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2014年3月18日 22:18

• chief complaint
○ demographics: name, gender, age
○ admission: type, date (was clinically/emergency admitted x days ago)
○ chief complaint (CC): onset, symptoms, duration / reason
• present illness
○ primary sx (SOCRATES): site, onset, character, radiation, association, time, exacerbating & alleviating factors, severity
○ systemic enquiry (important negatives):
○ constitutional sx: fever, chills, rigors, weight loss, malaise
○ functional status: exercise tolerance, activities, ambulation, sleep, intake, output, mood
• chronic illness
○ control: drug use, frequency, compliance
○ course: severity, complication, relapse
○ lifestyle: exercise, diet, activities
• perinatal hx
○ antenatal: maternal disease, exposure
○ labor: term, mode of delivery, complication, birth weight
○ neonatal: how long till discharge, complication
• developmental hx
○ development milestones: any delay (mentioned in MCHC?), regression
Gross motor Fine motor Speech Social
3m head control reach out vocalizes laugh
6m sit with support palmar grasp babbles peak-a-boo
9m sit without support pincer grasp (pencil) mama/papa stranger anxiety
1y walk alone casting 1 word bye bye
2y walk upstairs 2 feet line 2 word phrase dry by day
3y walk upstairs 1 feet circle 3 word sentence (SVO) parallel play
4y walk downstairs cross short story dress & undress
• immunization hx
○ public vaccine: BCG (0), Hep B (0,1m), DTaP-IPV & PCV (2,4,6m), MMR (1y, P1), V (P1)
○ private vaccine: rotavirus, influenza etc.
• medical hx
○ childhood illness & infection (eg. asthma, DM, epilepsy)
○ previous hospitalization
○ surgical procedures
• drug hx
○ medication: types, indication, side effect
○ drug allergy
• family hx
○ parents & siblings
○ familial illness: age of onset, death
○ parenteral consanguinity (marriage between close relatives)

• social hx
○ child: home, eduction, activities, diet, sex, suicide (HEADSS)
○ parents: main carer, marital status, occupation, education, health, financial status

PED 第 3 頁
2014年3月3日 20:41

• vitals
○ P: radial pulse, brachial pulse (infants)
○ BP: smaller cuff
○ RR: chest movement, abdominal movement (infants)
○ SaO2:
○ temp: infrared tympanic thermometer, axilla
• parameters
○ weight
○ height: 100 cm for age 4, + 5cm/yr until age 10
○ head circumference:

General Inspection
• introduction
○ greet child & parents
○ quick developmental assessment & mentality
walk (1y), run (2y)
palmar grasp (6m), pincer grasp (9m), casting (1y),
3 word sentence / age, name, sex (3y)
stranger anxiety (9m), wave hello / bye bye (1y)
• general (高矮肥瘦)
○ height
tall (Marfan, Klinefelter, Soto)
short (Down, Turner, Noonan, William, Prader Willi, Russell Silver, achondroplasia)
○ contour
fat (Prader Willi)
○ posture
• color (紅黃藍白黑)
○ erythema
○ jaundice
○ cyanosis DDx - facial rash
○ pallor • 1/2. malar rash (SLE) (sparing nasolabial fold)
DDx - Cushingoid
○ hyperpigmentation • 3. dermatomyositis (peri-orbital heliotropic rash)
• leukemia (central line, alopecia), ITP (bruises)
• head (大小奇怪頭) • 4. infantile eczema (scaly, dry)
• SLE (butterfly rash, joint inflam), sJIA
○ size: macrocephaly / microcephaly • nephrotic syndrome • 5. adenoma sebaceum (TS)
○ shape: brachycephaly • eczema, asthma (less likely) • 6. facial plethora (Cushing) (moon face)
○ fontanelle • hemangioma (Sturge-Weber in V1-2)
• face (眼耳口鼻頸) • port wine stain
○ contour: moon face (Cushingoid)
○ rash: adenoma sebaceum (TS), port wine stain (Sturge-Weber), neurofibroma (NF)
○ eye: peri-orbital swelling (nephrotic), down / up slanting, ptosis (Noonan), blue sclera (OI)
○ ear: low set (helix below horizontal line drawn between inner canthus), prominent ears (Fragile X)
○ mouth: prominent lips, widely spaced teeth (William), cleft lip & palate, protruding tongue, fasciculation (SMA)
○ nose: flat nasal, anteverted nostrils
○ neck: swelling (LN, goitre, thyroglossal cyst, cystic hygroma, SCM tumor)
• limb (手手腳腳走)
○ limb: prominent skin creases (achondroplasia), short / long legs
○ hands:
○ feet:
○ gait: hemiplegic, diplegic (tip-toeing), ataxic (wide based), waddling

