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Dr. Wargowski: So this series of videos
serves as a supplement to the podcast on screening
diagnosis and assessment of fetal alcohol
spectrum
disorders. So usually this portion of the
evaluation
comes in after the initial recognition of
a concern
about the possibility of a FASD. After information
has been gathered about alcohol exposure,
the growth
history of the child, and the child's developmental
and behavioral histories, then comes the physical
assessment. So the physical assessment basically
has
two parts. The first is to look for the three
cardinal features, physical features of prenatal
alcohol exposure, which are the short palpebral
fissures, the smooth philtrum and the thin
upper lip.
The assessment can go further though and also
include
evaluation for other characteristics that
occur at
lower frequency but are easy to assess and
can support
a diagnosis and in some cases have medical
implications for the individual being assessed,
and
these are things such as cervical spine abnormalities
that can limit mobility, radiohumeral synostosis
that
can limit pronation and supination at the
elbows and
short distal phalanges of the fingers. The
only tool
that you really need for this part of the
assessment
in addition to your usual diagnostic equipment
is a
ruler, ideally a transparent ruler, and even
more
ideally to have a few rulers with different
colors to
provide contrast against a range of skin tones.
Some
tips are to stablize the ruler against the
face by
holding your hand against a portion of the
face to try
to hold the ruler parallel in three dimensions
to the
palpebral fissure and to get as close as possible
to
the eye to get an accurate measurement. Also
ideal is
a neutral facial expression on the patient,
this can
be a little bit of a challenge in infants
at times, so
we will see sample exams initially of a child,
a
school age child to kind of give an overview
of the
exam and then of an infant and then also an
adolescent
to highlight some of the challenges that the
assessment presents in each of those age groups.
The physical assessment portion of the
diagnostic evaluation is actually fairly straight
forward, and I think simple enough once learned
to
be incorporated into a well child evaluation.
After typical measurements, recumbent length
in
children less than two years old or standing
height, in older children, weight and head
circumference, and actually the head circumference
needs to be done in children of all ages for
this
purpose and having all of those plotted on
standard
charts we can then move into the portion of
the
examination that's specific to looking for
manifestations of prenatal alcohol exposure.
So
Evan is doing a great job keeping a neutral
facial
expression, which is ideal, but obviously
not
always possible. We'll start by measuring
his
eyes. Evan I'm going to use this ruler just
to
measure across your eyes just like that. In
measuring the palpebral fissures it's best
to keep
the ruler in an angle parallel with the eye.
Really in three dimensions, so if the eye
is
slanted one way or another, you adjust the
ruler
this way. If the orbit is cated in or out,
you can
adjust the ruler this way to get the most
accurate
measurement. But really you just want to measure
from the inner margin of this eye, the inner
corner
to the outer corner where the skin portions
of the
eye lids come together. And for children with
epicampic folds or folds of skin over the
inner
margin, sometimes you have to account for
that a
little bit and add a couple of millimeters
to what
you can see. So for Evan, I'll put the ruler
just
like this, and then align my eye sight so
that I
get a good straight on view of the palpebral
fissure, and his right palpebral fissure measures
26 millimeters and then I do the same thing
on the
left side. Then I'd like to take a look in
your
mouth if you could tip your head back a little
bit
and open your mouth wide, very good. So I
can look
at the rough of your mouth or pallet and then
say,
ah, okay, and I can see his uvula which has
a nice
normal formation. Good. Close your mouth.
Now
what I'm going to have do you is I want to
see how
your neck moves if you can tuck your chin
down to
touch your chest. Very good. Okay, now bring
your
face back up and then tip your head back as
far as
you can. Good. Bring it back up. And then
I want
you to tip your head sideways so your ear
goes to
your shoulder. Very good. Okay, now try on
the
other side. So Even has nice normal neck mobility.
And then the final part is to look at the
hands and
the elbows. Evan if you would show me your
fingers
like this, let me look at the palmar creases.
