral dexamethasone"
+ ],
+ [
+ "3–5",
+ "Moderate — nebulised epinephrine + dexamethasone"
+ ],
+ [
+ "6–11",
+ "Severe — admit, continuous monitoring"
+ ],
+ [
+ "≥ 12",
+ "Impending respiratory failure — ICU / airway management"
+ ]
+ ]
+ },
+ "murmurGrade": {
+ "title": "Heart-murmur grading (Levine 1–6)",
+ "icon": "fa-wave-square",
+ "rows": [
+ [
+ "1/6",
+ "Very faint — heard only with concentration"
+ ],
+ [
+ "2/6",
+ "Soft but readily heard"
+ ],
+ [
+ "3/6",
+ "Moderately loud, no thrill"
+ ],
+ [
+ "4/6",
+ "Loud WITH a palpable thrill"
+ ],
+ [
+ "5/6",
+ "Very loud; audible with stethoscope just off the chest"
+ ],
+ [
+ "6/6",
+ "Audible without the stethoscope touching the chest"
+ ]
+ ]
+ },
+ "pulseAmp": {
+ "title": "Pulse amplitude grade (0–4)",
+ "icon": "fa-heart-pulse",
+ "rows": [
+ [
+ "0",
+ "Absent"
+ ],
+ [
+ "1+",
+ "Diminished, thready"
+ ],
+ [
+ "2+",
+ "Normal"
+ ],
+ [
+ "3+",
+ "Bounding"
+ ],
+ [
+ "4+",
+ "Bounding with visible pulsation (e.g., aortic regurgitation)"
+ ]
+ ]
+ },
+ "capRefill": {
+ "title": "Capillary refill time",
+ "icon": "fa-hand",
+ "rows": [
+ [
+ "< 2 sec",
+ "Normal"
+ ],
+ [
+ "2–3 sec",
+ "Borderline — consider hydration / perfusion"
+ ],
+ [
+ "≥ 3 sec",
+ "Delayed — dehydration, shock, low cardiac output"
+ ]
+ ]
+ }
+ },
+ "systemScales": {
+ "msk": [
+ "atr",
+ "beighton"
+ ],
+ "neuro": [
+ "mrc",
+ "dtr",
+ "plantar"
+ ],
+ "resp": [
+ "rr",
+ "spo2",
+ "silverman",
+ "westley"
+ ],
+ "cv": [
+ "murmurGrade",
+ "pulseAmp",
+ "capRefill"
+ ]
+ },
+ "aptmLegend": [
+ {
+ "letter": "A",
+ "color": "#dc2626",
+ "title": "Aortic area",
+ "location": "2nd ICS, right sternal border",
+ "listen": "S2 (aortic component), aortic stenosis, aortic regurgitation"
+ },
+ {
+ "letter": "P",
+ "color": "#2563eb",
+ "title": "Pulmonic area",
+ "location": "2nd ICS, left sternal border",
+ "listen": "S2 (pulmonic component), pulmonic stenosis, PDA, physiologic split of S2",
+ "innocent": "Pulmonary flow murmur (children, adolescents) — upper left sternal border"
+ },
+ {
+ "letter": "E",
+ "color": "#059669",
+ "title": "Erb's point",
+ "location": "3rd ICS, left sternal border",
+ "listen": "Aortic regurgitation (best here), transitional zone murmurs",
+ "innocent": "Still's murmur classically radiates to Erb's / LLSB"
+ },
+ {
+ "letter": "T",
+ "color": "#d97706",
+ "title": "Tricuspid area",
+ "location": "4th–5th ICS, lower left sternal border",
+ "listen": "Tricuspid regurgitation, VSD, S3/S4, holosystolic murmurs",
+ "innocent": "Still's murmur — vibratory, musical, age 3–7 y (loudest between LLSB and apex)"
+ },
+ {
+ "letter": "M",
+ "color": "#7c3aed",
+ "title": "Mitral area (apex)",
+ "location": "5th ICS, mid-clavicular line",
+ "listen": "S1, mitral regurgitation, mitral stenosis (with bell, left-lateral decubitus)"
+ }
+ ],
+ "innocentMurmurs": [
+ {
+ "name": "Still's (vibratory) murmur",
+ "age": "3–7 y (most common in children)",
+ "location": "LLSB, radiating to apex",
+ "character": "Low-frequency vibratory / musical systolic, grade 2–3/6, mid-systolic, \"twanging-string\" quality",
+ "confirm": "Louder supine, softer or disappears on standing or Valsalva. No radiation to neck/back. Normal S2."
+ },
+ {
+ "name": "Pulmonary flow murmur",
+ "age": "School-age and adolescents, thin chest",
+ "location": "Upper left sternal border (2nd–3rd ICS)",
+ "character": "Soft blowing early systolic ejection, grade 1–2/6, higher-pitched",
+ "confirm": "No ejection click. Physiologic split of S2. Louder supine, softer on standing. No radiation."
+ },
+ {
+ "name": "Venous hum",
+ "age": "Ages 3–8, disappears by adolescence",
+ "location": "Supraclavicular or infraclavicular area, usually right",
+ "character": "Soft continuous hum, louder in diastole. Only innocent continuous murmur.",
+ "confirm": "Disappears when supine OR when jugular vein is gently compressed (key maneuver). Turning head to opposite side also alters it."
+ },
+ {
+ "name": "Carotid bruit / supraclavicular bruit",
+ "age": "Children and adolescents",
+ "location": "Supraclavicular fossa, right > left; may radiate to carotid",
+ "character": "Brief early systolic, grade 2–3/6, higher-pitched than Still's",
+ "confirm": "Softer or disappears with hyperextension of the shoulders. Normal cardiac exam otherwise. No radiation below the clavicles."
+ },
+ {
+ "name": "Peripheral pulmonary stenosis (PPS, neonatal)",
+ "age": "Newborns and infants < 6–12 months",
+ "location": "Upper LSB, radiates to BOTH axillae and the back",
+ "character": "Soft systolic ejection murmur, grade 1–2/6",
+ "confirm": "Typical age + radiation to back/axillae. Resolves by age 1 as branch pulmonary arteries grow. Persistence or louder grade warrants echo."
+ }
+ ],
+ "respiratorySounds": [
+ {
+ "key": "normal",
+ "src": "/audio/respiratory/normal-vesicular.ogg",
+ "title": "Normal vesicular breath sounds",
+ "where": "Peripheral lung fields",
+ "features": "Soft, rustling. Inspiration louder and longer than expiration.",
+ "clinical": "Baseline — deviation elsewhere is what you listen for."
+ },
+ {
+ "key": "wheeze",
+ "src": "/audio/respiratory/wheeze.ogg",
+ "title": "Wheeze",
+ "where": "Diffuse in asthma; localised in foreign body",
+ "features": "Continuous, high-pitched, musical. Usually expiratory; biphasic if severe.",
+ "clinical": "Lower-airway narrowing — asthma, bronchiolitis, foreign body, bronchomalacia. Silent chest in severe asthma is an ominous sign."
+ },
+ {
+ "key": "stridor",
+ "src": "/audio/respiratory/stridor.ogg",
+ "title": "Stridor",
+ "where": "Louder over neck than chest — upper airway",
+ "features": "Continuous, high-pitched, harsh. Classically inspiratory (extrathoracic obstruction); biphasic if fixed.",
+ "clinical": "Croup, epiglottitis, foreign body, laryngomalacia (infant). Distinguish from wheeze by auscultating the neck — stridor is loudest there."
+ },
+ {
+ "key": "finecrackles",
+ "src": "/audio/respiratory/crackles-fine.ogg",
+ "title": "Fine (end-inspiratory) crackles",
+ "where": "Bibasilar in pulmonary edema/fibrosis; focal in pneumonia",
+ "features": "Discontinuous, brief, high-pitched. \"Velcro\" quality. Late inspiratory, do NOT clear with cough.",
+ "clinical": "Alveolar opening — pulmonary fibrosis, pulmonary edema, early pneumonia, atelectasis."
+ },
+ {
+ "key": "coarsecrackles",
+ "src": "/audio/respiratory/crackles-coarse.ogg",
+ "title": "Coarse crackles",
+ "where": "Lower lobes; either side",
+ "features": "Discontinuous, longer and louder than fine crackles. Lower-pitched. Can be early or late inspiratory; often clear partly with cough.",
+ "clinical": "Secretions in larger airways — bronchitis, later pneumonia, bronchiectasis, aspiration."
+ },
+ {
+ "key": "rhonchi",
+ "src": "/audio/respiratory/rhonchi.ogg",
+ "title": "Rhonchi",
+ "where": "Central or anywhere with airway secretions",
+ "features": "Continuous, low-pitched, snore-like. Typically expiratory. Clear or change with cough.",
+ "clinical": "Large-airway secretions — bronchitis, pneumonia with large-airway involvement, cystic fibrosis, bronchiectasis."
+ },
+ {
+ "key": "pleuralrub",
+ "src": "/audio/respiratory/pleural-rub.ogg",
+ "title": "Pleural friction rub",
+ "where": "Focal, often lateral or posterior lower chest",
+ "features": "Grating, creaky — \"leather on leather\". Biphasic (heard in inspiration and expiration). Does NOT clear with cough.",
+ "clinical": "Pleural inflammation — pleuritis, pulmonary embolism, pneumonia with pleural involvement, viral pleurisy."
+ }
+ ],
+ "cardiacSounds": [
+ {
+ "key": "normal",
+ "src": "/audio/cardiac/normal.ogg",
+ "title": "Normal heart sounds (S1, S2)",
+ "where": "All four classic auscultation points",
+ "rate": "~61 bpm reference",
+ "features": "\"lub-dub\": S1 (closure of mitral + tricuspid) louder at apex; S2 (closure of aortic + pulmonic) louder at base. Physiologic S2 split on inspiration.",
+ "clinical": "Reference for rhythm, rate, and the normal S1–S2 interval. Listen for what's changed — not just what's added."
+ },
+ {
+ "key": "infant-normal",
+ "src": "/audio/cardiac/infant-normal.ogg",
+ "title": "Infant normal heart sounds",
+ "where": "Infant chest — rate will be higher than adult",
+ "rate": "Pediatric reference (120–160 bpm range)",
+ "features": "Same S1–S2 pattern, faster rate. Short diastole makes murmurs easier to miss — careful auscultation needed.",
+ "clinical": "Reference for neonatal/infant rhythm. Any murmur in the first 72 h should prompt pre/postductal sat screening."
+ },
+ {
+ "key": "vsd",
+ "src": "/audio/cardiac/vsd.wav",
+ "title": "Ventricular septal defect (VSD)",
+ "where": "Lower left sternal border (4th ICS)",
+ "features": "Harsh, blowing, holosystolic (pansystolic) murmur — plateau shape through all of systole. Often accompanied by a thrill if large.",
+ "clinical": "Most common congenital heart defect. Small VSD: loud murmur, usually asymptomatic, may close spontaneously. Large VSD: softer murmur (less pressure gradient) but signs of heart failure, pulmonary hypertension."
+ },
+ {
+ "key": "mvp",
+ "src": "/audio/cardiac/mitral-prolapse.wav",
+ "title": "Mitral valve prolapse (MVP) — click + late systolic murmur",
+ "where": "Apex (5th ICS, mid-clavicular line)",
+ "features": "Mid-systolic click followed by a late-systolic crescendo murmur. Timing of click changes with maneuvers: earlier with standing or Valsalva, later with squatting.",
+ "clinical": "Often benign, especially in thin young women. Features suggesting need for echo: thickened/redundant leaflets, associated MR, symptoms (palpitations, chest pain), arrhythmias."
+ },
+ {
+ "key": "stills",
+ "src": "/audio/cardiac/stills-murmur.ogg",
+ "title": "Still's murmur (innocent)",
+ "where": "LLSB, radiating to apex",
+ "rate": "Classic age 3–7 y (this recording is a toddler)",
+ "features": "Low-frequency vibratory / musical systolic, grade 2–3/6, mid-systolic, \"twanging-string\" quality.",
+ "clinical": "The most common innocent murmur of childhood. Louder supine, softer or disappears on standing or Valsalva. Normal S2. No radiation to neck or back. No workup needed when classic."
+ },
+ {
+ "key": "functional",
+ "src": "/audio/cardiac/functional-murmur.wav",
+ "title": "Functional (innocent) murmur — adult female",
+ "where": "Left sternal border, soft systolic",
+ "features": "Soft systolic murmur in a structurally normal heart — often from increased cardiac output, thin chest wall, anemia, hyperthyroidism, or pregnancy.",
+ "clinical": "Benign if it meets the 7 S criteria. Investigate if loud (≥3/6), holosystolic, diastolic, radiating, or with thrill / symptoms."
+ }
+ ],
+ "peData": {
+ "newborn": {
+ "label": "Newborn (0–28 days)",
+ "msk": {
+ "overview": "Exam done warm, quiet, undressed. Focus: birth injury, DDH, congenital anomaly. All steps symmetric.",
+ "components": [
+ {
+ "name": "Resting posture",
+ "steps": [
+ {
+ "label": "Observe posture",
+ "method": "Place supine and undisturbed for 30s",
+ "normal": "Symmetric flexion at hips, knees, elbows"
+ },
+ {
+ "label": "Hand position",
+ "method": "Inspect resting hands",
+ "normal": "Loosely fisted; opens intermittently"
+ },
+ {
+ "label": "Symmetry",
+ "method": "Compare left vs right side at rest",
+ "normal": "Mirror-image posture"
+ }
+ ],
+ "abnormalHints": [
+ "Frog-leg (hypotonia)",
+ "Asymmetric arm (brachial plexus/clavicle fx)",
+ "Opisthotonos (CNS)",
+ "Persistent fisting with thumb in palm"
+ ]
+ },
+ {
+ "name": "Clavicles",
+ "steps": [
+ {
+ "label": "Palpate right clavicle",
+ "method": "Trace from sternoclavicular joint to acromion with index finger",
+ "normal": "Smooth, continuous, no step-off"
+ },
+ {
+ "label": "Palpate left clavicle",
+ "method": "Same technique on left side",
+ "normal": "Smooth, continuous"
+ },
+ {
+ "label": "Crepitus check",
+ "method": "Light pressure along length of clavicle while gently abducting arm",
+ "normal": "No crepitus, no pain response"
+ }
+ ],
+ "abnormalHints": [
+ "Palpable step-off or callus (fracture — LGA, shoulder dystocia)",
+ "Asymmetric Moro on affected side"
+ ]
+ },
+ {
+ "name": "Hips — DDH screen",
+ "steps": [
+ {
+ "label": "Thigh/gluteal folds",
+ "method": "Undress completely; compare skin-fold symmetry",
+ "normal": "Symmetric thigh and gluteal folds"
+ },
+ {
+ "label": "Abduction",
+ "method": "Flex hips 90°, abduct simultaneously",
+ "normal": "Both hips abduct to ≥75° symmetrically"
+ },
+ {
+ "label": "Barlow maneuver",
+ "method": "Thumb on medial thigh, flex hip 90°, adduct, apply gentle posterior pressure",
+ "normal": "No clunk or movement felt (negative)"
+ },
+ {
+ "label": "Ortolani maneuver",
+ "method": "From Barlow position: abduct and lift with fingers on greater trochanter",
+ "normal": "No clunk as hip returns (negative)"
+ },
+ {
+ "label": "Galeazzi sign",
+ "method": "Knees flexed together with feet on table; compare knee heights",
+ "normal": "Knees level — no leg-length discrepancy"
+ }
+ ],
+ "abnormalHints": [
+ "Palpable Ortolani clunk (dislocated, reducible)",
+ "Barlow clunk (dislocatable)",
+ "Limited abduction",
+ "Positive Galeazzi (shortened femur)"
+ ]
+ },
+ {
+ "name": "Spine and back",
+ "steps": [
+ {
+ "label": "Position prone",
+ "method": "Turn infant prone, support chest",
+ "normal": "Tolerates position, lifts head briefly"
+ },
+ {
+ "label": "Palpate midline",
+ "method": "Run finger from C-spine to coccyx",
+ "normal": "Straight midline, no step-offs or gaps"
+ },
+ {
+ "label": "Sacral inspection",
+ "method": "Inspect sacral dimple if present; measure depth, distance from anus",
+ "normal": "No dimple, or dimple <5mm deep and <2.5cm from anus"
+ },
+ {
+ "label": "Cutaneous markers",
+ "method": "Inspect midline skin from neck to coccyx",
+ "normal": "No hair tuft, hemangioma, lipoma, or sinus tract"
+ }
+ ],
+ "abnormalHints": [
+ "Deep sacral dimple (>5mm) or >2.5cm from anus — imaging",
+ "Hair tuft, hemangioma, lipoma (occult dysraphism)",
+ "Palpable defect"
+ ]
+ },
+ {
+ "name": "Upper extremities",
+ "steps": [
+ {
+ "label": "Spontaneous movement",
+ "method": "Observe both arms for 30s",
+ "normal": "Symmetric antigravity movement"
+ },
+ {
+ "label": "Digits",
+ "method": "Count and inspect fingers both hands",
+ "normal": "5 digits each, no webbing or duplication"
+ },
+ {
+ "label": "Palmar creases",
+ "method": "Inspect palmar creases",
+ "normal": "Normal triradiate creases"
+ }
+ ],
+ "abnormalHints": [
+ "Erb/Klumpke palsy (paucity of movement)",
+ "Polydactyly, syndactyly",
+ "Single transverse (simian) palmar crease"
+ ]
+ },
+ {
+ "name": "Lower extremities / feet",
+ "steps": [
+ {
+ "label": "Hip and knee range",
+ "method": "Gently flex, extend, internally/externally rotate each",
+ "normal": "Full symmetric range, no contracture"
+ },
+ {
+ "label": "Foot alignment",
+ "method": "Inspect resting foot position",
+ "normal": "Midline or mildly adducted forefoot"
+ },
+ {
+ "label": "Passive correction",
+ "method": "Gently attempt to bring foot to neutral",
+ "normal": "Fully correctable to neutral"
+ },
+ {
+ "label": "Stroke test",
+ "method": "Stroke lateral border of foot",
+ "normal": "Foot dorsiflexes and everts reflexively"
+ }
+ ],
+ "abnormalHints": [
+ "Rigid clubfoot (non-correctable talipes equinovarus)",
+ "Fixed metatarsus adductus",
+ "Rocker-bottom foot (trisomy 18)",
+ "Calcaneovalgus"
+ ]
+ }
+ ]
+ },
+ "neuro": {
+ "overview": "Primitive reflexes present and symmetric. Tone assessed passively and actively. Full exam 3–5 min on a quiet, fed infant.",
+ "components": [
+ {
+ "name": "Alertness and behavior",
+ "steps": [
+ {
+ "label": "State cycling",
+ "method": "Observe over 1–2 min for alert periods",
+ "normal": "Alert periods with spontaneous eye opening"
+ },
+ {
+ "label": "Response to voice",
+ "method": "Speak softly near ear",
+ "normal": "Quiets to voice or turns toward sound"
+ },
+ {
+ "label": "Consolability",
+ "method": "If crying, attempt to soothe with swaddling or voice",
+ "normal": "Consolable within 1–2 min"
+ }
+ ],
+ "abnormalHints": [
+ "Lethargy",
+ "Jitteriness not stopped by passive flexion",
+ "Irritability unrelieved by feeding"
+ ]
+ },
+ {
+ "name": "Cranial nerves",
+ "steps": [
+ {
+ "label": "CN II — pupil response",
+ "method": "Shine light in each eye",
+ "normal": "Pupils equal, reactive to light, direct and consensual"
+ },
+ {
+ "label": "CN II — blink to light",
+ "method": "Bright light in the line of sight",
+ "normal": "Reflex blink"
+ },
+ {
+ "label": "CN VII — facial symmetry at rest",
+ "method": "Observe resting face",
+ "normal": "Symmetric nasolabial folds"
+ },
+ {
+ "label": "CN VII — facial symmetry with cry",
+ "method": "Note face during a cry",
+ "normal": "Symmetric grimace"
+ },
+ {
+ "label": "CN IX, X, XII — suck and swallow",
+ "method": "Offer clean gloved finger, pacifier, or during feed",
+ "normal": "Strong coordinated suck-swallow, no choking"
+ }
+ ],
+ "abnormalHints": [
+ "Asymmetric face (CN VII injury — usually forceps)",
+ "Poor suck or uncoordinated swallow",
+ "Fixed or unequal pupil"
+ ]
+ },
+ {
+ "name": "Tone — passive",
+ "steps": [
+ {
+ "label": "Pull-to-sit",
+ "method": "Grasp hands/wrists, pull smoothly to sit",
+ "normal": "Brief head lag at term; not dramatic"
+ },
+ {
+ "label": "Ventral suspension",
+ "method": "Suspend prone over hand at chest",
+ "normal": "Head briefly lifts to horizontal; extremities flexed"
+ },
+ {
+ "label": "Arm recoil",
+ "method": "Extend both arms fully at elbows, release",
+ "normal": "Rapid return to flexion"
+ },
+ {
+ "label": "Popliteal angle",
+ "method": "Hip flexed 90°, extend knee maximally",
+ "normal": "≤110°"
+ }
+ ],
+ "abnormalHints": [
+ "Marked head lag (hypotonia)",
+ "Slip-through on vertical suspension",
+ "Hypertonia / scissoring",
+ "Floppy limbs with no recoil"
+ ]
+ },
+ {
+ "name": "Spontaneous movement",
+ "steps": [
+ {
+ "label": "Observe limbs",
+ "method": "Undisturbed over 1 min, note movement",
+ "normal": "Symmetric antigravity movement of all 4 limbs"
+ },
+ {
+ "label": "Quality of movement",
+ "method": "Note smoothness vs jitteriness",
+ "normal": "Smooth, mildly variable movements"
+ }
+ ],
+ "abnormalHints": [
+ "Paucity of movement in one limb",
+ "Coarse jitteriness",
+ "Clonic jerks",
+ "Tonic posturing"
+ ]
+ },
+ {
+ "name": "Primitive reflexes",
+ "steps": [
+ {
+ "label": "Moro",
+ "method": "Support head; allow 30° head drop or loud clap",
+ "normal": "Symmetric arm abduction then flexion, often cry"
+ },
+ {
+ "label": "Rooting",
+ "method": "Stroke cheek at corner of mouth",
+ "normal": "Turns head toward stroke and opens mouth"
+ },
+ {
+ "label": "Palmar grasp",
+ "method": "Press into palm with finger",
+ "normal": "Strong, symmetric finger flexion"
+ },
+ {
+ "label": "Plantar grasp",
+ "method": "Press ball of foot below toes",
+ "normal": "Toes flex around finger symmetrically"
+ },
+ {
+ "label": "Stepping",
+ "method": "Hold upright with feet touching surface",
+ "normal": "Alternating stepping movements"
+ },
+ {
+ "label": "Tonic neck (fencing)",
+ "method": "Turn head to one side with infant supine",
+ "normal": "Same-side arm extends, opposite flexes (not obligate)"
+ },
+ {
+ "label": "Galant",
+ "method": "Stroke paravertebrally from shoulder to buttock, one side",
+ "normal": "Trunk curves toward stroked side"
+ }
+ ],
+ "abnormalHints": [
+ "Absent or asymmetric Moro — CNS injury, brachial plexus, clavicle fx",
+ "Absent grasps — CNS depression",
+ "Obligate tonic neck is abnormal"
+ ]
+ },
+ {
+ "name": "Babinski (plantar response)",
+ "steps": [
+ {
+ "label": "Stroke lateral sole",
+ "method": "Firm stroke from heel toward toes along lateral plantar border",
+ "normal": "Up-going great toe with fanning (normal in newborn)"
+ },
+ {
+ "label": "Symmetry check",
+ "method": "Repeat opposite foot",
+ "normal": "Symmetric response"
+ }
+ ],
+ "abnormalHints": [
+ "Asymmetric response is always abnormal"
+ ]
+ }
+ ]
+ },
+ "resp": {
+ "overview": "Newborn respiratory transition — RDS, TTN, pneumonia, meconium aspiration dominate the differential. Normal RR ≤ 60. Grunting is an alarm sign.",
+ "components": [
+ {
+ "name": "Inspection",
+ "significance": "Detects distress and localises cause. Silverman score quantifies retraction severity.",
+ "pearl": "Grunting is physiologic PEEP against a partially closed glottis — always a sign of significant lung pathology in a newborn. Never dismiss it as fussy breathing.",
+ "steps": [
+ {
+ "label": "Respiratory rate",
+ "method": "Count over full 60 s, quiet and undisturbed.",
+ "normal": "40–60 /min; tachypnea > 60"
+ },
+ {
+ "label": "Work of breathing (Silverman)",
+ "method": "Inspect for upper-chest retraction, lower-chest retraction, xiphoid retraction, nasal flaring, grunting. Score 0–2 for each.",
+ "normal": "Total Silverman 0 — no distress"
+ },
+ {
+ "label": "Audible sounds",
+ "method": "Listen without stethoscope — stridor? grunting? wheeze across the room?",
+ "normal": "Quiet respirations"
+ },
+ {
+ "label": "Colour",
+ "method": "Inspect trunk and mucous membranes for central cyanosis; acrocyanosis (blue hands/feet) is normal in the first days.",
+ "normal": "Pink trunk and mucous membranes"
+ },
+ {
+ "label": "Chest shape",
+ "method": "Inspect AP:transverse diameter and symmetry.",
+ "normal": "Slightly barrel-shaped is normal; symmetric"
+ }
+ ],
+ "abnormalHints": [
+ "Grunting — RDS, pneumonia, sepsis, CHD",
+ "Retractions + tachypnea — RDS, TTN, pneumothorax",
+ "Central cyanosis — cyanotic CHD, severe lung disease, persistent pulmonary HTN",
+ "Asymmetric chest movement — pneumothorax, diaphragmatic hernia"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "significance": "Short stethoscope time in neonates because they fuss easily — get the most important zones first.",
+ "pearl": "Listen at the axilla, not just the anterior chest — pneumothorax can sound normal anteriorly. Auscultate both axillae systematically.",
+ "steps": [
+ {
+ "label": "Air entry — anterior",
+ "method": "Listen bilaterally at the upper and lower anterior chest.",
+ "normal": "Symmetric bilateral air entry"
+ },
+ {
+ "label": "Air entry — axillary",
+ "method": "Listen bilaterally at each axilla — this is the most sensitive area for detecting a small pneumothorax.",
+ "normal": "Clear and symmetric"
+ },
+ {
+ "label": "Adventitious sounds",
+ "method": "Listen for transmitted upper-airway sounds, crackles (RDS, pneumonia), grunting sounds.",
+ "normal": "No crackles, no wheeze, clear sounds"
+ },
+ {
+ "label": "Inspiration:expiration ratio",
+ "method": "Observe breath-sound timing.",
+ "normal": "Inspiration > expiration in length"
+ }
+ ],
+ "abnormalHints": [
+ "Asymmetric air entry — pneumothorax, diaphragmatic hernia, endobronchial intubation",
+ "Fine crackles — RDS, TTN, pneumonia",
+ "Absent breath sounds unilaterally — pneumothorax or selective intubation"
+ ]
+ }
+ ]
+ },
+ "cv": {
+ "overview": "Neonatal CV exam screens for CHD — the window of presentation is short and some lesions (duct-dependent) decompensate within hours of birth. Pre/postductal saturations + femoral pulses are the two fastest screens.",
+ "components": [
+ {
+ "name": "Inspection and pre/postductal saturations",
+ "significance": "Pre/postductal SpO₂ differential > 3% suggests a duct-dependent lesion or persistent pulmonary HTN. Universal CCHD screening uses this.",
+ "pearl": "Pulse ox on the right hand = preductal (proximal to PDA insertion). Foot = postductal. Both arms and both legs should match; a differential is a red flag for critical CHD.",
+ "steps": [
+ {
+ "label": "Central cyanosis",
+ "method": "Inspect tongue, lips, oral mucosa.",
+ "normal": "Pink mucous membranes"
+ },
+ {
+ "label": "Pre/postductal SpO₂",
+ "method": "Measure SpO₂ in right hand (preductal) AND either foot (postductal). Baby must be ≥24 hr old for CCHD screening.",
+ "normal": "Both ≥ 95% AND difference < 3%"
+ },
+ {
+ "label": "Peripheral perfusion",
+ "method": "Capillary refill on sternum; note mottling or distal cyanosis.",
+ "normal": "Capillary refill < 2 s, warm pink extremities"
+ },
+ {
+ "label": "Precordial activity",
+ "method": "Inspect anterior chest for hyperactive precordium.",
+ "normal": "Not visible or minimally visible"
+ }
+ ],
+ "abnormalHints": [
+ "Central cyanosis with SpO₂ < 95% → cyanotic CHD workup (4-extremity BP, ECG, hyperoxia test, echo)",
+ "Differential > 3% (pre > post) → duct-dependent systemic flow (HLHS, coarctation, interrupted arch)",
+ "Preductal < postductal — persistent pulmonary HTN with reversed shunt"
+ ]
+ },
+ {
+ "name": "Palpation and auscultation",
+ "significance": "Absent femoral pulses + arm-leg BP gradient = coarctation. Many CHD lesions manifest murmurs only after ductus closes (48–72 h).",
+ "pearl": "Always palpate femoral pulses before discharging any newborn. Absent femorals in a well-appearing baby can be the only finding in a ductal-dependent coarctation — catastrophic if missed.",
+ "steps": [
+ {
+ "label": "Apex beat",
+ "method": "Palpate at the 4th ICS left of sternum (apex is higher in newborns).",
+ "normal": "Palpable at 4th ICS, mid-clavicular or just lateral"
+ },
+ {
+ "label": "Femoral pulses",
+ "method": "Palpate both femoral pulses at the mid-inguinal point while simultaneously feeling the right brachial pulse — detects delay.",
+ "normal": "Present, symmetric, equal timing with brachial"
+ },
+ {
+ "label": "Auscultate each cardiac area",
+ "method": "Use pediatric diaphragm at each classic point; baby quiet if possible.",
+ "normal": "S1 S2 crisp; physiologic flow murmur sometimes present in the first 24–48 h"
+ },
+ {
+ "label": "Continuous murmur",
+ "method": "Listen below the left clavicle for a continuous (\"machinery\") murmur of PDA.",
+ "normal": "No continuous murmur after the first day of life in a term baby"
+ },
+ {
+ "label": "Four-limb BP (if any concern)",
+ "method": "Right arm, left arm, both legs.",
+ "normal": "Within 10 mmHg across limbs"
+ }
+ ],
+ "abnormalHints": [
+ "Absent femoral pulses — coarctation of the aorta (surgical emergency if duct-dependent)",
+ "Harsh holosystolic at LLSB — VSD",
+ "Continuous machinery murmur — PDA (expected in preterm; in term > 48 h is abnormal)",
+ "Gallop S3/S4 — heart failure",
+ "Single S2 — transposition, truncus, severe AS/PS"
+ ]
+ }
+ ]
+ }
+ },
+ "infant": {
+ "label": "Infant (1–12 months)",
+ "msk": {
+ "overview": "Continued DDH screen through 6 months. Watch motor progression and symmetry of tone/movement.",
+ "components": [
+ {
+ "name": "Hips — continued DDH screen",
+ "steps": [
+ {
+ "label": "Thigh-fold symmetry",
+ "method": "Inspect with infant supine, thighs flexed",
+ "normal": "Symmetric folds"
+ },
+ {
+ "label": "Barlow/Ortolani (through 3mo)",
+ "method": "As in newborn — thumb medial, flex 90°, adduct+push then abduct+lift",
+ "normal": "Negative bilaterally"
+ },
+ {
+ "label": "Abduction (any age)",
+ "method": "Flex 90°, abduct simultaneously",
+ "normal": "≥70° symmetric abduction"
+ },
+ {
+ "label": "Galeazzi",
+ "method": "Knees flexed feet flat on exam table",
+ "normal": "Knees equal height"
+ }
+ ],
+ "abnormalHints": [
+ "Clunk on Barlow/Ortolani (<3mo)",
+ "Limited abduction",
+ "Asymmetric folds",
+ "Positive Galeazzi"
+ ]
+ },
+ {
+ "name": "Gross-motor milestones (age-appropriate)",
+ "steps": [
+ {
+ "label": "Head control",
+ "method": "Prone, pull-to-sit, held upright",
+ "normal": "Age-appropriate: 2mo lifts head 45°; 4mo no head lag"
+ },
+ {
+ "label": "Rolling",
+ "method": "Observe on flat surface",
+ "normal": "Rolls back-to-front by 5–6mo"
+ },
+ {
+ "label": "Sitting",
+ "method": "Place in sitting position",
+ "normal": "Tripod sit by 6mo; sits without support by 7–8mo"
+ },
+ {
+ "label": "Standing",
+ "method": "Support under arms",
+ "normal": "Bears weight by 6mo; pulls to stand by 9mo"
+ }
+ ],
+ "abnormalHints": [
+ "Milestone delay by ≥2mo",
+ "Loss of previously attained milestone",
+ "Asymmetric use of limbs"
+ ]
+ },
+ {
+ "name": "Spine",
+ "steps": [
+ {
+ "label": "Palpate seated",
+ "method": "Run finger along spine with infant sitting or held upright",
+ "normal": "Midline, no step-offs"
+ },
+ {
+ "label": "Back curvature",
+ "method": "Inspect sitting and lying",
+ "normal": "Physiologic gentle kyphosis in early infancy; lumbar lordosis as sitting develops"
+ }
+ ],
+ "abnormalHints": [
+ "Fixed kyphoscoliosis",
+ "Sacral dimple with cutaneous marker",
+ "Step-off"
+ ]
+ },
+ {
+ "name": "Extremities",
+ "steps": [
+ {
+ "label": "Passive range",
+ "method": "Through each major joint",
+ "normal": "Full symmetric range"
+ },
+ {
+ "label": "Joint inspection",
+ "method": "Inspect for swelling, warmth, effusion",
+ "normal": "No swelling, warmth, or effusion"
+ },
+ {
+ "label": "Feet alignment",
+ "method": "Observe standing if pulling up, else passive positioning",
+ "normal": "Correctable or aligned feet; flexible"
+ }
+ ],
+ "abnormalHints": [
+ "Joint swelling/warmth (septic vs reactive arthritis)",
+ "Rigid clubfoot",
+ "Persistent asymmetric tone"
+ ]
+ }
+ ]
+ },
+ "neuro": {
+ "overview": "Primitive reflexes fading on schedule; protective reflexes emerging; gross motor and tone interlinked.",
+ "components": [
+ {
+ "name": "Alertness and social engagement",
+ "steps": [
+ {
+ "label": "Social smile",
+ "method": "Face-to-face interaction",
+ "normal": "Social smile by 6–8 weeks"
+ },
+ {
+ "label": "Tracking",
+ "method": "Move object across visual field",
+ "normal": "180° horizontal tracking by 3mo"
+ },
+ {
+ "label": "Engagement",
+ "method": "Face-to-face, voice, toys",
+ "normal": "Age-appropriate reciprocal interaction"
+ }
+ ],
+ "abnormalHints": [
+ "No social smile by 3mo",
+ "Absent tracking past 3mo",
+ "Poor engagement (developmental concern)"
+ ]
+ },
+ {
+ "name": "Cranial nerves",
+ "steps": [
+ {
+ "label": "Pupils",
+ "method": "Light response each eye",
+ "normal": "Equal reactive"
+ },
+ {
+ "label": "Eye alignment",
+ "method": "Inspect with gaze forward and in all directions",
+ "normal": "No strabismus past 4mo"
+ },
+ {
+ "label": "Facial symmetry",
+ "method": "Observe smile and cry",
+ "normal": "Symmetric"
+ },
+ {
+ "label": "Suck and swallow",
+ "method": "Observe feeding",
+ "normal": "Coordinated, no choking"
+ }
+ ],
+ "abnormalHints": [
+ "Persistent nystagmus",
+ "Strabismus past 4mo",
+ "Asymmetric face"
+ ]
+ },
+ {
+ "name": "Tone",
+ "steps": [
+ {
+ "label": "Pull-to-sit",
+ "method": "Gently pull wrists/hands",
+ "normal": "No head lag by 4mo"
+ },
+ {
+ "label": "Ventral suspension",
+ "method": "Support prone, observe",
+ "normal": "Head above horizontal, extremities actively flexed (age-dependent)"
+ },
+ {
+ "label": "Vertical suspension",
+ "method": "Support under arms, lift",
+ "normal": "Does not slip through hands"
+ }
+ ],
+ "abnormalHints": [
+ "Persistent head lag past 4mo (hypotonia)",
+ "Hypertonia / scissoring (UMN)",
+ "Slip-through on vertical suspension"
+ ]
+ },
+ {
+ "name": "Primitive reflex integration",
+ "steps": [
+ {
+ "label": "Moro",
+ "method": "Head drop or clap",
+ "normal": "Absent by 6mo"
+ },
+ {
+ "label": "Palmar grasp",
+ "method": "Press into palm",
+ "normal": "Integrated by 5–6mo; replaced by voluntary grasp"
+ },
+ {
+ "label": "Tonic neck",
+ "method": "Turn head to side",
+ "normal": "Absent by 6mo"
+ },
+ {
+ "label": "Rooting",
+ "method": "Stroke cheek",
+ "normal": "Absent by 3–4mo"
+ }
+ ],
+ "abnormalHints": [
+ "Persistence of any primitive reflex past 6mo warrants eval (CP, CNS injury)"
+ ]
+ },
+ {
+ "name": "Protective and postural reflexes",
+ "steps": [
+ {
+ "label": "Parachute",
+ "method": "Held prone, tilt head downward suddenly",
+ "normal": "Symmetric arm extension protectively by 9mo (emerges 6–9mo)"
+ },
+ {
+ "label": "Lateral propping",
+ "method": "Seated infant, gentle tilt to one side",
+ "normal": "Arm extends to catch by 6–7mo"
+ },
+ {
+ "label": "Landau",
+ "method": "Suspend prone",
+ "normal": "Extends head, spine, legs by 6mo"
+ }
+ ],
+ "abnormalHints": [
+ "Absent parachute after 12mo (concerning)",
+ "Asymmetric lateral propping",
+ "Absent Landau"
+ ]
+ }
+ ]
+ },
+ "resp": {
+ "overview": "Infant respiratory disease centers on bronchiolitis, reactive airways, and pneumonia. Normal RR ≤ 50 (< 2 mo: ≤ 60). Infants are obligate nose-breathers — nasal congestion alone can cause significant WOB.",
+ "components": [
+ {
+ "name": "Inspection",
+ "significance": "Infant distress signs escalate fast. Nasal flaring, tracheal tug, head bobbing = significant WOB. Apnea in an infant < 2 mo is an emergency.",
+ "pearl": "A quiet infant with retractions is more worrying than a crying one — exhausted infants stop crying and become hypoxic silently.",
+ "steps": [
+ {
+ "label": "Respiratory rate",
+ "method": "Count over full 60 s while quiet.",
+ "normal": "< 2 mo: ≤ 60; 2–12 mo: ≤ 50"
+ },
+ {
+ "label": "Work of breathing",
+ "method": "Inspect nasal flaring, subcostal/intercostal/suprasternal retractions, tracheal tug, head-bobbing, accessory muscle use.",
+ "normal": "No retractions, effortless breathing"
+ },
+ {
+ "label": "Audible sounds",
+ "method": "Stridor? Wheeze across the room? Grunting? Prolonged expiration?",
+ "normal": "Quiet respirations"
+ },
+ {
+ "label": "Colour and feeding history",
+ "method": "Central cyanosis? Poor feeding (feeding is an effort marker in infants)?",
+ "normal": "Pink, feeds well"
+ },
+ {
+ "label": "Apnea observation",
+ "method": "Watch for ≥ 20-s pauses or pauses < 20 s with bradycardia/cyanosis.",
+ "normal": "No apneas"
+ }
+ ],
+ "abnormalHints": [
+ "Grunting / persistent retractions — pneumonia, bronchiolitis, CHF",
+ "Wheeze — bronchiolitis (RSV), asthma, foreign body",
+ "Stridor — croup (6 mo–6 y), laryngomalacia (infant), foreign body",
+ "Apnea — bronchiolitis, sepsis, pertussis, seizure"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "significance": "Infants have a thin chest wall — sounds transmit widely. Symmetry, wheeze, and crackles are the main findings.",
+ "pearl": "In bronchiolitis, the classical finding is widespread end-inspiratory fine crackles PLUS expiratory wheeze. Tachypnea + retractions in an RSV-season infant confirms.",
+ "steps": [
+ {
+ "label": "Air entry — bilateral",
+ "method": "Warm stethoscope; listen at anterior chest and both axillae, both sides.",
+ "normal": "Symmetric air entry"
+ },
+ {
+ "label": "Wheeze",
+ "method": "Listen in expiration. Diffuse wheeze = lower airway; focal wheeze = foreign body or local obstruction.",
+ "normal": "No wheeze"
+ },
+ {
+ "label": "Crackles",
+ "method": "Listen in late inspiration. Focal = pneumonia; diffuse fine = bronchiolitis.",
+ "normal": "No crackles"
+ },
+ {
+ "label": "Prolonged expiration",
+ "method": "Note expiration:inspiration length ratio.",
+ "normal": "Inspiration ≥ expiration"
+ }
+ ],
+ "abnormalHints": [
+ "Focal crackles + fever — pneumonia",
+ "Diffuse wheeze + fine crackles in an RSV-season infant — bronchiolitis",
+ "Silent chest with extreme WOB — impending respiratory failure"
+ ]
+ }
+ ]
+ },
+ "cv": {
+ "overview": "Most CHD manifests in the first year as pulmonary blood-flow changes and the ductus closes. Infant CV exam = growth review + inspection + femoral pulses + auscultation. A harsh pan-systolic LLSB murmur in a 6-week-old = VSD until proven otherwise.",
+ "components": [
+ {
+ "name": "Inspection and functional assessment",
+ "significance": "Heart failure in infants presents as poor feeding, sweating during feeds (diaphoresis), tachypnea, and poor weight gain. These historical features predict bad exam findings.",
+ "pearl": "Ask \"Does the baby sweat while feeding?\" — infant CHF presents with diaphoresis on the forehead during feeds, well before peripheral edema appears.",
+ "steps": [
+ {
+ "label": "Growth trajectory",
+ "method": "Plot weight-for-age on WHO chart. Failure to thrive raises CHD concern.",
+ "normal": "Tracking ≥ 10th percentile or stable on personal curve"
+ },
+ {
+ "label": "Feeding history",
+ "method": "Ask about feed duration, sweating with feeds, tachypnea with feeds, tiring easily.",
+ "normal": "Feeds < 20 min, no diaphoresis, no tachypnea"
+ },
+ {
+ "label": "Central cyanosis",
+ "method": "Inspect tongue and oral mucosa.",
+ "normal": "Pink"
+ },
+ {
+ "label": "Clubbing",
+ "method": "Inspect finger nail beds (subtle in infants).",
+ "normal": "No clubbing"
+ },
+ {
+ "label": "Peripheral perfusion",
+ "method": "Cap refill, warmth of extremities.",
+ "normal": "Cap refill < 2 s, warm extremities"
+ }
+ ],
+ "abnormalHints": [
+ "Poor weight gain — consider CHF from L-to-R shunt (VSD, PDA, AVSD)",
+ "Diaphoresis with feeds — infant CHF",
+ "Tiring with feeds — significant CHD",
+ "Central cyanosis — cyanotic CHD (ToF, TGA, TA, etc.)"