RESP exam
• general
○ consciousness: agitated / confused
○ position: tripod (leaning forward, hands on knees; indicates upper airway obstruction)
○ color: pallor, central cyanosis
○ respiratory distress
nasal flaring & head nodding (neonates)
use of accessory mus: SCM contraction
○ sound
inability to complete sentence (severe distress)
stridor (upper airway obstruction)
wheeze (lower airway obstruction)
grunting (distress in infants)
hoarseness (vocal cord disease)
○ radial pulse
○ clubbing (
• ENT exam

PED 第 4 頁
grunting (distress in infants)
hoarseness (vocal cord disease)
○ radial pulse
○ clubbing (
• ENT exam
○ throat: inspect pharynx, tonsils
○ nose: inspect turbinates
○ ear: inspect tympanic memb, middle ear
• inspection
○ resp distress
use of SCM, substernal & intercostal insucking
paradoxical abd movement
○ chest wall deformity
hyperinflated / barrel shaped chest
Harrison sulcus
pectus excavatum (hollow chest): ↓ AP diameter of chest, may found in health children
pectus carinatum (pigeon chest): ↑ AP diameter of chest, always pathological
○ surgical scars
midline sternotomy (open heart repair)
R thoracotomy (BT shunt, lobectomy), L thoracotomy (PDA ligation, CoA repair, lobectomy)
• palpation
○ chest expansion difficult to assess in pediatrics (∵ smaller thoracic cage). ie. sometimes inspection alone is enough
○ apex beat
○ tracheal deviation
• percussion
○ do not use large force or it may mimic hyperresonant
○ no need for all intercostal space
• auscultation
○ no need to ask patient to take big breath (∵ noise only travel little distance)

CVS exam
• general
○ general
vitals: ↑ P (tachycardia), ↑ RR (tachypnea) (HF)
growth: height, weight, BMI
body build: tall stature (eg. Marfan), short stature (eg. Turner, William, Down, Noonan, HF from FFT)
○ face
facial dysmorphism
central cyanosis
resp distress: tachypnea, use of SCM, subcostal insucking (HF)
○ hands
clubbing: fingers (CHD, IE, suppurative lung diseases)
radial pulse (rate, rhythm, volume)
□ strong bounding & collapsing pulse (AR, PDA, large AVF, thyrotoxicosis)
□ weak pulse (AS, PS, HLHS, myocarditis, cardiomyopathy)
cold & pale extremities, prolonged capillary refill
○ lower limb
femoral pulse: weak & absent pulse / radio-femoral delay (CoA, IAA)
toe clubbing: (only = differential clubbing - PDA, Eisenmenger)
• CVS exam
○ precordial inspection
resp distress: intercostal insucking, paradoxical movement of diaphragm
chest deformities: Harrison sulcus (chronic SOB), pectus deformities
surgical scar: midline sternotomy (open heart repair), R thoracotomy (BT shunt, lobectomy), L thoracotomy (PDA ligation, CoA repair, lobectomy)
visible cardiac pulsation
○ apex (4-5th ICS, MCL)
heaving: LV pressure overload - AS, CoA, HT
deviated: LV volume overload - VSD, PDA, AR, MR
right sided: dextrocardia
○ parasternal heave
LLSB heaving: RV pressure overload - PS, pul HT
pre-cordial bulge: RV vol overload - TOF, AVSD, severe ASD, TR, PR
○ thrills (palpable murmur ≥ grade 4/6)
suprasternal pulsation: AS
carotid thrills: AS
infraclavicular: PDA
○ heart sound
muffled S2 by murmur = PSM!!! (distinguish from ESM)
loud P2: pul HT in L-R shunt
single P2: PS, TOF, pul atresia, TGA
fixed splitting of P2: ASD
○ heart murmur
continuous: PDA (infraclavicular), venous hum (↓ when lying supine)
ejection systolic (ESM): AS (RUSB), PS (LUSB), ASD (LUSB)
pan systolic (PSM): VSD & TOF (LLSB), MR (apex), TR (LLSB, pulsatile liver)
early diastolic (EDM): AR (LLSB)
mid diastolic (MDM): MS (apex)

