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“The whole art of medicine is in observation … but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that we can do.”10
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Temperature: Temperature instability, fever, or hypothermia may represent sepsis. Check the pulse. Tachycardia may signal sepsis, dehydration, anemia, supraventricular tachycardia, or toxic ingestion. Bradycardia may signal sepsis, hypoxia, or ingestion. When observing respirations, note the rate, quality, and look for intercostals retractions. Capillary refill is used to assess hydration and perfusion status. Pulse oximetry may identify hypoxia and is useful if there are signs of any respiratory distress. Weight is an important “vital sign” in an infant. Normal weight gain is usually the sign of a healthy infant. Any acute illness in infancy, especially during the neonatal period, the first month of life, is likely to cause the infant to stop gaining weight.
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The clinician should observe the infant with attention to the infant's color, quality of respirations (specifically noting any retractions), the infant's attentiveness, and the infant–parent interaction. An infant not interacting with the parents appropriately has a serious reason for crying. If the infant has paradoxical irritability (the crying increases rather decreases when picked up), consider meningeal or peritoneal irritation or fractures. Note the pitch of the cry, as this is important and will help the clinician decide the direction of the assessment. An infant with a high-pitched cry should be considered ill until proven otherwise. If the infant is ill-appearing, the history, physical examination, and resuscitation will be occurring simultaneously (Fig. 7-1).
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Initially, most of the physical examination of an infant can be done by observation with the infant in the parent's arms. The clinician should leave invasive examinations until last (fundoscopy, otoscopy, oropharynx examination, genital examination, and rectal examination). Completely undress the infant including the diaper. Lay the infant on its back on the examination table to assess movement of the extremities (asymmetry of movement may be the clue to a fracture) and for an adequate abdominal and genital examination. Inspect the genital area: look for symmetric testicles (testicular torsions) and abnormal masses (hernias) (Fig. 7-2).
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Inspect the infant's complete skin surface. Hair tourniquets (Fig. 7-3) hide under clothing as can signs of child abuse (unusual bruising pattern). In a retrospective review of infants who presented to the ED with excessive, prolonged crying without fever and without a cause that was apparent to the parents, the physical examination revealed the diagnosis in 41% of the cases and provided clues to the final diagnosis in another 13%.1 A complete physical examination should be performed with special focus upon the conditions known to cause persistent crying in infants (Table 7-1).
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