{ "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" ] } ] } } } }