PED 第 5 頁
○ radiation
carotid bruit: AS
infraclavicular: PDA
pos interscapular area: flow, PDA, collaterals of CoA PS as well?
• others
○ bilateral basal coarse crepitation (pul edema)
○ hepatomegaly (TR, CHF)
○ measure blood pressure

Abdominal exam
• general
○ growth
○ pallor (hemolysis, BM failure)
○ jaundice (hemolysis, liver disease, obstructive jaundice)
○ café au lait complexion (chronic renal failure)
○ lymphadenopathy (malignancy)
○ stigmata of CLD: clubbing, palmar erythema, leukonychia
○ ankle edema
• inspection
○ contour: generalized distension (ascites), localized swelling, umbilical hernia (Down, hypothyroidism, ascites, Beckwith)
○ skin: surgical scars, dilated veins (portal HT), striae (Cushing)
○ movement: peristalsis (pyloric stenosis), cough impulse
• palpation
○ tenderness
○ rigidity
○ guarding (not apparent in children)
○ mass: site, size, consistency, surface, border, attachment
○ ascites: shifting dullness
○ liver: lower border (normal 1-2 cm below costal margin), consistency, surface, border
○ spleen: lower border
○ kidney: ballotable (unilateral / bilateral), can get above it
○ bladder: suprapubic swelling DDx - hepatosplenomegaly
• percussion • hemolysis: thalassemia, hereditary spherocytosis, HDN
(only if abnormal finding) • neoplasm: leukemia, lymphoma, neuroblastoma
○ liver: dull • vascular: portal hypertension, heart failure
○ spleen: dull • biliary: biliary atresia, choledochal cyst
○ kidney: resonant • infection: bacterial (IE, salmonella), viral (mono, hepatitis, TORCH), parasitic
• auscultation (malaria)
○ bowel sounds • autoimmune: systemic JIA, SLE
○ renal bruit • metabolic: glycogen storage disease, mucopolysaccharidoses
○ liver bruit • liver tumor: benign (hemangioma, polycystic liver), malignant (hepatoblastoma)

Neurology exam
• tubes & drains
○ ventilator / tracheostomy (resp weakness - SMA, GBS)
○ feeding tubes (bulbar weakness)
○ walking aids, orthosis, splints
• general
○ consciousness & behavior CN5 motor
○ facial dysmorphism
○ head: microencephaly / macroencephaly, VP shunts, scar
○ skin: café au lait spots & neurofibroma (NF1), hypopigmented spots & adenoma sebaceum (TS)
○ back: cutaneous lesions in lumbosacral region (spina bifida) CN11 motor
checkmy l
inspection UMN LMN
○ posture hemiplegic (unilateral flexed UL, extended LL) frog-like position (hips abducted & limbs extended)
diplegic (scissoring of legs)
opisthotonus (persistent arching of neck & trunk)
○ mus wasting milder severe
pseudohypertrophy (DMD)
CN8 whisper
○ movement asymmetrical (hemiplegia)
choreoathetosis (dyskinetic CP) 3 nonrelated
○ surgical scars ankle (Achilles tenotomy to release spasticity)
mus tone
mid-thigh (mus biopsy for LMN lesions)
○ tone spasticity: velocity dependent + clasp knife effect flaccidity Marotorus
(pyramidal tract)
rigidity: velocity independent (extrapyramidal tract)
○ sign ankle clonus limb fasciculation
tongue fasciculation (SMA)

mus strength
○ raise arm hemiparesis proximal weakness (myopathy)
hand grip diparesis distal weakness (neuropathy)

PED 第 6 頁
○ hand grip diparesis distal weakness (neuropathy)
○ squatting tetraparesis
○ tip toe walk
tendon reflex
○ limb reflex hyperreflexia (brisk) hyporeflexia (absent)
○ Babinski sign upgoing (physiological in <age 1) downgoing / absent
UL: finger nose test (past-pointing, intention tremor)
LL: Romberg test (fall on open eyes), heel-shin test
pain & temp sensory level gloves & stocking loss
gait hemiplegic waddling
diplegic: tip-toeing: Gower sign (DMD)
ataxic: wide based