+ ]
+ },
+ {
+ "name": "Palpation and auscultation",
+ "significance": "Femoral pulses + 4-limb BP screen coarctation. A harsh holosystolic murmur at LLSB is almost always a VSD in this age.",
+ "pearl": "Listen over each of the 5 classic points as in the adult exam — the locations shift slightly with infant chest size but relative positions are the same. Also listen at the back: coarctation murmurs radiate there.",
+ "steps": [
+ {
+ "label": "Apex beat",
+ "method": "Palpate at 4th ICS mid-clavicular line.",
+ "normal": "Palpable at 4th ICS in infants"
+ },
+ {
+ "label": "Femoral pulses",
+ "method": "Palpate bilaterally, simultaneously with right brachial.",
+ "normal": "Present, equal, no delay vs brachial"
+ },
+ {
+ "label": "Listen at each classic area (APTM)",
+ "method": "See APTM diagram. Use pediatric stethoscope with both diaphragm and bell.",
+ "normal": "S1 and S2 crisp, no murmur or physiologic only"
+ },
+ {
+ "label": "Listen over the back (interscapular)",
+ "method": "Check for radiation of coarctation murmurs.",
+ "normal": "No radiating murmur"
+ }
+ ],
+ "abnormalHints": [
+ "Harsh holosystolic LLSB murmur — VSD",
+ "Continuous \"machinery\" murmur below left clavicle — PDA",
+ "Systolic ejection at ULSB + fixed split S2 — ASD",
+ "Ejection murmur at ULSB + cyanosis — tetralogy of Fallot",
+ "Absent femorals + radio-femoral delay — coarctation",
+ "Gallop + tachycardia — heart failure"
+ ]
+ }
+ ]
+ }
+ },
+ "toddler": {
+ "label": "Toddler (1–3 years)",
+ "msk": {
+ "overview": "Gait, physiologic alignment changes, in-toeing, joint range. Cooperation unpredictable — use play.",
+ "components": [
+ {
+ "name": "Gait",
+ "steps": [
+ {
+ "label": "Base of support",
+ "method": "Have child walk ~10 feet",
+ "normal": "Wide-based initially, narrowing by 2y"
+ },
+ {
+ "label": "Heel-strike",
+ "method": "Observe foot contact pattern",
+ "normal": "Heel-strike developing by 18mo, consistent by 2y"
+ },
+ {
+ "label": "Arm swing",
+ "method": "Observe reciprocal arm swing",
+ "normal": "Reciprocal arm swing by 18mo"
+ },
+ {
+ "label": "Symmetry",
+ "method": "Watch both sides in stance and swing",
+ "normal": "Symmetric stride length and cadence"
+ }
+ ],
+ "abnormalHints": [
+ "Toe-walking past 2y (idiopathic vs CP vs DMD)",
+ "Limp (Legg-Calvé-Perthes, transient synovitis, trauma)",
+ "Wide-based ataxia"
+ ]
+ },
+ {
+ "name": "Knee alignment",
+ "steps": [
+ {
+ "label": "Stand feet together",
+ "method": "Feet/medial malleoli touching; inspect knees",
+ "normal": "Genu varum resolving by 18–24mo; mild genu valgum common by 2–3y"
+ },
+ {
+ "label": "Intercondylar or intermalleolar distance",
+ "method": "Measure if alignment appears abnormal",
+ "normal": "<5cm intercondylar (varum) or <8cm intermalleolar (valgum)"
+ },
+ {
+ "label": "Symmetry",
+ "method": "Compare sides",
+ "normal": "Symmetric"
+ }
+ ],
+ "abnormalHints": [
+ "Persistent varum past 2y",
+ "Severe valgum >8cm",
+ "Unilateral (Blount disease, rickets)"
+ ]
+ },
+ {
+ "name": "Feet alignment",
+ "steps": [
+ {
+ "label": "In-toeing / out-toeing",
+ "method": "Observe foot angle during gait",
+ "normal": "Mild in-toeing common (tibial torsion, femoral anteversion)"
+ },
+ {
+ "label": "Arch during stance",
+ "method": "Stand flat, then on tiptoes",
+ "normal": "Flexible flat foot that forms arch on tiptoe"
+ },
+ {
+ "label": "Heel alignment",
+ "method": "View from behind standing",
+ "normal": "Neutral or mildly valgus heel"
+ }
+ ],
+ "abnormalHints": [
+ "Rigid flat foot (tarsal coalition)",
+ "Fixed metatarsus adductus",
+ "Severe in-toeing >15°"
+ ]
+ },
+ {
+ "name": "Joint range",
+ "steps": [
+ {
+ "label": "Hips",
+ "method": "Flex, abduct, rotate each hip",
+ "normal": "Full symmetric range, no pain"
+ },
+ {
+ "label": "Knees",
+ "method": "Flex, extend; palpate for effusion",
+ "normal": "Full range, no effusion, stable"
+ },
+ {
+ "label": "Ankles",
+ "method": "Dorsiflex, plantarflex, invert, evert",
+ "normal": "Full range"
+ },
+ {
+ "label": "Shoulders, elbows, wrists",
+ "method": "Through full range each",
+ "normal": "Full symmetric range"
+ }
+ ],
+ "abnormalHints": [
+ "Joint effusion (septic vs reactive)",
+ "Guarded or painful motion",
+ "Asymmetric limitation"
+ ]
+ },
+ {
+ "name": "Spine",
+ "steps": [
+ {
+ "label": "Inspect standing",
+ "method": "View spine from behind",
+ "normal": "Midline, no prominent curve"
+ },
+ {
+ "label": "Palpate midline",
+ "method": "Run finger along spinous processes",
+ "normal": "Midline, no step-off, no tenderness"
+ },
+ {
+ "label": "Shoulder/hip symmetry",
+ "method": "Compare shoulder and hip heights",
+ "normal": "Symmetric"
+ }
+ ],
+ "abnormalHints": [
+ "Fixed scoliosis",
+ "Abnormal kyphosis",
+ "Asymmetric shoulder/hip",
+ "Midline tenderness"
+ ]
+ }
+ ]
+ },
+ "neuro": {
+ "overview": "Shifting to adult-pattern exam. Primitive reflexes should be absent. Use play-based techniques.",
+ "components": [
+ {
+ "name": "Mental status and language",
+ "steps": [
+ {
+ "label": "Engagement",
+ "method": "Interaction with examiner/parent",
+ "normal": "Alert, interactive, age-appropriate"
+ },
+ {
+ "label": "Language — expressive",
+ "method": "Note spontaneous utterances",
+ "normal": "1y: 1–3 words; 2y: 2-word phrases; 3y: short sentences"
+ },
+ {
+ "label": "Language — receptive",
+ "method": "Ask to point to body parts or follow simple commands",
+ "normal": "Follows age-appropriate commands"
+ }
+ ],
+ "abnormalHints": [
+ "Language regression (autism, epileptic encephalopathy)",
+ "Poor engagement",
+ "No 2-word phrases by 2y"
+ ]
+ },
+ {
+ "name": "Cranial nerves",
+ "steps": [
+ {
+ "label": "CN II — pupil response",
+ "method": "Shine light each eye",
+ "normal": "Pupils equal reactive"
+ },
+ {
+ "label": "CN III, IV, VI — EOM",
+ "method": "Follow toy in H pattern",
+ "normal": "Full smooth tracking, no strabismus"
+ },
+ {
+ "label": "CN V — facial sensation",
+ "method": "Light touch on forehead, cheek, jaw",
+ "normal": "Responds to touch, symmetric"
+ },
+ {
+ "label": "CN VII — face",
+ "method": "Elicit smile, watch eye closure during cry",
+ "normal": "Symmetric face"
+ },
+ {
+ "label": "CN IX, X, XII — mouth",
+ "method": "Say \"ahh\"; stick out tongue",
+ "normal": "Palate rises symmetrically; tongue midline"
+ }
+ ],
+ "abnormalHints": [
+ "Strabismus",
+ "Facial asymmetry",
+ "Tongue deviation",
+ "Absent palate elevation"
+ ]
+ },
+ {
+ "name": "Motor — tone and bulk",
+ "steps": [
+ {
+ "label": "Passive tone",
+ "method": "Move each limb through full range",
+ "normal": "Normal resistance throughout"
+ },
+ {
+ "label": "Bulk inspection",
+ "method": "Inspect muscle bulk of thighs, calves, glutes",
+ "normal": "Symmetric, age-appropriate bulk"
+ },
+ {
+ "label": "Contracture check",
+ "method": "Test for heel-cord tightness, hamstring tightness",
+ "normal": "No contractures"
+ }
+ ],
+ "abnormalHints": [
+ "Spasticity (especially catch in ankles)",
+ "Hypotonia",
+ "Calf pseudo-hypertrophy (DMD)"
+ ]
+ },
+ {
+ "name": "Motor — functional strength",
+ "steps": [
+ {
+ "label": "Rising from floor",
+ "method": "Place flat on back; ask to stand up",
+ "normal": "Rises without using hands to push off thighs (no Gowers)"
+ },
+ {
+ "label": "Climbing stairs",
+ "method": "Observe or history",
+ "normal": "Climbs holding rail"
+ },
+ {
+ "label": "Squatting/getting up",
+ "method": "Encourage via play",
+ "normal": "Squats and rises without help"
+ }
+ ],
+ "abnormalHints": [
+ "Gowers sign (proximal weakness — DMD)",
+ "Unable to climb stairs at age expected",
+ "Calf pain on walking (myositis)"
+ ]
+ },
+ {
+ "name": "Deep tendon reflexes",
+ "steps": [
+ {
+ "label": "Patellar",
+ "method": "Sitting or supine with distraction (toy)",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Biceps",
+ "method": "Arm at rest, strike thumb on tendon",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Achilles",
+ "method": "With distraction",
+ "normal": "2+ symmetric"
+ }
+ ],
+ "abnormalHints": [
+ "Hyperreflexia or clonus (UMN, CP)",
+ "Absent reflexes (LMN, neuropathy)",
+ "Asymmetry"
+ ]
+ },
+ {
+ "name": "Coordination and gait",
+ "steps": [
+ {
+ "label": "Run",
+ "method": "Watch run ~10 feet",
+ "normal": "Runs with reciprocal arm swing by 2y"
+ },
+ {
+ "label": "Stairs",
+ "method": "Observe",
+ "normal": "Climbs with rail"
+ },
+ {
+ "label": "Kick ball",
+ "method": "Place ball; observe kick",
+ "normal": "Kicks by 2y"
+ },
+ {
+ "label": "Ataxia check",
+ "method": "Watch for fluency of movement",
+ "normal": "Smooth, no tremor"
+ }
+ ],
+ "abnormalHints": [
+ "Ataxic gait",
+ "Intention tremor",
+ "Clumsiness beyond age"
+ ]
+ },
+ {
+ "name": "Plantar response",
+ "steps": [
+ {
+ "label": "Stroke lateral sole",
+ "method": "Firm stroke from heel to toes",
+ "normal": "Down-going great toe (plantar flexion) by age 2"
+ }
+ ],
+ "abnormalHints": [
+ "Up-going toe after age 2 = UMN sign (Babinski positive)"
+ ]
+ }
+ ]
+ },
+ "resp": {
+ "overview": "Toddler respiratory disease: viral URIs, reactive airways, croup (6 mo–6 y classical age), foreign-body aspiration (age 1–3 is peak). Normal RR ≤ 40.",
+ "components": [
+ {
+ "name": "Inspection",
+ "pearl": "Sudden onset of unilateral wheeze + choking history in a toddler = foreign body until proven otherwise. CXR in expiration (or decubitus) helps show the trapped air.",
+ "steps": [
+ {
+ "label": "Respiratory rate",
+ "method": "Count over full 60 s if possible.",
+ "normal": "≤ 40 /min"
+ },
+ {
+ "label": "Work of breathing",
+ "method": "Retractions, nasal flaring, tracheal tug.",
+ "normal": "No retractions"
+ },
+ {
+ "label": "Audible sounds",
+ "method": "Stridor (croup), wheeze, barking cough.",
+ "normal": "Quiet respirations"
+ },
+ {
+ "label": "Drooling / posture",
+ "method": "Tripod positioning, drooling (epiglottitis in unvaccinated child).",
+ "normal": "No drooling, normal posture"
+ }
+ ],
+ "abnormalHints": [
+ "Barking cough + stridor — croup",
+ "Drooling + tripod + toxic — epiglottitis (emergency)",
+ "Sudden unilateral wheeze — foreign body aspiration"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "steps": [
+ {
+ "label": "Air entry",
+ "method": "Cooperation variable — listen quickly and systematically.",
+ "normal": "Symmetric"
+ },
+ {
+ "label": "Adventitious sounds",
+ "method": "Wheeze, crackles, stridor at the neck.",
+ "normal": "Clear lung fields"
+ },
+ {
+ "label": "Unilateral findings",
+ "method": "Focal wheeze, decreased air entry, or asymmetry — think foreign body or pneumonia.",
+ "normal": "Symmetric bilateral"
+ }
+ ],
+ "abnormalHints": [
+ "Unilateral decreased breath sounds + wheeze — foreign body",
+ "Focal crackles — pneumonia",
+ "Diffuse wheeze — asthma/RAD"
+ ]
+ }
+ ]
+ },
+ "cv": {
+ "overview": "Most hemodynamically significant CHD has been detected by this age. Innocent murmurs peak here (Still's murmur, venous hum). The exam is adult-pattern but with smaller chest and less cooperation.",
+ "components": [
+ {
+ "name": "Inspection and palpation",
+ "pearl": "Innocent murmurs are a normal finding in well toddlers — soft, systolic, at the LLSB, musical, and they change with position. Anything that doesn't fit that pattern deserves referral.",
+ "steps": [
+ {
+ "label": "General appearance + growth",
+ "method": "Happy, active, tracking growth.",
+ "normal": "Normal growth and activity"
+ },
+ {
+ "label": "Colour and clubbing",
+ "method": "Inspect tongue, nail beds.",
+ "normal": "Pink, no clubbing"
+ },
+ {
+ "label": "Apex beat",
+ "method": "Palpate at 5th ICS mid-clavicular line.",
+ "normal": "Located at 5th ICS MCL, tapping quality"
+ },
+ {
+ "label": "Peripheral pulses",
+ "method": "Brachial + femoral, symmetric and simultaneous.",
+ "normal": "Symmetric, no delay"
+ }
+ ],
+ "abnormalHints": [
+ "Tiring with play, poor growth — missed CHD",
+ "Cyanosis + clubbing — cyanotic CHD",
+ "Absent femorals — coarctation"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "steps": [
+ {
+ "label": "All 5 classic points",
+ "method": "See APTM diagram above — Aortic, Pulmonic, Erb's, Tricuspid, Mitral.",
+ "normal": "Crisp S1, S2 with physiologic split at pulmonic area"
+ },
+ {
+ "label": "Evaluate any murmur",
+ "method": "Timing, location, radiation, grade. Apply the \"7 S\" innocent-murmur criteria.",
+ "normal": "No murmur, or soft (≤ grade 2) innocent murmur"
+ },
+ {
+ "label": "Change with position",
+ "method": "Have toddler sit, stand, lie down — does the murmur change? Innocent murmurs typically disappear or soften with standing.",
+ "normal": "Murmur (if any) changes with position"
+ }
+ ],
+ "abnormalHints": [
+ "Harsh, loud (≥3/6), radiating, or diastolic murmur — not innocent, refer",
+ "Cyanosis + murmur — CHD workup",
+ "Fixed split S2 — ASD"
+ ]
+ }
+ ]
+ }
+ },
+ "preschool": {
+ "label": "Preschool (3–5 years)",
+ "msk": {
+ "overview": "Functional gait maneuvers, scoliosis screen, resolving physiologic alignment.",
+ "components": [
+ {
+ "name": "Gait — multiple patterns",
+ "steps": [
+ {
+ "label": "Normal gait",
+ "method": "Walk ~15 feet barefoot",
+ "normal": "Symmetric, smooth, reciprocal arm swing"
+ },
+ {
+ "label": "Heel walking",
+ "method": "Walk on heels only",
+ "normal": "Able by 4y"
+ },
+ {
+ "label": "Toe walking",
+ "method": "Walk on toes only",
+ "normal": "Able by 4y"
+ },
+ {
+ "label": "Tandem walking",
+ "method": "Heel-to-toe along a line for 5 steps",
+ "normal": "Able by 4y with minimal deviation"
+ },
+ {
+ "label": "Hopping",
+ "method": "Hop on one foot",
+ "normal": "3–5 hops on preferred foot by 4y"
+ }
+ ],
+ "abnormalHints": [
+ "Persistent toe-walking",
+ "Asymmetric stance/stride",
+ "Difficulty with any pattern"
+ ]
+ },
+ {
+ "name": "Alignment",
+ "steps": [
+ {
+ "label": "Knee alignment",
+ "method": "Stand feet together",
+ "normal": "Mild residual valgus resolving; neutral by 6–7y"
+ },
+ {
+ "label": "Foot arch",
+ "method": "Standing, then tiptoe",
+ "normal": "Arch forms on tiptoe (flexible flat foot)"
+ },
+ {
+ "label": "Heel position",
+ "method": "View from behind standing",
+ "normal": "Neutral or mild valgus"
+ }
+ ],
+ "abnormalHints": [
+ "Persistent unilateral varum",
+ "Rigid flat foot (no arch on tiptoe)",
+ "Pes cavus"
+ ]
+ },
+ {
+ "name": "Scoliosis screen (Adam forward-bend)",
+ "steps": [
+ {
+ "label": "Position",
+ "method": "Feet together, bend forward at waist, arms hanging, palms together",
+ "normal": "Arms and head relaxed"
+ },
+ {
+ "label": "View from behind",
+ "method": "Examiner at same height; look along back",
+ "normal": "Symmetric paraspinal contour"
+ },
+ {
+ "label": "View from side",
+ "method": "Side view for kyphosis",
+ "normal": "Smooth thoracic curve"
+ }
+ ],
+ "abnormalHints": [
+ "Rib hump (thoracic scoliosis)",
+ "Lumbar prominence",
+ "Asymmetric scapular height"
+ ]
+ },
+ {
+ "name": "Joint range and stability",
+ "steps": [
+ {
+ "label": "Active range",
+ "method": "Ask to perform full range at hips, knees, ankles, shoulders, elbows, wrists",
+ "normal": "Full symmetric range, no pain"
+ },
+ {
+ "label": "Knee stability",
+ "method": "Palpate for effusion; assess stability if complaint",
+ "normal": "Stable, no effusion"
+ },
+ {
+ "label": "Carrying angle (elbows)",
+ "method": "Arms at sides, palms forward",
+ "normal": "Normal valgus carrying angle"
+ }
+ ],
+ "abnormalHints": [
+ "Joint hypermobility (Beighton score)",
+ "Effusion",
+ "Pain with motion",
+ "Valgus >15°"
+ ]
+ },
+ {
+ "name": "Feet",
+ "steps": [
+ {
+ "label": "Standing inspection",
+ "method": "View from front and behind",
+ "normal": "Symmetric feet, neutral heel, flexible flat feet common"
+ },
+ {
+ "label": "Tiptoe",
+ "method": "Stand on tiptoes",
+ "normal": "Arch forms, symmetric"
+ },
+ {
+ "label": "Pes planus vs cavus",
+ "method": "Note arch height",
+ "normal": "Flexible flat foot or mild arch"
+ }
+ ],
+ "abnormalHints": [
+ "Rigid flat foot",
+ "Pes cavus (Charcot-Marie-Tooth)",
+ "Pain"
+ ]
+ }
+ ]
+ },
+ "neuro": {
+ "overview": "Formal pediatric neuro exam now feasible — most 4- and 5-year-olds cooperate with structured testing.",
+ "components": [
+ {
+ "name": "Mental status and language",
+ "steps": [
+ {
+ "label": "Orientation (age-appropriate)",
+ "method": "Ask name, age, where you are",
+ "normal": "Knows name and age by 3y; location by 4–5y"
+ },
+ {
+ "label": "Speech intelligibility",
+ "method": "Listen to spontaneous speech",
+ "normal": "Strangers understand by 4y"
+ },
+ {
+ "label": "Receptive language",
+ "method": "2- and 3-step commands",
+ "normal": "Follows 3-step commands by 4–5y"
+ }
+ ],
+ "abnormalHints": [
+ "Dysarthria",
+ "Expressive or receptive language delay",
+ "Inattention"
+ ]
+ },
+ {
+ "name": "Cranial nerves (II–XII)",
+ "steps": [
+ {
+ "label": "CN II — visual acuity",
+ "method": "HOTV chart or pictures at 10ft, each eye",
+ "normal": "20/30 or better by 4y; 20/25 by 5y"
+ },
+ {
+ "label": "CN II — visual fields",
+ "method": "Confrontation with toys from periphery",
+ "normal": "Full fields"
+ },
+ {
+ "label": "CN II — pupils",
+ "method": "Light response each eye",
+ "normal": "PERRL"
+ },
+ {
+ "label": "CN III, IV, VI — EOM",
+ "method": "Follow toy in H pattern; include convergence",
+ "normal": "Full EOM, convergence present"
+ },
+ {
+ "label": "CN V — sensation",
+ "method": "Light touch forehead, cheek, jaw each side",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "CN V — motor",
+ "method": "Clench teeth, palpate masseter",
+ "normal": "Symmetric strong bulk"
+ },
+ {
+ "label": "CN VII — face",
+ "method": "Smile, wrinkle forehead, close eyes, puff cheeks",
+ "normal": "Symmetric movement of all regions"
+ },
+ {
+ "label": "CN VIII — hearing",
+ "method": "Finger rub each ear or whispered words",
+ "normal": "Intact bilaterally"
+ },
+ {
+ "label": "CN IX, X — palate",
+ "method": "Open mouth, say \"ahh\"",
+ "normal": "Palate rises symmetrically, uvula midline"
+ },
+ {
+ "label": "CN XI — SCM/trapezius",
+ "method": "Shrug shoulders, turn head against resistance",
+ "normal": "Symmetric strength"
+ },
+ {
+ "label": "CN XII — tongue",
+ "method": "Stick tongue out, move side to side",
+ "normal": "Midline, no atrophy, full movement"
+ }
+ ],
+ "abnormalHints": [
+ "Strabismus (amblyopia risk)",
+ "Facial weakness",
+ "Tongue deviation/fasciculations",
+ "Uvula off-midline"
+ ]
+ },
+ {
+ "name": "Motor — tone, bulk, strength",
+ "steps": [
+ {
+ "label": "Tone inspection",
+ "method": "Passive range all four limbs",
+ "normal": "Normal tone throughout"
+ },
+ {
+ "label": "Bulk inspection",
+ "method": "Observe muscle bulk symmetry",
+ "normal": "Symmetric, age-appropriate"
+ },
+ {
+ "label": "Strength — shoulder abduction",
+ "method": "Arms out, push down against resistance",
+ "normal": "5/5 bilaterally"
+ },
+ {
+ "label": "Strength — elbow flexion",
+ "method": "Flex elbow against resistance",
+ "normal": "5/5 bilaterally"
+ },
+ {
+ "label": "Strength — grip",
+ "method": "Squeeze examiner's fingers",
+ "normal": "5/5 symmetric"
+ },
+ {
+ "label": "Strength — hip flexion",
+ "method": "Lift leg off table against resistance",
+ "normal": "5/5 bilaterally"
+ },
+ {
+ "label": "Strength — knee extension",
+ "method": "Straighten knee against resistance",
+ "normal": "5/5 bilaterally"
+ },
+ {
+ "label": "Strength — dorsiflexion",
+ "method": "Pull toes up against resistance",
+ "normal": "5/5 bilaterally"
+ }
+ ],
+ "abnormalHints": [
+ "Focal weakness",
+ "Gowers sign",
+ "Pseudohypertrophy (DMD)",
+ "Atrophy"
+ ]
+ },
+ {
+ "name": "Deep tendon reflexes",
+ "steps": [
+ {
+ "label": "Biceps",
+ "method": "Thumb on biceps tendon, strike",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Patellar",
+ "method": "Knees hanging, strike patellar tendon",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Achilles",
+ "method": "Slight dorsiflexion, strike Achilles tendon",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Plantar response",
+ "method": "Stroke lateral sole heel-to-toes",
+ "normal": "Down-going great toe"
+ }
+ ],
+ "abnormalHints": [
+ "Hyperreflexia or clonus (UMN)",
+ "Hyporeflexia (LMN)",
+ "Up-going plantar (Babinski — abnormal past 2y)",
+ "Asymmetry"
+ ]
+ },
+ {
+ "name": "Coordination",
+ "steps": [
+ {
+ "label": "Finger-to-nose",
+ "method": "Touch examiner's finger then own nose, repeat",
+ "normal": "Smooth, no dysmetria"
+ },
+ {
+ "label": "Heel-to-shin",
+ "method": "Run heel down opposite shin",
+ "normal": "Smooth bilaterally"
+ },
+ {
+ "label": "Rapid alternating movements",
+ "method": "Tap palm with opposite hand alternating palm/back",
+ "normal": "Rhythmic, symmetric"
+ },
+ {
+ "label": "Tandem walk",
+ "method": "Heel-to-toe for 5 steps",
+ "normal": "Minimal deviation"
+ }
+ ],
+ "abnormalHints": [
+ "Dysmetria",
+ "Dysdiadochokinesia",
+ "Intention tremor",
+ "Ataxic tandem"
+ ]
+ },
+ {
+ "name": "Sensory",
+ "steps": [
+ {
+ "label": "Light touch — hands",
+ "method": "Cotton wisp on palm/dorsum, eyes closed",
+ "normal": "Feels each touch"
+ },
+ {
+ "label": "Light touch — feet",
+ "method": "Same on dorsum of foot bilaterally",
+ "normal": "Feels each touch"
+ }
+ ],
+ "abnormalHints": [
+ "Focal sensory loss",
+ "Stocking-glove loss"
+ ]
+ },
+ {
+ "name": "Gait and Romberg",
+ "steps": [
+ {
+ "label": "Normal gait",
+ "method": "Walk ~20 feet",
+ "normal": "Smooth, symmetric"
+ },
+ {
+ "label": "Heel walk",
+ "method": "Walk on heels",
+ "normal": "Able without difficulty"
+ },
+ {
+ "label": "Toe walk",
+ "method": "Walk on toes",
+ "normal": "Able without difficulty"
+ },
+ {
+ "label": "Tandem",
+ "method": "Heel-to-toe",
+ "normal": "Intact"
+ },
+ {
+ "label": "Romberg (5y+)",
+ "method": "Feet together, eyes closed, stand 10s",
+ "normal": "Stable without sway"
+ }
+ ],
+ "abnormalHints": [
+ "Ataxic gait (cerebellar)",
+ "Romberg positive (dorsal column)",
+ "Circumduction (UMN)"
+ ]
+ }
+ ]
+ },
+ "resp": {
+ "overview": "Adult-pattern but shorter. Cooperation better than toddler. RR ≤ 30. Common: asthma/RAD, pneumonia, URIs.",
+ "components": [
+ {
+ "name": "Inspection",
+ "steps": [
+ {
+ "label": "Respiratory rate",
+ "method": "Count over full 60 s quietly.",
+ "normal": "≤ 30 /min"
+ },
+ {
+ "label": "Work of breathing",
+ "method": "Retractions, nasal flaring, accessory muscle use.",
+ "normal": "Effortless breathing"
+ },
+ {
+ "label": "Audible sounds",
+ "method": "Wheeze, stridor, cough quality (barking = croup).",
+ "normal": "Quiet"
+ },
+ {
+ "label": "Chest shape",
+ "method": "AP:transverse, hyperinflation signs.",
+ "normal": "Not barrel-chested"
+ }
+ ],
+ "abnormalHints": [
+ "Barrel chest — chronic asthma, cystic fibrosis",
+ "Retractions + wheeze — asthma exacerbation"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "steps": [
+ {
+ "label": "Systematic zones",
+ "method": "Upper, mid, lower fields anteriorly and posteriorly; axillae bilaterally. Cooperative deep breaths through mouth.",
+ "normal": "Symmetric vesicular sounds"
+ },
+ {
+ "label": "Wheeze",
+ "method": "Expiratory, diffuse (asthma) or focal (foreign body, rare at this age).",
+ "normal": "No wheeze"
+ },
+ {
+ "label": "Crackles",
+ "method": "Focal = pneumonia; diffuse fine = interstitial disease (rare in kids).",
+ "normal": "No crackles"
+ }
+ ],
+ "abnormalHints": [
+ "Focal crackles + fever — pneumonia",
+ "Diffuse wheeze — asthma",
+ "Prolonged expiration with wheeze — lower airway obstruction"
+ ]
+ }
+ ]
+ },
+ "cv": {
+ "overview": "Most CHD is detected by this age. Innocent murmurs peak in this range. Sports participation exams require thorough CV screening.",
+ "components": [
+ {
+ "name": "Inspection and palpation",
+ "steps": [
+ {
+ "label": "General and growth",
+ "method": "Track on growth curve; activity tolerance.",
+ "normal": "Normal growth, active"
+ },
+ {
+ "label": "Apex beat",
+ "method": "5th ICS mid-clavicular line.",
+ "normal": "Normal position and character"
+ },
+ {
+ "label": "Peripheral pulses",
+ "method": "Brachial + femoral simultaneously. BP in arm and leg if HTN.",
+ "normal": "Symmetric, no delay"
+ }
+ ],
+ "abnormalHints": [
+ "Absent femorals or arm-leg BP gradient — coarctation (always check in HTN screening)",
+ "Displaced apex — cardiomegaly"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "pearl": "The 7 \"S\" criteria and the 5 classic innocent murmurs (see panel above) handle most murmurs you'll find in this age group. Still's murmur is the single most common.",
+ "steps": [
+ {
+ "label": "All 5 classic points",
+ "method": "Walk through A → P → E → T → M with diaphragm then bell.",
+ "normal": "S1 S2 clear, physiologic S2 split at pulmonic, no added sounds"
+ },
+ {
+ "label": "Any murmur",
+ "method": "Characterise: timing, location, radiation, grade, character. Apply 7 S criteria + compare to innocent-murmur panel.",
+ "normal": "No murmur, or innocent flow murmur meeting all 7 S criteria"
+ },
+ {
+ "label": "Position change",
+ "method": "Standing vs supine. Innocent murmurs typically soften or disappear on standing.",
+ "normal": "Murmur (if any) changes with position"
+ },
+ {
+ "label": "Sports screening extras (if applicable)",
+ "method": "Screen for HOCM — murmur intensifies with Valsalva and standing (opposite of most).",
+ "normal": "No murmur worsening on Valsalva"
+ }
+ ],
+ "abnormalHints": [
+ "Murmur breaking any of the 7 S criteria — refer",
+ "Harsh systolic at LUSB + fixed split S2 — ASD",
+ "Murmur louder with Valsalva — HOCM (sports participation risk)",
+ "Diastolic murmur — always pathologic"
+ ]
+ }
+ ]
+ }
+ },
+ "school": {
+ "label": "School-age (6–11 years)",
+ "msk": {
+ "overview": "Scoliosis screening peri-puberty, sports overuse injuries, resolving alignment.",
+ "components": [
+ {
+ "name": "Scoliosis screen (forward-bend + scoliometer)",
+ "steps": [
+ {
+ "label": "Standing inspection",
+ "method": "Shoulders and iliac crest heights",
+ "normal": "Symmetric shoulder and pelvic heights"
+ },
+ {
+ "label": "Forward bend (Adam test)",
+ "method": "Feet together, bend forward at waist, arms hanging palms together",
+ "normal": "Symmetric paraspinal contour"
+ },
+ {
+ "label": "Rib hump",
+ "method": "View tangentially from behind at level of curve",
+ "normal": "No rib hump"
+ },
+ {
+ "label": "Lumbar prominence",
+ "method": "Same view at lumbar level",
+ "normal": "No prominence"
+ },
+ {
+ "label": "Scoliometer (if available)",
+ "method": "Place scoliometer across rib hump, read angle of trunk rotation",
+ "normal": "ATR < 5°; ≥7° → refer"
+ }
+ ],
+ "abnormalHints": [
+ "Rib hump",
+ "ATR ≥7°",
+ "Asymmetric shoulders or pelvis",
+ "Decompensation (plumb line offset)"
+ ]
+ },
+ {
+ "name": "Back and spine",
+ "steps": [
+ {
+ "label": "Posture inspection",
+ "method": "Standing, view front/back/side",
+ "normal": "Normal spinal curves; plumb line centered"
+ },
+ {
+ "label": "Palpate spinous processes",
+ "method": "From C2 to S1",
+ "normal": "No tenderness, no step-off"
+ },
+ {
+ "label": "Range of motion",
+ "method": "Flex, extend, lateral bend, rotate",
+ "normal": "Full painless range"
+ }
+ ],
+ "abnormalHints": [
+ "Midline tenderness",
+ "Step-off (spondylolisthesis)",
+ "Limited motion with pain"
+ ]
+ },
+ {
+ "name": "Alignment",
+ "steps": [
+ {
+ "label": "Knees",
+ "method": "Feet together, inspect",
+ "normal": "Neutral alignment by 6–7y"
+ },
+ {
+ "label": "Feet",
+ "method": "Stand, then tiptoes",
+ "normal": "Medial arch present, symmetric"
+ },
+ {
+ "label": "Leg lengths",
+ "method": "Supine, measure ASIS to medial malleolus if asymmetric",
+ "normal": "Equal within 1cm"
+ }
+ ],
+ "abnormalHints": [
+ "Residual valgum",
+ "Pes cavus",
+ "Leg-length discrepancy >1cm"
+ ]
+ },
+ {
+ "name": "Joint stability and sports exam (if active)",
+ "steps": [
+ {
+ "label": "Active range all joints",
+ "method": "Through full range",
+ "normal": "Full symmetric range, no pain or crepitus"
+ },
+ {
+ "label": "Knee — Lachman (if sports-active)",
+ "method": "Knee 20° flexion, stabilize femur, pull tibia forward",
+ "normal": "Firm endpoint, no laxity"
+ },
+ {
+ "label": "Knee — McMurray",
+ "method": "Flexed knee, rotate tibia while extending",
+ "normal": "No pain or click"
+ },
+ {
+ "label": "Shoulder — impingement (Neer/Hawkins)",
+ "method": "Passive shoulder flexion with arm in internal rotation",
+ "normal": "No pain"
+ },
+ {
+ "label": "Ankle stability",
+ "method": "Anterior drawer and talar tilt",
+ "normal": "No laxity"
+ }
+ ],
+ "abnormalHints": [
+ "ACL laxity (positive Lachman)",
+ "Meniscal click",
+ "Shoulder impingement",
+ "Ankle instability"
+ ]
+ },
+ {
+ "name": "Gait and functional movement",
+ "steps": [
+ {
+ "label": "Normal gait",
+ "method": "Walk 20 feet",
+ "normal": "Smooth, symmetric"
+ },
+ {
+ "label": "Single-leg stance",
+ "method": "Stand on one foot 10s each side",
+ "normal": "Stable without Trendelenburg drop"
