Physical Exam Key Points

1. General appearance. Does child appear well or ill, comfortable or uncomfortable, playful or timid?

2. Abdomen. Tender, tense, smooth suprapubic mass usually indicates a distended bladder. Prominence in left lower quadrant often indicates that sigmoid colon is distended with stool.

3. Back. Observe for lumbosacral skin abnormalities (café au lait spots, hemangiomas, fatty appearance, skin dimple or skin tag, tuft of hair, dermal vascular malformation, or subcutaneous lipomas).

4. Genitalia. Phimosis (if uncircumcised), meatal stenosis, and erythema of prepuce or glans may represent acute bal-anoposthitis; ecchymotic areas may represent physical or sexual abuse.

5. Rectal exam. Perform gently with a well-lubricated small finger. Position patient on side, with legs drawn into chest. Assess anal tone and rectal vault content for the following: loose or impacted stool; indurated mass in area of prostate and bladder neck, which could represent pelvic malignancy (rhab-domyosarcoma).

6. Neurologic exam. Check for sensation in perineum. Examine extremities for high arched foot, discrepancy in muscle size.

Laboratory Data. Obtain basic metabolic panel, CBC with differential, urine for analysis and culture. Radiographic and Other Studies

1. KUB. Useful in general assessment of bowel pattern, occult spinal dysraphism, abdominal masses, stool impaction.

2. Renal and bladder ultrasound. Evaluate appearance of bladder and kidneys for acute changes (bladder distention, ureteral or renal pelvis dilation) or chronic changes (bladder wall thickening and hydroureteronephrosis with parenchymal thinning and ureteral tortuosity).

3. Voiding cystourethrogram (VCUG). Can be performed elec-tively if ultrasound shows hydronephrosis or bladder wall thickening to rule out bladder outlet obstruction secondary to posterior urethral valves.

4. Urodynamic studies. May be necessary if neurologic or functional cause is suspected.

5. MRI scan of abdomen and lumbosacral spine. To exclude tethered cord or bladder abnormalities.

V. Plan. Determine if patient needs medical intervention (eg, catheterization) or simply assistance with elimination. If patient has signs and symptoms of UTI, a neurologic disorder, or abnormalities on ultrasound, intervention is more likely to be necessary.

A. Constipation. Give an enema and begin bowel program (ie, mineral oil or stool softeners). See Chapter 18, Constipation, V, C, p. 91.

0 0

Post a comment