Developmental assessment

r r r
r r
r r
r r
r r r
• general & observation
○ greet the parents & child
○ general inspection by observing height, head circumference, facial dysmorphism
○ quick assessment by observing child gait, playing with hands, speech and interaction
• gross motor
○ observe: posture, limb movement
○ pull to sit
put child's hands together and grab with one hand, another hand on the back of his head for caution
pull child to sit in SLOW motion, stop in 20-30° and observe for head control (3m)
○ hands behind child's back: sit with support (6m)
○ hands released: sit without support (9m)
○ supported standing
grab child under armpit and hold him up vertically
observe for stepping, weight supporting (12m)
○ observe child play & gait: cruising (12m), walk independently (15m), squad (18m), jump on 2 feet (2y)
○ demonstrate test: walk upstairs / downstairs
• fine motor
○ attract child with colorful toys: visual follow 90° (6 wks), 180° (3m)
○ approach child with one brick: reach out (3m), palmar grasp (6m)
○ give more bricks: one cube in each hand (6m), bang cubes (12m)
○ observe child play: mouthing (4m), hands transfer (6m), casting (12m), hand dominance (abnormal if <12m)
○ play with child on table, demonstrate building: tower of 3 (18m), train (2y) with chimney (2.5y), bridge (3y), stairs (4y)
Pen & paper
○ draw with child on table: scribbles (18m), vertical line (2y)
○ demonstrate drawing: circle (3y), cross (4y), triangle (5y)
• speech & language
○ observe child speech: babbling (6y), papa/mama (9m), 1 word (1y), 2 words phrase (2y), 3 words sentence (SVO) (3y)
○ what is your name? (2y)
○ how old are you? (2.5y)
○ are you a boy or girl? (beware of echolalia) (3y)
point out body parts (eye, ear, mouth, nose, arm, leg) (18m)

PED 第 7 頁
PE - Neonatal
2015年10月15日 20:03

• timing: 1-2 hrs after feeding, before sleeping
• thermal control: wrap in towel, avoid prolonged undressed, examine in incubator
• infection control: wash hands before touching every newborn, wear mask

APGAR scoring
• 1 min: how well baby tolerate birth process
• 5 min: how well baby tolerate extra-uterine environ
• appearance (skin color)
• pulse
• grimace (reflex irritability)
• activity (mus movement)
• respiration

Growth parameters
body weight 2500-4000 g
body length 48-52 (50) cm
head circumference 32-37 (35) cm
chest circumference 30-35 cm
abdominal circumference 31-33 cm

Size for gestational age

• small for gestational age (SGA): <10th percentile
• appropriate for gestational age (AGA): 10th-90th percentile
• large for gestational age (LGA): >90th percentile

• conscious state: sleeping, crying, irritable, unresponsive
• size, body proportion
• color: plethora (normal), pallor, cyanosis, jaundice (yellow, progressive from cranial to caudal direction)
• skin
○ bruising, vacuum bruising (circular mark on top of head), forceps mark (lunar mark on bil cheeks)
○ mottling, milia, lanugo, meconium stained (green)
• posture
• pigmentation & skin lesion
• generalized edema
• gross malformation & dysmorphic features

• size (head circumference) & shape
• sutures & fontanelles, ant fontanelle pressure
• scalp bruising (red / blue)
○ caput succedaneum (pitting edema of scalp with residual indentation)
○ cephalohematoma (swelling shift to surrounding area when pressure applied and shift back immed when released,
limited by cranial sutures)
○ subaponeurotic hemorrhagic

• dysmorphic features
• eye
○ dysconjugate eye movement (transient crossed, divergent is normal)
○ subconjunctival hemorrhage (normal from delivery pressure)
○ congenital cataracts & glaucoma (opacities)
• eyelid
○ edema may cause newborn unable to open eyes (normally resolve within few days)
• nose
○ choanal atresia
SOB, resp distress & cyanosis ∵ neonates are obligate nasal breather

