7948cad6f1
The final big piece of "everything in React + Tailwind". Login,
register, forgot-password, reset-password, and email-verification all
render from the React bundle now. The root path / serves the SPA,
vanilla index.html + public/js/* are no longer served by the server.
BACKEND — src/routes/auth.ts
New GET /api/auth/public-config (public — no auth required) returns
{ registrationEnabled, turnstileSiteKey, oidcEnabled,
disableLocalAuth, ssoButtonLabel }.
Single round-trip the React auth screen needs on mount. Reuses
existing DB settings; no new tables.
BACKEND — server.ts
• / and /index.html now send public/app/index.html (React SPA),
not public/index.html (vanilla).
• /auth, /reset-password, /verify-email explicitly route to the SPA
so the email links land on the React router.
• /app/*splat preserved as an alias so old bookmarks keep working.
• SPA fallback added after express.static so hard-refresh on
/encounter / /bedside / /settings etc. serves the React index
instead of 404ing. API paths and static-file extensions still
fall through to their existing handlers.
• The dead app.get('/') duplicate that also pointed at the vanilla
index is removed.
CLIENT — React auth flow
client/src/pages/Auth.tsx (new)
Login / register / forgot sub-forms with a single useQuery on
['public-config'] driving Turnstile + SSO button visibility.
Login flow handles all three vanilla-equivalent responses
(token / requires2FA / needsVerification). 2FA field reveals
inline when the server asks for it; resend-verification link
appears when needsVerification fires. SSO button renders
whenever oidcEnabled is true, even if local auth is disabled
(disableLocalAuth hides the login/register/forgot forms
entirely). HIPAA notice + APK download link preserved.
client/src/pages/ResetPassword.tsx (new)
Reads ?token=xxx from the URL, POSTs /api/auth/reset-password.
Confirm-password match, 8+ char validation, server
passwordWarning (pwned password) surfaces as an amber info box.
Redirects to /auth 2.5 s after success.
client/src/components/Turnstile.tsx (new)
Loads the challenges.cloudflare.com/turnstile script once,
renders a widget per form, calls onToken(token) on success and
onToken('') on error / expiry. If siteKey is null/empty (e2e
container with TURNSTILE_SITE_KEY="") renders nothing and
auto-reports empty — matches the vanilla no-key-no-widget
behaviour.
client/src/components/AuthGuard.tsx (new)
useQuery(['auth-me']) with retry: false. On 401/error redirects
to /auth?next=<current-url> so the deep link survives sign-in.
Used as a parent route in App.tsx wrapping every private page.
client/src/components/Layout.tsx
"← back to legacy app" link replaced with "Sign out" — calls
POST /api/auth/logout then window.location = /auth.
client/src/App.tsx
BrowserRouter no longer has basename (was "/app"). Public
routes: /auth, /reset-password. Everything else lives under
<AuthGuard> → <Layout>. Lazy-loaded Auth + ResetPassword join
the existing heavy-route code-split.
client/vite.config.ts
base stays "/app/" so hashed asset URLs resolve to
/app/assets/... (served unchanged by express.static).
shared/types.ts + client/src/shared/types.ts — additive:
PublicConfigOk { registrationEnabled, turnstileSiteKey,
oidcEnabled, disableLocalAuth, ssoButtonLabel }.
Bundle — Auth chunk splits out at 10.87 kB / 3.35 kB gz, lazy-loaded
only on the sign-in path; initial bundle unchanged at 343.97 kB /
106.59 kB gz.
Backend tsc + client tsc + vite build + 136/136 vitest all green.
1 line
No EOL
118 KiB
JavaScript
1 line
No EOL
118 KiB
JavaScript
import{i as e,n as t,t as n}from"./jsx-runtime-ByY1xr43.js";import{c as r,i}from"./index-BuU36CvS.js";var a=e(t(),1),o=[`newborn`,`infant`,`toddler`,`preschool`,`school`,`adolescent`],s=[`msk`,`neuro`,`resp`,`cv`],c={msk:`Musculoskeletal`,neuro:`Neuro`,resp:`Respiratory`,cv:`Cardiovascular`},l={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`]}]}}},u={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`]]}},d={msk:[`atr`,`beighton`],neuro:[`mrc`,`dtr`,`plantar`],resp:[`rr`,`spo2`,`silverman`,`westley`],cv:[`murmurGrade`,`pulseAmp`,`capRefill`]},f=[{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)`}],p=[{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.`}],m=[{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.`}],h=[{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. 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