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OK, now that I am emerging from my gadget-delirium, I am going to move on with our tour of the physical exam.

I have spent the past two posts going over the exam of the infant – first with the northern part, and then with the heart exam. This leaves us with only the southern hemi-baby to cover. While for most adults, this part of the exam would be an… umm… less than appetizing affair, the infant exam offers more than the RDA of cuteness in both the upper and lower parts. To put it frankly: even the butt of a baby is cute.

You may think that I am simply voicing an opinion, but it has been scientifically proven that a baby’s butt produces more people saying “awwww” than any other part of the human anatomy at any age. This is know by scientists as the aww to skin ratio (ASR). Some have proposed that instead of dividing the aww by the skin, it should be added together. This would cause the name to be changed to the aww to skin sum (ASS), but the scientific community has yet to stand behind this change. We will leave that controversy to the scientific journals.

So let’s start moving down the baby.

Abdomen

The abdominal exam of the newborn is the only time in which the examiner can feel normal kidneys. Why do I say this? First, it is good to know in case the question comes up on a game of Trivial Pursuit, but it is actually important to do whatever possible to uncover any early signs of problems. Enlarged kidneys, while usually first picked up on a prenatal ultrasound, can be signs of significant problems that may be averted through early intervention.

The examiner also feels for enlargement of the liver and spleen, as they can be signs of either problems with the GI tract or the immune system. This exam is quite a bit easier on the younger infant, as two factors come in to play as the child ages: the belly gets chubby, and the belly gets ticklish. A chubby abdomen on an infant (2 months and over) is a normal finding. Some parents (spurred by the fear of obesity) wonder if the child is eating too much. I generally tell parents that unless they are feeding the child cheeseburgers, french fries, and chicken nuggets, they should not worry. This is one of the only times it is OK to be fat. The amount of growth that the child needs to do necessitates the storage of a significant amount of fuel for that growth.

I have tried to make the same excuse for myself, but nobody seems to buy it.

Umbiliphobia

The newborn’s umbilical cord scares 98% of all parents. There is something very alien about this gooey stump coming out of the child’s navel, and so parents are often not aggressive enough at using alcohol on it to dry it out. They ask me if the alcohol hurts. I tell them to ask the child. The bottom line is that you can move it around as much as you need to so you can get the alcohol on the wet parts. The only thing I don’t recommend is picking the child up by the cord.

Click or Clunk

The hip exam is one of the more important parts of the infant physical exam. A certain percent of all children have a condition called Congenital Dislocation of the Hip. This is actually an inaccurate name, in that the hips are not dislocated, but instead dislocatable. The hip joint itself is not formed properly, so that the ball of the hip can come out of socket easily. This happens in roughly 1 in 100 children (mostly girls) and if it is not picked up, it can lead to lifelong hip problems. The exam of the hip is done by pushing down on the knees, rotating the legs away from midline, and pushing up with the fingers on the back of the hip. If CDH is present, it will come out of socket, resulting in a “clunk” feeling. Many medical students are taught to look for “hip clicks” on an infant, but a clicking sensation is not indicative of CDH. It must be a clunk.

The good news is that if this is picked up early enough, the child can be placed in a harness that will hold the hips in socket and prevent significant problems. The harness will not, however, get the child to gallop or even cantor.

A Little Testy

The genital exam on the infant girl is fairly unremarkable. Girls are uncomplicated in that way; they keep all of their parts on the inside. This does not mean that they are uncomplicated, but just that they keep their complicatedness hidden so that boys can be confused until they are approximately 90 years old.

The boy, on the other hand, leaves little to guesswork. If he has problems, they are generally there for all to see. First and foremost, the examiner looks for two testicles. The development of the testes in the fetus takes place in the abdomen near the kidneys. To function properly, however, they must reside in the scrotum, as the temperature is cooler (much like the people in Florida moving north for the summer). In most cases, the testes migrate without problem by the time the child is born. In some instances, however, the migration does not occur (perhaps they are caught up shopping at “South of the Border.” The significance of this lies in the fact that chronically undescended testes are significantly more prone to develop cancer when the child is older. While many of the undescended testicles eventually descend on their own (after they have bought enough fireworks), some end up being surgically moved.

The other boy issue in this region is that of the meatus. This is the hole where the urine comes out, and is usually covered by the foreskin in the uncircumcised child.  The location of this hole is important, as it will determine in which direction the urine will shoot and hit the father when he changes the diaper.  If the hole is on the bottom of the shaft, it is a condition called hypospadius. While a hypospadius boy may require surgery to fix the problem, may boys will simply be affected in the way they “write their name in the snow.”  Hyperspadius Epispadius (nod to Dino) is a more significant problem in that it is much more associated with other birth defects of the urinary tract.

Warm Buns

So we now come to the star of the show – the “other cheeks.”  One of the main problems encountered by the examiner is finding the self-control to resist pinching them.  Beside that, there are a few significant findings on the exam of the rear bumper of the child.

The most common “abnormality” to find is a Mongolian Spot.  These are not really abnormal in people of African or Asian descent, but can be mistaken for bruising.  Mongolian spots are not caused by fierce barbarians bent on dominating the world (that would be Mongols), but instead by melanin-containing cells below the skin.  They most commonly occur in the upper buttock region, but can also be found as far away as the shoulders.  They are harmless and disappear by the time the child is five.

Another abnormality seen is the sacral dimple.  This is a dimple on the lower part of the back and, if deep, can indicate problems with the closure of the spinal cord.  Most dimples back there, however, are just cute.

Limbs

To be brief (if that is possible for me), the exam of the limbs is a search for abnormalities of the formation of bones.  Some babies are born with extra fingers and toes (like the 12-fingered man in the Princess Bride), and some with too few.

The main focus, however, is on the feet, as they can have significant deformities at birth.  The main abnormality seen is the clubfoot deformity, which is a serious orthopedic problems that may require surgical correction.

The final concern parents have is that their child’s feet turn in toward each other when the child walks.  This condition, known as intoeing, is usually not a concern.  All babies have some degree of this, caused by the position of the baby in the womb.  This resolves with weight-bearing, and does not require the significant interventions of the past (including putting the shoes on opposite feet).

That’s All Baby

There is no more to be said.

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