Neonatal 第 9 頁
SOB, resp distress & cyanosis ∵ neonates are obligate nasal breather
inability to pass catheter through nostrils into throat
dx: nasal endoscopy, sinus X-ray, CT H&N
○ nasal flaring (dilatation during breathing, indicates resp distress)
○ flat nasal bridge
• mouth
○ cleft lip (unilateral / bilateral, extending to choanal)
○ cleft palate (
○ macroglossia (large tongue causing protrusion)
○ micrognathia (small jaw pushing tongue back causing poor feeding & breathing)
○ neonatal teeth (not a good sign at birth, ax/ syndromes)
• ears
○ position
○ size (microtia), shape (dysplastic ear → must refer for ENT for hearing test)
○ ext meatus patency
○ low set ears (below the horizontal line drawn between eyes)

• skin: redundant skin fold, web neck
• anterior mass: sternomastoid tumor, cystic hygroma
• clavicle: palpate for fracture

• chest insucking: subcostal & suprasternal insucking (resp distress)

• paradoxical abd movement: abdomen rises during inspiration (resp distress)
• shape
○ distended
○ scaphoid (abdomen sucked inwards ∵ gross diaphragmatic hernia)
• skin
○ venous congestion (portal hypertension)
• lesion
○ omphalocele
• umbilical cord
○ 2 arteries (smaller lumen), 1 vein (larger lumen)
○ meconium stained (green, fetal distress during in-utero)
• anus: position, patency (anorectal atresia causes IO, need emergency OT)

Genitalia exam
• ambiguous genitalis
• labia majoris & minoris: minoris more prominent (prematurity)
• clitoris: clitomegaly (virilization)
• penis: size, shape
• urethral meatus: position (hypo-/epispadia)
• scrotum
○ empty (undescended testis / cryptorchidism → palpable for abd mass)
○ swelling (inguinal hernia, hydrocele)

• limb: symmetry, deformities, length
• hand: palmar creases, digits (polydactyly, syndactyly, clinodactyly -
• foot: deformity,
• passive & active movement
• DDH: Barlow (displace) & Ortolani (replace) tests

• spinal deformity
○ scoliosis (S shaped / C shaped curve)
○ kyphosis (hunched back in thoracic area)
○ lordosis (
• lesion
○ meningomyelocele (cystic lesion arising from midline)
○ spina bifida occulta (cutaneous midline dimple, mass, tufts of hair, hemangioma)

Neonatal 第 10 頁
○ lordosis (
• lesion
○ meningomyelocele (cystic lesion arising from midline)
○ spina bifida occulta (cutaneous midline dimple, mass, tufts of hair, hemangioma)

Primitive reflexes
• retention of primitive reflexes after 6 month
• lack of secondary (age-appropriate) reflexes after 7 month
Rooting reflex strokes baby's cheek / mouth turn head to that side (important for searching the nipple for
Sucking reflex touch baby's roof of mouth sucking (important for eliciting milk expression in breast-
Palmar hand / foot stimulate baby's palm/sole with finger strong palmar grasp on examiner's finger enough to lift the baby
grasp reflex off bed
Asymmetric tonic rotate head to one side extension of UL & LL on face side, flexion on opp. side (fencing
neck reflex (ATNR) posture)
Moro reflex drop baby's head suddenly by giving bil upper limb extension, abduction & hand opening
less support
Parachute reflex drop baby's trunk downward / forward extension of arms
suddenly by giving less support

Determining gestational age (Ballard score)

• physical maturity: done within first 2 hr

• neuromuscular maturity (Ballard): done within first 24 hr

Neonatal 第 11 頁
r Perinatal asphyxia o
2015年10月15日 16:58

• hypoxia of neonates
• one of three common cause of neonatal death: congenital malformation, prematurity

antepartum (4-20%) w
intrapartum (50-80%) post-partum (10%)
maternal factors
• maternal hypotension
↓ placental gaseous exchange
• excess uterine contraction r•• hypoxia
hypotension (blood loss, shock)
• pre-eclampsia • placental abruption • anemia
fetal factors
• ruptured uterus
↓ umbilical cord flow V • infection

• syndromal disorder • cord compression (shoulder

• cord prolapse

• early
CVS myocardial failure, TR, shock, PPHN
RESP RDS, pul hemorrhage, meconium aspiration
RENAL oliguria, acute tubular necrosis
GI hemorrhage, ileus, NEC, hepatitis
NEURO hypoxic ischemic encephalopathy (HIE)
endocrine hypo/hyperglycemia, ↓ Na, ↑ K, ↓ Ca, ↑ PO4, acidosis
blood thrombocytopenia, DIC
• late
○ cerebral palsy
○ mental retardation
○ sensorineural deafness, blindness
○ epilepsy