There is, in the literature, what's called
a hockey
stick palmer crease where the distal crease
angles
up into the space between the first and second
fingers, but this is a very nonspecific finding.
More important is to look at the distal digits
and
see how long they are. Shortening or hypoplasia
of
the distal digits is another characteristic
finding, Evan doesn't have that either. Then
while
we're looking at the hands, keeping the elbow
bent,
we just pronate and supinate at the elbow
to check
for any signs of radioulnar synostosis, and
Evan
doesn't have that either. So as we would expect,
Evan has no signs of prenatal alcohol exposure.
And that's really the exam, looking for the
features that are characteristic of prenatal
alcoholism. Not too bad, huh?
Speaker: Next we'll seen a assessment of an
8 month old infant.
Dr. Wargowski: So Lucy has had her length
measured and her weight and her head circumference
and
now we're going to look at Lucy's eyes (crying)
and
Lucy's not happy. So obviously, anything we
can do to
engage her is very good and helpful. And we're
going
to measure right across her inner campal distance
there (crying). Here, look. And get a good
look at
her right palpebral fissure using the ruler
and
aligning it with the plain of her eye. You
did a very
good job, 24 millimeters. And now this is
getting in
the way here. And now we'll try the left one
(crying). And Lucy is cooperating very nicely
(rattle
shaking). Lucy? You like that card, don't
you. And
again, aligning the ruler to 24 millimeters
on the
left side. Your eyes match. Now can we trade?
What
do you think? You like this better? This has
a
picture. And what we want to do, again, is
compare
the lip and philtrum to the lip philtrum guide,
and
ideally you want to observe Lucy when she's
not making
a face, which is a challenge in an infant,
and I found
also that it can be successful to do this
part of the
exam during the history when the child's actually
not
engaged. Her lip and philturm are certainly
normal.
She's got the lip tucked in a little bit at
the moment
(crying). Now, look, what do we have here?
There,
now can you can see her lip and philtrum a
little bit
better. Obviously, a infants neck mobility
is a more
passive observation, and she has shown a fairly
normal
range of motion of her neck. We can still
do the hand
exam. Look for the shortening of the distal
phalanges
of the fingers and pronation and supination.
Let's
see on this side. I don't want you to plop
over
backwards. There, very good job.
Finally, an assessment of an adolescent.
So in older children, who are either going
through
or have been through puberty, there are some
changes in the face that sometimes throw off
the
initial impression of the physical characteristics
that we're looking for, but the cardinal features
are still present, so the evaluation really
isn't
much different, but I'd ask you to do now,
McKenzie, is take your glasses off now please.
What I want to do now first is measure across
your
eyes. So using the ruler, I'll measure from
the
inner corner of your left eye to the inner
corner
of your right eye, which is 3 centimeters.
And
then again angling the ruler to the plain
of the
eye, measure across your right eye, which
has a
palpebral fissure length of 29 millimeters,
and
then on the left do the same thing, and the
measurement again is 29 millimeters. Then
I'd like
to take a look at your ears, if you could
turn your
head that way for a minute so we can show
for the
camera, tuck your hair back here, maybe not,
there
we go. Just to look at the ridges again. And
she
has nice normal ear ridges, and then back
this way,
and again on this side, ear ridges look nice
and
normal. Let's look at your philtrum first,
so
again she has a nice neutral facial expression,
and
a very normally formed philtrum and upper
lip,
somewhere between a 2 and 3 . Okay. Now I'll
have you open your mouth and tip your head
back
just a little bit. Very good. Okay, and then
say
ah. Okay. Good. Nice normal pallet and uvula,
and you had your head half way there, tip
your head
back as far as you can reach, okay, good.
Then
bring it back down, now touch your chin to
your
chest. Very good. Bring your chin back up
and
then tip your head to your side put your ear
on
your shoulder and then on the other side.
Very
good. Nice normal neck mobility. Let's take
a
look at your hands. Again, nice normal distal
phalanges, and then we'll check pronation
and
supination and that seems fine. Very good.
Okay.
For more information contact the FASD
regional training center nearest you.
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