+ },
+ {
+ "label": "Squat",
+ "method": "Full squat and rise",
+ "normal": "Full squat without pain or asymmetry"
+ },
+ {
+ "label": "Hop on one foot",
+ "method": "5 hops each side",
+ "normal": "Able and symmetric"
+ }
+ ],
+ "abnormalHints": [
+ "Trendelenburg sign (hip abductor weakness)",
+ "Antalgic gait",
+ "Asymmetric squat",
+ "Pain with hop"
+ ]
+ }
+ ]
+ },
+ "neuro": {
+ "overview": "Adult-pattern six-component exam: mental status, CN, motor, reflexes, sensory, coordination/gait.",
+ "components": [
+ {
+ "name": "Mental status",
+ "steps": [
+ {
+ "label": "Orientation",
+ "method": "Name, age, school, city, day of week",
+ "normal": "Oriented x 4"
+ },
+ {
+ "label": "Attention",
+ "method": "Count backward from 20; days of week backward",
+ "normal": "Intact"
+ },
+ {
+ "label": "3-item recall",
+ "method": "Ball-flag-tree; ask at 3 and 5 min",
+ "normal": "3/3 recall at 5 min"
+ },
+ {
+ "label": "Language",
+ "method": "Name common objects; repeat a sentence",
+ "normal": "Fluent, no paraphasia"
+ }
+ ],
+ "abnormalHints": [
+ "Inattention (ADHD features)",
+ "Memory deficits",
+ "Word-finding difficulty",
+ "Perseveration"
+ ]
+ },
+ {
+ "name": "Cranial nerves (II–XII)",
+ "steps": [
+ {
+ "label": "CN II — acuity",
+ "method": "Snellen at 20ft each eye with corrective lenses if worn",
+ "normal": "20/20 or baseline"
+ },
+ {
+ "label": "CN II — fields",
+ "method": "Confrontation, 4 quadrants each eye",
+ "normal": "Full fields"
+ },
+ {
+ "label": "CN II — fundoscopy (if indicated)",
+ "method": "Direct ophthalmoscopy — disc, vessels, macula",
+ "normal": "Sharp disc, normal cup-disc ratio, no papilledema"
+ },
+ {
+ "label": "CN II, III — pupils",
+ "method": "Direct and consensual light, accommodation",
+ "normal": "PERRLA"
+ },
+ {
+ "label": "CN III, IV, VI — EOM",
+ "method": "Follow finger in H pattern; convergence",
+ "normal": "Full EOM, no nystagmus, convergence intact"
+ },
+ {
+ "label": "CN V — sensation",
+ "method": "Light touch V1 (forehead), V2 (cheek), V3 (jaw) each side",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "CN V — motor",
+ "method": "Clench teeth, palpate masseter/temporalis; jaw opening",
+ "normal": "Symmetric strength"
+ },
+ {
+ "label": "CN VII",
+ "method": "Raise eyebrows, close eyes tight, smile/show teeth, puff cheeks",
+ "normal": "Symmetric movement, all regions"
+ },
+ {
+ "label": "CN VIII",
+ "method": "Finger rub each ear; Weber/Rinne if deficit",
+ "normal": "Hears bilaterally"
+ },
+ {
+ "label": "CN IX, X",
+ "method": "Palate elevation with \"ahh\"; uvula midline; voice quality",
+ "normal": "Symmetric elevation, uvula midline, normal voice"
+ },
+ {
+ "label": "CN XI",
+ "method": "Shrug shoulders against resistance; head turn against resistance",
+ "normal": "5/5 SCM and trapezius"
+ },
+ {
+ "label": "CN XII",
+ "method": "Stick tongue out; side-to-side",
+ "normal": "Midline, no atrophy or fasciculations"
+ }
+ ],
+ "abnormalHints": [
+ "Papilledema (increased ICP)",
+ "Focal cranial nerve deficit — any warrants workup",
+ "Tongue fasciculations (LMN/MND)"
+ ]
+ },
+ {
+ "name": "Motor — bulk, tone, strength",
+ "steps": [
+ {
+ "label": "Bulk inspection",
+ "method": "Shoulders, thighs, calves, intrinsic hand muscles",
+ "normal": "Symmetric, no atrophy"
+ },
+ {
+ "label": "Tone",
+ "method": "Passive range at elbows, wrists, knees, ankles",
+ "normal": "Normal resistance throughout"
+ },
+ {
+ "label": "Strength — deltoids",
+ "method": "Shoulder abduction against resistance",
+ "normal": "5/5 bilaterally"
+ },
+ {
+ "label": "Strength — biceps",
+ "method": "Elbow flexion against resistance",
+ "normal": "5/5"
+ },
+ {
+ "label": "Strength — triceps",
+ "method": "Elbow extension against resistance",
+ "normal": "5/5"
+ },
+ {
+ "label": "Strength — grip",
+ "method": "Squeeze 2 fingers",
+ "normal": "5/5 symmetric"
+ },
+ {
+ "label": "Strength — finger abduction",
+ "method": "Spread fingers against resistance",
+ "normal": "5/5"
+ },
+ {
+ "label": "Strength — hip flexion",
+ "method": "Lift leg supine against resistance",
+ "normal": "5/5"
+ },
+ {
+ "label": "Strength — knee extension",
+ "method": "Straighten knee against resistance",
+ "normal": "5/5"
+ },
+ {
+ "label": "Strength — dorsiflexion",
+ "method": "Pull toes up against resistance",
+ "normal": "5/5"
+ },
+ {
+ "label": "Strength — plantarflexion",
+ "method": "Push foot down against resistance",
+ "normal": "5/5"
+ }
+ ],
+ "abnormalHints": [
+ "Focal weakness (localize)",
+ "Spasticity (UMN)",
+ "Atrophy",
+ "Fasciculations"
+ ]
+ },
+ {
+ "name": "Deep tendon reflexes",
+ "steps": [
+ {
+ "label": "Biceps (C5-C6)",
+ "method": "Thumb on tendon, strike",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Triceps (C7-C8)",
+ "method": "Strike triceps tendon",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Brachioradialis (C5-C6)",
+ "method": "Strike distal radius",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Patellar (L3-L4)",
+ "method": "Knees hanging, strike tendon",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Achilles (S1)",
+ "method": "Slight dorsiflexion, strike tendon",
+ "normal": "2+ symmetric"
+ },
+ {
+ "label": "Plantar response",
+ "method": "Stroke lateral sole heel-to-toes",
+ "normal": "Down-going bilaterally"
+ },
+ {
+ "label": "Clonus",
+ "method": "Rapid dorsiflexion at ankle",
+ "normal": "No sustained clonus"
+ }
+ ],
+ "abnormalHints": [
+ "Hyperreflexia with clonus (UMN: stroke, MS, cord lesion)",
+ "Hyporeflexia (LMN, neuropathy, myopathy)",
+ "Asymmetry",
+ "Up-going Babinski",
+ "Sustained clonus"
+ ]
+ },
+ {
+ "name": "Sensory",
+ "steps": [
+ {
+ "label": "Light touch — upper",
+ "method": "Cotton wisp dorsum of hands, eyes closed",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Light touch — lower",
+ "method": "Same on dorsum of feet",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Pain — upper",
+ "method": "Broken Q-tip or pin on hands",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Pain — lower",
+ "method": "Same on feet",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Vibration",
+ "method": "128 Hz tuning fork at distal IP joint of great toes",
+ "normal": "Feels vibration; counts down seconds"
+ },
+ {
+ "label": "Proprioception",
+ "method": "Move great toe up/down with eyes closed",
+ "normal": "Identifies direction correctly"
+ }
+ ],
+ "abnormalHints": [
+ "Dermatomal loss (nerve root)",
+ "Stocking-glove (neuropathy)",
+ "Loss of vibration/proprioception (dorsal column — B12, tabes, MS)"
+ ]
+ },
+ {
+ "name": "Coordination",
+ "steps": [
+ {
+ "label": "Finger-nose-finger",
+ "method": "Touch examiner finger then own nose, examiner moves target",
+ "normal": "Smooth, accurate, no dysmetria"
+ },
+ {
+ "label": "Heel-to-shin",
+ "method": "Supine: heel down opposite shin",
+ "normal": "Smooth, on-target"
+ },
+ {
+ "label": "Rapid alternating movements",
+ "method": "Supinate/pronate hand on knee rapidly",
+ "normal": "Rhythmic, symmetric"
+ },
+ {
+ "label": "Fine motor",
+ "method": "Finger tapping (thumb to each finger in sequence)",
+ "normal": "Rhythmic, accurate"
+ }
+ ],
+ "abnormalHints": [
+ "Dysmetria (past-pointing, overshoot)",
+ "Intention tremor",
+ "Dysdiadochokinesia"
+ ]
+ },
+ {
+ "name": "Gait and Romberg",
+ "steps": [
+ {
+ "label": "Normal gait",
+ "method": "Walk 20 feet",
+ "normal": "Narrow-based, smooth, reciprocal arm swing"
+ },
+ {
+ "label": "Heel walk",
+ "method": "Walk on heels",
+ "normal": "Able without difficulty"
+ },
+ {
+ "label": "Toe walk",
+ "method": "Walk on toes",
+ "normal": "Able without difficulty"
+ },
+ {
+ "label": "Tandem",
+ "method": "Heel-to-toe along a line",
+ "normal": "Minimal deviation, 10+ steps"
+ },
+ {
+ "label": "Romberg",
+ "method": "Feet together, eyes closed, 30s",
+ "normal": "Stable without fall or significant sway"
+ }
+ ],
+ "abnormalHints": [
+ "Wide-based (cerebellar)",
+ "Steppage (peripheral neuropathy)",
+ "Scissoring (UMN)",
+ "Romberg positive (dorsal column)",
+ "Circumduction"
+ ]
+ }
+ ]
+ },
+ "resp": {
+ "overview": "Nearly adult-pattern. Exam the same as adolescent with slightly more flexibility in cooperation. RR ≤ 30 in younger school-age, ≤ 20 in older. Sports history relevant (exercise-induced asthma).",
+ "components": [
+ {
+ "name": "Inspection",
+ "steps": [
+ {
+ "label": "Respiratory rate",
+ "method": "Count over 60 s.",
+ "normal": "≤ 30 (6–11 y)"
+ },
+ {
+ "label": "Work of breathing",
+ "method": "Retractions, accessory muscles.",
+ "normal": "Effortless"
+ },
+ {
+ "label": "Audible sounds",
+ "method": "Listen for wheeze, stridor.",
+ "normal": "Quiet"
+ },
+ {
+ "label": "Chest shape",
+ "method": "Barrel chest, pectus deformities.",
+ "normal": "Normal shape"
+ },
+ {
+ "label": "Clubbing",
+ "method": "Schamroth window test.",
+ "normal": "No clubbing"
+ }
+ ],
+ "abnormalHints": [
+ "Clubbing — CF, chronic hypoxemia, bronchiectasis",
+ "Barrel chest — chronic asthma, CF"
+ ]
+ },
+ {
+ "name": "Palpation and percussion",
+ "steps": [
+ {
+ "label": "Tracheal position",
+ "method": "Middle finger in suprasternal notch.",
+ "normal": "Midline"
+ },
+ {
+ "label": "Chest expansion",
+ "method": "Hands laterally, thumbs meeting at spine. Deep breath.",
+ "normal": "Symmetric 3–5 cm"
+ },
+ {
+ "label": "Tactile fremitus",
+ "method": "Ulnar side of hand; \"ninety-nine\". Compare sides.",
+ "normal": "Symmetric"
+ },
+ {
+ "label": "Percussion",
+ "method": "Pleximeter + plexor technique. Compare sides.",
+ "normal": "Resonant throughout"
+ }
+ ],
+ "abnormalHints": [
+ "Deviated trachea — pneumothorax, effusion, collapse",
+ "Dull percussion — consolidation, effusion",
+ "Hyper-resonant — pneumothorax, hyperinflation"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "steps": [
+ {
+ "label": "Systematic zones",
+ "method": "Six anterior + four lateral + six posterior zones, compare side-to-side.",
+ "normal": "Symmetric vesicular sounds"
+ },
+ {
+ "label": "Adventitious sounds",
+ "method": "Wheeze, crackles, rhonchi, rub, stridor at neck. Use sounds library for reference.",
+ "normal": "No added sounds"
+ },
+ {
+ "label": "Cough re-listen",
+ "method": "Secretions (rhonchi, coarse crackles) should clear; fibrosis crackles do not.",
+ "normal": "Secretion-based sounds clear with cough"
+ }
+ ],
+ "abnormalHints": [
+ "Focal crackles + fever — pneumonia",
+ "Diffuse fine crackles — early interstitial disease",
+ "Expiratory wheeze — asthma / RAD"
+ ]
+ }
+ ]
+ },
+ "cv": {
+ "overview": "Nearly adult-pattern. Sports participation screening is a key indication in this age. HOCM screening (family history of sudden cardiac death, exertional syncope, murmur louder with Valsalva) is specifically relevant.",
+ "components": [
+ {
+ "name": "Inspection and palpation",
+ "pearl": "For sports participation exams, always ask about exertional symptoms (syncope, chest pain, unexpected fatigue) AND family history of sudden cardiac death before age 50. Screening exam alone catches only ~3% of HOCM.",
+ "steps": [
+ {
+ "label": "General and growth",
+ "method": "Track on growth curve; review activity tolerance.",
+ "normal": "Normal growth, age-appropriate activity"
+ },
+ {
+ "label": "Colour and clubbing",
+ "method": "Inspect mucous membranes and nail beds.",
+ "normal": "Pink, no clubbing"
+ },
+ {
+ "label": "Apex beat",
+ "method": "Palpate at 5th ICS mid-clavicular line.",
+ "normal": "Normal position, tapping character"
+ },
+ {
+ "label": "Peripheral pulses",
+ "method": "Simultaneous brachial + femoral.",
+ "normal": "Symmetric, no delay"
+ },
+ {
+ "label": "Blood pressure",
+ "method": "Measure BP with appropriately sized cuff. If elevated, check both arms and one leg.",
+ "normal": "Age-appropriate (< 120/80 roughly by 10+ years)"
+ }
+ ],
+ "abnormalHints": [
+ "Exertional syncope — HOCM, arrhythmia, LQTS",
+ "BP differential — coarctation",
+ "Displaced apex — cardiomegaly"
+ ]
+ },
+ {
+ "name": "Auscultation",
+ "steps": [
+ {
+ "label": "All 5 classic points",
+ "method": "See APTM diagram. A → P → E → T → M with diaphragm and bell.",
+ "normal": "S1, S2 clear with physiologic split at P, no added sounds"
+ },
+ {
+ "label": "Grade any murmur",
+ "method": "Levine 1–6 (see scales above); characterise timing, location, radiation.",
+ "normal": "No murmur, or innocent flow murmur meeting all 7 S criteria"
+ },
+ {
+ "label": "Innocent vs pathologic",
+ "method": "Apply 7 S criteria; compare to innocent-murmur panel.",
+ "normal": "Innocent murmur (if present) clearly fits all 7 S features"
+ },
+ {
+ "label": "Dynamic maneuvers",
+ "method": "Standing: HOCM louder; most others soften. Valsalva: HOCM louder.",
+ "normal": "Murmur (if any) softens on standing and Valsalva"
+ }
+ ],
+ "abnormalHints": [
+ "Murmur louder with Valsalva / standing — HOCM (sports disqualification considerations)",
+ "Any diastolic murmur",
+ "Murmur ≥ grade 3, radiating, or with thrill"
+ ]
+ }
+ ]
+ }
+ },
+ "adolescent": {
+ "label": "Adolescent (12–21 years)",
+ "msk": {
+ "overview": "Sports-related injuries, adolescent scoliosis, apophyseal overuse, hypermobility screening.",
+ "components": [
+ {
+ "name": "Scoliosis screen",
+ "steps": [
+ {
+ "label": "Standing inspection",
+ "method": "Patient undressed to waist (keep privacy); compare shoulders, iliac crests, scapular heights",
+ "normal": "Symmetric shoulders and pelvis"
+ },
+ {
+ "label": "Forward bend (Adam)",
+ "method": "Feet together, bend forward, arms hanging palms together",
+ "normal": "Symmetric paraspinal contour"
+ },
+ {
+ "label": "Scoliometer",
+ "method": "Place across thoracic and lumbar regions at maximum prominence",
+ "normal": "ATR <5°; 5–6° monitor; ≥7° refer"
+ },
+ {
+ "label": "Plumb line check",
+ "method": "Drop plumb from C7; note where it falls",
+ "normal": "Passes through gluteal cleft (compensated)"
+ },
+ {
+ "label": "Leg lengths",
+ "method": "Supine; ASIS to medial malleolus each side",
+ "normal": "Within 1cm"
+ }
+ ],
+ "abnormalHints": [
+ "Rib/lumbar hump",
+ "ATR ≥7°",
+ "Decompensation (plumb off gluteal cleft)",
+ "Leg-length discrepancy driving apparent curve"
+ ]
+ },
+ {
+ "name": "Back pain evaluation (if complaint)",
+ "steps": [
+ {
+ "label": "Inspect and palpate",
+ "method": "Spinous processes, paraspinal muscles, SI joints",
+ "normal": "Non-tender"
+ },
+ {
+ "label": "Range of motion",
+ "method": "Flex, extend, lateral bend, rotate",
+ "normal": "Full painless range"
+ },
+ {
+ "label": "Single-leg hyperextension (stork)",
+ "method": "Stand on one foot, extend back — each side",
+ "normal": "No pain (negative for spondylolysis)"
+ },
+ {
+ "label": "Straight-leg raise",
+ "method": "Supine, lift straight leg to 70°+",
+ "normal": "No radicular pain to 70°"
+ },
+ {
+ "label": "SI joint tests",
+ "method": "FABER, SI compression",
+ "normal": "No pain"
+ }
+ ],
+ "abnormalHints": [
+ "Spondylolysis (positive stork test)",
+ "Radicular pain (disc herniation)",
+ "SI joint pathology",
+ "Inflammatory back pain pattern"
+ ]
+ },
+ {
+ "name": "Joint stability — sports-specific",
+ "steps": [
+ {
+ "label": "Knee — Lachman",
+ "method": "Knee 20° flexion, stabilize femur, pull tibia anteriorly",
+ "normal": "Firm endpoint, no laxity (ACL intact)"
+ },
+ {
+ "label": "Knee — anterior drawer",
+ "method": "Knee 90°, pull tibia forward",
+ "normal": "No excess anterior translation"
+ },
+ {
+ "label": "Knee — varus/valgus stress",
+ "method": "Stress at 0 and 30° flexion",
+ "normal": "No gap opening (LCL/MCL intact)"
+ },
+ {
+ "label": "Knee — McMurray",
+ "method": "Flex, rotate tibia while extending",
+ "normal": "No pain or click"
+ },
+ {
+ "label": "Shoulder — apprehension",
+ "method": "Abduct and externally rotate",
+ "normal": "No apprehension"
+ },
+ {
+ "label": "Shoulder — Neer/Hawkins",
+ "method": "Passive flexion with internal rotation",
+ "normal": "No pain"
+ },
+ {
+ "label": "Ankle — anterior drawer",
+ "method": "Pull heel forward with tibia stabilized",
+ "normal": "No laxity"
+ },
+ {
+ "label": "Ankle — talar tilt",
+ "method": "Invert heel with tibia stabilized",
+ "normal": "No excess tilt"
+ }
+ ],
+ "abnormalHints": [
+ "ACL/PCL tear",
+ "MCL/LCL laxity",
+ "Meniscal injury",
+ "Shoulder instability/impingement",
+ "Ankle ligament laxity"
+ ]
+ },
+ {
+ "name": "Apophysitis and overuse screen",
+ "steps": [
+ {
+ "label": "Tibial tubercle",
+ "method": "Palpate with knee flexed",
+ "normal": "Non-tender"
+ },
+ {
+ "label": "Calcaneal apophysis",
+ "method": "Palpate posterior calcaneus",
+ "normal": "Non-tender"
+ },
+ {
+ "label": "Iliac apophyses",
+ "method": "Palpate ASIS, AIIS, iliac crest",
+ "normal": "Non-tender"
+ },
+ {
+ "label": "Rotator cuff",
+ "method": "Empty-can (Jobe) test",
+ "normal": "No pain or weakness"
+ }
+ ],
+ "abnormalHints": [
+ "Osgood-Schlatter (tibial tubercle tender)",
+ "Sever (calcaneal tender)",
+ "Iliac apophysitis",
+ "Rotator cuff tendinopathy"
+ ]
+ },
+ {
+ "name": "Hypermobility screen (Beighton)",
+ "steps": [
+ {
+ "label": "Fifth finger extension",
+ "method": "Passive extension of fifth MCP to >90°",
+ "normal": "No hyperextension (1 pt each side if positive)"
+ },
+ {
+ "label": "Thumb to forearm",
+ "method": "Passive flexion of thumb to touch forearm",
+ "normal": "Does not reach (1 pt each side if positive)"
+ },
+ {
+ "label": "Elbow hyperextension",
+ "method": "Hyperextension >10°",
+ "normal": "No hyperextension (1 pt each side if positive)"
+ },
+ {
+ "label": "Knee hyperextension",
+ "method": "Hyperextension >10°",
+ "normal": "No hyperextension (1 pt each side if positive)"
+ },
+ {
+ "label": "Palms to floor",
+ "method": "Feet together, bend forward, palms flat on floor with knees straight",
+ "normal": "Cannot reach (1 pt if positive)"
+ }
+ ],
+ "abnormalHints": [
+ "Beighton ≥5/9 suggests hypermobility spectrum (hEDS workup if with other features)"
+ ]
+ },
+ {
+ "name": "Alignment and gait",
+ "steps": [
+ {
+ "label": "Standing alignment",
+ "method": "View knees, feet",
+ "normal": "Neutral alignment, medial arch"
+ },
+ {
+ "label": "Normal gait",
+ "method": "Walk 20 feet",
+ "normal": "Symmetric, smooth"
+ },
+ {
+ "label": "Functional movements",
+ "method": "Squat, single-leg stance, hop",
+ "normal": "Full symmetric function"
+ }
+ ],
+ "abnormalHints": [
+ "Antalgic gait",
+ "Trendelenburg",
+ "Asymmetric squat"
+ ]
+ }
+ ]
+ },
+ "neuro": {
+ "overview": "Full adult-pattern neuro exam across six pillars: mental status, cranial nerves, motor, reflexes, sensory, coordination/gait. In adolescents, screen concussion sequelae if sports-active; frontal release signs must be absent.",
+ "components": [
+ {
+ "name": "Mental status",
+ "significance": "Detects cognitive change (concussion, substance use, mood disorder, rare neurodegenerative disease).",
+ "pearl": "Attention precedes memory. A patient who can't attend (serial 7s, months backward) will fail memory even with intact hippocampus — distinguish before calling it a memory problem.",
+ "steps": [
+ {
+ "label": "Orientation",
+ "method": "Name, age, date, location, situation",
+ "normal": "Oriented x 4"
+ },
+ {
+ "label": "Attention",
+ "method": "Count backward from 100 by 7s (serial 7s) or months of year backward",
+ "normal": "Intact"
+ },
+ {
+ "label": "Short-term memory",
+ "method": "3-item registration and recall at 5 min",
+ "normal": "3/3 recall"
+ },
+ {
+ "label": "Language",
+ "method": "Object naming; sentence repetition; reading; writing",
+ "normal": "Fluent, no paraphasia, comprehends written and spoken"
+ },
+ {
+ "label": "Executive function",
+ "method": "Similarities (apple/orange); interpret proverb",
+ "normal": "Abstract, age-appropriate"
+ }
+ ],
+ "abnormalHints": [
+ "Post-concussion cognitive changes",
+ "Mood or personality changes",
+ "Subtle executive dysfunction",
+ "Word-finding difficulty"
+ ]
+ },
+ {
+ "name": "Cranial nerves (II–XII, full formal exam)",
+ "significance": "Localises brainstem, base-of-skull, and specific nerve pathology. Subtle deficits (RAPD, mild facial weakness, Horner) are easily missed — exam discipline matters.",
+ "pearl": "The fastest screen for a CN deficit is asking the patient to speak, smile, look around, and swallow water. What's preserved in everyday function tells you what's likely intact — then examine formally to confirm and to catch the subtle.",
+ "steps": [
+ {
+ "label": "CN I (if indicated)",
+ "method": "Coffee or cinnamon each nostril separately",
+ "normal": "Identifies both"
+ },
+ {
+ "label": "CN II — acuity",
+ "method": "Snellen at 20ft each eye; corrective lenses if worn",
+ "normal": "20/20 or baseline"
+ },
+ {
+ "label": "CN II — fields",
+ "method": "Confrontation, 4 quadrants each eye",
+ "normal": "Full fields"
+ },
+ {
+ "label": "CN II — fundoscopy",
+ "method": "Direct ophthalmoscopy — disc, vessels, macula",
+ "normal": "Sharp disc, normal cup/disc, no papilledema"
+ },
+ {
+ "label": "CN II, III — pupils",
+ "method": "Direct, consensual, swinging flashlight, accommodation",
+ "normal": "PERRLA, no RAPD"
+ },
+ {
+ "label": "CN III, IV, VI — EOM",
+ "method": "H pattern, convergence, note nystagmus or ptosis",
+ "normal": "Full conjugate movement, no nystagmus, convergence intact"
+ },
+ {
+ "label": "CN V — sensation",
+ "method": "Light touch V1, V2, V3 each side",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "CN V — motor",
+ "method": "Clench jaw, palpate masseter/temporalis; lateral jaw movement",
+ "normal": "Symmetric strength and bulk"
+ },
+ {
+ "label": "CN V — corneal reflex (if indicated)",
+ "method": "Cotton wisp to cornea",
+ "normal": "Blinks bilaterally"
+ },
+ {
+ "label": "CN VII",
+ "method": "Wrinkle forehead, close eyes against resistance, smile/bare teeth, puff cheeks",
+ "normal": "Symmetric all four movements"
+ },
+ {
+ "label": "CN VIII — hearing",
+ "method": "Finger rub each ear; Weber (midline) + Rinne (air > bone) if deficit",
+ "normal": "Equal bilaterally"
+ },
+ {
+ "label": "CN IX, X",
+ "method": "Palate elevation with \"ahh\"; uvula midline; voice; gag (if indicated)",
+ "normal": "Symmetric palate, uvula midline, normal voice"
+ },
+ {
+ "label": "CN XI",
+ "method": "Shoulder shrug and head turn against resistance",
+ "normal": "5/5 SCM and trapezius bilaterally"
+ },
+ {
+ "label": "CN XII",
+ "method": "Tongue protrusion, side to side; inspect for fasciculations/atrophy",
+ "normal": "Midline, no atrophy or fasciculations, full movement"
+ }
+ ],
+ "abnormalHints": [
+ "Any focal cranial nerve deficit",
+ "Papilledema",
+ "RAPD",
+ "Nystagmus",
+ "Facial asymmetry",
+ "Tongue deviation"
+ ]
+ },
+ {
+ "name": "Motor — bulk, tone, strength",
+ "significance": "Localises lesion to UMN vs LMN vs muscle vs junction. Pattern of weakness (proximal vs distal, symmetric vs focal) narrows differential.",
+ "pearl": "Pronator drift is the most sensitive screen for subtle UMN weakness — a normal-feeling arm that drifts down with eyes closed still has corticospinal tract dysfunction. Always do it even when formal strength is 5/5.",
+ "steps": [
+ {
+ "label": "Bulk inspection",
+ "method": "Inspect shoulders, biceps, thighs, calves, dorsal interossei (between metacarpals) of hands.",
+ "normal": "Symmetric bulk; no atrophy, no pseudohypertrophy"
+ },
+ {
+ "label": "Tone — upper",
+ "method": "Passive flex-extend elbow and pronate-supinate wrist at slow then quick speeds. Then pronator drift: arms outstretched, palms up, eyes closed for 10 s.",
+ "normal": "Smooth passive range; no drift, no pronation of the outstretched hand"
+ },
+ {
+ "label": "Tone — lower",
+ "method": "Passive knee flexion-extension; quick ankle dorsiflexion to check for catch. Heel-slap test: roll thigh and watch for ankle swing.",
+ "normal": "Normal resistance, no catch, symmetric"
+ },
+ {
+ "label": "Strength — deltoid (C5)",
+ "method": "Patient abducts both arms to 90°. Examiner pushes down on each arm just above the elbow while patient resists. Compare sides.",
+ "normal": "Holds against full resistance — MRC 5/5 bilaterally"
+ },
+ {
+ "label": "Strength — biceps (C5–C6)",
+ "method": "Elbow flexed 90°, supinated. Examiner grasps wrist and pulls to extend while patient resists.",
+ "normal": "Holds against full resistance — 5/5"
+ },
+ {
+ "label": "Strength — triceps (C7)",
+ "method": "Elbow flexed 90°. Examiner pushes wrist toward shoulder while patient extends against resistance.",
+ "normal": "Extends against full resistance — 5/5"
+ },
+ {
+ "label": "Strength — wrist extension (C6–C7)",
+ "method": "Patient makes fist, extends wrist. Examiner pushes down on knuckles while patient holds wrist up.",
+ "normal": "Holds against full resistance — 5/5"
+ },
+ {
+ "label": "Strength — finger flexion / grip (C8)",
+ "method": "Patient grips two of examiner's crossed fingers as hard as possible. Compare sides.",
+ "normal": "Strong symmetric grip — 5/5"
+ },
+ {
+ "label": "Strength — finger abduction (T1)",
+ "method": "Patient spreads fingers wide. Examiner squeezes index and little fingers together while patient resists.",
+ "normal": "Holds fingers apart — 5/5"
+ },
+ {
+ "label": "Strength — hip flexion (L2–L3)",
+ "method": "Supine. Patient lifts straight leg 30° off table. Examiner pushes down on thigh just above knee while patient resists.",
+ "normal": "Holds thigh up against full resistance — 5/5"
+ },
+ {
+ "label": "Strength — knee extension (L3–L4)",
+ "method": "Sitting, knee 90°. Patient straightens knee while examiner pushes distal shin down.",
+ "normal": "Extends against full resistance — 5/5"
+ },
+ {
+ "label": "Strength — ankle dorsiflexion (L4–L5)",
+ "method": "Patient pulls toes and foot up toward shin. Examiner pushes foot down at the dorsum.",
+ "normal": "Holds dorsiflexion against full resistance — 5/5; preserved heel-walk"
+ },
+ {
+ "label": "Strength — great toe extension (L5)",
+ "method": "Patient extends great toe up while examiner pushes it down with thumb.",
+ "normal": "Holds against full resistance — 5/5 (classic L5 test)"
+ },
+ {
+ "label": "Strength — ankle plantarflexion (S1)",
+ "method": "Patient pushes foot down against examiner's hand at the ball. OR ask patient to toe-walk 10 steps (more sensitive — unilateral plantarflexion weakness shows immediately).",
+ "normal": "Full power; toe-walks symmetrically — 5/5"
+ }
+ ],
+ "abnormalHints": [
+ "Focal weakness → localise by myotome",
+ "Pronator drift (subtle UMN, always check even with 5/5)",
+ "Spasticity / catch (UMN)",
+ "Atrophy (LMN, disuse)",
+ "Fasciculations (MND, ALS)",
+ "Pseudohypertrophy of calves (DMD in a young male)"
+ ]
+ },
+ {
+ "name": "Deep tendon reflexes",
+ "significance": "Reflex pattern (increased, decreased, asymmetric) localises UMN vs LMN vs root vs peripheral nerve. Inexpensive and fast, but asymmetry is the most informative finding.",
+ "pearl": "A reinforced reflex is still a reflex. If you can't elicit it initially, use Jendrassik (teeth clench or pull interlocked fingers apart) to boost — absent reflexes without reinforcement aren't truly absent.",
+ "steps": [
+ {
+ "label": "Biceps (C5–C6)",
+ "method": "Patient's arm relaxed across lap. Examiner places thumb firmly on biceps tendon at the cubital fossa, strikes thumb with reflex hammer. Compare both sides sequentially.",
+ "normal": "2+ symmetric — visible contraction of biceps, slight elbow flexion"
+ },
+ {
+ "label": "Brachioradialis (C5–C6)",
+ "method": "Arm relaxed. Strike the distal radius about 3 cm proximal to the wrist, on its radial (thumb) side.",
+ "normal": "2+ symmetric — elbow flexion and slight forearm supination"
+ },
+ {
+ "label": "Triceps (C7)",
+ "method": "Support the patient's arm at the wrist with elbow at 90°. Strike the triceps tendon just above the olecranon.",
+ "normal": "2+ symmetric — triceps contraction, slight elbow extension"
+ },
+ {
+ "label": "Finger flexors — Hoffmann sign",
+ "method": "Grasp the middle finger's distal phalanx, flick it downward quickly and release. Watch the thumb and index finger.",
+ "normal": "Negative — no thumb flexion, no index flexion (positive = corticospinal tract dysfunction)"
+ },
+ {
+ "label": "Patellar (L3–L4)",
+ "method": "Patient sits with knees hanging freely off the table. Strike the patellar tendon just below the patella.",
+ "normal": "2+ symmetric — quadriceps contraction with knee extension"
+ },
+ {
+ "label": "Achilles (S1)",
+ "method": "Patient's knee slightly flexed and leg externally rotated, or kneeling on a chair. Slightly dorsiflex the foot and strike the Achilles tendon.",
+ "normal": "2+ symmetric — plantar flexion of the foot"
+ },
+ {
+ "label": "Plantar response (Babinski)",
+ "method": "Stroke the lateral aspect of the sole firmly from the heel toward the little toe, then curve across the ball of the foot.",
+ "normal": "Toes flex downward (plantar flexion, \"down-going\") bilaterally in anyone ≥ 2 years"