• clinical signs
○ ↓ HR
○ ↓ RR
○ ↓ tone & reflex
○ pale / blue skin color
○ meconium stained liquor
○ seizures
○ fetal bradycardia: sudden & sustained
○ no fetal HR variability

○ deceleration: persistent, late, variable
• Apgar score: 0-3 beyond 5 mins
• CTB: acute non-focal cerebral abnormalities
• fetal biophysical profile (BPS)
○ fetal movement: reduced
○ fetal tone: hypotonia
○ fetal breathing: reduced
amniotic fluid vol: reduced

Neonatal 第 12 頁
○ amniotic fluid vol: reduced


N • fetal: metabolic acidosis in umbilical cord arterial blood (pH <7, base deficit = 12 mmol/L)
• neonatal: early onset of severe / moderate neonatal encephalopathy in infants ≥ 34 wk
• exclusion of other causes

Tx - neonatal resuscitation

• airway
○ neck slightly extended
○ suction of airway to clear secretion
• breathing
○ tactile stimulation for breathing if apneic
○ oxygen therapy
○ ventilation (if inadequate resp effort, poor CO, unconscious, poor protective reflex)
• circulation
○ ext chest compression if HR <60/min
○ inotropes: adrenaline
○ volume expander
• temperature
○ dry body & remove wet linen
○ place under radiant heater
• metabolic
○ electrolytes correction
○ acid-base correction: bicarbonate
○ glycemic correction: dextrose

Neonatal 第 13 頁
NHypoxic-ischemic encephalopathy (HIE)
2016年1月17日 3:52

• acute ischemic brain injury due to perinatal asphyxia

• due to systemic hypoxemia & reduced cerebral blood flow
• main cause of neonatal death worldwide, happens in 1: 1000 newborn


Respi as

neuro PPHN shock log

Ex - perinatal asphyxia
• antepartum (4-20%)
a TE
○ maternal anemia, hypotension
○ placental insufficiency: pre-eclampsia

• intrapartum (50-80%)
○ birth trauma: shoulder dystocia, breech extraction
○ placental abruption
○ cord prolapse
• postpartum (10%)
○ pulmonary:
○ cardiac: blood loss, septic shock, congenital heart disease


Stage 1 (mild) Stage 2 (moderate) Stage 3 (severe)

Neonatal 第 14 頁
Stage 1 (mild) Stage 2 (moderate) Stage 3 (severe)
gen • irritable • lethargic
r• comatose
neuro • ↑ reflex • ↓ tone • ↓ tone
• ↓ primitive reflex • ↓ reflex
• early onset seizure • no primitive reflex
CVS • pupil dilated • ↓ HR • ↓ HR
• irregular breathing • apneic
• pupil constricted • pupil fixed
px resolves in 24 hr resolves in 1-2 wks N
30-40% mortality, 80% cerebral palsy

• metabolic acidemia (pH <7) from umbilical artery blood
• Apgar score 0-3 for ≥ 5 min
• neurological cx: seizures, coma, hypotonia
• multi organ involvement

• blood
○ CBC: anemia, infection
muffin ○ RFT: renal failure

○ LFT: liver failure
○ clotting: coagulopathy, DIC r
○ ABG: resp failure, metabolic acidosis
○ troponin: heart dysfunction
• imaging
○ MRI brain: bil hyperintense signals in basal ganglia & thalamus, absence of normal signal in int capsule
○ amplitude-integrated EEG: monitor seizure activity
○ cranial USG: hemorrhage, swelling, ↑ white matter echogenicity

• resuscitation
○ monitor vitals, neuro signs,
○ A: intubation
○ B: oxygen therapy + ventilation
○ C: set up IV access
• supportive tx
○ dextrose for hypoglycemia
○ IVF & inotropes for hypovolemia
○ benzodiazepine for seizures
• hypothermia therapy
○ 33-33.5°C for 72 hr
○ started within 6 hrs of injury

Neonatal 第 15 頁
N Birth trauma
2015年11月28日 19:53

• size
○ macrosomia / LGA baby (eg. GDM)
○ cephalopelvic disproportion (CPD)
• position
○ malpresentation
I ○ shoulder dystocia

