The first part of the general examination that the Physician Assistant Exam (PANCE) will cover is getting a good look at the newborn. By look, this doesn’t mean seeing how cute the baby is. This means looking at the newborn with a medical eye. For example, does the baby have a good pinkish skin color? Is the baby premature or small in stature? Does the baby have a good cry?
Pay attention to posture — not your own but the newborn’s. The baby should have more of a flexed posture. Then check the newborn’s body and reflexes.
Examine the baby’s body
After the general examination, start at the baby’s noggin and work your way down:
Check the newborn’s head.
On the head, the child may have mild scalp bruising or mild scalp edema. This is normal and is often a result of the childbirth process. Also pay attention to the fontanelles.
A bulging fontanelle can be a sign of a central nervous system infection (meningitis), increased intracranial pressure (hydrocephalus), or even a subdural hematoma. Note that crying can also cause the fontanelle to bulge. In that case, the bulging should go away when the baby stops crying.
From the head, work your way down, focusing on the eyes, ears, mouth, and tongue. Then look at the neck, shoulders, and clavicles.
Here you’re looking for symmetry. Any asymmetry can be a sign of a congenital problem.
Do a good heart and lung examination.
Be aware that the “normal” for newborns and infants is different from what it is for adults. For a newborn, the normal respiratory rate is 40 to 60 breaths per minute, and the normal pulse is 120 to 160 beats per minute.
Examine the abdomen.
On abdominal examination in a newborn, you should be able to palpate a liver edge (this isn’t pathologic, as it is in adults). The spleen tip shouldn’t be palpable. Concerning the umbilical cord, the normal anatomy is one vein and two arteries. The skin should be inspected for any lesions.
Work your way down from the abdomen to the hips.
Concerning the hips, you want to be sure that the newborn doesn’t have a congenital hip click. Hip maneuvers are likely topics of a test question.
You can use Barlow’s maneuver and the Ortolani test to detect a congenital hip dislocation. Usually, Barlow’s maneuver is done first. It tests for hips that are original in position but may be dislocated out of position. If a hip click is present, then do Ortolani’s maneuver as a confirmatory test. Ortolani tests are for already dislocated hips that may be put back in place.
Check reflexes
The reflexes present in a newborn are pretty good to know for the PANCE. If these reflexes are absent, some badness going on, and you need to investigate more.
The sucking reflex is present at birth for obvious reasons. The grasping reflex is present as well. Put something in the hands of a newborn, and the baby will put his or her fingers around it and not let go. This reflex can last for several months after birth.
The Moro reflex, or startle reflex, is present in the newborn but goes away after a few months. Say the newborn is surprised for some reason. The head goes back and the legs extend forward. The hands go up straight. You may see flexion of the thumb and digits, then becoming clenched fists. If the Moro reflex is absent, it suggests possible damage to the brain or central nervous system.
The APGAR on the PANCE
An APGAR score is given to a child immediately after birth. The number indicates how well the newborn is doing at 1 minute and then at 5 minutes after the birth. You look at five factors:
Skin color (should be pinkish)
Pulse (should be 140 to 160 beats per minute)
Reflexes
Muscle tone
Respiration (whether the neonate is having any breathing difficulties)
Although the score is named after Dr. Virginia Apgar, APGAR makes a great acronym: appearance, pulse, grimace, activity, respiration.
For each factor, the infant is assigned a score of 0 to 2. For example, if the infant’s heart rate is less than 100 beats per minute, he or she gets a score of 1 for the pulse category. If it’s greater than 100 beats per minute, the newborn gets a score of 2 for that category. No pulse at all merits a 0.
A total score of 7 or greater means that the infant is in good shape, and a score of less than 7 means that the infant is in trouble.