+ },
+ {
+ "label": "Ankle clonus",
+ "method": "Knee slightly bent. Support the shin with one hand, quickly and sharply dorsiflex the foot with the other, hold in dorsiflexion.",
+ "normal": "≤ 3 non-sustained beats is acceptable; sustained rhythmic oscillation = pathological clonus (UMN)"
+ }
+ ],
+ "abnormalHints": [
+ "Hyperreflexia + sustained clonus = UMN (MS, myelopathy, cord lesion, stroke)",
+ "Symmetric hyporeflexia = peripheral polyneuropathy, GBS, myopathy, hypothyroid, B12 deficiency",
+ "Asymmetric hyporeflexia = radiculopathy at that segment",
+ "Hoffmann positive = corticospinal tract dysfunction at cervical cord or above",
+ "Up-going Babinski after age 2 = UMN (always abnormal)"
+ ]
+ },
+ {
+ "name": "Sensory",
+ "steps": [
+ {
+ "label": "Light touch — upper",
+ "method": "Cotton wisp, dorsum of hands, eyes closed",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Light touch — lower",
+ "method": "Dorsum of feet",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Pain — upper",
+ "method": "Broken Q-tip sharp end, hands",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Pain — lower",
+ "method": "Same on feet",
+ "normal": "Intact, symmetric"
+ },
+ {
+ "label": "Temperature (if indicated)",
+ "method": "Cold tuning fork each area",
+ "normal": "Intact"
+ },
+ {
+ "label": "Vibration",
+ "method": "128 Hz tuning fork at distal IP of great toes; count seconds to fade",
+ "normal": "Feels vibration; appropriate duration"
+ },
+ {
+ "label": "Proprioception",
+ "method": "Move great toe up/down with eyes closed",
+ "normal": "Identifies direction correctly"
+ },
+ {
+ "label": "Two-point discrimination (if indicated)",
+ "method": "Blunt calipers on fingertip",
+ "normal": "<5mm on fingertip"
+ },
+ {
+ "label": "Stereognosis (if indicated)",
+ "method": "Identify coin/key in hand with eyes closed",
+ "normal": "Correct identification"
+ }
+ ],
+ "abnormalHints": [
+ "Dermatomal loss (nerve root)",
+ "Stocking-glove loss (length-dependent neuropathy)",
+ "Dorsal column loss (B12, tabes, MS — positive Romberg, vibration loss)",
+ "Cortical deficit (astereognosis, impaired 2-pt)"
+ ]
+ },
+ {
+ "name": "Coordination",
+ "steps": [
+ {
+ "label": "Finger-nose-finger",
+ "method": "Alternate examiner's finger and own nose; examiner moves target",
+ "normal": "Smooth, accurate bilaterally"
+ },
+ {
+ "label": "Heel-to-shin",
+ "method": "Supine: heel down opposite shin and back",
+ "normal": "Smooth, accurate"
+ },
+ {
+ "label": "Rapid alternating (Dysdiadochokinesis)",
+ "method": "Supinate/pronate hand rapidly on thigh",
+ "normal": "Rhythmic, symmetric"
+ },
+ {
+ "label": "Finger tapping",
+ "method": "Thumb to each finger in sequence rapidly",
+ "normal": "Rhythmic, smooth, symmetric"
+ }
+ ],
+ "abnormalHints": [
+ "Dysmetria (cerebellar)",
+ "Intention tremor",
+ "Dysdiadochokinesia",
+ "Decomposed movement"
+ ]
+ },
+ {
+ "name": "Gait and Romberg",
+ "steps": [
+ {
+ "label": "Normal gait",
+ "method": "Walk 20 feet",
+ "normal": "Narrow-based, smooth, reciprocal arm swing"
+ },
+ {
+ "label": "Heel walk",
+ "method": "Walk on heels only",
+ "normal": "Able without difficulty"
+ },
+ {
+ "label": "Toe walk",
+ "method": "Walk on toes only",
+ "normal": "Able without difficulty"
+ },
+ {
+ "label": "Tandem",
+ "method": "Heel-to-toe along a line, 10+ steps",
+ "normal": "Minimal deviation"
+ },
+ {
+ "label": "Romberg",
+ "method": "Feet together, eyes open then closed, 30s",
+ "normal": "Stable — no significant sway or fall with eyes closed"
+ },
+ {
+ "label": "Single-leg stance",
+ "method": "10s each side, eyes open",
+ "normal": "Stable without drift"
+ }
+ ],
+ "abnormalHints": [
+ "Ataxic (wide-based — cerebellar)",
+ "Steppage (peripheral neuropathy / foot drop)",
+ "Circumduction (UMN hemiparesis)",
+ "Scissoring",
+ "Romberg positive (dorsal column)"
+ ]
+ },
+ {
+ "name": "Frontal release / primitive reflexes",
+ "steps": [
+ {
+ "label": "Grasp reflex",
+ "method": "Stroke palm",
+ "normal": "Absent"
+ },
+ {
+ "label": "Snout reflex",
+ "method": "Tap upper lip",
+ "normal": "No lip pucker"
+ },
+ {
+ "label": "Glabellar tap",
+ "method": "Tap between eyebrows — should habituate after 3–4 taps",
+ "normal": "Habituates (no sustained blink)"
+ },
+ {
+ "label": "Palmomental",
+ "method": "Stroke thenar eminence",
+ "normal": "No ipsilateral chin twitch"
+ }
+ ],
+ "abnormalHints": [
+ "Presence suggests frontal lobe pathology, neurodegenerative disease, or severe TBI — rare in adolescence but relevant in post-concussion workup"
+ ]
+ }
+ ]
+ },
+ "resp": {
+ "overview": "Systematic respiratory exam: inspection → palpation → percussion → auscultation → special maneuvers. Always start from observation — rate, pattern, work of breathing, and audible sounds (stridor, grunting) can be diagnostic before the stethoscope touches the chest.",
+ "components": [
+ {
+ "name": "Inspection — observation before touching",
+ "significance": "Detects respiratory distress and localises the level of airway compromise before any equipment is used. High yield: RR, WOB, audible sounds, chest shape, colour.",
+ "pearl": "Audible stridor at rest from across the room = upper-airway obstruction, often urgent. Grunting in an infant = significant distress — never dismiss as fussiness.",
+ "steps": [
+ {
+ "label": "Respiratory rate",
+ "method": "Count over a full 60 seconds (not 15×4) — children normally breathe irregularly. Count while the patient is calm, before any interaction.",
+ "normal": "Within age-appropriate range (see scales card above)"
+ },
+ {
+ "label": "Respiratory pattern",
+ "method": "Observe depth, regularity, and inspiration:expiration ratio. Watch for prolonged expiration, paradoxical chest-abdominal movement, or apneas.",
+ "normal": "Regular, I:E ratio ~1:2, no pauses > 10 s in an infant"
+ },
+ {
+ "label": "Work of breathing",
+ "method": "Inspect for nasal flaring, suprasternal/intercostal/subcostal retractions, accessory muscle use (SCM, abdominals), tripod positioning, head-bobbing in infants.",
+ "normal": "No retractions; breathing effortless"
+ },
+ {
+ "label": "Audible sounds (no stethoscope)",
+ "method": "Listen at the bedside without the stethoscope. Grunting? Stridor? Wheezing audible across the room? Hoarse voice?",
+ "normal": "No audible stridor, grunting, or wheeze"
+ },
+ {
+ "label": "Chest shape and symmetry",
+ "method": "Inspect from front and lateral. Note AP-to-transverse diameter, pectus excavatum/carinatum, chest wall asymmetry.",
+ "normal": "AP:transverse ~1:2 (not barrel-chested); symmetric"
+ },
+ {
+ "label": "Colour and perfusion",
+ "method": "Inspect lips, tongue, nail beds for central cyanosis. Check peripheral perfusion (capillary refill, mottling).",
+ "normal": "Pink, cap refill < 2 s, no cyanosis"
+ },
+ {
+ "label": "Clubbing",
+ "method": "Inspect fingernails: Schamroth sign (reverse a finger against its mirror — normal forms a diamond-shaped window, clubbed does not).",
+ "normal": "Normal nail angle, Schamroth window present"
+ }
+ ],
+ "abnormalHints": [
+ "Audible stridor — upper airway (croup, epiglottitis, foreign body, laryngomalacia)",
+ "Grunting in infant — significant distress",
+ "Tripod positioning, accessory muscle use — severe distress",
+ "Barrel chest — chronic air-trapping (asthma, CF)",
+ "Central cyanosis — significant hypoxemia",
+ "Clubbing in a child — cystic fibrosis, chronic hypoxemia, bronchiectasis, cyanotic CHD"
+ ]
+ },
+ {
+ "name": "Palpation",
+ "significance": "Localises pathology: consolidation increases tactile fremitus; pneumothorax/effusion decreases it. Trachea deviates AWAY from expanding lesions and TOWARD collapsing ones.",
+ "pearl": "Tracheal deviation is one of the fastest bedside clues to mediastinal shift — tension pneumothorax pushes it away, lobar collapse pulls it toward. Palpate with the middle finger in the suprasternal notch.",
+ "steps": [
+ {
+ "label": "Tracheal position",
+ "method": "Patient sitting upright, neck slightly extended. Place middle finger in the suprasternal notch, check equal distance to each SCM.",
+ "normal": "Midline"
+ },
+ {
+ "label": "Chest expansion — symmetry",
+ "method": "Hands on lateral chest wall with thumbs meeting at the spine (posterior) or xiphoid (anterior). Patient takes a deep breath. Watch thumbs separate symmetrically.",
+ "normal": "Symmetric 3–5 cm separation"
+ },
+ {
+ "label": "Tactile fremitus",
+ "method": "Ulnar surface of hand on chest wall. Ask patient to say \"ninety-nine\" repeatedly. Move hand systematically across each zone, comparing sides.",
+ "normal": "Equal mild vibration bilaterally over lung fields"
+ },
+ {
+ "label": "Chest wall tenderness",
+ "method": "Palpate ribs, costochondral junctions, sternum, and intercostal spaces.",
+ "normal": "No tenderness"
+ },
+ {
+ "label": "Subcutaneous emphysema",
+ "method": "Gentle palpation along clavicles, neck, chest wall.",
+ "normal": "No crepitus under skin"
+ }
+ ],
+ "abnormalHints": [
+ "Tracheal deviation — tension pneumothorax, large pleural effusion (away); upper lobe collapse (toward)",
+ "Asymmetric expansion — pneumothorax, large effusion, lobar collapse, phrenic palsy",
+ "Increased fremitus — consolidation (pneumonia), lobar pneumonia",
+ "Decreased/absent fremitus — pleural effusion, pneumothorax, obstruction",
+ "Costochondral tenderness — costochondritis, trauma",
+ "Subcutaneous emphysema — pneumothorax, tracheobronchial injury"
+ ]
+ },
+ {
+ "name": "Percussion",
+ "significance": "Differentiates air (hyper-resonant), fluid (dull), and consolidated lung (dull) without imaging. Well-performed percussion detects a pleural effusion > 300 mL or a pneumothorax with ~90% sensitivity.",
+ "pearl": "Pleximeter fingertip must be flat against the chest wall — lift other fingers off. The \"feel\" of a percussion note is as informative as the sound: dullness has a dense, reflected quality; hyper-resonance feels hollow and springy.",
+ "steps": [
+ {
+ "label": "Technique",
+ "method": "Place middle finger of non-dominant hand (pleximeter) flat on chest wall; strike distal IP joint with tip of dominant middle finger (plexor) using a quick wrist flick.",
+ "normal": "N/A — technique step"
+ },
+ {
+ "label": "Systematic zones",
+ "method": "Percuss from apex to base, comparing side-to-side at each level. Include anterior, lateral (mid-axillary), and posterior fields.",
+ "normal": "Resonant throughout lung fields"
+ },
+ {
+ "label": "Cardiac dullness",
+ "method": "Percuss from resonant lung toward the heart border. Left sternal border dullness starts at the 3rd–5th ICS.",
+ "normal": "Dullness beginning at the expected cardiac border"
+ },
+ {
+ "label": "Hepatic dullness",
+ "method": "Right 5th–6th ICS mid-clavicular line transitions from resonant to dull.",
+ "normal": "Liver edge dullness at expected level"
+ },
+ {
+ "label": "Diaphragmatic excursion",
+ "method": "Patient inhales fully then exhales fully; mark level of dullness at each end. Difference is diaphragm excursion.",
+ "normal": "3–5 cm excursion bilaterally"
+ }
+ ],
+ "abnormalHints": [
+ "Hyper-resonant — pneumothorax, emphysematous bulla, severe asthma attack",
+ "Dull — consolidation, pleural effusion (stony dull), atelectasis, pleural thickening, large mass",
+ "Raised diaphragm (loss of excursion) — effusion, paralysis, subdiaphragmatic pathology"
+ ]
+ },
+ {
+ "name": "Auscultation — normal breath sounds",
+ "significance": "Breath sound quality varies by location. Bronchial sounds heard peripherally = consolidation; absent breath sounds = pneumothorax, effusion, obstruction.",
+ "pearl": "Always compare corresponding points side-to-side sequentially — your ear calibrates to \"normal\" one side and immediately hears asymmetry. Listen through a full respiratory cycle at each zone.",
+ "steps": [
+ {
+ "label": "Technique",
+ "method": "Diaphragm of stethoscope directly on skin (not over clothing). Patient breathes slowly and deeply through an open mouth.",
+ "normal": "N/A — technique"
+ },
+ {
+ "label": "Vesicular sounds (peripheral)",
+ "method": "Listen over lung fields away from the sternum. Play the \"Normal vesicular\" sample above for reference.",
+ "normal": "Soft, low-pitched, inspiration > expiration in length and loudness"
+ },
+ {
+ "label": "Bronchovesicular (over main bronchi)",
+ "method": "Listen at the 1st–2nd ICS anteriorly and between scapulae posteriorly.",
+ "normal": "Intermediate pitch, inspiration = expiration"
+ },
+ {
+ "label": "Bronchial (over trachea)",
+ "method": "Listen directly over the manubrium or trachea.",
+ "normal": "Harsh, high-pitched, expiration > inspiration"
+ },
+ {
+ "label": "Systematic comparison",
+ "method": "Six zones anteriorly (upper/mid/lower × L/R), four lateral, six posterior. Compare side-to-side at each zone.",
+ "normal": "Symmetric breath sounds at every paired zone"
+ }
+ ],
+ "abnormalHints": [
+ "Bronchial sounds heard peripherally — consolidation (pneumonia)",
+ "Absent/diminished breath sounds — pneumothorax, effusion, severe obstruction, obesity / muscular chest",
+ "Prolonged expiration — lower airway obstruction (asthma, bronchiolitis)"
+ ]
+ },
+ {
+ "name": "Auscultation — adventitious sounds",
+ "significance": "Adventitious (added) sounds are the key diagnostic finding. Timing (inspiratory vs expiratory vs biphasic), character (continuous vs discontinuous), and location are all informative.",
+ "pearl": "Ask the patient to cough and re-listen. Secretions (rhonchi, some coarse crackles) clear or change; fine crackles of fibrosis or early pneumonia do not. The cough test separates two differential groups in one maneuver.",
+ "steps": [
+ {
+ "label": "Listen for wheeze",
+ "method": "Continuous musical sounds, typically expiratory. Use the \"Wheeze\" sample for reference.",
+ "normal": "No wheeze"
+ },
+ {
+ "label": "Listen for crackles — fine",
+ "method": "Short, high-pitched, discontinuous \"Velcro\" sounds. Typically end-inspiratory, bibasilar. Use the \"Fine crackles\" sample.",
+ "normal": "No crackles"
+ },
+ {
+ "label": "Listen for crackles — coarse",
+ "method": "Longer, lower-pitched, louder than fine. Use the \"Coarse crackles\" sample.",
+ "normal": "No crackles"
+ },
+ {
+ "label": "Listen for rhonchi",
+ "method": "Low-pitched, continuous, snore-like. Often change with cough. Use the \"Rhonchi\" sample.",
+ "normal": "No rhonchi"
+ },
+ {
+ "label": "Listen for pleural rub",
+ "method": "Grating, creaky, biphasic, does NOT clear with cough. Use the \"Pleural rub\" sample.",
+ "normal": "No pleural rub"
+ },
+ {
+ "label": "Listen at the neck (for stridor)",
+ "method": "Place stethoscope over the anterior neck. Stridor is loudest here and differentiates from wheeze (loudest over chest). Use the \"Stridor\" sample.",
+ "normal": "No stridor"
+ },
+ {
+ "label": "Listen for expiratory grunting (infants)",
+ "method": "Often audible without a stethoscope at the bedside — short, low-pitched sound at the end of each expiration (glottal closure against exhaled air).",
+ "normal": "No grunting"
+ },
+ {
+ "label": "Cough re-listen",
+ "method": "Have patient cough forcefully; re-listen to any abnormal area. Note if the sound clears or changes.",
+ "normal": "Any secretion-based sound should clear or change with cough"
+ }
+ ],
+ "abnormalHints": [
+ "Wheeze — asthma, bronchiolitis, foreign body (localised), anaphylaxis",
+ "Fine crackles — pulmonary edema, interstitial lung disease, early pneumonia",
+ "Coarse crackles — bronchitis, pneumonia, bronchiectasis, aspiration",
+ "Rhonchi — large-airway secretions",
+ "Pleural rub — pleurisy, PE, pneumonia with pleural involvement",
+ "Stridor — upper airway obstruction (croup, epiglottitis, FB)"
+ ]
+ },
+ {
+ "name": "Special maneuvers — transmitted voice sounds",
+ "significance": "Vocal resonance tests detect consolidation (increased transmission) and effusion/pneumothorax (decreased). Useful when auscultation suggests asymmetry.",
+ "pearl": "Whispered pectoriloquy is the most sensitive of the three — whispered words transmitted clearly through consolidated lung. If \"one, two, three\" whispered becomes clearly audible over one lung zone, there is consolidation underneath.",
+ "steps": [
+ {
+ "label": "Bronchophony",
+ "method": "Patient says \"ninety-nine\" in normal voice. Listen at each lung zone with the stethoscope.",
+ "normal": "Muffled, indistinct sound"
+ },
+ {
+ "label": "Egophony",
+ "method": "Patient says \"ee\" continuously. Listen over any suspicious area.",
+ "normal": "\"Ee\" sounds like \"ee\" (no change)"
+ },
+ {
+ "label": "Whispered pectoriloquy",
+ "method": "Patient whispers \"one, two, three\" or \"ninety-nine\". Listen over each zone.",
+ "normal": "Whisper is faint and indistinct"
+ }
+ ],
+ "abnormalHints": [
+ "Bronchophony increased — consolidation",
+ "Egophony positive (\"ee\" → \"A\" / \"ay\") — consolidation, sometimes top of an effusion",
+ "Whispered pectoriloquy positive (whisper clearly audible) — consolidation"
+ ]
+ }
+ ]
+ },
+ "cv": {
+ "overview": "Systematic cardiovascular exam: inspection → palpation → auscultation at the five classic points → peripheral vascular exam. Always palpate the apex BEFORE auscultating — knowing where the apex lies tells you where to put the stethoscope and flags cardiomegaly immediately.",
+ "components": [
+ {
+ "name": "Inspection",
+ "significance": "Detects obvious precordial activity, chest-wall signs of congenital heart disease, and systemic markers (cyanosis, clubbing, dysmorphic features).",
+ "pearl": "Clubbing + central cyanosis in a well-appearing adolescent = cyanotic congenital heart disease until proven otherwise. Inspect the fingernails before reaching for the stethoscope.",
+ "steps": [
+ {
+ "label": "General appearance",
+ "method": "Observe body habitus, features suggesting syndromic CHD (Turner, Down, Marfan, Williams).",
+ "normal": "No dysmorphic features, appropriate growth"
+ },
+ {
+ "label": "Central cyanosis",
+ "method": "Inspect lips, tongue, and oral mucosa for bluish discoloration.",
+ "normal": "Pink oral mucosa, no cyanosis"
+ },
+ {
+ "label": "Peripheral cyanosis / clubbing",
+ "method": "Inspect nail beds; do Schamroth's window (oppose nails of 4th fingers — normally forms a diamond-shaped window).",
+ "normal": "Pink nail beds, Schamroth window present"
+ },
+ {
+ "label": "Precordial bulge",
+ "method": "Inspect anterior chest wall tangentially for asymmetric prominence over the heart.",
+ "normal": "Symmetric chest, no bulge"
+ },
+ {
+ "label": "Visible apex beat",
+ "method": "Inspect for a visible cardiac impulse at the 5th ICS mid-clavicular line.",
+ "normal": "Apex may be visible in thin patients; should not be displaced"
+ },
+ {
+ "label": "Neck veins (JVP)",
+ "method": "Patient reclined 45°, head turned slightly left. Observe the right internal jugular pulsation; measure vertical height above the sternal angle.",
+ "normal": "≤ 4 cm above sternal angle (≤ 9 cm H₂O from right atrium)"
+ }
+ ],
+ "abnormalHints": [
+ "Central cyanosis — right-to-left shunt, severe hypoxemia",
+ "Clubbing — cyanotic CHD, chronic hypoxemia",
+ "Precordial bulge — long-standing cardiomegaly (grew during skeletal growth)",
+ "Visible apex displaced lateral/inferior — cardiomegaly",
+ "Elevated JVP — right-heart failure, fluid overload, cardiac tamponade"
+ ]
+ },
+ {
+ "name": "Palpation",
+ "significance": "Localises the apex (confirms cardiac size), detects thrills (loud murmurs), and identifies a parasternal heave (RV hypertrophy).",
+ "pearl": "If you feel a thrill, the murmur is at least grade 4/6 — grade your murmur as ≥4 even if it sounds less impressive. Thrill = loud, palpable turbulence.",
+ "steps": [
+ {
+ "label": "Apex beat — localise",
+ "method": "Feel with the tips of the fingers at the 5th ICS mid-clavicular line. If not found, roll the patient to the left lateral decubitus position.",
+ "normal": "Located at 5th ICS, mid-clavicular line, less than 2 cm in diameter"
+ },
+ {
+ "label": "Apex character",
+ "method": "Describe: tapping (normal), heaving (pressure overload, e.g. AS/HTN), thrusting (volume overload, e.g. AR/MR), dyskinetic (MI/aneurysm).",
+ "normal": "Brief tapping quality"
+ },
+ {
+ "label": "Parasternal heave",
+ "method": "Place the heel of the hand along the left sternal border. Sustained outward movement with each systole = heave.",
+ "normal": "No heave"
+ },
+ {
+ "label": "Thrills",
+ "method": "Use the palmar aspect of the hand at each of the 5 auscultation areas (A, P, E, T, M). A thrill = palpable turbulence.",
+ "normal": "No thrills"
+ },
+ {
+ "label": "Peripheral pulses — upper",
+ "method": "Palpate radial pulses bilaterally, then brachial. Note rate, rhythm, volume, and symmetry.",
+ "normal": "Symmetric 2+ pulses, regular rhythm, age-appropriate rate"
+ },
+ {
+ "label": "Peripheral pulses — lower",
+ "method": "Palpate femoral pulses. Compare to brachial — radio-femoral or brachio-femoral delay suggests coarctation of the aorta.",
+ "normal": "Femoral pulses 2+ symmetric, no delay relative to radial"
+ }
+ ],
+ "abnormalHints": [
+ "Apex displaced laterally/inferiorly — cardiomegaly",
+ "Heaving apex — pressure overload (AS, HTN)",
+ "Thrusting apex — volume overload (AR, MR)",
+ "Thrill over precordium — always pathological; at least grade 4/6 murmur",
+ "Parasternal heave — RV hypertrophy (pulmonary HTN, pulmonary stenosis, VSD with Eisenmenger)",
+ "Radio-femoral delay — coarctation of the aorta (always check in a hypertensive adolescent)"
+ ]
+ },
+ {
+ "name": "Auscultation — approach",
+ "significance": "Systematic technique ensures every relevant finding is detected. Listen at all 5 points, with both diaphragm and bell, in supine/sitting/left-lateral positions as needed.",
+ "pearl": "Time every murmur by simultaneously palpating the carotid pulse with the fingers of your free hand. Pulse = systole. Murmur heard during the pulse = systolic; in between pulses = diastolic.",
+ "steps": [
+ {
+ "label": "Positioning",
+ "method": "Patient supine, head of bed at 30°. Exam room quiet, patient relaxed. Warm the stethoscope first.",
+ "normal": "N/A — technique"
+ },
+ {
+ "label": "Diaphragm technique",
+ "method": "Firm contact with skin. Detects HIGH-pitched sounds: S1, S2, systolic ejection murmurs, AR, MR.",
+ "normal": "N/A — technique"
+ },
+ {
+ "label": "Bell technique",
+ "method": "Very light contact — enough to make a seal but not stretch the skin. Detects LOW-pitched sounds: S3, S4, mitral stenosis rumble.",
+ "normal": "N/A — technique"
+ },
+ {
+ "label": "Listen at each of the 5 points",
+ "method": "A → P → E → T → M in order, each with diaphragm then bell. Spend a full cycle at each zone.",
+ "normal": "S1 crisp, S2 clear (splits physiologically on inspiration at P), no added sounds, no murmur"
+ },
+ {
+ "label": "Left lateral decubitus position",
+ "method": "If apex murmur suspected. Roll patient to left side. Listen at the apex with the BELL for mitral stenosis rumble or S3/S4.",
+ "normal": "No added sounds, no diastolic rumble"
+ },
+ {
+ "label": "Sitting forward, held expiration",
+ "method": "Patient leans forward, exhales fully, holds. Listen at left lower sternal border and Erb's point with the DIAPHRAGM for aortic regurgitation (soft early diastolic decrescendo).",
+ "normal": "No early-diastolic murmur"
+ }
+ ],
+ "abnormalHints": [
+ "Fixed split S2 (no change with respiration) — ASD",
+ "Loud S2 at pulmonic area — pulmonary HTN",
+ "S3 — volume overload, CHF (can be normal in young athletes)",
+ "S4 — stiff ventricle (HTN, HCM, ischemia)",
+ "Audible opening snap — mitral stenosis (rare in children)"
+ ]
+ },
+ {
+ "name": "Auscultation — heart sounds and murmurs",
+ "significance": "Characterising a murmur by timing, location, radiation, pitch, quality, and dynamic maneuvers narrows the differential.",
+ "pearl": "Innocent murmurs in children share 7 \"S\" features: Soft (≤ grade 2), Systolic, Short, Single (no added S3/S4), Small (localised, non-radiating), Sweet (musical), Sensitive to position/respiration (louder supine, softer standing). Anything breaking this pattern deserves workup.",
+ "steps": [
+ {
+ "label": "S1",
+ "method": "Listen at the apex (mitral). Coincides with the carotid pulse upstroke. Mitral + tricuspid closure.",
+ "normal": "Single, crisp, single-component sound"
+ },
+ {
+ "label": "S2",
+ "method": "Listen at the pulmonic area in HELD INSPIRATION and HELD EXPIRATION. Note whether S2 splits physiologically (wider in inspiration, narrower/absent in expiration).",
+ "normal": "Physiologic split (widens on inspiration, narrows on expiration)"
+ },
+ {
+ "label": "S3 / S4 gallops",
+ "method": "Bell at the apex in left lateral decubitus. S3 = early diastole (after S2), low-pitched. S4 = late diastole (just before S1).",
+ "normal": "Absent in adults; S3 can be normal in young athletes under age 30"
+ },
+ {
+ "label": "Identify murmur — timing",
+ "method": "Time vs carotid pulse. Systolic (during pulse) vs diastolic (between pulses) vs continuous.",
+ "normal": "No murmur, or only soft innocent flow murmur"
+ },
+ {
+ "label": "Identify murmur — location + radiation",
+ "method": "Where loudest? Does it radiate? AS → carotids. MR → axilla. Coarctation → back.",
+ "normal": "N/A — characterise only if murmur present"
+ },
+ {
+ "label": "Identify murmur — character",
+ "method": "Crescendo-decrescendo (ejection) vs holosystolic (plateau) vs decrescendo early-diastolic (AR, PR) vs mid-diastolic rumble (MS, TS).",
+ "normal": "N/A — characterise only if murmur present"
+ },
+ {
+ "label": "Grade intensity",
+ "method": "Levine 1–6 scale (see scales card above).",
+ "normal": "No murmur, or grade ≤ 2 soft innocent flow murmur"
+ },
+ {
+ "label": "Dynamic maneuvers",
+ "method": "Standing: ↑HOCM, ↑MVP click (earlier). Squatting: opposite. Valsalva: ↑HOCM, most others decrease.",
+ "normal": "No significant change with posture"
+ }
+ ],
+ "abnormalHints": [
+ "Holosystolic murmur at apex → axilla — mitral regurgitation",
+ "Holosystolic at lower left sternal border (LLSB) — VSD, tricuspid regurgitation",
+ "Systolic ejection at upper right sternal border → carotids — aortic stenosis",
+ "Systolic ejection at upper left sternal border — pulmonary stenosis",
+ "Continuous \"machinery\" below left clavicle — PDA",
+ "Early diastolic at Erb's point, leaning forward — aortic regurgitation",
+ "Diastolic rumble at apex, bell in left-lateral — mitral stenosis",
+ "Fixed split S2 + systolic flow murmur — ASD"
+ ]
+ },
+ {
+ "name": "Peripheral vascular exam",
+ "significance": "Coarctation of the aorta hides until BP and pulses are checked in all four extremities. Differential diagnosis of a hypertensive adolescent should include this in the first 60 seconds.",
+ "pearl": "Four-limb BP measurement is mandatory in any adolescent with hypertension or a murmur. Upper-extremity BP > lower-extremity BP (or brachio-femoral delay) = coarctation until excluded.",
+ "steps": [
+ {
+ "label": "Four-limb blood pressure",
+ "method": "Measure BP in right arm, left arm, and at least one leg. Use appropriately sized cuff (bladder width 40% of limb circumference, length 80–100%).",
+ "normal": "Arm BPs within 10 mmHg of each other; leg systolic within 20 mmHg of arm systolic (may be higher)"
+ },
+ {
+ "label": "Radial pulses",
+ "method": "Palpate both radials simultaneously — note any delay or asymmetry.",
+ "normal": "Simultaneous, symmetric, 2+"
+ },
+ {
+ "label": "Radio-femoral delay",
+ "method": "Palpate radial and femoral simultaneously. Feel the femoral as clearly \"after\" the radial = delay.",
+ "normal": "No delay"
+ },
+ {
+ "label": "Femoral pulses",
+ "method": "Palpate both femoral pulses at the mid-inguinal point. Compare amplitude to radials.",
+ "normal": "Symmetric 2+ pulses, equal amplitude to radial"
+ },
+ {
+ "label": "Dorsalis pedis + posterior tibialis",
+ "method": "Palpate in both feet.",
+ "normal": "2+ pulses bilaterally"
+ },
+ {
+ "label": "Capillary refill",
+ "method": "Press and release the nail bed; time to normal colour.",
+ "normal": "< 2 sec"
+ }
+ ],
+ "abnormalHints": [
+ "Asymmetric upper-extremity BP (> 10 mmHg) — subclavian stenosis or coarctation at the origin",
+ "Upper >> lower-extremity BP — coarctation of the aorta",
+ "Diminished or absent femoral pulses with brachio-femoral delay — coarctation",
+ "Bounding pulses with wide pulse pressure — AR, PDA, arteriovenous fistula, thyrotoxicosis, anemia",
+ "Weak thready pulses — low output state (heart failure, shock, hypovolemia)",
+ "Prolonged capillary refill — dehydration, shock, cold stress"
+ ]
+ }
+ ]
+ }
+ }
+ }
+}
diff --git a/public/js/peGuide.js b/public/js/peGuide.js
index 73369e6..a60579c 100644
--- a/public/js/peGuide.js
+++ b/public/js/peGuide.js
@@ -15,1321 +15,41 @@
// step array and produces a Technique + Findings narrative.