• maternal
○ prolonged labor
○ instrumental delivery
• fetal
○ prematurity

• Caput succedaneum / excessive moulding
○ ex: Ventouse delivery

○ pitting edema of presenting scalp
○ rapidly resolves
• Cephalhematoma / subperiosteal hematoma
○ ex: Ventouse delivery
○ fluctuant swelling on scalp, limited by suture lines
○ usu in parietal bones
○ resolves over weeks
○ cx: anemia, prolonged jaundice, infection
• Subaponeurotic / subgaleal hematoma (rare)
○ ex: Ventouse delivery, fetal coagulopathy
○ galeal aponeurosis, large potential space for large hemorrhage
○ sx: fluctuant swelling, NOT limited by suture lines.
○ cx: anemia, shock, death

• traumatic cyanosis
○ bruising & petechiae of presenting part
• lacerations

○ linear wound with bleeding
○ ex: forceps mark (U-shaped), Ventouse cap, scalp electrodes, scalp pH sampling
○ tx: close with suture

• brachial plexus palsy
Erb's palsy (C5-C7)
○ ex: shoulder dystocia

○ arm is flaccid with pronated forearm & flexed wrist (ie. waiter's tip position)
○ recovers within 6 weeks in 2/3 cases
○ X-ray clavicle to exclude clavicular fracture
○ tx: physiotherapy
fKlumpke's palsy (C8-T1)
○ involving intrinsic mus of hand
○ rarely ax/ Horner syndrome
phrenic n. palsy (C3-C5)
○ affect breathing
○ life-threatening
• facial n. palsy
○ ex: forceps delivery, pressure on face by maternal ischial spine

○ facial asymmetry (lack of eye closure & lower facial movement), worse on crying
recovers in 1-2 weeks

Neonatal 第 16 頁
○ recovers in 1-2 weeks
○ tx: eye care with methylcellulose (lubrication)

• clavicular fracture*
○ tx: no treatment
• long bone fractures (2%)
○ ex: macrosomia, CPD, shoulder dystocia
○ lower avulsion fractures of femoral / tibial epiphysis
○ mid-shaft fractures of femur / humerus
○ sx: asymmetrical paralysis of limb, obvious deformity & swelling
○ tx: analgesia, limb immobilization
• skull fracture
○ ex: forceps delivery, pressure against maternal pelvic bone prominence
○ depressed skull fracture needs urgent neurosurgical tx
○ linear fracture need no tx
○ cx: intracranial hemorrhage

Soft tissue
• sternocleidomastoid tumor
○ overstretching of mus leading to intramuscular hematoma
○ sx: non-tender swelling during head turning, torticollis (turns away from affected mus)
○ tx: physiotherapy
• fat necrosis
○ ex: pressure over bony prominences, eg. forceps
○ tender, red, subcutaneous swelling
○ risk of hypercalcemia if extensive, ie. need to monitor serum lvl
○ tx: resolve spontaneously

Neonatal 第 17 頁
ru Neonatal infection
2016年2月5日 17:29

• perinatal acquired micro-organisms infection causing neonatal pneumonia

early onset (<48 hrs) late onset (>48 hrs)
source from mother from ext environment
• via placental blood flow
• via amniotic fluid
• via genital tract passage
• prolonged / premature pre-labor rupture • indwelling catheter
of membrane (PPROM) • invasive skin procedure

u• Streptococcus agalactiae (GBS)
• chorioamnionitis r
• endotracheal tube
• Staphy aureus, Strep
• Listeria monocytogenes • E. coli, Pseudomonas, Klebsiella
• Neisseria gonorrhoeae, Chlamydia
trachomatis, syphilis
• congenital TORCH infection

• fever
• pallor, jaundice
• poor feeding, vomiting

• apnea, SOB
• jaundice
• irritability, lethargy
• seizures
• pneumonia

• meningitis
• septicemia
• conjunctivitis: sticky eyes, eyelid edema, conjunctival injection
(eg. gonorrhea, chlamydia, Staphy, Strep)

• blood
○ CRP: 24-48 hrs after initial sepsis screen, monitor for Abio response
• micbio
○ skin swab
○ blood culture
○ urine smear & culture
○ CSF smear & culture

• empirical antibiotics

○ G+ve cover: penicillin, cloxacillin, vancomycin
○ G-ve cover: 3rd gen cephalosporin, aminoglycosides

Neonatal 第 18 頁