// ============================================================
- // ────────────────────────────────────────────────────────────
- // GRADING SCALES — universal reference shown at top of each system
- // ────────────────────────────────────────────────────────────
- var SCALES = {
- mrc: {
- title: 'MRC strength grade (0–5)',
- icon: 'fa-hand-fist',
- rows: [
- ['5', 'Normal power — holds against full resistance'],
- ['4', 'Reduced — moves against gravity + some resistance'],
- ['3', 'Moves against gravity only (no added resistance)'],
- ['2', 'Full range with gravity eliminated (horizontal plane)'],
- ['1', 'Flicker / trace contraction, no joint movement'],
- ['0', 'No contraction']
- ]
- },
- dtr: {
- title: 'Deep-tendon reflex grade (0–4+)',
- icon: 'fa-circle-dot',
- rows: [
- ['0', 'Absent'],
- ['1+', 'Hypoactive — trace, only with reinforcement'],
- ['2+', 'Normal'],
- ['3+', 'Brisk — may still be normal in anxious patients'],
- ['4+', 'Hyperactive with sustained clonus — always abnormal']
- ]
- },
- plantar: {
- title: 'Plantar response (Babinski)',
- icon: 'fa-shoe-prints',
- rows: [
- ['Down-going', 'Normal in anyone ≥ 2 years'],
- ['Up-going', 'Normal < 2 years; abnormal after — UMN lesion'],
- ['Asymmetric', 'Always abnormal at any age']
- ]
- },
- beighton: {
- title: 'Beighton hypermobility score (0–9)',
- icon: 'fa-hands',
- rows: [
- ['≤ 3', 'Normal flexibility'],
- ['4', 'Borderline — consider in context'],
- ['≥ 5', 'Hypermobility spectrum; screen for hEDS if other features present']
- ]
- },
- atr: {
- title: 'Scoliometer — angle of trunk rotation',
- icon: 'fa-ruler',
- rows: [
- ['< 5°', 'Normal, no follow-up'],
- ['5–6°', 'Borderline — re-check at each visit'],
- ['≥ 7°', 'Refer for PA/lateral spine x-ray + orthopedic evaluation']
- ]
- },
- rr: {
- title: 'Respiratory rate — upper limit by age (awake)',
- icon: 'fa-lungs',
- rows: [
- ['Newborn', '≤ 60 /min'],
- ['< 2 months', '≤ 60 /min (WHO tachypnea cutoff)'],
- ['2–12 months', '≤ 50 /min (WHO tachypnea cutoff)'],
- ['1–5 years', '≤ 40 /min (WHO tachypnea cutoff)'],
- ['6–11 years', '≤ 30 /min'],
- ['≥ 12 years', '≤ 20 /min (adult pattern)']
- ]
- },
- spo2: {
- title: 'Pulse oximetry (SpO₂) — at room air',
- icon: 'fa-heart-pulse',
- rows: [
- ['≥ 95%', 'Normal'],
- ['92–94%', 'Mild hypoxemia — investigate cause'],
- ['< 92%', 'Moderate hypoxemia — supplemental O₂'],
- ['< 88%', 'Severe — urgent intervention; target ≥ 90% acutely']
- ]
- },
- silverman: {
- title: 'Silverman–Andersen retraction score (neonatal, 0–10)',
- icon: 'fa-baby',
- rows: [
- ['0', 'No respiratory distress'],
- ['1–3', 'Mild — close observation'],
- ['4–6', 'Moderate distress — consider CPAP / support'],
- ['7–10', 'Severe — imminent respiratory failure, intubate']
- ]
- },
- westley: {
- title: 'Westley croup severity score',
- icon: 'fa-stethoscope',
- rows: [
- ['≤ 2', 'Mild — home management, cool mist, oral dexamethasone'],
- ['3–5', 'Moderate — nebulised epinephrine + dexamethasone'],
- ['6–11', 'Severe — admit, continuous monitoring'],
- ['≥ 12', 'Impending respiratory failure — ICU / airway management']
- ]
- },
- murmurGrade: {
- title: 'Heart-murmur grading (Levine 1–6)',
- icon: 'fa-wave-square',
- rows: [
- ['1/6', 'Very faint — heard only with concentration'],
- ['2/6', 'Soft but readily heard'],
- ['3/6', 'Moderately loud, no thrill'],
- ['4/6', 'Loud WITH a palpable thrill'],
- ['5/6', 'Very loud; audible with stethoscope just off the chest'],
- ['6/6', 'Audible without the stethoscope touching the chest']
- ]
- },
- pulseAmp: {
- title: 'Pulse amplitude grade (0–4)',
- icon: 'fa-heart-pulse',
- rows: [
- ['0', 'Absent'],
- ['1+', 'Diminished, thready'],
- ['2+', 'Normal'],
- ['3+', 'Bounding'],
- ['4+', 'Bounding with visible pulsation (e.g., aortic regurgitation)']
- ]
- },
- capRefill: {
- title: 'Capillary refill time',
- icon: 'fa-hand',
- rows: [
- ['< 2 sec', 'Normal'],
- ['2–3 sec', 'Borderline — consider hydration / perfusion'],
- ['≥ 3 sec', 'Delayed — dehydration, shock, low cardiac output']
- ]
+ var SCALES = {};
+ var SYSTEM_SCALES = {};
+ var APTM_LEGEND = [];
+ var INNOCENT_MURMURS = [];
+ var RESP_SOUNDS = [];
+ var CARDIAC_SOUNDS = [];
+ var PE_DATA = {};
+ var PE_GUIDE_DATA_URL = '/data/pe-guide.json';
+ var peGuideDataPromise = null;
+
+ function applyPeGuideData(data) {
+ data = data || {};
+ SCALES = data.scales || {};
+ SYSTEM_SCALES = data.systemScales || {};
+ APTM_LEGEND = data.aptmLegend || [];
+ INNOCENT_MURMURS = data.innocentMurmurs || [];
+ RESP_SOUNDS = data.respiratorySounds || [];
+ CARDIAC_SOUNDS = data.cardiacSounds || [];
+ PE_DATA = data.peData || {};
+ }
+
+ function loadPeGuideData() {
+ if (!peGuideDataPromise) {
+ peGuideDataPromise = fetch(PE_GUIDE_DATA_URL)
+ .then(function (r) {
+ if (!r.ok) throw new Error('Failed to load PE Guide data');
+ return r.json();
+ })
+ .then(function (data) {
+ applyPeGuideData(data);
+ return data;
+ });
}
- };
- // Which scales are relevant per system
- var SYSTEM_SCALES = {
- msk: ['atr', 'beighton'],
- neuro: ['mrc', 'dtr', 'plantar'],
- resp: ['rr', 'spo2', 'silverman', 'westley'],
- cv: ['murmurGrade', 'pulseAmp', 'capRefill']
- };
-
- // ────────────────────────────────────────────────────────────
- // APTM DIAGRAM — the 5 classic auscultation points
- // ────────────────────────────────────────────────────────────
- // Inline SVG showing: Aortic, Pulmonic, Erb's, Tricuspid, Mitral.
- // Rendered at the top of the cardiovascular system view.
- // Patient faces viewer — viewer's LEFT = patient's right.
- var APTM_SVG =
- '';
-
- var APTM_LEGEND = [
- { letter: 'A', color: '#dc2626', title: 'Aortic area', location: '2nd ICS, right sternal border', listen: 'S2 (aortic component), aortic stenosis, aortic regurgitation' },
- { letter: 'P', color: '#2563eb', title: 'Pulmonic area', location: '2nd ICS, left sternal border', listen: 'S2 (pulmonic component), pulmonic stenosis, PDA, physiologic split of S2',
- innocent: 'Pulmonary flow murmur (children, adolescents) — upper left sternal border' },
- { letter: 'E', color: '#059669', title: 'Erb\'s point', location: '3rd ICS, left sternal border', listen: 'Aortic regurgitation (best here), transitional zone murmurs',
- innocent: 'Still\'s murmur classically radiates to Erb\'s / LLSB' },
- { letter: 'T', color: '#d97706', title: 'Tricuspid area', location: '4th–5th ICS, lower left sternal border', listen: 'Tricuspid regurgitation, VSD, S3/S4, holosystolic murmurs',
- innocent: 'Still\'s murmur — vibratory, musical, age 3–7 y (loudest between LLSB and apex)' },
- { letter: 'M', color: '#7c3aed', title: 'Mitral area (apex)', location: '5th ICS, mid-clavicular line', listen: 'S1, mitral regurgitation, mitral stenosis (with bell, left-lateral decubitus)' }
- ];
-
- // ────────────────────────────────────────────────────────────
- // INNOCENT MURMURS — the classic benign murmurs of childhood
- // ────────────────────────────────────────────────────────────
- var INNOCENT_MURMURS = [
- { name: 'Still\'s (vibratory) murmur',
- age: '3–7 y (most common in children)',
- location: 'LLSB, radiating to apex',
- character: 'Low-frequency vibratory / musical systolic, grade 2–3/6, mid-systolic, "twanging-string" quality',
- confirm: 'Louder supine, softer or disappears on standing or Valsalva. No radiation to neck/back. Normal S2.' },
- { name: 'Pulmonary flow murmur',
- age: 'School-age and adolescents, thin chest',
- location: 'Upper left sternal border (2nd–3rd ICS)',
- character: 'Soft blowing early systolic ejection, grade 1–2/6, higher-pitched',
- confirm: 'No ejection click. Physiologic split of S2. Louder supine, softer on standing. No radiation.' },
- { name: 'Venous hum',
- age: 'Ages 3–8, disappears by adolescence',
- location: 'Supraclavicular or infraclavicular area, usually right',
- character: 'Soft continuous hum, louder in diastole. Only innocent continuous murmur.',
- confirm: 'Disappears when supine OR when jugular vein is gently compressed (key maneuver). Turning head to opposite side also alters it.' },
- { name: 'Carotid bruit / supraclavicular bruit',
- age: 'Children and adolescents',
- location: 'Supraclavicular fossa, right > left; may radiate to carotid',
- character: 'Brief early systolic, grade 2–3/6, higher-pitched than Still\'s',
- confirm: 'Softer or disappears with hyperextension of the shoulders. Normal cardiac exam otherwise. No radiation below the clavicles.' },
- { name: 'Peripheral pulmonary stenosis (PPS, neonatal)',
- age: 'Newborns and infants < 6–12 months',
- location: 'Upper LSB, radiates to BOTH axillae and the back',
- character: 'Soft systolic ejection murmur, grade 1–2/6',
- confirm: 'Typical age + radiation to back/axillae. Resolves by age 1 as branch pulmonary arteries grow. Persistence or louder grade warrants echo.' }
- ];
-
- // ────────────────────────────────────────────────────────────
- // RESPIRATORY SOUNDS LIBRARY
- // ────────────────────────────────────────────────────────────
- // Displayed as a dedicated card at the top of the Respiratory system.
- // src = real recording path served from /public/audio/respiratory/.
- var RESP_SOUNDS = [
- { key: 'normal', src: '/audio/respiratory/normal-vesicular.ogg', title: 'Normal vesicular breath sounds',
- where: 'Peripheral lung fields',
- features: 'Soft, rustling. Inspiration louder and longer than expiration.',
- clinical: 'Baseline — deviation elsewhere is what you listen for.' },
- { key: 'wheeze', src: '/audio/respiratory/wheeze.ogg', title: 'Wheeze',
- where: 'Diffuse in asthma; localised in foreign body',
- features: 'Continuous, high-pitched, musical. Usually expiratory; biphasic if severe.',
- clinical: 'Lower-airway narrowing — asthma, bronchiolitis, foreign body, bronchomalacia. Silent chest in severe asthma is an ominous sign.' },
- { key: 'stridor', src: '/audio/respiratory/stridor.ogg', title: 'Stridor',
- where: 'Louder over neck than chest — upper airway',
- features: 'Continuous, high-pitched, harsh. Classically inspiratory (extrathoracic obstruction); biphasic if fixed.',
- clinical: 'Croup, epiglottitis, foreign body, laryngomalacia (infant). Distinguish from wheeze by auscultating the neck — stridor is loudest there.' },
- { key: 'finecrackles', src: '/audio/respiratory/crackles-fine.ogg', title: 'Fine (end-inspiratory) crackles',
- where: 'Bibasilar in pulmonary edema/fibrosis; focal in pneumonia',
- features: 'Discontinuous, brief, high-pitched. "Velcro" quality. Late inspiratory, do NOT clear with cough.',
- clinical: 'Alveolar opening — pulmonary fibrosis, pulmonary edema, early pneumonia, atelectasis.' },
- { key: 'coarsecrackles', src: '/audio/respiratory/crackles-coarse.ogg', title: 'Coarse crackles',
- where: 'Lower lobes; either side',
- features: 'Discontinuous, longer and louder than fine crackles. Lower-pitched. Can be early or late inspiratory; often clear partly with cough.',
- clinical: 'Secretions in larger airways — bronchitis, later pneumonia, bronchiectasis, aspiration.' },
- { key: 'rhonchi', src: '/audio/respiratory/rhonchi.ogg', title: 'Rhonchi',
- where: 'Central or anywhere with airway secretions',
- features: 'Continuous, low-pitched, snore-like. Typically expiratory. Clear or change with cough.',
- clinical: 'Large-airway secretions — bronchitis, pneumonia with large-airway involvement, cystic fibrosis, bronchiectasis.' },
- { key: 'pleuralrub', src: '/audio/respiratory/pleural-rub.ogg', title: 'Pleural friction rub',
- where: 'Focal, often lateral or posterior lower chest',
- features: 'Grating, creaky — "leather on leather". Biphasic (heard in inspiration and expiration). Does NOT clear with cough.',
- clinical: 'Pleural inflammation — pleuritis, pulmonary embolism, pneumonia with pleural involvement, viral pleurisy.' }
- ];
-
- // ────────────────────────────────────────────────────────────
- // CARDIAC SOUNDS LIBRARY — real recordings from Wikimedia Commons
- // ────────────────────────────────────────────────────────────
- var CARDIAC_SOUNDS = [
- { key: 'normal', src: '/audio/cardiac/normal.ogg', title: 'Normal heart sounds (S1, S2)',
- where: 'All four classic auscultation points', rate: '~61 bpm reference',
- features: '"lub-dub": S1 (closure of mitral + tricuspid) louder at apex; S2 (closure of aortic + pulmonic) louder at base. Physiologic S2 split on inspiration.',
- clinical: 'Reference for rhythm, rate, and the normal S1–S2 interval. Listen for what\'s changed — not just what\'s added.' },
- { key: 'infant-normal', src: '/audio/cardiac/infant-normal.ogg', title: 'Infant normal heart sounds',
- where: 'Infant chest — rate will be higher than adult', rate: 'Pediatric reference (120–160 bpm range)',
- features: 'Same S1–S2 pattern, faster rate. Short diastole makes murmurs easier to miss — careful auscultation needed.',
- clinical: 'Reference for neonatal/infant rhythm. Any murmur in the first 72 h should prompt pre/postductal sat screening.' },
- { key: 'vsd', src: '/audio/cardiac/vsd.wav', title: 'Ventricular septal defect (VSD)',
- where: 'Lower left sternal border (4th ICS)',
- features: 'Harsh, blowing, holosystolic (pansystolic) murmur — plateau shape through all of systole. Often accompanied by a thrill if large.',
- clinical: 'Most common congenital heart defect. Small VSD: loud murmur, usually asymptomatic, may close spontaneously. Large VSD: softer murmur (less pressure gradient) but signs of heart failure, pulmonary hypertension.' },
- { key: 'mvp', src: '/audio/cardiac/mitral-prolapse.wav', title: 'Mitral valve prolapse (MVP) — click + late systolic murmur',
- where: 'Apex (5th ICS, mid-clavicular line)',
- features: 'Mid-systolic click followed by a late-systolic crescendo murmur. Timing of click changes with maneuvers: earlier with standing or Valsalva, later with squatting.',
- clinical: 'Often benign, especially in thin young women. Features suggesting need for echo: thickened/redundant leaflets, associated MR, symptoms (palpitations, chest pain), arrhythmias.' },
- { key: 'stills', src: '/audio/cardiac/stills-murmur.ogg', title: 'Still\'s murmur (innocent)',
- where: 'LLSB, radiating to apex', rate: 'Classic age 3–7 y (this recording is a toddler)',
- features: 'Low-frequency vibratory / musical systolic, grade 2–3/6, mid-systolic, "twanging-string" quality.',
- clinical: 'The most common innocent murmur of childhood. Louder supine, softer or disappears on standing or Valsalva. Normal S2. No radiation to neck or back. No workup needed when classic.' },
- { key: 'functional', src: '/audio/cardiac/functional-murmur.wav', title: 'Functional (innocent) murmur — adult female',
- where: 'Left sternal border, soft systolic',
- features: 'Soft systolic murmur in a structurally normal heart — often from increased cardiac output, thin chest wall, anemia, hyperthyroidism, or pregnancy.',
- clinical: 'Benign if it meets the 7 S criteria. Investigate if loud (≥3/6), holosystolic, diastolic, radiating, or with thrill / symptoms.' }
- ];
-
- // ────────────────────────────────────────────────────────────
- // DATA
- // ────────────────────────────────────────────────────────────
- var PE_DATA = {
-
- newborn: {
- label: 'Newborn (0–28 days)',
- msk: {
- overview: 'Exam done warm, quiet, undressed. Focus: birth injury, DDH, congenital anomaly. All steps symmetric.',
- components: [
- { name: 'Resting posture', steps: [
- { label: 'Observe posture', method: 'Place supine and undisturbed for 30s', normal: 'Symmetric flexion at hips, knees, elbows' },
- { label: 'Hand position', method: 'Inspect resting hands', normal: 'Loosely fisted; opens intermittently' },
- { label: 'Symmetry', method: 'Compare left vs right side at rest', normal: 'Mirror-image posture' }
- ], abnormalHints: ['Frog-leg (hypotonia)', 'Asymmetric arm (brachial plexus/clavicle fx)', 'Opisthotonos (CNS)', 'Persistent fisting with thumb in palm'] },
-
- { name: 'Clavicles', steps: [
- { label: 'Palpate right clavicle', method: 'Trace from sternoclavicular joint to acromion with index finger', normal: 'Smooth, continuous, no step-off' },
- { label: 'Palpate left clavicle', method: 'Same technique on left side', normal: 'Smooth, continuous' },
- { label: 'Crepitus check', method: 'Light pressure along length of clavicle while gently abducting arm', normal: 'No crepitus, no pain response' }
- ], abnormalHints: ['Palpable step-off or callus (fracture — LGA, shoulder dystocia)', 'Asymmetric Moro on affected side'] },
-
- { name: 'Hips — DDH screen', steps: [
- { label: 'Thigh/gluteal folds', method: 'Undress completely; compare skin-fold symmetry', normal: 'Symmetric thigh and gluteal folds' },
- { label: 'Abduction', method: 'Flex hips 90°, abduct simultaneously', normal: 'Both hips abduct to ≥75° symmetrically' },
- { label: 'Barlow maneuver', method: 'Thumb on medial thigh, flex hip 90°, adduct, apply gentle posterior pressure', normal: 'No clunk or movement felt (negative)' },
- { label: 'Ortolani maneuver', method: 'From Barlow position: abduct and lift with fingers on greater trochanter', normal: 'No clunk as hip returns (negative)' },
- { label: 'Galeazzi sign', method: 'Knees flexed together with feet on table; compare knee heights', normal: 'Knees level — no leg-length discrepancy' }
- ], abnormalHints: ['Palpable Ortolani clunk (dislocated, reducible)', 'Barlow clunk (dislocatable)', 'Limited abduction', 'Positive Galeazzi (shortened femur)'] },
-
- { name: 'Spine and back', steps: [
- { label: 'Position prone', method: 'Turn infant prone, support chest', normal: 'Tolerates position, lifts head briefly' },
- { label: 'Palpate midline', method: 'Run finger from C-spine to coccyx', normal: 'Straight midline, no step-offs or gaps' },
- { label: 'Sacral inspection', method: 'Inspect sacral dimple if present; measure depth, distance from anus', normal: 'No dimple, or dimple <5mm deep and <2.5cm from anus' },
- { label: 'Cutaneous markers', method: 'Inspect midline skin from neck to coccyx', normal: 'No hair tuft, hemangioma, lipoma, or sinus tract' }
- ], abnormalHints: ['Deep sacral dimple (>5mm) or >2.5cm from anus — imaging', 'Hair tuft, hemangioma, lipoma (occult dysraphism)', 'Palpable defect'] },
-
- { name: 'Upper extremities', steps: [
- { label: 'Spontaneous movement', method: 'Observe both arms for 30s', normal: 'Symmetric antigravity movement' },
- { label: 'Digits', method: 'Count and inspect fingers both hands', normal: '5 digits each, no webbing or duplication' },
- { label: 'Palmar creases', method: 'Inspect palmar creases', normal: 'Normal triradiate creases' }
- ], abnormalHints: ['Erb/Klumpke palsy (paucity of movement)', 'Polydactyly, syndactyly', 'Single transverse (simian) palmar crease'] },
-
- { name: 'Lower extremities / feet', steps: [
- { label: 'Hip and knee range', method: 'Gently flex, extend, internally/externally rotate each', normal: 'Full symmetric range, no contracture' },
- { label: 'Foot alignment', method: 'Inspect resting foot position', normal: 'Midline or mildly adducted forefoot' },
- { label: 'Passive correction', method: 'Gently attempt to bring foot to neutral', normal: 'Fully correctable to neutral' },
- { label: 'Stroke test', method: 'Stroke lateral border of foot', normal: 'Foot dorsiflexes and everts reflexively' }
- ], abnormalHints: ['Rigid clubfoot (non-correctable talipes equinovarus)', 'Fixed metatarsus adductus', 'Rocker-bottom foot (trisomy 18)', 'Calcaneovalgus'] }
- ]
- },
- neuro: {
- overview: 'Primitive reflexes present and symmetric. Tone assessed passively and actively. Full exam 3–5 min on a quiet, fed infant.',
- components: [
- { name: 'Alertness and behavior', steps: [
- { label: 'State cycling', method: 'Observe over 1–2 min for alert periods', normal: 'Alert periods with spontaneous eye opening' },
- { label: 'Response to voice', method: 'Speak softly near ear', normal: 'Quiets to voice or turns toward sound' },
- { label: 'Consolability', method: 'If crying, attempt to soothe with swaddling or voice', normal: 'Consolable within 1–2 min' }
- ], abnormalHints: ['Lethargy', 'Jitteriness not stopped by passive flexion', 'Irritability unrelieved by feeding'] },
-
- { name: 'Cranial nerves', steps: [
- { label: 'CN II — pupil response', method: 'Shine light in each eye', normal: 'Pupils equal, reactive to light, direct and consensual' },
- { label: 'CN II — blink to light', method: 'Bright light in the line of sight', normal: 'Reflex blink' },
- { label: 'CN VII — facial symmetry at rest', method: 'Observe resting face', normal: 'Symmetric nasolabial folds' },
- { label: 'CN VII — facial symmetry with cry', method: 'Note face during a cry', normal: 'Symmetric grimace' },
- { label: 'CN IX, X, XII — suck and swallow', method: 'Offer clean gloved finger, pacifier, or during feed', normal: 'Strong coordinated suck-swallow, no choking' }
- ], abnormalHints: ['Asymmetric face (CN VII injury — usually forceps)', 'Poor suck or uncoordinated swallow', 'Fixed or unequal pupil'] },
-
- { name: 'Tone — passive', steps: [
- { label: 'Pull-to-sit', method: 'Grasp hands/wrists, pull smoothly to sit', normal: 'Brief head lag at term; not dramatic' },
- { label: 'Ventral suspension', method: 'Suspend prone over hand at chest', normal: 'Head briefly lifts to horizontal; extremities flexed' },
- { label: 'Arm recoil', method: 'Extend both arms fully at elbows, release', normal: 'Rapid return to flexion' },
- { label: 'Popliteal angle', method: 'Hip flexed 90°, extend knee maximally', normal: '≤110°' }
- ], abnormalHints: ['Marked head lag (hypotonia)', 'Slip-through on vertical suspension', 'Hypertonia / scissoring', 'Floppy limbs with no recoil'] },
-
- { name: 'Spontaneous movement', steps: [
- { label: 'Observe limbs', method: 'Undisturbed over 1 min, note movement', normal: 'Symmetric antigravity movement of all 4 limbs' },
- { label: 'Quality of movement', method: 'Note smoothness vs jitteriness', normal: 'Smooth, mildly variable movements' }
- ], abnormalHints: ['Paucity of movement in one limb', 'Coarse jitteriness', 'Clonic jerks', 'Tonic posturing'] },
-
- { name: 'Primitive reflexes', steps: [
- { label: 'Moro', method: 'Support head; allow 30° head drop or loud clap', normal: 'Symmetric arm abduction then flexion, often cry' },
- { label: 'Rooting', method: 'Stroke cheek at corner of mouth', normal: 'Turns head toward stroke and opens mouth' },
- { label: 'Palmar grasp', method: 'Press into palm with finger', normal: 'Strong, symmetric finger flexion' },
- { label: 'Plantar grasp', method: 'Press ball of foot below toes', normal: 'Toes flex around finger symmetrically' },
- { label: 'Stepping', method: 'Hold upright with feet touching surface', normal: 'Alternating stepping movements' },
- { label: 'Tonic neck (fencing)', method: 'Turn head to one side with infant supine', normal: 'Same-side arm extends, opposite flexes (not obligate)' },
- { label: 'Galant', method: 'Stroke paravertebrally from shoulder to buttock, one side', normal: 'Trunk curves toward stroked side' }
- ], abnormalHints: ['Absent or asymmetric Moro — CNS injury, brachial plexus, clavicle fx', 'Absent grasps — CNS depression', 'Obligate tonic neck is abnormal'] },
-
- { name: 'Babinski (plantar response)', steps: [
- { label: 'Stroke lateral sole', method: 'Firm stroke from heel toward toes along lateral plantar border', normal: 'Up-going great toe with fanning (normal in newborn)' },
- { label: 'Symmetry check', method: 'Repeat opposite foot', normal: 'Symmetric response' }
- ], abnormalHints: ['Asymmetric response is always abnormal'] }
- ]
- },
- resp: {
- overview: 'Newborn respiratory transition — RDS, TTN, pneumonia, meconium aspiration dominate the differential. Normal RR ≤ 60. Grunting is an alarm sign.',
- components: [
- { name: 'Inspection',
- significance: 'Detects distress and localises cause. Silverman score quantifies retraction severity.',
- pearl: 'Grunting is physiologic PEEP against a partially closed glottis — always a sign of significant lung pathology in a newborn. Never dismiss it as fussy breathing.',
- steps: [
- { label: 'Respiratory rate', method: 'Count over full 60 s, quiet and undisturbed.', normal: '40–60 /min; tachypnea > 60' },
- { label: 'Work of breathing (Silverman)', method: 'Inspect for upper-chest retraction, lower-chest retraction, xiphoid retraction, nasal flaring, grunting. Score 0–2 for each.', normal: 'Total Silverman 0 — no distress' },
- { label: 'Audible sounds', method: 'Listen without stethoscope — stridor? grunting? wheeze across the room?', normal: 'Quiet respirations' },
- { label: 'Colour', method: 'Inspect trunk and mucous membranes for central cyanosis; acrocyanosis (blue hands/feet) is normal in the first days.', normal: 'Pink trunk and mucous membranes' },
- { label: 'Chest shape', method: 'Inspect AP:transverse diameter and symmetry.', normal: 'Slightly barrel-shaped is normal; symmetric' }
- ],
- abnormalHints: ['Grunting — RDS, pneumonia, sepsis, CHD', 'Retractions + tachypnea — RDS, TTN, pneumothorax', 'Central cyanosis — cyanotic CHD, severe lung disease, persistent pulmonary HTN', 'Asymmetric chest movement — pneumothorax, diaphragmatic hernia'] },
- { name: 'Auscultation',
- significance: 'Short stethoscope time in neonates because they fuss easily — get the most important zones first.',
- pearl: 'Listen at the axilla, not just the anterior chest — pneumothorax can sound normal anteriorly. Auscultate both axillae systematically.',
- steps: [
- { label: 'Air entry — anterior', method: 'Listen bilaterally at the upper and lower anterior chest.', normal: 'Symmetric bilateral air entry' },
- { label: 'Air entry — axillary', method: 'Listen bilaterally at each axilla — this is the most sensitive area for detecting a small pneumothorax.', normal: 'Clear and symmetric' },
- { label: 'Adventitious sounds', method: 'Listen for transmitted upper-airway sounds, crackles (RDS, pneumonia), grunting sounds.', normal: 'No crackles, no wheeze, clear sounds' },
- { label: 'Inspiration:expiration ratio', method: 'Observe breath-sound timing.', normal: 'Inspiration > expiration in length' }
- ],
- abnormalHints: ['Asymmetric air entry — pneumothorax, diaphragmatic hernia, endobronchial intubation', 'Fine crackles — RDS, TTN, pneumonia', 'Absent breath sounds unilaterally — pneumothorax or selective intubation'] }
- ]
- },
- cv: {
- overview: 'Neonatal CV exam screens for CHD — the window of presentation is short and some lesions (duct-dependent) decompensate within hours of birth. Pre/postductal saturations + femoral pulses are the two fastest screens.',
- components: [
- { name: 'Inspection and pre/postductal saturations',
- significance: 'Pre/postductal SpO₂ differential > 3% suggests a duct-dependent lesion or persistent pulmonary HTN. Universal CCHD screening uses this.',
- pearl: 'Pulse ox on the right hand = preductal (proximal to PDA insertion). Foot = postductal. Both arms and both legs should match; a differential is a red flag for critical CHD.',
- steps: [
- { label: 'Central cyanosis', method: 'Inspect tongue, lips, oral mucosa.', normal: 'Pink mucous membranes' },
- { label: 'Pre/postductal SpO₂', method: 'Measure SpO₂ in right hand (preductal) AND either foot (postductal). Baby must be ≥24 hr old for CCHD screening.', normal: 'Both ≥ 95% AND difference < 3%' },
- { label: 'Peripheral perfusion', method: 'Capillary refill on sternum; note mottling or distal cyanosis.', normal: 'Capillary refill < 2 s, warm pink extremities' },
- { label: 'Precordial activity', method: 'Inspect anterior chest for hyperactive precordium.', normal: 'Not visible or minimally visible' }
- ],
- abnormalHints: ['Central cyanosis with SpO₂ < 95% → cyanotic CHD workup (4-extremity BP, ECG, hyperoxia test, echo)', 'Differential > 3% (pre > post) → duct-dependent systemic flow (HLHS, coarctation, interrupted arch)', 'Preductal < postductal — persistent pulmonary HTN with reversed shunt'] },
- { name: 'Palpation and auscultation',
- significance: 'Absent femoral pulses + arm-leg BP gradient = coarctation. Many CHD lesions manifest murmurs only after ductus closes (48–72 h).',
- pearl: 'Always palpate femoral pulses before discharging any newborn. Absent femorals in a well-appearing baby can be the only finding in a ductal-dependent coarctation — catastrophic if missed.',
- steps: [
- { label: 'Apex beat', method: 'Palpate at the 4th ICS left of sternum (apex is higher in newborns).', normal: 'Palpable at 4th ICS, mid-clavicular or just lateral' },
- { label: 'Femoral pulses', method: 'Palpate both femoral pulses at the mid-inguinal point while simultaneously feeling the right brachial pulse — detects delay.', normal: 'Present, symmetric, equal timing with brachial' },
- { label: 'Auscultate each cardiac area', method: 'Use pediatric diaphragm at each classic point; baby quiet if possible.', normal: 'S1 S2 crisp; physiologic flow murmur sometimes present in the first 24–48 h' },
- { label: 'Continuous murmur', method: 'Listen below the left clavicle for a continuous ("machinery") murmur of PDA.', normal: 'No continuous murmur after the first day of life in a term baby' },
- { label: 'Four-limb BP (if any concern)', method: 'Right arm, left arm, both legs.', normal: 'Within 10 mmHg across limbs' }
- ],
- abnormalHints: ['Absent femoral pulses — coarctation of the aorta (surgical emergency if duct-dependent)', 'Harsh holosystolic at LLSB — VSD', 'Continuous machinery murmur — PDA (expected in preterm; in term > 48 h is abnormal)', 'Gallop S3/S4 — heart failure', 'Single S2 — transposition, truncus, severe AS/PS'] }
- ]
- }
- },
-
- infant: {
- label: 'Infant (1–12 months)',
- msk: {
- overview: 'Continued DDH screen through 6 months. Watch motor progression and symmetry of tone/movement.',
- components: [
- { name: 'Hips — continued DDH screen', steps: [
- { label: 'Thigh-fold symmetry', method: 'Inspect with infant supine, thighs flexed', normal: 'Symmetric folds' },
- { label: 'Barlow/Ortolani (through 3mo)', method: 'As in newborn — thumb medial, flex 90°, adduct+push then abduct+lift', normal: 'Negative bilaterally' },
- { label: 'Abduction (any age)', method: 'Flex 90°, abduct simultaneously', normal: '≥70° symmetric abduction' },
- { label: 'Galeazzi', method: 'Knees flexed feet flat on exam table', normal: 'Knees equal height' }
- ], abnormalHints: ['Clunk on Barlow/Ortolani (<3mo)', 'Limited abduction', 'Asymmetric folds', 'Positive Galeazzi'] },
-
- { name: 'Gross-motor milestones (age-appropriate)', steps: [
- { label: 'Head control', method: 'Prone, pull-to-sit, held upright', normal: 'Age-appropriate: 2mo lifts head 45°; 4mo no head lag' },
- { label: 'Rolling', method: 'Observe on flat surface', normal: 'Rolls back-to-front by 5–6mo' },
- { label: 'Sitting', method: 'Place in sitting position', normal: 'Tripod sit by 6mo; sits without support by 7–8mo' },
- { label: 'Standing', method: 'Support under arms', normal: 'Bears weight by 6mo; pulls to stand by 9mo' }
- ], abnormalHints: ['Milestone delay by ≥2mo', 'Loss of previously attained milestone', 'Asymmetric use of limbs'] },
-
- { name: 'Spine', steps: [
- { label: 'Palpate seated', method: 'Run finger along spine with infant sitting or held upright', normal: 'Midline, no step-offs' },
- { label: 'Back curvature', method: 'Inspect sitting and lying', normal: 'Physiologic gentle kyphosis in early infancy; lumbar lordosis as sitting develops' }
- ], abnormalHints: ['Fixed kyphoscoliosis', 'Sacral dimple with cutaneous marker', 'Step-off'] },
-
- { name: 'Extremities', steps: [
- { label: 'Passive range', method: 'Through each major joint', normal: 'Full symmetric range' },
- { label: 'Joint inspection', method: 'Inspect for swelling, warmth, effusion', normal: 'No swelling, warmth, or effusion' },
- { label: 'Feet alignment', method: 'Observe standing if pulling up, else passive positioning', normal: 'Correctable or aligned feet; flexible' }
- ], abnormalHints: ['Joint swelling/warmth (septic vs reactive arthritis)', 'Rigid clubfoot', 'Persistent asymmetric tone'] }
- ]
- },
- neuro: {
- overview: 'Primitive reflexes fading on schedule; protective reflexes emerging; gross motor and tone interlinked.',
- components: [
- { name: 'Alertness and social engagement', steps: [
- { label: 'Social smile', method: 'Face-to-face interaction', normal: 'Social smile by 6–8 weeks' },
- { label: 'Tracking', method: 'Move object across visual field', normal: '180° horizontal tracking by 3mo' },
- { label: 'Engagement', method: 'Face-to-face, voice, toys', normal: 'Age-appropriate reciprocal interaction' }
- ], abnormalHints: ['No social smile by 3mo', 'Absent tracking past 3mo', 'Poor engagement (developmental concern)'] },
-
- { name: 'Cranial nerves', steps: [
- { label: 'Pupils', method: 'Light response each eye', normal: 'Equal reactive' },
- { label: 'Eye alignment', method: 'Inspect with gaze forward and in all directions', normal: 'No strabismus past 4mo' },
- { label: 'Facial symmetry', method: 'Observe smile and cry', normal: 'Symmetric' },
- { label: 'Suck and swallow', method: 'Observe feeding', normal: 'Coordinated, no choking' }
- ], abnormalHints: ['Persistent nystagmus', 'Strabismus past 4mo', 'Asymmetric face'] },
-
- { name: 'Tone', steps: [
- { label: 'Pull-to-sit', method: 'Gently pull wrists/hands', normal: 'No head lag by 4mo' },
- { label: 'Ventral suspension', method: 'Support prone, observe', normal: 'Head above horizontal, extremities actively flexed (age-dependent)' },
- { label: 'Vertical suspension', method: 'Support under arms, lift', normal: 'Does not slip through hands' }
- ], abnormalHints: ['Persistent head lag past 4mo (hypotonia)', 'Hypertonia / scissoring (UMN)', 'Slip-through on vertical suspension'] },
-
- { name: 'Primitive reflex integration', steps: [
- { label: 'Moro', method: 'Head drop or clap', normal: 'Absent by 6mo' },
- { label: 'Palmar grasp', method: 'Press into palm', normal: 'Integrated by 5–6mo; replaced by voluntary grasp' },
- { label: 'Tonic neck', method: 'Turn head to side', normal: 'Absent by 6mo' },
- { label: 'Rooting', method: 'Stroke cheek', normal: 'Absent by 3–4mo' }
- ], abnormalHints: ['Persistence of any primitive reflex past 6mo warrants eval (CP, CNS injury)'] },
-
- { name: 'Protective and postural reflexes', steps: [
- { label: 'Parachute', method: 'Held prone, tilt head downward suddenly', normal: 'Symmetric arm extension protectively by 9mo (emerges 6–9mo)' },
- { label: 'Lateral propping', method: 'Seated infant, gentle tilt to one side', normal: 'Arm extends to catch by 6–7mo' },
- { label: 'Landau', method: 'Suspend prone', normal: 'Extends head, spine, legs by 6mo' }
- ], abnormalHints: ['Absent parachute after 12mo (concerning)', 'Asymmetric lateral propping', 'Absent Landau'] }
- ]
- },
- resp: {
- overview: 'Infant respiratory disease centers on bronchiolitis, reactive airways, and pneumonia. Normal RR ≤ 50 (< 2 mo: ≤ 60). Infants are obligate nose-breathers — nasal congestion alone can cause significant WOB.',
- components: [
- { name: 'Inspection',
- significance: 'Infant distress signs escalate fast. Nasal flaring, tracheal tug, head bobbing = significant WOB. Apnea in an infant < 2 mo is an emergency.',
- pearl: 'A quiet infant with retractions is more worrying than a crying one — exhausted infants stop crying and become hypoxic silently.',
- steps: [
- { label: 'Respiratory rate', method: 'Count over full 60 s while quiet.', normal: '< 2 mo: ≤ 60; 2–12 mo: ≤ 50' },
- { label: 'Work of breathing', method: 'Inspect nasal flaring, subcostal/intercostal/suprasternal retractions, tracheal tug, head-bobbing, accessory muscle use.', normal: 'No retractions, effortless breathing' },
- { label: 'Audible sounds', method: 'Stridor? Wheeze across the room? Grunting? Prolonged expiration?', normal: 'Quiet respirations' },
- { label: 'Colour and feeding history', method: 'Central cyanosis? Poor feeding (feeding is an effort marker in infants)?', normal: 'Pink, feeds well' },
- { label: 'Apnea observation', method: 'Watch for ≥ 20-s pauses or pauses < 20 s with bradycardia/cyanosis.', normal: 'No apneas' }
- ],
- abnormalHints: ['Grunting / persistent retractions — pneumonia, bronchiolitis, CHF', 'Wheeze — bronchiolitis (RSV), asthma, foreign body', 'Stridor — croup (6 mo–6 y), laryngomalacia (infant), foreign body', 'Apnea — bronchiolitis, sepsis, pertussis, seizure'] },
- { name: 'Auscultation',
- significance: 'Infants have a thin chest wall — sounds transmit widely. Symmetry, wheeze, and crackles are the main findings.',
- pearl: 'In bronchiolitis, the classical finding is widespread end-inspiratory fine crackles PLUS expiratory wheeze. Tachypnea + retractions in an RSV-season infant confirms.',
- steps: [
- { label: 'Air entry — bilateral', method: 'Warm stethoscope; listen at anterior chest and both axillae, both sides.', normal: 'Symmetric air entry' },
- { label: 'Wheeze', method: 'Listen in expiration. Diffuse wheeze = lower airway; focal wheeze = foreign body or local obstruction.', normal: 'No wheeze' },
- { label: 'Crackles', method: 'Listen in late inspiration. Focal = pneumonia; diffuse fine = bronchiolitis.', normal: 'No crackles' },
- { label: 'Prolonged expiration', method: 'Note expiration:inspiration length ratio.', normal: 'Inspiration ≥ expiration' }
- ],
- abnormalHints: ['Focal crackles + fever — pneumonia', 'Diffuse wheeze + fine crackles in an RSV-season infant — bronchiolitis', 'Silent chest with extreme WOB — impending respiratory failure'] }
- ]
- },
- cv: {
- overview: 'Most CHD manifests in the first year as pulmonary blood-flow changes and the ductus closes. Infant CV exam = growth review + inspection + femoral pulses + auscultation. A harsh pan-systolic LLSB murmur in a 6-week-old = VSD until proven otherwise.',
- components: [
- { name: 'Inspection and functional assessment',
- significance: 'Heart failure in infants presents as poor feeding, sweating during feeds (diaphoresis), tachypnea, and poor weight gain. These historical features predict bad exam findings.',
- pearl: 'Ask "Does the baby sweat while feeding?" — infant CHF presents with diaphoresis on the forehead during feeds, well before peripheral edema appears.',
- steps: [
- { label: 'Growth trajectory', method: 'Plot weight-for-age on WHO chart. Failure to thrive raises CHD concern.', normal: 'Tracking ≥ 10th percentile or stable on personal curve' },
- { label: 'Feeding history', method: 'Ask about feed duration, sweating with feeds, tachypnea with feeds, tiring easily.', normal: 'Feeds < 20 min, no diaphoresis, no tachypnea' },
- { label: 'Central cyanosis', method: 'Inspect tongue and oral mucosa.', normal: 'Pink' },
- { label: 'Clubbing', method: 'Inspect finger nail beds (subtle in infants).', normal: 'No clubbing' },
- { label: 'Peripheral perfusion', method: 'Cap refill, warmth of extremities.', normal: 'Cap refill < 2 s, warm extremities' }
- ],
- abnormalHints: ['Poor weight gain — consider CHF from L-to-R shunt (VSD, PDA, AVSD)', 'Diaphoresis with feeds — infant CHF', 'Tiring with feeds — significant CHD', 'Central cyanosis — cyanotic CHD (ToF, TGA, TA, etc.)'] },
- { name: 'Palpation and auscultation',
- significance: 'Femoral pulses + 4-limb BP screen coarctation. A harsh holosystolic murmur at LLSB is almost always a VSD in this age.',
- pearl: 'Listen over each of the 5 classic points as in the adult exam — the locations shift slightly with infant chest size but relative positions are the same. Also listen at the back: coarctation murmurs radiate there.',
- steps: [
- { label: 'Apex beat', method: 'Palpate at 4th ICS mid-clavicular line.', normal: 'Palpable at 4th ICS in infants' },
- { label: 'Femoral pulses', method: 'Palpate bilaterally, simultaneously with right brachial.', normal: 'Present, equal, no delay vs brachial' },
- { label: 'Listen at each classic area (APTM)', method: 'See APTM diagram. Use pediatric stethoscope with both diaphragm and bell.', normal: 'S1 and S2 crisp, no murmur or physiologic only' },
- { label: 'Listen over the back (interscapular)', method: 'Check for radiation of coarctation murmurs.', normal: 'No radiating murmur' }
- ],
- abnormalHints: ['Harsh holosystolic LLSB murmur — VSD', 'Continuous "machinery" murmur below left clavicle — PDA', 'Systolic ejection at ULSB + fixed split S2 — ASD', 'Ejection murmur at ULSB + cyanosis — tetralogy of Fallot', 'Absent femorals + radio-femoral delay — coarctation', 'Gallop + tachycardia — heart failure'] }
- ]
- }
- },
-
- toddler: {
- label: 'Toddler (1–3 years)',
- msk: {
- overview: 'Gait, physiologic alignment changes, in-toeing, joint range. Cooperation unpredictable — use play.',
- components: [
- { name: 'Gait', steps: [
- { label: 'Base of support', method: 'Have child walk ~10 feet', normal: 'Wide-based initially, narrowing by 2y' },
- { label: 'Heel-strike', method: 'Observe foot contact pattern', normal: 'Heel-strike developing by 18mo, consistent by 2y' },
- { label: 'Arm swing', method: 'Observe reciprocal arm swing', normal: 'Reciprocal arm swing by 18mo' },
- { label: 'Symmetry', method: 'Watch both sides in stance and swing', normal: 'Symmetric stride length and cadence' }
- ], abnormalHints: ['Toe-walking past 2y (idiopathic vs CP vs DMD)', 'Limp (Legg-Calvé-Perthes, transient synovitis, trauma)', 'Wide-based ataxia'] },
-
- { name: 'Knee alignment', steps: [
- { label: 'Stand feet together', method: 'Feet/medial malleoli touching; inspect knees', normal: 'Genu varum resolving by 18–24mo; mild genu valgum common by 2–3y' },
- { label: 'Intercondylar or intermalleolar distance', method: 'Measure if alignment appears abnormal', normal: '<5cm intercondylar (varum) or <8cm intermalleolar (valgum)' },
- { label: 'Symmetry', method: 'Compare sides', normal: 'Symmetric' }
- ], abnormalHints: ['Persistent varum past 2y', 'Severe valgum >8cm', 'Unilateral (Blount disease, rickets)'] },
-
- { name: 'Feet alignment', steps: [
- { label: 'In-toeing / out-toeing', method: 'Observe foot angle during gait', normal: 'Mild in-toeing common (tibial torsion, femoral anteversion)' },
- { label: 'Arch during stance', method: 'Stand flat, then on tiptoes', normal: 'Flexible flat foot that forms arch on tiptoe' },
- { label: 'Heel alignment', method: 'View from behind standing', normal: 'Neutral or mildly valgus heel' }
- ], abnormalHints: ['Rigid flat foot (tarsal coalition)', 'Fixed metatarsus adductus', 'Severe in-toeing >15°'] },
-
- { name: 'Joint range', steps: [
- { label: 'Hips', method: 'Flex, abduct, rotate each hip', normal: 'Full symmetric range, no pain' },
- { label: 'Knees', method: 'Flex, extend; palpate for effusion', normal: 'Full range, no effusion, stable' },
- { label: 'Ankles', method: 'Dorsiflex, plantarflex, invert, evert', normal: 'Full range' },
- { label: 'Shoulders, elbows, wrists', method: 'Through full range each', normal: 'Full symmetric range' }
- ], abnormalHints: ['Joint effusion (septic vs reactive)', 'Guarded or painful motion', 'Asymmetric limitation'] },
-
- { name: 'Spine', steps: [
- { label: 'Inspect standing', method: 'View spine from behind', normal: 'Midline, no prominent curve' },
- { label: 'Palpate midline', method: 'Run finger along spinous processes', normal: 'Midline, no step-off, no tenderness' },
- { label: 'Shoulder/hip symmetry', method: 'Compare shoulder and hip heights', normal: 'Symmetric' }
- ], abnormalHints: ['Fixed scoliosis', 'Abnormal kyphosis', 'Asymmetric shoulder/hip', 'Midline tenderness'] }
- ]
- },
- neuro: {
- overview: 'Shifting to adult-pattern exam. Primitive reflexes should be absent. Use play-based techniques.',
- components: [
- { name: 'Mental status and language', steps: [
- { label: 'Engagement', method: 'Interaction with examiner/parent', normal: 'Alert, interactive, age-appropriate' },
- { label: 'Language — expressive', method: 'Note spontaneous utterances', normal: '1y: 1–3 words; 2y: 2-word phrases; 3y: short sentences' },
- { label: 'Language — receptive', method: 'Ask to point to body parts or follow simple commands', normal: 'Follows age-appropriate commands' }
- ], abnormalHints: ['Language regression (autism, epileptic encephalopathy)', 'Poor engagement', 'No 2-word phrases by 2y'] },
-
- { name: 'Cranial nerves', steps: [
- { label: 'CN II — pupil response', method: 'Shine light each eye', normal: 'Pupils equal reactive' },
- { label: 'CN III, IV, VI — EOM', method: 'Follow toy in H pattern', normal: 'Full smooth tracking, no strabismus' },
- { label: 'CN V — facial sensation', method: 'Light touch on forehead, cheek, jaw', normal: 'Responds to touch, symmetric' },
- { label: 'CN VII — face', method: 'Elicit smile, watch eye closure during cry', normal: 'Symmetric face' },
- { label: 'CN IX, X, XII — mouth', method: 'Say "ahh"; stick out tongue', normal: 'Palate rises symmetrically; tongue midline' }
- ], abnormalHints: ['Strabismus', 'Facial asymmetry', 'Tongue deviation', 'Absent palate elevation'] },
-
- { name: 'Motor — tone and bulk', steps: [
- { label: 'Passive tone', method: 'Move each limb through full range', normal: 'Normal resistance throughout' },
- { label: 'Bulk inspection', method: 'Inspect muscle bulk of thighs, calves, glutes', normal: 'Symmetric, age-appropriate bulk' },
- { label: 'Contracture check', method: 'Test for heel-cord tightness, hamstring tightness', normal: 'No contractures' }
- ], abnormalHints: ['Spasticity (especially catch in ankles)', 'Hypotonia', 'Calf pseudo-hypertrophy (DMD)'] },
-
- { name: 'Motor — functional strength', steps: [
- { label: 'Rising from floor', method: 'Place flat on back; ask to stand up', normal: 'Rises without using hands to push off thighs (no Gowers)' },
- { label: 'Climbing stairs', method: 'Observe or history', normal: 'Climbs holding rail' },
- { label: 'Squatting/getting up', method: 'Encourage via play', normal: 'Squats and rises without help' }
- ], abnormalHints: ['Gowers sign (proximal weakness — DMD)', 'Unable to climb stairs at age expected', 'Calf pain on walking (myositis)'] },
-
- { name: 'Deep tendon reflexes', steps: [
- { label: 'Patellar', method: 'Sitting or supine with distraction (toy)', normal: '2+ symmetric' },
- { label: 'Biceps', method: 'Arm at rest, strike thumb on tendon', normal: '2+ symmetric' },
- { label: 'Achilles', method: 'With distraction', normal: '2+ symmetric' }
- ], abnormalHints: ['Hyperreflexia or clonus (UMN, CP)', 'Absent reflexes (LMN, neuropathy)', 'Asymmetry'] },
-
- { name: 'Coordination and gait', steps: [
- { label: 'Run', method: 'Watch run ~10 feet', normal: 'Runs with reciprocal arm swing by 2y' },
- { label: 'Stairs', method: 'Observe', normal: 'Climbs with rail' },
- { label: 'Kick ball', method: 'Place ball; observe kick', normal: 'Kicks by 2y' },
- { label: 'Ataxia check', method: 'Watch for fluency of movement', normal: 'Smooth, no tremor' }
- ], abnormalHints: ['Ataxic gait', 'Intention tremor', 'Clumsiness beyond age'] },
-
- { name: 'Plantar response', steps: [
- { label: 'Stroke lateral sole', method: 'Firm stroke from heel to toes', normal: 'Down-going great toe (plantar flexion) by age 2' }
- ], abnormalHints: ['Up-going toe after age 2 = UMN sign (Babinski positive)'] }
- ]
- },
- resp: {
- overview: 'Toddler respiratory disease: viral URIs, reactive airways, croup (6 mo–6 y classical age), foreign-body aspiration (age 1–3 is peak). Normal RR ≤ 40.',
- components: [
- { name: 'Inspection',
- pearl: 'Sudden onset of unilateral wheeze + choking history in a toddler = foreign body until proven otherwise. CXR in expiration (or decubitus) helps show the trapped air.',
- steps: [
- { label: 'Respiratory rate', method: 'Count over full 60 s if possible.', normal: '≤ 40 /min' },
- { label: 'Work of breathing', method: 'Retractions, nasal flaring, tracheal tug.', normal: 'No retractions' },
- { label: 'Audible sounds', method: 'Stridor (croup), wheeze, barking cough.', normal: 'Quiet respirations' },
- { label: 'Drooling / posture', method: 'Tripod positioning, drooling (epiglottitis in unvaccinated child).', normal: 'No drooling, normal posture' }
- ],
- abnormalHints: ['Barking cough + stridor — croup', 'Drooling + tripod + toxic — epiglottitis (emergency)', 'Sudden unilateral wheeze — foreign body aspiration'] },
- { name: 'Auscultation',
- steps: [
- { label: 'Air entry', method: 'Cooperation variable — listen quickly and systematically.', normal: 'Symmetric' },
- { label: 'Adventitious sounds', method: 'Wheeze, crackles, stridor at the neck.', normal: 'Clear lung fields' },
- { label: 'Unilateral findings', method: 'Focal wheeze, decreased air entry, or asymmetry — think foreign body or pneumonia.', normal: 'Symmetric bilateral' }
- ],
- abnormalHints: ['Unilateral decreased breath sounds + wheeze — foreign body', 'Focal crackles — pneumonia', 'Diffuse wheeze — asthma/RAD'] }
- ]
- },
- cv: {
- overview: 'Most hemodynamically significant CHD has been detected by this age. Innocent murmurs peak here (Still\'s murmur, venous hum). The exam is adult-pattern but with smaller chest and less cooperation.',
- components: [
- { name: 'Inspection and palpation',
- pearl: 'Innocent murmurs are a normal finding in well toddlers — soft, systolic, at the LLSB, musical, and they change with position. Anything that doesn\'t fit that pattern deserves referral.',
- steps: [
- { label: 'General appearance + growth', method: 'Happy, active, tracking growth.', normal: 'Normal growth and activity' },
- { label: 'Colour and clubbing', method: 'Inspect tongue, nail beds.', normal: 'Pink, no clubbing' },
- { label: 'Apex beat', method: 'Palpate at 5th ICS mid-clavicular line.', normal: 'Located at 5th ICS MCL, tapping quality' },
- { label: 'Peripheral pulses', method: 'Brachial + femoral, symmetric and simultaneous.', normal: 'Symmetric, no delay' }
- ],
- abnormalHints: ['Tiring with play, poor growth — missed CHD', 'Cyanosis + clubbing — cyanotic CHD', 'Absent femorals — coarctation'] },
- { name: 'Auscultation',
- steps: [
- { label: 'All 5 classic points', method: 'See APTM diagram above — Aortic, Pulmonic, Erb\'s, Tricuspid, Mitral.', normal: 'Crisp S1, S2 with physiologic split at pulmonic area' },
- { label: 'Evaluate any murmur', method: 'Timing, location, radiation, grade. Apply the "7 S" innocent-murmur criteria.', normal: 'No murmur, or soft (≤ grade 2) innocent murmur' },
- { label: 'Change with position', method: 'Have toddler sit, stand, lie down — does the murmur change? Innocent murmurs typically disappear or soften with standing.', normal: 'Murmur (if any) changes with position' }
- ],
- abnormalHints: ['Harsh, loud (≥3/6), radiating, or diastolic murmur — not innocent, refer', 'Cyanosis + murmur — CHD workup', 'Fixed split S2 — ASD'] }
- ]
- }
- },
-
- preschool: {
- label: 'Preschool (3–5 years)',
- msk: {
- overview: 'Functional gait maneuvers, scoliosis screen, resolving physiologic alignment.',
- components: [
- { name: 'Gait — multiple patterns', steps: [
- { label: 'Normal gait', method: 'Walk ~15 feet barefoot', normal: 'Symmetric, smooth, reciprocal arm swing' },
- { label: 'Heel walking', method: 'Walk on heels only', normal: 'Able by 4y' },
- { label: 'Toe walking', method: 'Walk on toes only', normal: 'Able by 4y' },
- { label: 'Tandem walking', method: 'Heel-to-toe along a line for 5 steps', normal: 'Able by 4y with minimal deviation' },
- { label: 'Hopping', method: 'Hop on one foot', normal: '3–5 hops on preferred foot by 4y' }
- ], abnormalHints: ['Persistent toe-walking', 'Asymmetric stance/stride', 'Difficulty with any pattern'] },
-
- { name: 'Alignment', steps: [
- { label: 'Knee alignment', method: 'Stand feet together', normal: 'Mild residual valgus resolving; neutral by 6–7y' },
- { label: 'Foot arch', method: 'Standing, then tiptoe', normal: 'Arch forms on tiptoe (flexible flat foot)' },
- { label: 'Heel position', method: 'View from behind standing', normal: 'Neutral or mild valgus' }
- ], abnormalHints: ['Persistent unilateral varum', 'Rigid flat foot (no arch on tiptoe)', 'Pes cavus'] },
-
- { name: 'Scoliosis screen (Adam forward-bend)', steps: [
- { label: 'Position', method: 'Feet together, bend forward at waist, arms hanging, palms together', normal: 'Arms and head relaxed' },
- { label: 'View from behind', method: 'Examiner at same height; look along back', normal: 'Symmetric paraspinal contour' },
- { label: 'View from side', method: 'Side view for kyphosis', normal: 'Smooth thoracic curve' }
- ], abnormalHints: ['Rib hump (thoracic scoliosis)', 'Lumbar prominence', 'Asymmetric scapular height'] },
-
- { name: 'Joint range and stability', steps: [
- { label: 'Active range', method: 'Ask to perform full range at hips, knees, ankles, shoulders, elbows, wrists', normal: 'Full symmetric range, no pain' },
- { label: 'Knee stability', method: 'Palpate for effusion; assess stability if complaint', normal: 'Stable, no effusion' },
- { label: 'Carrying angle (elbows)', method: 'Arms at sides, palms forward', normal: 'Normal valgus carrying angle' }
- ], abnormalHints: ['Joint hypermobility (Beighton score)', 'Effusion', 'Pain with motion', 'Valgus >15°'] },
-
- { name: 'Feet', steps: [
- { label: 'Standing inspection', method: 'View from front and behind', normal: 'Symmetric feet, neutral heel, flexible flat feet common' },
- { label: 'Tiptoe', method: 'Stand on tiptoes', normal: 'Arch forms, symmetric' },
- { label: 'Pes planus vs cavus', method: 'Note arch height', normal: 'Flexible flat foot or mild arch' }
- ], abnormalHints: ['Rigid flat foot', 'Pes cavus (Charcot-Marie-Tooth)', 'Pain'] }
- ]
- },
- neuro: {
- overview: 'Formal pediatric neuro exam now feasible — most 4- and 5-year-olds cooperate with structured testing.',
- components: [
- { name: 'Mental status and language', steps: [
- { label: 'Orientation (age-appropriate)', method: 'Ask name, age, where you are', normal: 'Knows name and age by 3y; location by 4–5y' },
- { label: 'Speech intelligibility', method: 'Listen to spontaneous speech', normal: 'Strangers understand by 4y' },
- { label: 'Receptive language', method: '2- and 3-step commands', normal: 'Follows 3-step commands by 4–5y' }
- ], abnormalHints: ['Dysarthria', 'Expressive or receptive language delay', 'Inattention'] },
-
- { name: 'Cranial nerves (II–XII)', steps: [
- { label: 'CN II — visual acuity', method: 'HOTV chart or pictures at 10ft, each eye', normal: '20/30 or better by 4y; 20/25 by 5y' },
- { label: 'CN II — visual fields', method: 'Confrontation with toys from periphery', normal: 'Full fields' },
- { label: 'CN II — pupils', method: 'Light response each eye', normal: 'PERRL' },
- { label: 'CN III, IV, VI — EOM', method: 'Follow toy in H pattern; include convergence', normal: 'Full EOM, convergence present' },
- { label: 'CN V — sensation', method: 'Light touch forehead, cheek, jaw each side', normal: 'Intact, symmetric' },
- { label: 'CN V — motor', method: 'Clench teeth, palpate masseter', normal: 'Symmetric strong bulk' },
- { label: 'CN VII — face', method: 'Smile, wrinkle forehead, close eyes, puff cheeks', normal: 'Symmetric movement of all regions' },
- { label: 'CN VIII — hearing', method: 'Finger rub each ear or whispered words', normal: 'Intact bilaterally' },
- { label: 'CN IX, X — palate', method: 'Open mouth, say "ahh"', normal: 'Palate rises symmetrically, uvula midline' },
- { label: 'CN XI — SCM/trapezius', method: 'Shrug shoulders, turn head against resistance', normal: 'Symmetric strength' },
- { label: 'CN XII — tongue', method: 'Stick tongue out, move side to side', normal: 'Midline, no atrophy, full movement' }
- ], abnormalHints: ['Strabismus (amblyopia risk)', 'Facial weakness', 'Tongue deviation/fasciculations', 'Uvula off-midline'] },
-
- { name: 'Motor — tone, bulk, strength', steps: [
- { label: 'Tone inspection', method: 'Passive range all four limbs', normal: 'Normal tone throughout' },
- { label: 'Bulk inspection', method: 'Observe muscle bulk symmetry', normal: 'Symmetric, age-appropriate' },
- { label: 'Strength — shoulder abduction', method: 'Arms out, push down against resistance', normal: '5/5 bilaterally' },
- { label: 'Strength — elbow flexion', method: 'Flex elbow against resistance', normal: '5/5 bilaterally' },
- { label: 'Strength — grip', method: 'Squeeze examiner\'s fingers', normal: '5/5 symmetric' },
- { label: 'Strength — hip flexion', method: 'Lift leg off table against resistance', normal: '5/5 bilaterally' },
- { label: 'Strength — knee extension', method: 'Straighten knee against resistance', normal: '5/5 bilaterally' },
- { label: 'Strength — dorsiflexion', method: 'Pull toes up against resistance', normal: '5/5 bilaterally' }
- ], abnormalHints: ['Focal weakness', 'Gowers sign', 'Pseudohypertrophy (DMD)', 'Atrophy'] },
-
- { name: 'Deep tendon reflexes', steps: [
- { label: 'Biceps', method: 'Thumb on biceps tendon, strike', normal: '2+ symmetric' },
- { label: 'Patellar', method: 'Knees hanging, strike patellar tendon', normal: '2+ symmetric' },
- { label: 'Achilles', method: 'Slight dorsiflexion, strike Achilles tendon', normal: '2+ symmetric' },
- { label: 'Plantar response', method: 'Stroke lateral sole heel-to-toes', normal: 'Down-going great toe' }
- ], abnormalHints: ['Hyperreflexia or clonus (UMN)', 'Hyporeflexia (LMN)', 'Up-going plantar (Babinski — abnormal past 2y)', 'Asymmetry'] },
-
- { name: 'Coordination', steps: [
- { label: 'Finger-to-nose', method: 'Touch examiner\'s finger then own nose, repeat', normal: 'Smooth, no dysmetria' },
- { label: 'Heel-to-shin', method: 'Run heel down opposite shin', normal: 'Smooth bilaterally' },
- { label: 'Rapid alternating movements', method: 'Tap palm with opposite hand alternating palm/back', normal: 'Rhythmic, symmetric' },
- { label: 'Tandem walk', method: 'Heel-to-toe for 5 steps', normal: 'Minimal deviation' }
- ], abnormalHints: ['Dysmetria', 'Dysdiadochokinesia', 'Intention tremor', 'Ataxic tandem'] },
-
- { name: 'Sensory', steps: [
- { label: 'Light touch — hands', method: 'Cotton wisp on palm/dorsum, eyes closed', normal: 'Feels each touch' },
- { label: 'Light touch — feet', method: 'Same on dorsum of foot bilaterally', normal: 'Feels each touch' }
- ], abnormalHints: ['Focal sensory loss', 'Stocking-glove loss'] },
-
- { name: 'Gait and Romberg', steps: [
- { label: 'Normal gait', method: 'Walk ~20 feet', normal: 'Smooth, symmetric' },
- { label: 'Heel walk', method: 'Walk on heels', normal: 'Able without difficulty' },
- { label: 'Toe walk', method: 'Walk on toes', normal: 'Able without difficulty' },
- { label: 'Tandem', method: 'Heel-to-toe', normal: 'Intact' },
- { label: 'Romberg (5y+)', method: 'Feet together, eyes closed, stand 10s', normal: 'Stable without sway' }
- ], abnormalHints: ['Ataxic gait (cerebellar)', 'Romberg positive (dorsal column)', 'Circumduction (UMN)'] }
- ]
- },
- resp: {
- overview: 'Adult-pattern but shorter. Cooperation better than toddler. RR ≤ 30. Common: asthma/RAD, pneumonia, URIs.',
- components: [
- { name: 'Inspection',
- steps: [
- { label: 'Respiratory rate', method: 'Count over full 60 s quietly.', normal: '≤ 30 /min' },
- { label: 'Work of breathing', method: 'Retractions, nasal flaring, accessory muscle use.', normal: 'Effortless breathing' },
- { label: 'Audible sounds', method: 'Wheeze, stridor, cough quality (barking = croup).', normal: 'Quiet' },
- { label: 'Chest shape', method: 'AP:transverse, hyperinflation signs.', normal: 'Not barrel-chested' }
- ],
- abnormalHints: ['Barrel chest — chronic asthma, cystic fibrosis', 'Retractions + wheeze — asthma exacerbation'] },
- { name: 'Auscultation',
- steps: [
- { label: 'Systematic zones', method: 'Upper, mid, lower fields anteriorly and posteriorly; axillae bilaterally. Cooperative deep breaths through mouth.', normal: 'Symmetric vesicular sounds' },
- { label: 'Wheeze', method: 'Expiratory, diffuse (asthma) or focal (foreign body, rare at this age).', normal: 'No wheeze' },
- { label: 'Crackles', method: 'Focal = pneumonia; diffuse fine = interstitial disease (rare in kids).', normal: 'No crackles' }
- ],
- abnormalHints: ['Focal crackles + fever — pneumonia', 'Diffuse wheeze — asthma', 'Prolonged expiration with wheeze — lower airway obstruction'] }
- ]
- },
- cv: {
- overview: 'Most CHD is detected by this age. Innocent murmurs peak in this range. Sports participation exams require thorough CV screening.',
- components: [
- { name: 'Inspection and palpation',
- steps: [
- { label: 'General and growth', method: 'Track on growth curve; activity tolerance.', normal: 'Normal growth, active' },
- { label: 'Apex beat', method: '5th ICS mid-clavicular line.', normal: 'Normal position and character' },
- { label: 'Peripheral pulses', method: 'Brachial + femoral simultaneously. BP in arm and leg if HTN.', normal: 'Symmetric, no delay' }
- ],
- abnormalHints: ['Absent femorals or arm-leg BP gradient — coarctation (always check in HTN screening)', 'Displaced apex — cardiomegaly'] },
- { name: 'Auscultation',
- pearl: 'The 7 "S" criteria and the 5 classic innocent murmurs (see panel above) handle most murmurs you\'ll find in this age group. Still\'s murmur is the single most common.',
- steps: [
- { label: 'All 5 classic points', method: 'Walk through A → P → E → T → M with diaphragm then bell.', normal: 'S1 S2 clear, physiologic S2 split at pulmonic, no added sounds' },
- { label: 'Any murmur', method: 'Characterise: timing, location, radiation, grade, character. Apply 7 S criteria + compare to innocent-murmur panel.', normal: 'No murmur, or innocent flow murmur meeting all 7 S criteria' },
- { label: 'Position change', method: 'Standing vs supine. Innocent murmurs typically soften or disappear on standing.', normal: 'Murmur (if any) changes with position' },
- { label: 'Sports screening extras (if applicable)', method: 'Screen for HOCM — murmur intensifies with Valsalva and standing (opposite of most).', normal: 'No murmur worsening on Valsalva' }
- ],
- abnormalHints: ['Murmur breaking any of the 7 S criteria — refer', 'Harsh systolic at LUSB + fixed split S2 — ASD', 'Murmur louder with Valsalva — HOCM (sports participation risk)', 'Diastolic murmur — always pathologic'] }
- ]
- }
- },
-
- school: {
- label: 'School-age (6–11 years)',
- msk: {
- overview: 'Scoliosis screening peri-puberty, sports overuse injuries, resolving alignment.',
- components: [
- { name: 'Scoliosis screen (forward-bend + scoliometer)', steps: [
- { label: 'Standing inspection', method: 'Shoulders and iliac crest heights', normal: 'Symmetric shoulder and pelvic heights' },
- { label: 'Forward bend (Adam test)', method: 'Feet together, bend forward at waist, arms hanging palms together', normal: 'Symmetric paraspinal contour' },
- { label: 'Rib hump', method: 'View tangentially from behind at level of curve', normal: 'No rib hump' },
- { label: 'Lumbar prominence', method: 'Same view at lumbar level', normal: 'No prominence' },
- { label: 'Scoliometer (if available)', method: 'Place scoliometer across rib hump, read angle of trunk rotation', normal: 'ATR < 5°; ≥7° → refer' }
- ], abnormalHints: ['Rib hump', 'ATR ≥7°', 'Asymmetric shoulders or pelvis', 'Decompensation (plumb line offset)'] },
-
- { name: 'Back and spine', steps: [
- { label: 'Posture inspection', method: 'Standing, view front/back/side', normal: 'Normal spinal curves; plumb line centered' },
- { label: 'Palpate spinous processes', method: 'From C2 to S1', normal: 'No tenderness, no step-off' },
- { label: 'Range of motion', method: 'Flex, extend, lateral bend, rotate', normal: 'Full painless range' }
- ], abnormalHints: ['Midline tenderness', 'Step-off (spondylolisthesis)', 'Limited motion with pain'] },
-
- { name: 'Alignment', steps: [
- { label: 'Knees', method: 'Feet together, inspect', normal: 'Neutral alignment by 6–7y' },
- { label: 'Feet', method: 'Stand, then tiptoes', normal: 'Medial arch present, symmetric' },
- { label: 'Leg lengths', method: 'Supine, measure ASIS to medial malleolus if asymmetric', normal: 'Equal within 1cm' }
- ], abnormalHints: ['Residual valgum', 'Pes cavus', 'Leg-length discrepancy >1cm'] },
-
- { name: 'Joint stability and sports exam (if active)', steps: [
- { label: 'Active range all joints', method: 'Through full range', normal: 'Full symmetric range, no pain or crepitus' },
- { label: 'Knee — Lachman (if sports-active)', method: 'Knee 20° flexion, stabilize femur, pull tibia forward', normal: 'Firm endpoint, no laxity' },
- { label: 'Knee — McMurray', method: 'Flexed knee, rotate tibia while extending', normal: 'No pain or click' },
- { label: 'Shoulder — impingement (Neer/Hawkins)', method: 'Passive shoulder flexion with arm in internal rotation', normal: 'No pain' },
- { label: 'Ankle stability', method: 'Anterior drawer and talar tilt', normal: 'No laxity' }
- ], abnormalHints: ['ACL laxity (positive Lachman)', 'Meniscal click', 'Shoulder impingement', 'Ankle instability'] },
-
- { name: 'Gait and functional movement', steps: [
- { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Smooth, symmetric' },
- { label: 'Single-leg stance', method: 'Stand on one foot 10s each side', normal: 'Stable without Trendelenburg drop' },
- { label: 'Squat', method: 'Full squat and rise', normal: 'Full squat without pain or asymmetry' },
- { label: 'Hop on one foot', method: '5 hops each side', normal: 'Able and symmetric' }
- ], abnormalHints: ['Trendelenburg sign (hip abductor weakness)', 'Antalgic gait', 'Asymmetric squat', 'Pain with hop'] }
- ]
- },
- neuro: {
- overview: 'Adult-pattern six-component exam: mental status, CN, motor, reflexes, sensory, coordination/gait.',
- components: [
- { name: 'Mental status', steps: [
- { label: 'Orientation', method: 'Name, age, school, city, day of week', normal: 'Oriented x 4' },
- { label: 'Attention', method: 'Count backward from 20; days of week backward', normal: 'Intact' },
- { label: '3-item recall', method: 'Ball-flag-tree; ask at 3 and 5 min', normal: '3/3 recall at 5 min' },
- { label: 'Language', method: 'Name common objects; repeat a sentence', normal: 'Fluent, no paraphasia' }
- ], abnormalHints: ['Inattention (ADHD features)', 'Memory deficits', 'Word-finding difficulty', 'Perseveration'] },
-
- { name: 'Cranial nerves (II–XII)', steps: [
- { label: 'CN II — acuity', method: 'Snellen at 20ft each eye with corrective lenses if worn', normal: '20/20 or baseline' },
- { label: 'CN II — fields', method: 'Confrontation, 4 quadrants each eye', normal: 'Full fields' },
- { label: 'CN II — fundoscopy (if indicated)', method: 'Direct ophthalmoscopy — disc, vessels, macula', normal: 'Sharp disc, normal cup-disc ratio, no papilledema' },
- { label: 'CN II, III — pupils', method: 'Direct and consensual light, accommodation', normal: 'PERRLA' },
- { label: 'CN III, IV, VI — EOM', method: 'Follow finger in H pattern; convergence', normal: 'Full EOM, no nystagmus, convergence intact' },
- { label: 'CN V — sensation', method: 'Light touch V1 (forehead), V2 (cheek), V3 (jaw) each side', normal: 'Intact, symmetric' },
- { label: 'CN V — motor', method: 'Clench teeth, palpate masseter/temporalis; jaw opening', normal: 'Symmetric strength' },
- { label: 'CN VII', method: 'Raise eyebrows, close eyes tight, smile/show teeth, puff cheeks', normal: 'Symmetric movement, all regions' },
- { label: 'CN VIII', method: 'Finger rub each ear; Weber/Rinne if deficit', normal: 'Hears bilaterally' },
- { label: 'CN IX, X', method: 'Palate elevation with "ahh"; uvula midline; voice quality', normal: 'Symmetric elevation, uvula midline, normal voice' },
- { label: 'CN XI', method: 'Shrug shoulders against resistance; head turn against resistance', normal: '5/5 SCM and trapezius' },
- { label: 'CN XII', method: 'Stick tongue out; side-to-side', normal: 'Midline, no atrophy or fasciculations' }
- ], abnormalHints: ['Papilledema (increased ICP)', 'Focal cranial nerve deficit — any warrants workup', 'Tongue fasciculations (LMN/MND)'] },
-
- { name: 'Motor — bulk, tone, strength', steps: [
- { label: 'Bulk inspection', method: 'Shoulders, thighs, calves, intrinsic hand muscles', normal: 'Symmetric, no atrophy' },
- { label: 'Tone', method: 'Passive range at elbows, wrists, knees, ankles', normal: 'Normal resistance throughout' },
- { label: 'Strength — deltoids', method: 'Shoulder abduction against resistance', normal: '5/5 bilaterally' },
- { label: 'Strength — biceps', method: 'Elbow flexion against resistance', normal: '5/5' },
- { label: 'Strength — triceps', method: 'Elbow extension against resistance', normal: '5/5' },
- { label: 'Strength — grip', method: 'Squeeze 2 fingers', normal: '5/5 symmetric' },
- { label: 'Strength — finger abduction', method: 'Spread fingers against resistance', normal: '5/5' },
- { label: 'Strength — hip flexion', method: 'Lift leg supine against resistance', normal: '5/5' },
- { label: 'Strength — knee extension', method: 'Straighten knee against resistance', normal: '5/5' },
- { label: 'Strength — dorsiflexion', method: 'Pull toes up against resistance', normal: '5/5' },
- { label: 'Strength — plantarflexion', method: 'Push foot down against resistance', normal: '5/5' }
- ], abnormalHints: ['Focal weakness (localize)', 'Spasticity (UMN)', 'Atrophy', 'Fasciculations'] },
-
- { name: 'Deep tendon reflexes', steps: [
- { label: 'Biceps (C5-C6)', method: 'Thumb on tendon, strike', normal: '2+ symmetric' },
- { label: 'Triceps (C7-C8)', method: 'Strike triceps tendon', normal: '2+ symmetric' },
- { label: 'Brachioradialis (C5-C6)', method: 'Strike distal radius', normal: '2+ symmetric' },
- { label: 'Patellar (L3-L4)', method: 'Knees hanging, strike tendon', normal: '2+ symmetric' },
- { label: 'Achilles (S1)', method: 'Slight dorsiflexion, strike tendon', normal: '2+ symmetric' },
- { label: 'Plantar response', method: 'Stroke lateral sole heel-to-toes', normal: 'Down-going bilaterally' },
- { label: 'Clonus', method: 'Rapid dorsiflexion at ankle', normal: 'No sustained clonus' }
- ], abnormalHints: ['Hyperreflexia with clonus (UMN: stroke, MS, cord lesion)', 'Hyporeflexia (LMN, neuropathy, myopathy)', 'Asymmetry', 'Up-going Babinski', 'Sustained clonus'] },
-
- { name: 'Sensory', steps: [
- { label: 'Light touch — upper', method: 'Cotton wisp dorsum of hands, eyes closed', normal: 'Intact, symmetric' },
- { label: 'Light touch — lower', method: 'Same on dorsum of feet', normal: 'Intact, symmetric' },
- { label: 'Pain — upper', method: 'Broken Q-tip or pin on hands', normal: 'Intact, symmetric' },
- { label: 'Pain — lower', method: 'Same on feet', normal: 'Intact, symmetric' },
- { label: 'Vibration', method: '128 Hz tuning fork at distal IP joint of great toes', normal: 'Feels vibration; counts down seconds' },
- { label: 'Proprioception', method: 'Move great toe up/down with eyes closed', normal: 'Identifies direction correctly' }
- ], abnormalHints: ['Dermatomal loss (nerve root)', 'Stocking-glove (neuropathy)', 'Loss of vibration/proprioception (dorsal column — B12, tabes, MS)'] },
-
- { name: 'Coordination', steps: [
- { label: 'Finger-nose-finger', method: 'Touch examiner finger then own nose, examiner moves target', normal: 'Smooth, accurate, no dysmetria' },
- { label: 'Heel-to-shin', method: 'Supine: heel down opposite shin', normal: 'Smooth, on-target' },
- { label: 'Rapid alternating movements', method: 'Supinate/pronate hand on knee rapidly', normal: 'Rhythmic, symmetric' },
- { label: 'Fine motor', method: 'Finger tapping (thumb to each finger in sequence)', normal: 'Rhythmic, accurate' }
- ], abnormalHints: ['Dysmetria (past-pointing, overshoot)', 'Intention tremor', 'Dysdiadochokinesia'] },
-
- { name: 'Gait and Romberg', steps: [
- { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Narrow-based, smooth, reciprocal arm swing' },
- { label: 'Heel walk', method: 'Walk on heels', normal: 'Able without difficulty' },
- { label: 'Toe walk', method: 'Walk on toes', normal: 'Able without difficulty' },
- { label: 'Tandem', method: 'Heel-to-toe along a line', normal: 'Minimal deviation, 10+ steps' },
- { label: 'Romberg', method: 'Feet together, eyes closed, 30s', normal: 'Stable without fall or significant sway' }
- ], abnormalHints: ['Wide-based (cerebellar)', 'Steppage (peripheral neuropathy)', 'Scissoring (UMN)', 'Romberg positive (dorsal column)', 'Circumduction'] }
- ]
- },
- resp: {
- overview: 'Nearly adult-pattern. Exam the same as adolescent with slightly more flexibility in cooperation. RR ≤ 30 in younger school-age, ≤ 20 in older. Sports history relevant (exercise-induced asthma).',
- components: [
- { name: 'Inspection',
- steps: [
- { label: 'Respiratory rate', method: 'Count over 60 s.', normal: '≤ 30 (6–11 y)' },
- { label: 'Work of breathing', method: 'Retractions, accessory muscles.', normal: 'Effortless' },
- { label: 'Audible sounds', method: 'Listen for wheeze, stridor.', normal: 'Quiet' },
- { label: 'Chest shape', method: 'Barrel chest, pectus deformities.', normal: 'Normal shape' },
- { label: 'Clubbing', method: 'Schamroth window test.', normal: 'No clubbing' }
- ],
- abnormalHints: ['Clubbing — CF, chronic hypoxemia, bronchiectasis', 'Barrel chest — chronic asthma, CF'] },
- { name: 'Palpation and percussion',
- steps: [
- { label: 'Tracheal position', method: 'Middle finger in suprasternal notch.', normal: 'Midline' },
- { label: 'Chest expansion', method: 'Hands laterally, thumbs meeting at spine. Deep breath.', normal: 'Symmetric 3–5 cm' },
- { label: 'Tactile fremitus', method: 'Ulnar side of hand; "ninety-nine". Compare sides.', normal: 'Symmetric' },
- { label: 'Percussion', method: 'Pleximeter + plexor technique. Compare sides.', normal: 'Resonant throughout' }
- ],
- abnormalHints: ['Deviated trachea — pneumothorax, effusion, collapse', 'Dull percussion — consolidation, effusion', 'Hyper-resonant — pneumothorax, hyperinflation'] },
- { name: 'Auscultation',
- steps: [
- { label: 'Systematic zones', method: 'Six anterior + four lateral + six posterior zones, compare side-to-side.', normal: 'Symmetric vesicular sounds' },
- { label: 'Adventitious sounds', method: 'Wheeze, crackles, rhonchi, rub, stridor at neck. Use sounds library for reference.', normal: 'No added sounds' },
- { label: 'Cough re-listen', method: 'Secretions (rhonchi, coarse crackles) should clear; fibrosis crackles do not.', normal: 'Secretion-based sounds clear with cough' }
- ],
- abnormalHints: ['Focal crackles + fever — pneumonia', 'Diffuse fine crackles — early interstitial disease', 'Expiratory wheeze — asthma / RAD'] }
- ]
- },
- cv: {
- overview: 'Nearly adult-pattern. Sports participation screening is a key indication in this age. HOCM screening (family history of sudden cardiac death, exertional syncope, murmur louder with Valsalva) is specifically relevant.',
- components: [
- { name: 'Inspection and palpation',
- pearl: 'For sports participation exams, always ask about exertional symptoms (syncope, chest pain, unexpected fatigue) AND family history of sudden cardiac death before age 50. Screening exam alone catches only ~3% of HOCM.',
- steps: [
- { label: 'General and growth', method: 'Track on growth curve; review activity tolerance.', normal: 'Normal growth, age-appropriate activity' },
- { label: 'Colour and clubbing', method: 'Inspect mucous membranes and nail beds.', normal: 'Pink, no clubbing' },
- { label: 'Apex beat', method: 'Palpate at 5th ICS mid-clavicular line.', normal: 'Normal position, tapping character' },
- { label: 'Peripheral pulses', method: 'Simultaneous brachial + femoral.', normal: 'Symmetric, no delay' },
- { label: 'Blood pressure', method: 'Measure BP with appropriately sized cuff. If elevated, check both arms and one leg.', normal: 'Age-appropriate (< 120/80 roughly by 10+ years)' }
- ],
- abnormalHints: ['Exertional syncope — HOCM, arrhythmia, LQTS', 'BP differential — coarctation', 'Displaced apex — cardiomegaly'] },
- { name: 'Auscultation',
- steps: [
- { label: 'All 5 classic points', method: 'See APTM diagram. A → P → E → T → M with diaphragm and bell.', normal: 'S1, S2 clear with physiologic split at P, no added sounds' },
- { label: 'Grade any murmur', method: 'Levine 1–6 (see scales above); characterise timing, location, radiation.', normal: 'No murmur, or innocent flow murmur meeting all 7 S criteria' },
- { label: 'Innocent vs pathologic', method: 'Apply 7 S criteria; compare to innocent-murmur panel.', normal: 'Innocent murmur (if present) clearly fits all 7 S features' },
- { label: 'Dynamic maneuvers', method: 'Standing: HOCM louder; most others soften. Valsalva: HOCM louder.', normal: 'Murmur (if any) softens on standing and Valsalva' }
- ],
- abnormalHints: ['Murmur louder with Valsalva / standing — HOCM (sports disqualification considerations)', 'Any diastolic murmur', 'Murmur ≥ grade 3, radiating, or with thrill'] }
- ]
- }
- },
-
- adolescent: {
- label: 'Adolescent (12–21 years)',
- msk: {
- overview: 'Sports-related injuries, adolescent scoliosis, apophyseal overuse, hypermobility screening.',
- components: [
- { name: 'Scoliosis screen', steps: [
- { label: 'Standing inspection', method: 'Patient undressed to waist (keep privacy); compare shoulders, iliac crests, scapular heights', normal: 'Symmetric shoulders and pelvis' },
- { label: 'Forward bend (Adam)', method: 'Feet together, bend forward, arms hanging palms together', normal: 'Symmetric paraspinal contour' },
- { label: 'Scoliometer', method: 'Place across thoracic and lumbar regions at maximum prominence', normal: 'ATR <5°; 5–6° monitor; ≥7° refer' },
- { label: 'Plumb line check', method: 'Drop plumb from C7; note where it falls', normal: 'Passes through gluteal cleft (compensated)' },
- { label: 'Leg lengths', method: 'Supine; ASIS to medial malleolus each side', normal: 'Within 1cm' }
- ], abnormalHints: ['Rib/lumbar hump', 'ATR ≥7°', 'Decompensation (plumb off gluteal cleft)', 'Leg-length discrepancy driving apparent curve'] },
-
- { name: 'Back pain evaluation (if complaint)', steps: [
- { label: 'Inspect and palpate', method: 'Spinous processes, paraspinal muscles, SI joints', normal: 'Non-tender' },
- { label: 'Range of motion', method: 'Flex, extend, lateral bend, rotate', normal: 'Full painless range' },
- { label: 'Single-leg hyperextension (stork)', method: 'Stand on one foot, extend back — each side', normal: 'No pain (negative for spondylolysis)' },
- { label: 'Straight-leg raise', method: 'Supine, lift straight leg to 70°+', normal: 'No radicular pain to 70°' },
- { label: 'SI joint tests', method: 'FABER, SI compression', normal: 'No pain' }
- ], abnormalHints: ['Spondylolysis (positive stork test)', 'Radicular pain (disc herniation)', 'SI joint pathology', 'Inflammatory back pain pattern'] },
-
- { name: 'Joint stability — sports-specific', steps: [
- { label: 'Knee — Lachman', method: 'Knee 20° flexion, stabilize femur, pull tibia anteriorly', normal: 'Firm endpoint, no laxity (ACL intact)' },
- { label: 'Knee — anterior drawer', method: 'Knee 90°, pull tibia forward', normal: 'No excess anterior translation' },
- { label: 'Knee — varus/valgus stress', method: 'Stress at 0 and 30° flexion', normal: 'No gap opening (LCL/MCL intact)' },
- { label: 'Knee — McMurray', method: 'Flex, rotate tibia while extending', normal: 'No pain or click' },
- { label: 'Shoulder — apprehension', method: 'Abduct and externally rotate', normal: 'No apprehension' },
- { label: 'Shoulder — Neer/Hawkins', method: 'Passive flexion with internal rotation', normal: 'No pain' },
- { label: 'Ankle — anterior drawer', method: 'Pull heel forward with tibia stabilized', normal: 'No laxity' },
- { label: 'Ankle — talar tilt', method: 'Invert heel with tibia stabilized', normal: 'No excess tilt' }
- ], abnormalHints: ['ACL/PCL tear', 'MCL/LCL laxity', 'Meniscal injury', 'Shoulder instability/impingement', 'Ankle ligament laxity'] },
-
- { name: 'Apophysitis and overuse screen', steps: [
- { label: 'Tibial tubercle', method: 'Palpate with knee flexed', normal: 'Non-tender' },
- { label: 'Calcaneal apophysis', method: 'Palpate posterior calcaneus', normal: 'Non-tender' },
- { label: 'Iliac apophyses', method: 'Palpate ASIS, AIIS, iliac crest', normal: 'Non-tender' },
- { label: 'Rotator cuff', method: 'Empty-can (Jobe) test', normal: 'No pain or weakness' }
- ], abnormalHints: ['Osgood-Schlatter (tibial tubercle tender)', 'Sever (calcaneal tender)', 'Iliac apophysitis', 'Rotator cuff tendinopathy'] },
-
- { name: 'Hypermobility screen (Beighton)', steps: [
- { label: 'Fifth finger extension', method: 'Passive extension of fifth MCP to >90°', normal: 'No hyperextension (1 pt each side if positive)' },
- { label: 'Thumb to forearm', method: 'Passive flexion of thumb to touch forearm', normal: 'Does not reach (1 pt each side if positive)' },
- { label: 'Elbow hyperextension', method: 'Hyperextension >10°', normal: 'No hyperextension (1 pt each side if positive)' },
- { label: 'Knee hyperextension', method: 'Hyperextension >10°', normal: 'No hyperextension (1 pt each side if positive)' },
- { label: 'Palms to floor', method: 'Feet together, bend forward, palms flat on floor with knees straight', normal: 'Cannot reach (1 pt if positive)' }
- ], abnormalHints: ['Beighton ≥5/9 suggests hypermobility spectrum (hEDS workup if with other features)'] },
-
- { name: 'Alignment and gait', steps: [
- { label: 'Standing alignment', method: 'View knees, feet', normal: 'Neutral alignment, medial arch' },
- { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Symmetric, smooth' },
- { label: 'Functional movements', method: 'Squat, single-leg stance, hop', normal: 'Full symmetric function' }
- ], abnormalHints: ['Antalgic gait', 'Trendelenburg', 'Asymmetric squat'] }
- ]
- },
- neuro: {
- overview: 'Full adult-pattern neuro exam across six pillars: mental status, cranial nerves, motor, reflexes, sensory, coordination/gait. In adolescents, screen concussion sequelae if sports-active; frontal release signs must be absent.',
- components: [
- { name: 'Mental status',
- significance: 'Detects cognitive change (concussion, substance use, mood disorder, rare neurodegenerative disease).',
- pearl: 'Attention precedes memory. A patient who can\'t attend (serial 7s, months backward) will fail memory even with intact hippocampus — distinguish before calling it a memory problem.',
- steps: [
- { label: 'Orientation', method: 'Name, age, date, location, situation', normal: 'Oriented x 4' },
- { label: 'Attention', method: 'Count backward from 100 by 7s (serial 7s) or months of year backward', normal: 'Intact' },
- { label: 'Short-term memory', method: '3-item registration and recall at 5 min', normal: '3/3 recall' },
- { label: 'Language', method: 'Object naming; sentence repetition; reading; writing', normal: 'Fluent, no paraphasia, comprehends written and spoken' },
- { label: 'Executive function', method: 'Similarities (apple/orange); interpret proverb', normal: 'Abstract, age-appropriate' }
- ], abnormalHints: ['Post-concussion cognitive changes', 'Mood or personality changes', 'Subtle executive dysfunction', 'Word-finding difficulty'] },
-
- { name: 'Cranial nerves (II–XII, full formal exam)',
- significance: 'Localises brainstem, base-of-skull, and specific nerve pathology. Subtle deficits (RAPD, mild facial weakness, Horner) are easily missed — exam discipline matters.',
- pearl: 'The fastest screen for a CN deficit is asking the patient to speak, smile, look around, and swallow water. What\'s preserved in everyday function tells you what\'s likely intact — then examine formally to confirm and to catch the subtle.',
- steps: [
- { label: 'CN I (if indicated)', method: 'Coffee or cinnamon each nostril separately', normal: 'Identifies both' },
- { label: 'CN II — acuity', method: 'Snellen at 20ft each eye; corrective lenses if worn', normal: '20/20 or baseline' },
- { label: 'CN II — fields', method: 'Confrontation, 4 quadrants each eye', normal: 'Full fields' },
- { label: 'CN II — fundoscopy', method: 'Direct ophthalmoscopy — disc, vessels, macula', normal: 'Sharp disc, normal cup/disc, no papilledema' },
- { label: 'CN II, III — pupils', method: 'Direct, consensual, swinging flashlight, accommodation', normal: 'PERRLA, no RAPD' },
- { label: 'CN III, IV, VI — EOM', method: 'H pattern, convergence, note nystagmus or ptosis', normal: 'Full conjugate movement, no nystagmus, convergence intact' },
- { label: 'CN V — sensation', method: 'Light touch V1, V2, V3 each side', normal: 'Intact, symmetric' },
- { label: 'CN V — motor', method: 'Clench jaw, palpate masseter/temporalis; lateral jaw movement', normal: 'Symmetric strength and bulk' },
- { label: 'CN V — corneal reflex (if indicated)', method: 'Cotton wisp to cornea', normal: 'Blinks bilaterally' },
- { label: 'CN VII', method: 'Wrinkle forehead, close eyes against resistance, smile/bare teeth, puff cheeks', normal: 'Symmetric all four movements' },
- { label: 'CN VIII — hearing', method: 'Finger rub each ear; Weber (midline) + Rinne (air > bone) if deficit', normal: 'Equal bilaterally' },
- { label: 'CN IX, X', method: 'Palate elevation with "ahh"; uvula midline; voice; gag (if indicated)', normal: 'Symmetric palate, uvula midline, normal voice' },
- { label: 'CN XI', method: 'Shoulder shrug and head turn against resistance', normal: '5/5 SCM and trapezius bilaterally' },
- { label: 'CN XII', method: 'Tongue protrusion, side to side; inspect for fasciculations/atrophy', normal: 'Midline, no atrophy or fasciculations, full movement' }
- ], abnormalHints: ['Any focal cranial nerve deficit', 'Papilledema', 'RAPD', 'Nystagmus', 'Facial asymmetry', 'Tongue deviation'] },
-
- { name: 'Motor — bulk, tone, strength',
- significance: 'Localises lesion to UMN vs LMN vs muscle vs junction. Pattern of weakness (proximal vs distal, symmetric vs focal) narrows differential.',
- pearl: 'Pronator drift is the most sensitive screen for subtle UMN weakness — a normal-feeling arm that drifts down with eyes closed still has corticospinal tract dysfunction. Always do it even when formal strength is 5/5.',
- steps: [
- { label: 'Bulk inspection', method: 'Inspect shoulders, biceps, thighs, calves, dorsal interossei (between metacarpals) of hands.', normal: 'Symmetric bulk; no atrophy, no pseudohypertrophy' },
- { label: 'Tone — upper', method: 'Passive flex-extend elbow and pronate-supinate wrist at slow then quick speeds. Then pronator drift: arms outstretched, palms up, eyes closed for 10 s.', normal: 'Smooth passive range; no drift, no pronation of the outstretched hand' },
- { label: 'Tone — lower', method: 'Passive knee flexion-extension; quick ankle dorsiflexion to check for catch. Heel-slap test: roll thigh and watch for ankle swing.', normal: 'Normal resistance, no catch, symmetric' },
- { label: 'Strength — deltoid (C5)', method: 'Patient abducts both arms to 90°. Examiner pushes down on each arm just above the elbow while patient resists. Compare sides.', normal: 'Holds against full resistance — MRC 5/5 bilaterally' },
- { label: 'Strength — biceps (C5–C6)', method: 'Elbow flexed 90°, supinated. Examiner grasps wrist and pulls to extend while patient resists.', normal: 'Holds against full resistance — 5/5' },
- { label: 'Strength — triceps (C7)', method: 'Elbow flexed 90°. Examiner pushes wrist toward shoulder while patient extends against resistance.', normal: 'Extends against full resistance — 5/5' },
- { label: 'Strength — wrist extension (C6–C7)', method: 'Patient makes fist, extends wrist. Examiner pushes down on knuckles while patient holds wrist up.', normal: 'Holds against full resistance — 5/5' },
- { label: 'Strength — finger flexion / grip (C8)', method: 'Patient grips two of examiner\'s crossed fingers as hard as possible. Compare sides.', normal: 'Strong symmetric grip — 5/5' },
- { label: 'Strength — finger abduction (T1)', method: 'Patient spreads fingers wide. Examiner squeezes index and little fingers together while patient resists.', normal: 'Holds fingers apart — 5/5' },
- { label: 'Strength — hip flexion (L2–L3)', method: 'Supine. Patient lifts straight leg 30° off table. Examiner pushes down on thigh just above knee while patient resists.', normal: 'Holds thigh up against full resistance — 5/5' },
- { label: 'Strength — knee extension (L3–L4)', method: 'Sitting, knee 90°. Patient straightens knee while examiner pushes distal shin down.', normal: 'Extends against full resistance — 5/5' },
- { label: 'Strength — ankle dorsiflexion (L4–L5)', method: 'Patient pulls toes and foot up toward shin. Examiner pushes foot down at the dorsum.', normal: 'Holds dorsiflexion against full resistance — 5/5; preserved heel-walk' },
- { label: 'Strength — great toe extension (L5)', method: 'Patient extends great toe up while examiner pushes it down with thumb.', normal: 'Holds against full resistance — 5/5 (classic L5 test)' },
- { label: 'Strength — ankle plantarflexion (S1)', method: 'Patient pushes foot down against examiner\'s hand at the ball. OR ask patient to toe-walk 10 steps (more sensitive — unilateral plantarflexion weakness shows immediately).', normal: 'Full power; toe-walks symmetrically — 5/5' }
- ], abnormalHints: ['Focal weakness → localise by myotome', 'Pronator drift (subtle UMN, always check even with 5/5)', 'Spasticity / catch (UMN)', 'Atrophy (LMN, disuse)', 'Fasciculations (MND, ALS)', 'Pseudohypertrophy of calves (DMD in a young male)'] },
-
- { name: 'Deep tendon reflexes',
- significance: 'Reflex pattern (increased, decreased, asymmetric) localises UMN vs LMN vs root vs peripheral nerve. Inexpensive and fast, but asymmetry is the most informative finding.',
- pearl: 'A reinforced reflex is still a reflex. If you can\'t elicit it initially, use Jendrassik (teeth clench or pull interlocked fingers apart) to boost — absent reflexes without reinforcement aren\'t truly absent.',
- steps: [
- { label: 'Biceps (C5–C6)', method: 'Patient\'s arm relaxed across lap. Examiner places thumb firmly on biceps tendon at the cubital fossa, strikes thumb with reflex hammer. Compare both sides sequentially.', normal: '2+ symmetric — visible contraction of biceps, slight elbow flexion' },
- { label: 'Brachioradialis (C5–C6)', method: 'Arm relaxed. Strike the distal radius about 3 cm proximal to the wrist, on its radial (thumb) side.', normal: '2+ symmetric — elbow flexion and slight forearm supination' },
- { label: 'Triceps (C7)', method: 'Support the patient\'s arm at the wrist with elbow at 90°. Strike the triceps tendon just above the olecranon.', normal: '2+ symmetric — triceps contraction, slight elbow extension' },
- { label: 'Finger flexors — Hoffmann sign', method: 'Grasp the middle finger\'s distal phalanx, flick it downward quickly and release. Watch the thumb and index finger.', normal: 'Negative — no thumb flexion, no index flexion (positive = corticospinal tract dysfunction)' },
- { label: 'Patellar (L3–L4)', method: 'Patient sits with knees hanging freely off the table. Strike the patellar tendon just below the patella.', normal: '2+ symmetric — quadriceps contraction with knee extension' },
- { label: 'Achilles (S1)', method: 'Patient\'s knee slightly flexed and leg externally rotated, or kneeling on a chair. Slightly dorsiflex the foot and strike the Achilles tendon.', normal: '2+ symmetric — plantar flexion of the foot' },
- { label: 'Plantar response (Babinski)', method: 'Stroke the lateral aspect of the sole firmly from the heel toward the little toe, then curve across the ball of the foot.', normal: 'Toes flex downward (plantar flexion, "down-going") bilaterally in anyone ≥ 2 years' },
- { label: 'Ankle clonus', method: 'Knee slightly bent. Support the shin with one hand, quickly and sharply dorsiflex the foot with the other, hold in dorsiflexion.', normal: '≤ 3 non-sustained beats is acceptable; sustained rhythmic oscillation = pathological clonus (UMN)' }
- ], abnormalHints: ['Hyperreflexia + sustained clonus = UMN (MS, myelopathy, cord lesion, stroke)', 'Symmetric hyporeflexia = peripheral polyneuropathy, GBS, myopathy, hypothyroid, B12 deficiency', 'Asymmetric hyporeflexia = radiculopathy at that segment', 'Hoffmann positive = corticospinal tract dysfunction at cervical cord or above', 'Up-going Babinski after age 2 = UMN (always abnormal)'] },
-
- { name: 'Sensory', steps: [
- { label: 'Light touch — upper', method: 'Cotton wisp, dorsum of hands, eyes closed', normal: 'Intact, symmetric' },
- { label: 'Light touch — lower', method: 'Dorsum of feet', normal: 'Intact, symmetric' },
- { label: 'Pain — upper', method: 'Broken Q-tip sharp end, hands', normal: 'Intact, symmetric' },
- { label: 'Pain — lower', method: 'Same on feet', normal: 'Intact, symmetric' },
- { label: 'Temperature (if indicated)', method: 'Cold tuning fork each area', normal: 'Intact' },
- { label: 'Vibration', method: '128 Hz tuning fork at distal IP of great toes; count seconds to fade', normal: 'Feels vibration; appropriate duration' },
- { label: 'Proprioception', method: 'Move great toe up/down with eyes closed', normal: 'Identifies direction correctly' },
- { label: 'Two-point discrimination (if indicated)', method: 'Blunt calipers on fingertip', normal: '<5mm on fingertip' },
- { label: 'Stereognosis (if indicated)', method: 'Identify coin/key in hand with eyes closed', normal: 'Correct identification' }
- ], abnormalHints: ['Dermatomal loss (nerve root)', 'Stocking-glove loss (length-dependent neuropathy)', 'Dorsal column loss (B12, tabes, MS — positive Romberg, vibration loss)', 'Cortical deficit (astereognosis, impaired 2-pt)'] },
-
- { name: 'Coordination', steps: [
- { label: 'Finger-nose-finger', method: 'Alternate examiner\'s finger and own nose; examiner moves target', normal: 'Smooth, accurate bilaterally' },
- { label: 'Heel-to-shin', method: 'Supine: heel down opposite shin and back', normal: 'Smooth, accurate' },
- { label: 'Rapid alternating (Dysdiadochokinesis)', method: 'Supinate/pronate hand rapidly on thigh', normal: 'Rhythmic, symmetric' },
- { label: 'Finger tapping', method: 'Thumb to each finger in sequence rapidly', normal: 'Rhythmic, smooth, symmetric' }
- ], abnormalHints: ['Dysmetria (cerebellar)', 'Intention tremor', 'Dysdiadochokinesia', 'Decomposed movement'] },
-
- { name: 'Gait and Romberg', steps: [
- { label: 'Normal gait', method: 'Walk 20 feet', normal: 'Narrow-based, smooth, reciprocal arm swing' },
- { label: 'Heel walk', method: 'Walk on heels only', normal: 'Able without difficulty' },
- { label: 'Toe walk', method: 'Walk on toes only', normal: 'Able without difficulty' },
- { label: 'Tandem', method: 'Heel-to-toe along a line, 10+ steps', normal: 'Minimal deviation' },
- { label: 'Romberg', method: 'Feet together, eyes open then closed, 30s', normal: 'Stable — no significant sway or fall with eyes closed' },
- { label: 'Single-leg stance', method: '10s each side, eyes open', normal: 'Stable without drift' }
- ], abnormalHints: ['Ataxic (wide-based — cerebellar)', 'Steppage (peripheral neuropathy / foot drop)', 'Circumduction (UMN hemiparesis)', 'Scissoring', 'Romberg positive (dorsal column)'] },
-
- { name: 'Frontal release / primitive reflexes', steps: [
- { label: 'Grasp reflex', method: 'Stroke palm', normal: 'Absent' },
- { label: 'Snout reflex', method: 'Tap upper lip', normal: 'No lip pucker' },
- { label: 'Glabellar tap', method: 'Tap between eyebrows — should habituate after 3–4 taps', normal: 'Habituates (no sustained blink)' },
- { label: 'Palmomental', method: 'Stroke thenar eminence', normal: 'No ipsilateral chin twitch' }
- ], abnormalHints: ['Presence suggests frontal lobe pathology, neurodegenerative disease, or severe TBI — rare in adolescence but relevant in post-concussion workup'] }
- ]
- },
- resp: {
- overview: 'Systematic respiratory exam: inspection → palpation → percussion → auscultation → special maneuvers. Always start from observation — rate, pattern, work of breathing, and audible sounds (stridor, grunting) can be diagnostic before the stethoscope touches the chest.',
- components: [
- { name: 'Inspection — observation before touching',
- significance: 'Detects respiratory distress and localises the level of airway compromise before any equipment is used. High yield: RR, WOB, audible sounds, chest shape, colour.',
- pearl: 'Audible stridor at rest from across the room = upper-airway obstruction, often urgent. Grunting in an infant = significant distress — never dismiss as fussiness.',
- steps: [
- { label: 'Respiratory rate', method: 'Count over a full 60 seconds (not 15×4) — children normally breathe irregularly. Count while the patient is calm, before any interaction.', normal: 'Within age-appropriate range (see scales card above)' },
- { label: 'Respiratory pattern', method: 'Observe depth, regularity, and inspiration:expiration ratio. Watch for prolonged expiration, paradoxical chest-abdominal movement, or apneas.', normal: 'Regular, I:E ratio ~1:2, no pauses > 10 s in an infant' },
- { label: 'Work of breathing', method: 'Inspect for nasal flaring, suprasternal/intercostal/subcostal retractions, accessory muscle use (SCM, abdominals), tripod positioning, head-bobbing in infants.', normal: 'No retractions; breathing effortless' },
- { label: 'Audible sounds (no stethoscope)', method: 'Listen at the bedside without the stethoscope. Grunting? Stridor? Wheezing audible across the room? Hoarse voice?', normal: 'No audible stridor, grunting, or wheeze' },
- { label: 'Chest shape and symmetry', method: 'Inspect from front and lateral. Note AP-to-transverse diameter, pectus excavatum/carinatum, chest wall asymmetry.', normal: 'AP:transverse ~1:2 (not barrel-chested); symmetric' },
- { label: 'Colour and perfusion', method: 'Inspect lips, tongue, nail beds for central cyanosis. Check peripheral perfusion (capillary refill, mottling).', normal: 'Pink, cap refill < 2 s, no cyanosis' },
- { label: 'Clubbing', method: 'Inspect fingernails: Schamroth sign (reverse a finger against its mirror — normal forms a diamond-shaped window, clubbed does not).', normal: 'Normal nail angle, Schamroth window present' }
- ],
- abnormalHints: ['Audible stridor — upper airway (croup, epiglottitis, foreign body, laryngomalacia)', 'Grunting in infant — significant distress', 'Tripod positioning, accessory muscle use — severe distress', 'Barrel chest — chronic air-trapping (asthma, CF)', 'Central cyanosis — significant hypoxemia', 'Clubbing in a child — cystic fibrosis, chronic hypoxemia, bronchiectasis, cyanotic CHD'] },
-
- { name: 'Palpation',
- significance: 'Localises pathology: consolidation increases tactile fremitus; pneumothorax/effusion decreases it. Trachea deviates AWAY from expanding lesions and TOWARD collapsing ones.',
- pearl: 'Tracheal deviation is one of the fastest bedside clues to mediastinal shift — tension pneumothorax pushes it away, lobar collapse pulls it toward. Palpate with the middle finger in the suprasternal notch.',
- steps: [
- { label: 'Tracheal position', method: 'Patient sitting upright, neck slightly extended. Place middle finger in the suprasternal notch, check equal distance to each SCM.', normal: 'Midline' },
- { label: 'Chest expansion — symmetry', method: 'Hands on lateral chest wall with thumbs meeting at the spine (posterior) or xiphoid (anterior). Patient takes a deep breath. Watch thumbs separate symmetrically.', normal: 'Symmetric 3–5 cm separation' },
- { label: 'Tactile fremitus', method: 'Ulnar surface of hand on chest wall. Ask patient to say "ninety-nine" repeatedly. Move hand systematically across each zone, comparing sides.', normal: 'Equal mild vibration bilaterally over lung fields' },
- { label: 'Chest wall tenderness', method: 'Palpate ribs, costochondral junctions, sternum, and intercostal spaces.', normal: 'No tenderness' },
- { label: 'Subcutaneous emphysema', method: 'Gentle palpation along clavicles, neck, chest wall.', normal: 'No crepitus under skin' }
- ],
- abnormalHints: ['Tracheal deviation — tension pneumothorax, large pleural effusion (away); upper lobe collapse (toward)', 'Asymmetric expansion — pneumothorax, large effusion, lobar collapse, phrenic palsy', 'Increased fremitus — consolidation (pneumonia), lobar pneumonia', 'Decreased/absent fremitus — pleural effusion, pneumothorax, obstruction', 'Costochondral tenderness — costochondritis, trauma', 'Subcutaneous emphysema — pneumothorax, tracheobronchial injury'] },
-
- { name: 'Percussion',
- significance: 'Differentiates air (hyper-resonant), fluid (dull), and consolidated lung (dull) without imaging. Well-performed percussion detects a pleural effusion > 300 mL or a pneumothorax with ~90% sensitivity.',
- pearl: 'Pleximeter fingertip must be flat against the chest wall — lift other fingers off. The "feel" of a percussion note is as informative as the sound: dullness has a dense, reflected quality; hyper-resonance feels hollow and springy.',
- steps: [
- { label: 'Technique', method: 'Place middle finger of non-dominant hand (pleximeter) flat on chest wall; strike distal IP joint with tip of dominant middle finger (plexor) using a quick wrist flick.', normal: 'N/A — technique step' },
- { label: 'Systematic zones', method: 'Percuss from apex to base, comparing side-to-side at each level. Include anterior, lateral (mid-axillary), and posterior fields.', normal: 'Resonant throughout lung fields' },
- { label: 'Cardiac dullness', method: 'Percuss from resonant lung toward the heart border. Left sternal border dullness starts at the 3rd–5th ICS.', normal: 'Dullness beginning at the expected cardiac border' },
- { label: 'Hepatic dullness', method: 'Right 5th–6th ICS mid-clavicular line transitions from resonant to dull.', normal: 'Liver edge dullness at expected level' },
- { label: 'Diaphragmatic excursion', method: 'Patient inhales fully then exhales fully; mark level of dullness at each end. Difference is diaphragm excursion.', normal: '3–5 cm excursion bilaterally' }
- ],
- abnormalHints: ['Hyper-resonant — pneumothorax, emphysematous bulla, severe asthma attack', 'Dull — consolidation, pleural effusion (stony dull), atelectasis, pleural thickening, large mass', 'Raised diaphragm (loss of excursion) — effusion, paralysis, subdiaphragmatic pathology'] },
-
- { name: 'Auscultation — normal breath sounds',
- significance: 'Breath sound quality varies by location. Bronchial sounds heard peripherally = consolidation; absent breath sounds = pneumothorax, effusion, obstruction.',
- pearl: 'Always compare corresponding points side-to-side sequentially — your ear calibrates to "normal" one side and immediately hears asymmetry. Listen through a full respiratory cycle at each zone.',
- steps: [
- { label: 'Technique', method: 'Diaphragm of stethoscope directly on skin (not over clothing). Patient breathes slowly and deeply through an open mouth.', normal: 'N/A — technique' },
- { label: 'Vesicular sounds (peripheral)', method: 'Listen over lung fields away from the sternum. Play the "Normal vesicular" sample above for reference.', normal: 'Soft, low-pitched, inspiration > expiration in length and loudness' },
- { label: 'Bronchovesicular (over main bronchi)', method: 'Listen at the 1st–2nd ICS anteriorly and between scapulae posteriorly.', normal: 'Intermediate pitch, inspiration = expiration' },
- { label: 'Bronchial (over trachea)', method: 'Listen directly over the manubrium or trachea.', normal: 'Harsh, high-pitched, expiration > inspiration' },
- { label: 'Systematic comparison', method: 'Six zones anteriorly (upper/mid/lower × L/R), four lateral, six posterior. Compare side-to-side at each zone.', normal: 'Symmetric breath sounds at every paired zone' }
- ],
- abnormalHints: ['Bronchial sounds heard peripherally — consolidation (pneumonia)', 'Absent/diminished breath sounds — pneumothorax, effusion, severe obstruction, obesity / muscular chest', 'Prolonged expiration — lower airway obstruction (asthma, bronchiolitis)'] },
-
- { name: 'Auscultation — adventitious sounds',
- significance: 'Adventitious (added) sounds are the key diagnostic finding. Timing (inspiratory vs expiratory vs biphasic), character (continuous vs discontinuous), and location are all informative.',
- pearl: 'Ask the patient to cough and re-listen. Secretions (rhonchi, some coarse crackles) clear or change; fine crackles of fibrosis or early pneumonia do not. The cough test separates two differential groups in one maneuver.',
- steps: [
- { label: 'Listen for wheeze', method: 'Continuous musical sounds, typically expiratory. Use the "Wheeze" sample for reference.', normal: 'No wheeze' },
- { label: 'Listen for crackles — fine', method: 'Short, high-pitched, discontinuous "Velcro" sounds. Typically end-inspiratory, bibasilar. Use the "Fine crackles" sample.', normal: 'No crackles' },
- { label: 'Listen for crackles — coarse', method: 'Longer, lower-pitched, louder than fine. Use the "Coarse crackles" sample.', normal: 'No crackles' },
- { label: 'Listen for rhonchi', method: 'Low-pitched, continuous, snore-like. Often change with cough. Use the "Rhonchi" sample.', normal: 'No rhonchi' },
- { label: 'Listen for pleural rub', method: 'Grating, creaky, biphasic, does NOT clear with cough. Use the "Pleural rub" sample.', normal: 'No pleural rub' },
- { label: 'Listen at the neck (for stridor)', method: 'Place stethoscope over the anterior neck. Stridor is loudest here and differentiates from wheeze (loudest over chest). Use the "Stridor" sample.', normal: 'No stridor' },
- { label: 'Listen for expiratory grunting (infants)', method: 'Often audible without a stethoscope at the bedside — short, low-pitched sound at the end of each expiration (glottal closure against exhaled air).', normal: 'No grunting' },
- { label: 'Cough re-listen', method: 'Have patient cough forcefully; re-listen to any abnormal area. Note if the sound clears or changes.', normal: 'Any secretion-based sound should clear or change with cough' }
- ],
- abnormalHints: ['Wheeze — asthma, bronchiolitis, foreign body (localised), anaphylaxis', 'Fine crackles — pulmonary edema, interstitial lung disease, early pneumonia', 'Coarse crackles — bronchitis, pneumonia, bronchiectasis, aspiration', 'Rhonchi — large-airway secretions', 'Pleural rub — pleurisy, PE, pneumonia with pleural involvement', 'Stridor — upper airway obstruction (croup, epiglottitis, FB)'] },
-
- { name: 'Special maneuvers — transmitted voice sounds',
- significance: 'Vocal resonance tests detect consolidation (increased transmission) and effusion/pneumothorax (decreased). Useful when auscultation suggests asymmetry.',
- pearl: 'Whispered pectoriloquy is the most sensitive of the three — whispered words transmitted clearly through consolidated lung. If "one, two, three" whispered becomes clearly audible over one lung zone, there is consolidation underneath.',
- steps: [
- { label: 'Bronchophony', method: 'Patient says "ninety-nine" in normal voice. Listen at each lung zone with the stethoscope.', normal: 'Muffled, indistinct sound' },
- { label: 'Egophony', method: 'Patient says "ee" continuously. Listen over any suspicious area.', normal: '"Ee" sounds like "ee" (no change)' },
- { label: 'Whispered pectoriloquy', method: 'Patient whispers "one, two, three" or "ninety-nine". Listen over each zone.', normal: 'Whisper is faint and indistinct' }
- ],
- abnormalHints: ['Bronchophony increased — consolidation', 'Egophony positive ("ee" → "A" / "ay") — consolidation, sometimes top of an effusion', 'Whispered pectoriloquy positive (whisper clearly audible) — consolidation'] }
- ]
- },
- cv: {
- overview: 'Systematic cardiovascular exam: inspection → palpation → auscultation at the five classic points → peripheral vascular exam. Always palpate the apex BEFORE auscultating — knowing where the apex lies tells you where to put the stethoscope and flags cardiomegaly immediately.',
- components: [
- { name: 'Inspection',
- significance: 'Detects obvious precordial activity, chest-wall signs of congenital heart disease, and systemic markers (cyanosis, clubbing, dysmorphic features).',
- pearl: 'Clubbing + central cyanosis in a well-appearing adolescent = cyanotic congenital heart disease until proven otherwise. Inspect the fingernails before reaching for the stethoscope.',
- steps: [
- { label: 'General appearance', method: 'Observe body habitus, features suggesting syndromic CHD (Turner, Down, Marfan, Williams).', normal: 'No dysmorphic features, appropriate growth' },
- { label: 'Central cyanosis', method: 'Inspect lips, tongue, and oral mucosa for bluish discoloration.', normal: 'Pink oral mucosa, no cyanosis' },
- { label: 'Peripheral cyanosis / clubbing', method: 'Inspect nail beds; do Schamroth\'s window (oppose nails of 4th fingers — normally forms a diamond-shaped window).', normal: 'Pink nail beds, Schamroth window present' },
- { label: 'Precordial bulge', method: 'Inspect anterior chest wall tangentially for asymmetric prominence over the heart.', normal: 'Symmetric chest, no bulge' },
- { label: 'Visible apex beat', method: 'Inspect for a visible cardiac impulse at the 5th ICS mid-clavicular line.', normal: 'Apex may be visible in thin patients; should not be displaced' },
- { label: 'Neck veins (JVP)', method: 'Patient reclined 45°, head turned slightly left. Observe the right internal jugular pulsation; measure vertical height above the sternal angle.', normal: '≤ 4 cm above sternal angle (≤ 9 cm H₂O from right atrium)' }
- ],
- abnormalHints: ['Central cyanosis — right-to-left shunt, severe hypoxemia', 'Clubbing — cyanotic CHD, chronic hypoxemia', 'Precordial bulge — long-standing cardiomegaly (grew during skeletal growth)', 'Visible apex displaced lateral/inferior — cardiomegaly', 'Elevated JVP — right-heart failure, fluid overload, cardiac tamponade'] },
-
- { name: 'Palpation',
- significance: 'Localises the apex (confirms cardiac size), detects thrills (loud murmurs), and identifies a parasternal heave (RV hypertrophy).',
- pearl: 'If you feel a thrill, the murmur is at least grade 4/6 — grade your murmur as ≥4 even if it sounds less impressive. Thrill = loud, palpable turbulence.',
- steps: [
- { label: 'Apex beat — localise', method: 'Feel with the tips of the fingers at the 5th ICS mid-clavicular line. If not found, roll the patient to the left lateral decubitus position.', normal: 'Located at 5th ICS, mid-clavicular line, less than 2 cm in diameter' },
- { label: 'Apex character', method: 'Describe: tapping (normal), heaving (pressure overload, e.g. AS/HTN), thrusting (volume overload, e.g. AR/MR), dyskinetic (MI/aneurysm).', normal: 'Brief tapping quality' },
- { label: 'Parasternal heave', method: 'Place the heel of the hand along the left sternal border. Sustained outward movement with each systole = heave.', normal: 'No heave' },
- { label: 'Thrills', method: 'Use the palmar aspect of the hand at each of the 5 auscultation areas (A, P, E, T, M). A thrill = palpable turbulence.', normal: 'No thrills' },
- { label: 'Peripheral pulses — upper', method: 'Palpate radial pulses bilaterally, then brachial. Note rate, rhythm, volume, and symmetry.', normal: 'Symmetric 2+ pulses, regular rhythm, age-appropriate rate' },
- { label: 'Peripheral pulses — lower', method: 'Palpate femoral pulses. Compare to brachial — radio-femoral or brachio-femoral delay suggests coarctation of the aorta.', normal: 'Femoral pulses 2+ symmetric, no delay relative to radial' }
- ],
- abnormalHints: ['Apex displaced laterally/inferiorly — cardiomegaly', 'Heaving apex — pressure overload (AS, HTN)', 'Thrusting apex — volume overload (AR, MR)', 'Thrill over precordium — always pathological; at least grade 4/6 murmur', 'Parasternal heave — RV hypertrophy (pulmonary HTN, pulmonary stenosis, VSD with Eisenmenger)', 'Radio-femoral delay — coarctation of the aorta (always check in a hypertensive adolescent)'] },
-
- { name: 'Auscultation — approach',
- significance: 'Systematic technique ensures every relevant finding is detected. Listen at all 5 points, with both diaphragm and bell, in supine/sitting/left-lateral positions as needed.',
- pearl: 'Time every murmur by simultaneously palpating the carotid pulse with the fingers of your free hand. Pulse = systole. Murmur heard during the pulse = systolic; in between pulses = diastolic.',
- steps: [
- { label: 'Positioning', method: 'Patient supine, head of bed at 30°. Exam room quiet, patient relaxed. Warm the stethoscope first.', normal: 'N/A — technique' },
- { label: 'Diaphragm technique', method: 'Firm contact with skin. Detects HIGH-pitched sounds: S1, S2, systolic ejection murmurs, AR, MR.', normal: 'N/A — technique' },
- { label: 'Bell technique', method: 'Very light contact — enough to make a seal but not stretch the skin. Detects LOW-pitched sounds: S3, S4, mitral stenosis rumble.', normal: 'N/A — technique' },
- { label: 'Listen at each of the 5 points', method: 'A → P → E → T → M in order, each with diaphragm then bell. Spend a full cycle at each zone.', normal: 'S1 crisp, S2 clear (splits physiologically on inspiration at P), no added sounds, no murmur' },
- { label: 'Left lateral decubitus position', method: 'If apex murmur suspected. Roll patient to left side. Listen at the apex with the BELL for mitral stenosis rumble or S3/S4.', normal: 'No added sounds, no diastolic rumble' },
- { label: 'Sitting forward, held expiration', method: 'Patient leans forward, exhales fully, holds. Listen at left lower sternal border and Erb\'s point with the DIAPHRAGM for aortic regurgitation (soft early diastolic decrescendo).', normal: 'No early-diastolic murmur' }
- ],
- abnormalHints: ['Fixed split S2 (no change with respiration) — ASD', 'Loud S2 at pulmonic area — pulmonary HTN', 'S3 — volume overload, CHF (can be normal in young athletes)', 'S4 — stiff ventricle (HTN, HCM, ischemia)', 'Audible opening snap — mitral stenosis (rare in children)'] },
-
- { name: 'Auscultation — heart sounds and murmurs',
- significance: 'Characterising a murmur by timing, location, radiation, pitch, quality, and dynamic maneuvers narrows the differential.',
- pearl: 'Innocent murmurs in children share 7 "S" features: Soft (≤ grade 2), Systolic, Short, Single (no added S3/S4), Small (localised, non-radiating), Sweet (musical), Sensitive to position/respiration (louder supine, softer standing). Anything breaking this pattern deserves workup.',
- steps: [
- { label: 'S1', method: 'Listen at the apex (mitral). Coincides with the carotid pulse upstroke. Mitral + tricuspid closure.', normal: 'Single, crisp, single-component sound' },
- { label: 'S2', method: 'Listen at the pulmonic area in HELD INSPIRATION and HELD EXPIRATION. Note whether S2 splits physiologically (wider in inspiration, narrower/absent in expiration).', normal: 'Physiologic split (widens on inspiration, narrows on expiration)' },
- { label: 'S3 / S4 gallops', method: 'Bell at the apex in left lateral decubitus. S3 = early diastole (after S2), low-pitched. S4 = late diastole (just before S1).', normal: 'Absent in adults; S3 can be normal in young athletes under age 30' },
- { label: 'Identify murmur — timing', method: 'Time vs carotid pulse. Systolic (during pulse) vs diastolic (between pulses) vs continuous.', normal: 'No murmur, or only soft innocent flow murmur' },
- { label: 'Identify murmur — location + radiation', method: 'Where loudest? Does it radiate? AS → carotids. MR → axilla. Coarctation → back.', normal: 'N/A — characterise only if murmur present' },
- { label: 'Identify murmur — character', method: 'Crescendo-decrescendo (ejection) vs holosystolic (plateau) vs decrescendo early-diastolic (AR, PR) vs mid-diastolic rumble (MS, TS).', normal: 'N/A — characterise only if murmur present' },
- { label: 'Grade intensity', method: 'Levine 1–6 scale (see scales card above).', normal: 'No murmur, or grade ≤ 2 soft innocent flow murmur' },
- { label: 'Dynamic maneuvers', method: 'Standing: ↑HOCM, ↑MVP click (earlier). Squatting: opposite. Valsalva: ↑HOCM, most others decrease.', normal: 'No significant change with posture' }
- ],
- abnormalHints: ['Holosystolic murmur at apex → axilla — mitral regurgitation', 'Holosystolic at lower left sternal border (LLSB) — VSD, tricuspid regurgitation', 'Systolic ejection at upper right sternal border → carotids — aortic stenosis', 'Systolic ejection at upper left sternal border — pulmonary stenosis', 'Continuous "machinery" below left clavicle — PDA', 'Early diastolic at Erb\'s point, leaning forward — aortic regurgitation', 'Diastolic rumble at apex, bell in left-lateral — mitral stenosis', 'Fixed split S2 + systolic flow murmur — ASD'] },
-
- { name: 'Peripheral vascular exam',
- significance: 'Coarctation of the aorta hides until BP and pulses are checked in all four extremities. Differential diagnosis of a hypertensive adolescent should include this in the first 60 seconds.',
- pearl: 'Four-limb BP measurement is mandatory in any adolescent with hypertension or a murmur. Upper-extremity BP > lower-extremity BP (or brachio-femoral delay) = coarctation until excluded.',
- steps: [
- { label: 'Four-limb blood pressure', method: 'Measure BP in right arm, left arm, and at least one leg. Use appropriately sized cuff (bladder width 40% of limb circumference, length 80–100%).', normal: 'Arm BPs within 10 mmHg of each other; leg systolic within 20 mmHg of arm systolic (may be higher)' },
- { label: 'Radial pulses', method: 'Palpate both radials simultaneously — note any delay or asymmetry.', normal: 'Simultaneous, symmetric, 2+' },
- { label: 'Radio-femoral delay', method: 'Palpate radial and femoral simultaneously. Feel the femoral as clearly "after" the radial = delay.', normal: 'No delay' },
- { label: 'Femoral pulses', method: 'Palpate both femoral pulses at the mid-inguinal point. Compare amplitude to radials.', normal: 'Symmetric 2+ pulses, equal amplitude to radial' },
- { label: 'Dorsalis pedis + posterior tibialis', method: 'Palpate in both feet.', normal: '2+ pulses bilaterally' },
- { label: 'Capillary refill', method: 'Press and release the nail bed; time to normal colour.', normal: '< 2 sec' }
- ],
- abnormalHints: ['Asymmetric upper-extremity BP (> 10 mmHg) — subclavian stenosis or coarctation at the origin', 'Upper >> lower-extremity BP — coarctation of the aorta', 'Diminished or absent femoral pulses with brachio-femoral delay — coarctation', 'Bounding pulses with wide pulse pressure — AR, PDA, arteriovenous fistula, thyrotoxicosis, anemia', 'Weak thready pulses — low output state (heart failure, shock, hypovolemia)', 'Prolonged capillary refill — dehydration, shock, cold stress'] }
- ]
- }
- }
- };
+ return peGuideDataPromise;
+ }
// ────────────────────────────────────────────────────────────
// STATE + RENDER
@@ -1343,10 +63,15 @@
document.addEventListener('tabChanged', function (e) {
if (e.detail.tab !== 'peguide' || _inited) return;
_inited = true;
- init();
+ init().catch(function (err) {
+ console.error('[PEGuide] init error', err);
+ var content = document.getElementById('pe-content');
+ if (content) content.innerHTML = 'Unable to load PE Guide data.
';
+ });
});
- function init() {
+ async function init() {
+ await loadPeGuideData();
var ageSelect = document.getElementById('pe-age-group');
var content = document.getElementById('pe-content');
var actions = document.getElementById('pe-actions');
diff --git a/test/pe-guide-data.test.js b/test/pe-guide-data.test.js
new file mode 100644
index 0000000..339ce32
--- /dev/null
+++ b/test/pe-guide-data.test.js
@@ -0,0 +1,28 @@
+const { test } = require('node:test');
+const assert = require('node:assert/strict');
+const fs = require('node:fs');
+const path = require('node:path');
+
+const root = path.join(__dirname, '..');
+
+function read(relativePath) {
+ return fs.readFileSync(path.join(root, relativePath), 'utf8');
+}
+
+test('PE Guide static content is loaded from JSON data', () => {
+ const source = read('public/js/peGuide.js');
+ const data = JSON.parse(read('public/data/pe-guide.json'));
+
+ assert.match(source, /PE_GUIDE_DATA_URL = '\/data\/pe-guide\.json'/);
+ assert.match(source, /async function init\(\)/);
+ assert.match(source, /await loadPeGuideData\(\)/);
+ assert.doesNotMatch(source, /newborn:\s*\{/);
+
+ assert.deepEqual(Object.keys(data.peData), ['newborn', 'infant', 'toddler', 'preschool', 'school', 'adolescent']);
+ assert.ok(data.peData.newborn.msk.components.length > 0);
+ assert.ok(data.peData.adolescent.cv.components.length > 0);
+ assert.ok(data.scales.mrc.rows.length > 0);
+ assert.ok(data.systemScales.cv.includes('murmurGrade'));
+ assert.ok(data.respiratorySounds.length >= 7);
+ assert.ok(data.cardiacSounds.length >= 6);
+});